The Care Quality Commission (CQC) has downgraded the rating of Culrose Residential Home from requires improvement to inadequate following an inspection in July.
Culrose Residential Home, run by CareEast Limited, is a care home providing personal and nursing care for up to 32 older people in Diss, Norfolk.
This inspection was prompted in part by an incident in which a person in the service was seriously injured. CQC are currently investigating this issue to decide whether further regulatory action needs to be taken and will report on this when able to do so. The information shared with CQC about the incident indicated potential equipment safety concerns which were examined during this inspection and the findings are in this report.
As well as dropping from requires improvement to inadequate overall, the home has also dropped from requires improvement to inadequate for how safe, effective, and well-led it is. This inspection didn’t look at how caring or responsive the home was, so these remain rated good.
CQC has placed the service into special measures to focus the provider’s attention on making rapid and widespread improvements. CQC will closely monitor the service during this time to keep people safe and will inspect again to assess if improvements are made.
Gill Hodgson-Reilly, CQC deputy director of operations in the East of England, said:
“When we inspected Culrose Residential Home, we were disappointed to find leaders had failed to identify and respond effectively to many issues affecting people’s safety in the home, including care that wasn’t adapted to people’s individual needs.
“For example, we previously raised concerns with leaders about managing people’s risks, but found this had continued to deteriorate. Our inspectors found many care plans had insufficient or conflicting information for staff on caring for people safely.
“Additionally, some care plans also contained conflicting or generic information on people’s ability to make choices in their own care. This didn’t respect their human rights.
“We were also concerned about the high number of falls that people were having. We saw there weren’t always enough staff to respond quickly to call bells or alerts that people had stood up. In one incident, inspectors saw staff took 16 minutes to respond to an alert, at which time the person was found on the floor with a head wound. Leaders were aware of the high number of falls but hadn’t connected this with poor response times or staffing.
“While people told us they felt confident in the skills of staff, these shortfalls in leadership aren’t acceptable. Leaders must learn when things go wrong, support improvements, and improve oversight of the home to ensure people are being cared for safely.
“We’ve told the provider where improvements are needed and will continue to monitor the service closely, including through future inspections, to make sure these are carried out. If we’re not assured people are receiving safe care, we won’t hesitate to take further action.”
Inspectors also found:
- Inspectors saw one person with dementia was being deprived of their liberty without any assessment of their mental capacity or an application to do so legally, which violated their human rights. Their care plan didn’t include guidance for staff on how to support them when they experienced distress, and they were being given a medicine that can have sedative effects most days despite not showing any danger to themselves or others
- The service had failed to ensure all equipment for moving and handling had been serviced to ensure it was safe, and staff hadn’t noticed part of a hoist had broken off
- People’s environment wasn’t always kept clean and inspectors saw soiled chairs, unclean floors and damaged surfaces
- Staff didn’t always identify or report signs of potential abuse, such as unexplained bruising
- Many staff lacked training in key areas needed to support people safely, including first aid, dementia awareness, moving and handling, and safeguarding. The provider had identified this but hadn’t responded quickly.
However:
- Staff said they felt supported by leaders and able to raise concerns or make suggestions
- Staff managed people’s medicines safely.