The Care Quality Commission (CQC) has rated Bloomsbury House in Sutton Coldfield, as inadequate and placed it into special measures to protect people, following an inspection in September last year.
Bloomsbury Home is run by Senex Limited and provides personal care for up to 24 older people, some of whom have dementia, physical disabilities, or sensory impairments. At the time of inspection there were 11 residents.
The inspection was carried out to follow up on the progress of improvements they were told to make by CQC at its previous inspection.
The home’s overall rating, and the areas of safe and well-led were again rated as inadequate. Effective, caring and responsive were re-rated as requires improvement.
During the inspection, CQC found four breaches of regulations in relation to providing person-centred care, consent, safe care and treatment, and governance.
The home remains in special measures, which means it will be kept under close review to ensure people are safe whilst improvements are being made. CQC has begun the process of taking regulatory action to address the concerns which Senex Limited has the right to appeal.
Amanda Lyndon, CQC deputy director of operations in the midlands said:
During our inspection of Bloomsbury House we found few improvements had been made to address the areas of concern we found at our last inspection, which meant the home was still putting people at risk of harm. Leaders at the service still didn’t have a full grasp of the issues or how to solve them effectively.
For example, they had introduced systems to monitor the home which weren’t always effective and we found the same concerns as identified at our last inspection. This included not always reviewing incidents and looking at patterns to make improvements and they couldn’t demonstrate how safeguarding concerns had been investigated.
Leaders also hadn’t ensured staff had received all the training they needed to support people. We saw people were being moved and handled in unsafe ways as a result which put them at risk of avoidable harm. Staff also lacked understanding on how to support residents who were living with dementia, including how to manage distress. They responded to some people’s distress by leaving them alone to calm down, which might not be everyone’s preference, without clear reasoning behind this.
We found some improvement in how staff monitored people’s weights and dietary requirements, but we still had concerns around how they were identifying and addressing risks. The home used a generic form to monitor people’s fluid intake which didn’t account for variation in people’s individual fluid requirements to reduce their risk of skin integrity or urinary issues. After we raised this, the registered manager introduced a new process.
In addition, people’s care plans weren’t always accurate or reflective of their needs. Staff hadn’t always updated care plans when incidents happened or when people’s medical needs changed. Some people weren’t involved in planning their care and the home didn’t always promote their independence.
We expect to see rapid and widespread improvements and will continue to monitor people living at Bloomsbury House closely to keep them safe while this happens.
Inspectors found:
- There was not enough equipment to enable staff to support people to transfer safely from a sitting to standing position, such as hoists or stand aids.
- Not all staff had received training to use fire extinguishers and plans to safely evacuate people in the event of a fire lacked detail.
- Staff were observed wearing jewellery and nail polish while providing care, which posed infections risks. On two days of the inspection, two communal hand sanitiser dispensers were found empty.
- Staff did not always follow health professionals’ guidance, such as encouraging people to use equipment for them to reduce the risk of skin damage, although they made appropriate referrals when needed.
- Leaders hadn’t ensured staff understood the principles of the Mental Capacity Act and whether decisions were made in people’s best interest.
- Although the home had systems in place to administer medicines, some staff did not dispose of some medicines safely. After inspectors raised this, the registered manager introduced a new process.
However:
- People said they were happy with the care provided and staff knew them well.
- Renovations were ongoing to make the environment more dementia-friendly.
The report will be published on CQC’s website in the coming days.
