The Care Quality Commission (CQC) has told The Branksome Care Home in Buxton, to make urgent improvements to keep people safe, following an inspection in March.
The Branksome Care Home provides nursing and personal care for up to 34 people. At the time of the inspection, there were 29 people living at the home.
The service was previously inspected last October, when it was rated inadequate overall, and it was placed in special measures.
Following this latest inspection, the overall rating remains inadequate. It is also rated inadequate for being safe, effective, responsive and well-led, and requires improvement for being caring.
The service will remain in special measures, which means it will be closely monitored and re-inspected within six months to assess whether improvements have been made. If sufficient improvements are not made within that time, CQC will take further action.
Natalie Reed, CQC’s head of adult social care inspection, said:
“When we inspected The Branksome Care Home we found a service that wasn’t providing safe care for the people living there. Staff had limited understanding of how to support people in a way which upholds their dignity, choices and human rights.
“We found a catalogue of errors, with each one seriously putting people in harm’s way. Staff didn’t support people at risk of choking to eat or drink, putting them at serious risk. Also, people had unexplained injuries, such as cuts or bruising, but nobody was aware how these happened, and nothing was done to investigate these or make the local safeguarding team aware so they could carry out an independent review to keep people safe.
“Sadly, this was just the tip of the iceberg, yet some people living there had come to regard this poor standard of care as acceptable. When relatives complained about the service, they were either ignored, or no apology was given.
“We have told the provider they must make urgent improvements to the service and if we are not satisfied sufficient improvements have been made, we will not hesitate to use our legal powers to ensure people are safe.”
Inspectors found the following issues at the service:
- People at risk of choking were left alone with their food. This was against their health care professional guidance which stated they should be fully supported to eat and drink. Staff on duty did not always know which people were at risk of choking
- One person was prescribed a controlled drug as pain relief which should be given whenever they needed it, but there was none in the home. This meant this person was at risk of being in pain unnecessarily
- People's care records contained documents showing staff had noticed bruising, skin tears and other marks on people's skin. These injuries had not been investigated, discussed with the person and their relative or referred to the local safeguarding team for independent review
- People's communication needs were reviewed but were not always met. Signage around the home, such as menus and activity plans were typed in a way that people with sensory loss would not easily understand. The provider was informed about this at the last inspection and had failed to make changes to improve this
- The provider failed to work in partnership with external professionals. There were multiple times when healthcare professional guidance was not followed. Referrals to safeguarding professionals were not always made and support from commissioners had not been sought since the last inspection
- There was information about people's individual needs and preferences, including any cultural requirements in their care plans. However, staff did not have easy access to care plans and the documents were not always easy to follow so it was not clear how staff could support people to always follow their cultural beliefs
- The majority of the staff were kind and caring, however, inspectors saw some staff interactions with people that were not. During one mealtime a staff member walked up behind a person and try to move them in their seat to sit up straight. They had not warned the person they were going to do this, the person appeared shocked and upset. The staff member did not apologise to the person.
Full details of the inspection are given in the report published on our website.
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