The Care Quality Commission (CQC) has rated Holmewood Residential Care Home in Cockermouth, Cumbria, inadequate, and placed it in special measures to protect people following an inspection in July and August.
Holmewood Residential Care Home provides personal care to up to 26 older people.
The inspection was carried out as part of CQC’s continual checks on the safety and quality of healthcare services.
Following the inspection, the overall rating for the home is inadequate, as well as the areas of safe, effective, responsive, caring and well-led. The service was previously rated requires improvement overall, and for being well-led. Safe was rated inadequate, and effective, caring and responsive were rated good.
The service has been placed in special measures which means it will be kept under close review to make sure people are safe and, if CQC do not propose to cancel the provider's registration, there will be a re-inspection to check for significant improvements.
Karen Knapton, CQC deputy director of operations in the north, said:
“When we inspected Holmewood Residential Care Home, we found a home where leaders didn’t have a good understanding of the issues it faced which had resulted in deterioration in the standard of care being provided since our last inspection. We found incredibly serious safety concerns that leaders were unaware of, and they must urgently address these to prevent people from being harmed.
“We weren’t the only ones who were concerned about leaders’ ability to keep people safe. Staff also told us they were worried people at the home were unsafe, not getting their needs met and were scared someone was going to come to harm due to unsafe practices.
“It was concerning to see that people’s health conditions and end of life care wasn’t being managed properly. We had to request a GP visit for four people during the inspection, as staff were unaware people needed urgent help, which is unacceptable.
“Leaders also failed to create a safe environment for people to live in. We saw a broken staircase that hadn’t been secured and equipment left lying around posing a trip hazard. Equipment wasn’t being used safely either, like people’s feet not being properly secured in wheelchairs which could lead to serious injury.
“In addition, the home was often understaffed which put people at risk of not having their needs met. We saw people's call bells or requests for help not being responded to in a timely way which caused distress and put people at risk of harm.
“We will continue to monitor the service closely to ensure the necessary improvements are made and keep people safe during this time. If improvements are not made by the time we next inspect, we will not hesitate to take further enforcement action.”
Inspectors found:
- Information about risks to people was not always effectively assessed, monitored, or managed
- High water temperatures in cold water outlets created the potential for legionella growth and there were no control measures in place to manage this
- People were at risk because of poor infection prevention and control practices
- There was little evidence of learning from events or taking action to improve safety
- The provider didn’t always ensure there were enough staff with the right mix of skills to support people
- Systems weren’t always safe or robust to ensure suitable staff were recruited to work with vulnerable adults
- The provider failed to ensure people had an adequate supply of medicines prescribed to meet their health needs effectively.
The report will be published on CQC’s website in the next few days.