The Care Quality Commission (CQC) has rated Seaton Court, a residential care home in Burntwood, Staffordshire inadequate and placed it in special measures following an inspection in March.
This unannounced inspection was prompted in part due to concerns received about staffing levels, how risks to people were managed, as well as an incident where a person using the service sustained a serious injury and died. CQC is assessing whether it needs to take any further regulatory action in relation to this incident.
The service provides accommodation and personal care for up to 68 people and was providing care for 31 people at the time of the inspection.
As well as the overall rating dropping from good to inadequate following this inspection, the ratings have declined from good to inadequate for how safe and well-led the service is. The ratings for being caring, effective and responsive to people’s needs 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 and re-inspected to check sufficient improvements have been made.
Andy Brand, CQC deputy director of operations in the midlands, said:
“When we inspected Seaton Court, it was concerning that the care being provided wasn’t of the standard that people should be able to expect.
“Leaders didn’t implement effective systems to ensure people were safe. People weren’t always protected from potential abuse and neglect as systems didn’t show where incidents might have occurred, and they hadn’t been investigated or referred to appropriate services when people were at risk of harm.
“Additionally, we identified several incidents which hadn’t been identified as possible abuse or neglect. For example, one person had a scald from a hot drink given to them by staff, this wasn’t investigated, and nothing had been done to prevent it from happening again.
“People's dignity wasn’t maintained; their independence wasn’t promoted, and they didn’t feel like staff listened to them. People were left in bed all day without having their personal care needs met. One person had a large stain on their nightwear, they told us they had spilled a drink the day before and they hadn’t been able to change their clothing. Another person told us they had raised concerns about insects in their room which was distressing them, however after telling staff, nothing had been done to address the problem.
“Following our inspection, we reported our findings to the provider, so they know the areas where we expect to see rapid improvement. If sufficient progress has not been made, we will not hesitate to take further action to ensure people’s safety and wellbeing.”
Inspectors found:
- People's safety was not appropriately managed. Risks to people's safety were not always managed as staff were not following peoples risk assessments and care plans
- Medicines were not always managed appropriately. People had not received their medicines in line with their prescriber's instructions and medicines were not stored safely
- There were insufficient staff to meet people's needs meaning staff were not able to give people the care they needed at the time they needed it
- Staff were not always recruited safely. There was limited information held about agency staff working with people at the home
- Staff were not consistently following guidance for preventing the spread of infection at the home. Incidents were not always investigated appropriately, and actions taken to prevent future occurrence
- 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
- People did not receive effective support with eating and drinking. Staff were unaware of risks to people and their dietary needs
- People's needs and care plans were not understood by staff
- People were not always supported to make decisions about their care
- Staff were rushed and peoples care was delivered in a task-based way which was not person-centred.