‘Inadequate’ care home put in special measures
ARUNCORN care home where ‘serious’ incidents including falls and assaults went unreported has been placed in special measures and graded ‘inadequate’ by the regulator.
St Luke’s on Palacefields received the lowest rating in the safety, effectiveness and leadership categories following four visits from the Care Quality Commission (CQC) in October and December.
Inspectors found that the manager had failed to notify the CQC of incidents required to be reported by law including deaths, serious injuries and safeguarding incidents.
St Luke’s, which is managed by Widnes-based Community Integrated Care (CIC), had not informed the CQC of any events since July 2016.
The CQC said the quality and safety of service had deteriorated at the home since it was last inspected in 2016 and regulatory breaches relating to safety, staff training and support and good governance were found.
The home was graded as ‘requires improvement’ for how caring and responsive it is.
St Luke’s now has six months to turn round its performance or face having its registration cancelled and has said it took ‘immediate’ action to resolve all of the issues raised by the regulator including changing the manager and backed by a comprehensive review.
It has also apologised following the damning inspection report, which said that although service users told ● the CQC they felt safe, relatives had concerns and the regulator had found multiple incidents not reported to the relevant agencies.
Inspectors found that in November and December 2016 and August 2017, three service users had fallen and suffered a head injury and in January and April last year another resident had fallen and broken their hip.
All of them needed to go to hospital but there had been ‘no analysis of these accidents and no notifications’.
In September, a client hit another in the mouth causing an injury to their lip, and in July there were six assaults between residents but none was reported to the appropriate authorities.
One residents had been ‘assaultive’ towards care workers and tried to scratch them but a risk assessment had not taken place over possible cross contamination and infection.
Despite there being a whistleblowing policy in place, staff did not know the law protected them.
However, updates had taken place by the second day of the inspection so that safeguarding incidents were being reported and employees were aware of their legal protections.
Other areas of concern included a lack of infection control training and lack of up-to-date or adequate risk assessments.
There were areas of praise in the report such as for the ‘varied programme of activities’ and, in addition, relatives and residents had said staff were caring.
However, inspectors recorded multiple breaches.
These included stocks of prescribed eyelid cleansing gel to prevention infection that had run out and reordered 12 days before the inspection but not followed up, and the same person was prescribed a dietary supplement but there was no record of them being given.
In addition, no fire drills had taken place, care plans were not always being updated after accidents, staff were not aware of who had been properly trained in the deprivation of liberty safeguards aspects of the Mental Capacity Act 2005, and care plans were lacking in detail such as over how to deal with residents who show behaviours that challenge the service, In their opening summary, the inspector said: “We found that there was a risk that people’s behaviour was not managed consistently and the risk to their health, welfare and safety was not managed effectively.
“Accidents and untoward occurrences were not monitored by the registered provider to ensure any trends were identified.
“Shortfalls in recording meant that we could not be sure that medicines were always given to people as prescribed by their doctor.”
Richard Whitby, CIC director of older people’s services, said: “We are dedicated to delivering safe, well-led, quality services.
“When CQC identified concerns at St Luke’s, we took immediate action, developing a robust plan to resolve all issues.
“A new and experienced service manager has been appointed to lead the home, and together with our regional management, clinical governance and quality teams, we are working in close partnership with Halton Borough Council, and CQC, to give the service focused support in all necessary areas.
“As part of this work all care planning documentation has been updated, and a thorough review of staff training needs has taken place.
“All reporting issues have been resolved, and we are modernising the way in which we deliver medication, through the introduction of a new electronic medication management system, which will give us a greater degree of accuracy in medication administration.
“We would like to apologise to the people we support and their loved ones for the outcome of this inspection and assure them of our absolute commitment to restoring the service to the high standards we set for ourselves.”