The Care Quality Commission (CQC) has rated Church Farm Care Home in Norfolk inadequate and placed it in special measures to protect people following an inspection in October and November.
Church Farm Care Home, run by Hewitt-Hill Limited, is a residential care home providing personal care and support for up to 40 people. The care home provides support to people aged 65 years and over, most living with dementia. At the time of our inspection, there were 36 people using the service. This was the first time the service had been rated since this new provider took over the service.
Following this inspection, the service has been rated inadequate overall. It has also been rated inadequate for all five key questions including how safe, effective, caring, responsive and well-led the service was.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made. CQC has also taken additional enforcement action, which will be reported on when legally able to do so.
Gill Hodgson-Reilly, CQC deputy director of operations in the east of England, said:
“When we visited Church Farm Care Home, it was extremely worrying to find that the care home was rated inadequate across all five key areas of our inspection. We had serious concerns around the safety and wellbeing of people living there.
“It was clear to us that the service wasn’t well-led. The new provider hadn’t conducted thorough reviews and assessments when they took over the service, so weren’t aware of the areas where improvements needed to be made. This poor leadership was behind most of the issues we found.
“The service wasn’t meeting people’s basic needs in areas like making sure they eat and drink enough. We looked at food records and found some people hadn’t eaten anything for 24 hours and one person hadn't eaten anything for three days. This is unacceptable and we made referrals to the local safeguarding team and told leaders at the time of the inspection to address this immediately.
“People's privacy and dignity wasn’t always respected. For example when people were being moved with special equipment in areas where others could see, their personal care items to control bowel movements were kept in hallway and in plain view in people's rooms. Staff also failed to respond quickly to people’s requests for assistance with using the toilet, which is undignified and can be very distressing for people.
“There was a risk of a closed culture developing in this service because leaders hadn’t created an environment where staff or people using the service were being listened to. Staff had low morale and didn’t feel confident that they could report concerns. Many staff members were visibly upset during our discussions.
“We were also incredibly concerned about how the home were managing medicines and safeguarding and made referrals to external agencies to keep people safe.
“We have taken enforcement action against the provider to focus their attention on the areas where we want to see immediate and widespread improvements. We’ve put the home in special measures to keep people safe while these improvements are being made. If sufficient progress hasn’t been made, we will not hesitate to take further action to ensure people’s safety and wellbeing.”
Inspectors also found:
- Inspectors requested support for the home from the local authority’s quality assurance team and their medicine optimisation team due to the serious concerns they found around medicines management
- Inspectors also made referrals to the local authority’s safeguarding team, due to the level of risk and concern identified during this inspection
- Incidents weren't always reported to CQC in line with the provider’s regulatory requirements
- The care home is not a well-maintained care environment with damaged surfaces and furniture, making it hard to clean
- There are issues with medicines management. People didn't always receive their medicines on time or in a safe way and stock levels weren't monitored meaning things like pain relief might not be available when people needed it. They also weren’t being stored safely; they were in unlocked cabinets in communal areas where anybody could access them without staff present
- People’s care wasn’t personalised to their specific health needs. That included preventing falls from happening where it was a known risk, monitoring people’s bowel movements and taking care of their mental health
- The quality of information shared between staff at their shift handover meetings was poor. The level of information didn't cover individual risks.
However:
- People were able to receive visitors without restrictions which is in line with best practice guidance and good for people’s well-being.
The report will be published on CQC’s website in the next few days.