The Care Quality Commission (CQC) has rated Breach House, Stourbridge, West Midlands inadequate overall, following an inspection in June.
Breach House is a residential care home, run by Golden Age Care Ltd, providing personal and nursing care for up to 34 older people. At the time of this inspection there were 18 people living at the home.
CQC carried out an unannounced comprehensive inspection after receiving concerning information regarding staffing, management of risks and lack of management oversight.
Following the inspection, the overall rating for the service has declined from requires improvement to inadequate. The ratings for being safe, effective and well-led have dropped from requires improvement to inadequate, and the ratings for being caring and responsive to people’s needs have declined from good to inadequate.
Due to concerns found at the home, the local authority has moved everyone out to alternative services that meets their needs.
Amanda Lyndon, CQC head of inspection for adult social care, said:
“When we inspected Breach House, we found a service that didn’t meet people's individual needs and preferences. The service wasn’t well-led and leaders failed to identify and act on risk to protect people from coming to harm.
“We were concerned that some people had damage to their skin and wounds from poorly managed care. Staff were unclear about what to look for in relation to monitoring this. Someone else needed thickened fluids due to a risk of choking. This wasn’t in their care plan or risk assessment so staff didn’t always provide this which could put them at serious risk.
“Additionally, someone had unexplained bruising to their palm and wrist. The home had no record of this, and staff couldn’t explain how it happened or if it was being investigated. Also, there had been no referral to the adult safeguarding team until after our inspection.
“Another person told staff they required pain relief and had to wait four hours for it which is totally unacceptable.
“We have told the provider what improvements need to be made to address the concerns identified.”
Inspectors found the following during this inspection:
- People's care plans and risk assessments did not contain the information staff needed to provide safe and effective care. Important information regarding people's known risks was missing
- There was not always access to health services in a timely way. One person had raised with staff that they did not have good vision through their glasses. There was no evidence that any action had been taken about this
- Medicines were not always administered in line with their prescriptions. People's medicines were missed due to time constraints without the medical advice or authorisation to do so safely
- People were not always treated with dignity and respect. Some people told us they were not always spoken with in a manner that was respectful
- There was a lack of involvement from people and their families with care planning
- There were no systems in place to seek feedback from people using the service. People did not always feel they could raise concerns with the staff supporting them.