The Care Quality Commission (CQC) has rated The Beeches in Lincolnshire, inadequate and placed it in special measures following an inspection in February.
This unannounced focused inspection was prompted following information received in relation to the provider's response to incidents, the level of care being provided to people and risks in the environment.
The Beeches is a residential care home providing personal care for up to 22 people aged 65 and over. There were 19 people using the service at the time of the inspection.
Following this inspection, the care home’s overall rating, as well as for being well-led, has dropped from requires improvement to inadequate. Safe has declined from good to inadequate. Effective was not included in this inspection and remains rated requires improvement. Caring and responsive were also not included and remain rated good.
The service is now in special measures which means it will be kept under close review by CQC and re-inspected to check on the progress of improvements.
Greg Rielly, CQC deputy director of operations in the midlands, said:
“During our inspection of The Beeches, we found people weren’t safe and were at risk of avoidable harm. It was concerning that people weren’t protected from the risk of abuse or helped to have maximum choice and control of their lives.
“The provider had failed to improve the quality of the service which has been rated requires improvement for the last three inspections, and further concerns were identified at this visit which has resulted in CQC taking enforcement action.
“We found risks to people weren’t always mitigated following incidents. For example, an incident record showed a person had choked on food and a staff member supported them by slapping their back. A referral to a specialist to assess this person's eating and drinking wasn’t made until over a month after the incident which left the person at continued risk of choking which is totally unacceptable.
“People weren’t always protected from abuse. Someone was involved in an incident of alleged abuse which put another person at risk. The provider was aware of this but failed to assess or mitigate ongoing risks. Once raised by inspectors, a risk assessment was put in place, however this failed to clearly show how staff could keep people safe which must be addressed.
“There were safety issues with the environment. Several wardrobes weren’t attached to walls and this created a risk of them falling onto people who used furniture for support when walking. However, since the inspection, the provider has informed us they have now been fixed to walls to keep people safe. Additionally, people were at risk of scalding from excessively hot water from some taps. The provider was aware of this risk but didn’t take action until this was raised by inspectors.
“However, staff were kind and caring and wanted people to achieve good outcomes. People told us they felt safe.
"The decline in these standards isn’t good enough and we’ve told the provider at The Beeches what they must do to improve, as nobody should ever have to live in a service which is unsafe.
“We will continue to monitor The Beeches closely to ensure the necessary improvements are made urgently to keep people safe and free from harm. If we are not assured people are receiving safe care, we will not hesitate to take further enforcement action, even if this results in closure of the service.”
Inspectors found:
- Systems to keep people safe were not effective to identify and prevent risks to people's safety
- The provider had failed to recognise their system for identifying how many staff were needed on duty was not robust
- People were not always supported to take their medicines safely
- There were environmental risks to people's safety with furniture that wasn't safely secured
- The provider had not followed best practice guidelines in relation to infection prevention and control
- Staff were not always safely recruited
- People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support good practice.