The Care Quality Commission (CQC) has taken action to protect people at Bramcote Hills Care Home in Nottingham, following an inspection in July, which sees its overall rating drop from good to inadequate and placed in special measures.
Bramcote Hills, run by Savace Limited, provides nursing and personal care to older people and people living with dementia. At the time of the inspection, the service was supporting 49 people with personal care needs.
This inspection was carried out in response to concerns raised with CQC about the service.
Due to issues found at this inspection, CQC has imposed conditions on Savace Limited’s registration, meaning they must update CQC weekly on staffing numbers and they must ask CQC before admitting residents to the home.
CQC also issued them with two warning notices for failing to meet regulations relating to person centred care, dignity and respect, need to consent, safe care and treatment, good governance and staffing.
As well as the overall rating for the home declining from good to inadequate, so have the ratings for being safe and caring. Effective and responsive have dropped from good to requires improvement. Well-led has gone down from requires improvement to inadequate.
The service will be kept under close review by CQC to keep people safe and it will continue to monitor to check sufficient improvements are being made. If CQC doesn’t see rapid and widespread improvements, further action will be taken.
Greg Rielly, CQC deputy director of operations in the midlands, said:
“When we inspected Bramcote Hills Care Home, it was disappointing to see such a deterioration in the quality of care being provided since our previous inspection, and we identified shortfalls that compromised people’s safety and wellbeing.
“The home wasn’t well-led. The management team lacked the knowledge and skills to ensure the service was a safe place for people to live. It was concerning that they weren’t already aware of the concerns we identified, due to their poor oversight. For example, there wasn’t enough staff to protect people from harm, which people had raised this previously, but management team hadn’t taken any action to address it, which meant people were at risk of harm.
“We found systems and processes weren’t in place to involve people who had experienced accidents or incidents. This meant learning from these didn’t take place in order to reduce the risk of them happening again.
“Inspectors saw one person who had capacity to make their own decisions, were using bed bedrails. However, they told us they weren’t aware they had the freedom to make their own decision not to use them. This meant people were at risk of institutional abuse which is totally unacceptable.
“People were at risk of neglect and harm. We saw someone in bed soaked in urine and shouted for staff to help. A member of staff walked past and totally ignored them. Another person had dried faeces on their clothes and bedsheets, however staff weren’t supporting them to wash to maintain their dignity or follow appropriate infection control measures to prevent the risk of infection.
“We have told leaders where we expect to see rapid, widespread improvements and will continue to monitor the home closely to keep people safe during this time. We will return to check on their progress and won’t hesitate to take further action if people aren’t receiving the care they have a right to expect.”
Inspectors found:
- The service did not provide adequate staffing levels to ensure care was carried out in a safe and effective way
- They did not have clear processes and systems in place to have robust oversight of the service to identify risks or concerns meaning necessary improvements could not be made to the care people received
- Care plans were not reflective of people’s health care needs
- They did not have a system in place to ensure people were always safe when they were in communal areas
- Some windows could be opened wider than the guidance from the Health and Safety Executive. This meant there was a potential risk people could climb out
- People’s dining experience was poorly managed. There were times people were waiting for over 40 minutes before a meal was served to them.
The report will be published on CQC’s website in the next few days.