The Care Quality Commission (CQC) has published a report following an inspection at Abbeyfield Loughborough care home, in October.
This inspection was carried out to follow up on actions CQC told the provider to take at the last inspection.
Abbeyfield Loughborough, run by Abbeyfield Loughborough Society Limited, is a care home specialising in dementia care. The service provides accommodation and personal care for up to 64 people. At the time of our inspection, there were 57 people using the service.
Following this inspection, the service’s overall rating has dropped from requires improvement to inadequate, as have the ratings for being safe and well-led. Effective has dropped from good to inadequate, however, how caring and responsive the service is, wasn’t rated at this inspection so remain rated as good.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made.
Craig Howarth, CQC deputy director of operations in the midlands, said:
When we visited Abbeyfield Loughborough, it was disappointing to see such a significant shortfall of strong leadership. We found leaders and the culture they created didn’t assure the delivery of high-quality care for people using the service.
We found the provider hadn’t put systems in place to ensure risks had been identified and mitigated. For example, one person was described in their care plan as displaying difficult behaviour towards staff and required support during personal care, however, there wasn’t any record approving physical interventions and charts failed to show how staff had provided personal care. On the day of our inspection, four staff assisted the person, one of whom showed us bruising and marks on their arms and described how the person had kicked, punched and scratched staff during this process. Furthermore, we were concerned staff hadn’t been trained to provide this level of support which also put people at risk of staff using inappropriate physical interventions.
The provider and staff’s lack of understanding and knowledge of how to support people with complex care needs put everyone at the service at risk of harm, including staff. For example, one person at risk of harm from head injuries through crawling around the floor, had been found wedged behind furniture and in communal toilets due to a lack of supervision. It was clear that staff weren’t sure how to provide the support the person needed to prevent this from happening. The provider had failed to take any timely action to increase personalised support to safeguard this person. This is totally unacceptable.
Also, we found that the provider wasn’t always acting in line with the duty of candour when incidents occurred. We found a sexualised incident hadn’t been referred to the local authority safeguarding team or CQC. Additionally, we found a relative hadn’t been informed that a person had sustained a head injury due to staff poor practice during assisted moving.
This poor care is unacceptable, and following the inspection we informed provider that they needed to make significant improvements. We will continue to monitor the service closely, including through future inspections, to determine whether the issues we identified are addressed so people using the service receive the care they have a right to expect.
Inspectors found:
- Staff lacked the understanding and skills needed to effectively support people living with complex dementia.
- Staffing levels were not sufficient to meet people's individual needs and keep them safe from harm.
- People did not receive the support they needed to have enough to eat and drink or to maintain their wellbeing and hygiene.
- People were not consistently supported to maintain their oral hygiene and mitigate risks around oral care.
- People's medicines were not always administered or managed safely.
- People were protected from the risk of infections, though some areas of the premises required updating and decorating.
- The premises did not fully support the needs of people living with dementia.
- Care planning documentation was not always detailed with information regarding people's individual needs and did not provide the guidance staff needed to deliver person centred care.
- People were not 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.
- Consent had been given by relatives and external agencies without the legal authorisation to do so.