The Care Quality Commission (CQC) has taken action to protect people living at Cheriton Care Home in Amersham, Buckinghamshire, following inspections in March and April.
Cheriton Care Home is a residential care home providing personal care to up to 27 older people and people with dementia, run by Cheriton (Amersham) Ltd.
CQC carried out an unannounced comprehensive inspection to review information held about the service. At the time of the inspection, 19 people were living there.
Following the inspection, the overall rating for the service deteriorated from requires improvement to inadequate and it was placed in special measures. Caring and responsive, safe, effective and well-led moved from requires improvement to inadequate.
After the inspection, CQC served the provider with two warning notices to ensure the safe care and treatment of the people living there, and also to make sure more effective management was introduced into the service.
Rebecca Bauers, CQC’s head of inspection for adult social care, said:
“We expect health and social care providers to ensure the people living in their care are provided with safe care and treatment, and have the choices, dignity, and independence that most people take for granted. When we inspected Cheriton Care Home, we found people were living in unacceptable conditions.
“There were not enough suitably qualified and experienced staff in the service to support people’s individual care needs, and the culture within the service was poor. Basic checks hadn’t been carried out to ensure people were living in clean, hygienic conditions and their human rights were being met.
“We found beds had been made with stained linen. In addition, people were often left unstimulated with little interaction with staff, especially at mealtimes.
“People weren’t being protected from risk of harm. On one occasion we found staff didn’t respond when someone was coughing while eating their lunch. Nobody checked to see if that person was choking and needed help. Another person's care plan hadn’t been updated to include guidance from a speech and language therapist which was in place to ensure they could swallow their meals safely.
“Risk assessments hadn’t been put in place for all known risks. For example, one person was known to tamper with an upstairs fire door, removing a bolt which allowed the door to open onto a fire escape. We found the bolt was broken and so people could easily push the door open and fall down the fire escape steps. In addition, a window-restrictor had been removed on a window which opened onto the fire escape to air a person’s room. This could put the person at risk of falling out of the window.
“The quality of care had deteriorated since our last inspection and the provider had failed to recognise this which has put people at risk of harm. We have issued two warning notices to ensure the provider makes the necessary improvements. We will continue to monitor the service closely and will return to check these have been made within six months. If we are not satisfied, we will not hesitate to follow up with further enforcement action.”
Inspectors found the following during this inspection:
- People spoke positively about the manager. But in the manager’s absence, the provider was not aware how the home operated, and they could not locate records which should be in everyday use
- 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
- Staff did not fully understand about mental capacity. Inspectors found some applications to deprive people of their liberty had been made for people who didn’t lack capacity and could make their own decisions
- Staff did not always follow good hygiene practices at the home to prevent the spread of infection
- Care plans were not always focused on the full needs of the person or written specifically for their circumstances. Some information about medical conditions was generalised and did not provide details of any symptoms the person experienced
- People were not always offered choices at mealtimes and inspectors were not confident dietary needs were being managed effectively as there was little understanding about the needs of people with diabetes. Food was cut up for some people without there being a need recorded in their care plans
- The provider hadn’t made improvements to make the environment more suitable for people with dementia. Memory boxes had been placed outside some bedrooms, but none of them were being used. Memory boxes are meant to contain items which are meaningful to a person with dementia, such as a wedding photograph, letter from a loved one, or postcard from a favourite holiday destination
- The provider was unable to provide evidence of learning from accidents and incidents.
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