Care home found to be ‘inadequate’ for safety
INSPECTORS GIVE OVERALL RATING OF ‘REQUIRES IMPROVEMENT’
NO action had been taken to reduce the number of unwitnessed falls at a care home, inspectors said after a recent visit.
Woodmarket House was at the centre of a Local Government and Social Care Ombudsman investigation after a string of incidents in
2017.
But when Care Quality Commission (CQC) inspectors visited the Lutterworth home in September, they saw evidence of seven unwitnessed falls and said there “had not been any effective analysis or action taken to reduce the number of falls”.
When assessing whether the facility – which was caring for 38 people aged over 65 at the time of their visit – was safe, inspectors gave an inadequate rating.
The home was rated requires improvement overall.
Errors and mistakes witnessed by inspectors included:
■ One resident had experienced a 5kg weight loss in six weeks. No nutritional assessment had been carried out.
■ A frequent faller ended up needing hospital treatment after two falls.
The person was known to be unwell and experiencing confusion and hallucination, but no additional support was offered.
■ One resident told inspectors that they had waited 45 minutes for assistance after pressing their call bell.
■ Another was injured when they fell from their wheelchair as staff transferred them. The person sustained a skin tear and no changes were made to their risk assessment following the incident.
■ Another resident had no care plan after seven days at the home and as a result was almost fed a meal containing ingredients they had intolerance to.
■ The risk of choking was not being managed for one resident who had swallowing difficulties.
■ Inspectors witnessed one person spilling dinner in their lap and another struggling to get food on to their fork, with no help offered.
Medication running out meant one resident was in “constant pain” for a week.
The medicine audit had not identified the person going without the painkillers for seven days.
This was despite the fact a previous safeguarding investigation showed another person had been without medication for three weeks.
A safeguarding investigation was under way at the time of the CQC’s inspection. It had not concluded when the CQC report was published.
Staffing numbers were found to be not sufficient.
Inspectors found evidence that between September 2 and 23, the required staffing numbers were not met on 31 occasions.
The provider said three staff were needed for a night shift.
The report said: “This meant if two staff were assisting one person there was only one staff member remaining to meet the needs and monitor the safety of 37 people, many of whom were at risk of falling and had high dependency needs.”
There was also evidence on some nights there were only two members of staff on duty.
Inspectors said that the number of unwitnessed falls “may have had a direct correlation to insufficient staffing numbers”.
The Mercury made several attempts to contact the home’s owner, Leicestershire County Care Limited, and is yet to receive a statement.