The Care Quality Commission (CQC) has rated Pinford End House Nursing Home, in Suffolk, inadequate and placed it in special measures to protect people following an inspection in September 2023.
This inspection was prompted in part due to concerns we received about personal care, incident reporting and escalation, and medicines management.
The service provides personal, nursing and end of life care. At the time of this inspection there were 35 people using the service.
Following this inspection, the service’s overall rating has dropped from requires improvement to inadequate, which is the same for safe and well-led. Effective has dropped from good to inadequate. Caring and responsive have dropped from good to requires improvement.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and monitored to check sufficient improvements have been made.
Catriona Eglinton, CQC deputy director of operations, said:
“When we inspected Pinford End House Nursing Home, we found there were significant shortfalls in service leadership and leaders had created a culture which didn’t ensure people received high-quality care. Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found here.
“We found leaders didn’t manage staff well and when talking to inspectors about their experiences of working at the service, some staff were visibly upset. They told us there wasn’t regular supervision or staff meetings. They also told us staff morale was low and the atmosphere was unpleasant as, according to one member of staff, leaders were more focused on money than people’s care.
"Inspectors found that medicines were managed poorly. For example, one person needed their medication administered in a particular way, but this wasn’t put in place and therefore, they hadn’t received their medication, putting them at risk of harm. The registered manager said the delays were due to a lack of signed paperwork.
“We found the provider failed to provide accurate reporting and risk assessments when people required personalised care. For example, there were ineffective risk assessment plans and guidance for people at risk of choking, so, staff weren’t sure what actions to take to keep people safe from harm. Also, some people spent long periods of time in sedentary positions without being helped to move. This put people at increased risk of harm and skin breakdown. We found there were gaps in records showing they hadn’t been helped to move in up to nine hours.
“We have reported our findings to the provider, and they know what they must address. We will monitor the service to ensure people are receiving safe care. If sufficient progress hasn’t been made, we will not hesitate to take action to ensure people’s safety and well-being.”
Inspectors found:
- The provider's governance systems and audit processes continued not to be robust enough to ensure shortfalls were identified and addressed
- The provider had failed to take action in response to fire safety concerns highlighted following external fire inspection visits
- Fire safety procedures were unclear, and staff including agency nurses with overall responsibility for the safety of the building did not have access to the training and information they needed to respond in an emergency
- The provider did not always respond to safeguarding concerns in line with their own policy and local protocols
- When events including safeguarding incidents had occurred, records did not evidence what action had been taken. There was no evidence lessons were learnt when things went wrong
- The safety of people at risk of choking, inadequate food and fluid intake and those at risk of acquiring pressure wounds had not been effectively monitored to ensure their safety and wellbeing
- Regular checks continued not to be carried out on medical devices, such as suction machines to ensure they remained in good working order for when needed in an emergency. There were insufficient trained or supervised staff to safely meet the needs of people. People told us there was not always enough staff to meet their needs
- People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The report will be published on the CQC website in the next few days.