The Care Quality Commission (CQC) has published a report following an inspection at John Sturrock care home in Leeds in September and October.
CQC carried out an unannounced focused inspection to look at whether the care home is safe and well-led. This was after receiving information of concern about a closed culture developing, a high number of safeguarding incidents, medicine errors, as well as incidents which needed to involve the police.
Following this inspection, the service remains rated as requires improvement overall and for being safe. The rating for how well-led the service is moves down from requires improvement to inadequate. Inspectors did not look at how effective, caring or responsive the service is, therefore effective remains as requires improvement, caring and responsive remain as good.
John Sturrock care home, run by Thomas Owen Care Limited provides personal and nursing care for to up to 40 people, including people living with long term mental health conditions or dementia. The provider was also caring for people with learning disabilities and autistic people. There were 40 people living in the home at the time of the inspection.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people, said:
“When we inspected John Sturrock care home, we found a service that wasn’t being managed well enough to keep people safe. We were concerned about signs of a closed culture developing, which can lead to people being put at risk of harm and have a very negative impact on their day to day lives.
“We found people weren’t always protected from the risk of harm and there were a high number of incidents that had happened between people using the service. Managers weren’t taking into account known risks to people to prevent incidents from happening again.
“We were concerned that people weren’t supported to have maximum choice and control of their lives. Some people's planned care included use of restrictions however, not all staff had been trained to restrain people in a safe way and these interventions weren’t always kept to a minimum.
“The provider has started to make improvements and is aware what further changes are necessary to keep people safe. We will continue to monitor the service closely to ensure that these are made. If we’re not satisfied that sufficient improvements have been made, we will not hesitate to take action.”
Inspectors found the following:
- Most safeguarding incidents had been appropriately reported, but during this inspection we asked the provider to report another two that had not been identified
- Care plans were not always individualised or reflective of the person's needs
- People's medicines were not always administered safely
- Management systems were not robust enough to ensure consistent recording and analysis of accidents, incidents and complaints. We found gaps in staff training and supervision
- The requirements of the Mental Capacity Act were not always followed. We found some people who lacked capacity, had restrictions on their care and this was not properly assessed and documented.
Full details of the inspection are given in the report published on our website.
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