Regulator tells St George’s Park Centre it is not protecting the welfare and safety of its residents

6 April 2011

Care Quality Commission (CQC) inspectors who visited St George's Park Care Centre in Telford, Shropshire, found that it was failing to meet 15 out of 16 essential standards.

Providers have a legal responsibility to make sure they are meeting all the essential standards of quality and safety.

Inspectors visited the home three times from December 2010 to January 2011 after concerns about the safety of people in the home triggered an unannounced review.

The compliance review outlines thirteen areas where inspectors had major concerns:

Respecting and involving people who use services

Residents were not supported to make decisions about how they were cared for or supported. Their views were not taken into account and they were not encouraged to care for themselves. Residents were not involved in how services were run or treated with dignity and respect. For example, no residents spoken to could recall staff asking them what they thought about their care and how it was delivered.

Consent to care and treatment

The home did not have systems in place to gain and review consent from residents, which is important in a setting for people with dementia who may have difficulty in communicating. For example, one person's medical notes recorded they should not be resuscitated if they died but checks had not been made to see if it was an informed decision discussed with their GP.

Care and welfare of people who use services

Assessments were not routinely undertaken to ensure safe and appropriate care was delivered. For example, some residents were found unshaven and some had not been bathed for two months.

Meeting nutritional needs

Residents were not supported to eat and drink in a dignified, relaxed and friendly atmosphere. There was no recognition that people with dementia were at nutritional risk so measures to reduce the risk were not in place.

Cooperating with other providers

The provider did not share information with other organisations concerned with their wellbeing and so residents’ needs were not being met; for example, inspectors found many residents underweight yet there was no system to refer to GPs or dieticians for advice.

Safeguarding people who use services from abuse

Staff were not acting to protect residents from abuse. This was evident from lack of training, a disproportionate number of safeguarding referrals and evidence of potential neglect with some residents not bathed for two months.

Cleanliness and infection control

The provider did not offer a clean and healthy environment. The dementia unit (Rydal) offered a poor standard of living and cleanliness. People smelt of urine and faeces and looked unkempt and dishevelled. Residents were seen wearing clothes that were un-ironed, out of shape and ill fitting. Visitors to the home reported their relatives had been seen wearing clothes that didn't belong to them. Bins were overflowing and the bathrooms and toilets were all dirty.

Management of medicines

The home's inability to manage medicines put residents' health and welfare at risk and may have led to some residents experiencing pain and discomfort.

Safety and suitability of premises

The design and layout of the building is accessible but the way it was being used made it unsafe for people living at the home. For example, there were multiple fire safety issues with free standing heaters and fire doors propped open. The exterior of the building was in a poor condition and the standards of cleanliness, decorating and the quality of furniture in the dementia unit were inadequate.

Safety, availability and suitability of equipment

The home's equipment, including wheelchairs, assisted baths, hoists, slings and sit on scales were not clean and there wasn’t enough equipment to meet everyone's needs.

Assessing and monitoring the quality of service provision

The quality of service at the home was not being monitored. The provider was not investigating poor practice and was not learning from events to make sure residents were receiving safe care.

The review outlines one area where inspectors had minor concerns:

Requirements relating to workers

The care home carries out some but not all checks when they employ staff.

The review identifies moderate concerns in two areas.

Staffing

There were insufficient staff with the right knowledge, experience, qualifications and skills to support people and to make sure residents' health and welfare needs were met.

Supporting workers

Staff were not properly trained and supervised so that people were cared for by competent staff. The home’s own staff survey showed staff did not feel supported by the management or organisation.

CQC regional director Andrea Gordon said:

“When inspectors visited this home, they were extremely concerned and advised the provider of our broad range of enforcement powers, delivering a tough three-week deadline for a complete turnaround in services. We were clear with the home that if improvements were not immediate and significant we would take steps that could lead to the closure of St George's.

“Given the breadth and severity of the concerns identified at this home, we seriously considered moving straight to this course of action, which always needs to be weighed up against the impact that closure will have on a vulnerable group of residents.  But before taking this step, we gave the provider three weeks to demonstrate dramatic and wholesale improvements.

“The provider has succeeded in implementing very significant improvements in services at the home, although it is regrettable that these were only achieved following the threat of radical action. We will continue to monitor this location very closely indeed to ensure these improvements are sustained and built upon, and that residents are receiving the care they deserve.”

Ends

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors