The Care Quality Commission (CQC) has taken action to protect people living at South Haven Lodge Care Home and rated it inadequate, following an unannounced inspection in September and October.
South Haven Lodge Care Home, run by Aurem Care (South Haven Lodge) Limited, is a residential care home which provides personal and nursing care. At the time of the inspection 30 to 31 people were living in the home and it was undergoing a change in management.
CQC carried out an inspection following concerns received about the home regarding safeguarding, staffing levels and training, care standards and the home’s management.
Following the inspection, CQC issued three warning notices to Aurem Care (South Haven Lodge) Limited for breaches in regulations relating to people’s dignity and respect, consent, and safeguarding.
Due to the seriousness of the concerns, CQC took action to immediately suspend the ratings of the service following the inspection in the autumn. This was to ensure people looking for information about South Haven Lodge Care Home were aware that CQC wasn’t assured they were an accurate reflection of the care being provided.
It has also been placed in special measures which means it will be kept under close review by CQC to keep people safe whilst it is being monitored to ensure sufficient improvements are being made. CQC is also using its regulatory powers further.
Following this inspection, the home has been rated as inadequate overall and for the areas of safe and well-led. Caring and effective have been rated as requires improvement. The home had been rated under its previous provider as requires improvement overall. Responsive was not looked at as part of this question and retains its previous rating of good.
Neil Cox, CQC deputy director of operations in the south, said:
At our inspection of South Haven Lodge Care Home, we were disappointed to find people’s basic support needs weren’t being met.
We weren’t assured that people were safe or protected from the risk of avoidable harm. Staff couldn’t demonstrate they understood their role in safeguarding people from abuse. One person’s care plan said they posed a risk to female staff and residents, but it lacked guidance on how to manage this. The care plan said the person should be supervised by staff when they were out of their room, but throughout the inspection they were seen unsupervised. We immediately raised our safeguarding concerns to the local authority.
We were very concerned about the risk of neglect to people living at the home. Leaders hadn’t recognised or responded to people’s needs which meant care wasn’t person-centred, safe or effective. Throughout the inspection people appeared unkempt, and staff said not all staff could be bothered to shower people. We saw people were often ignored by staff, and we saw people weren’t supported when they experienced anxiety and frustration.
What was most concerning is the way people were made to feel, in a place that was supposed to be their home. There were instances where people showed signs of being distressed and staff often ignored them, or did not afford them the dignity they deserved. People were relying on staff to act as their advocates to keep them safe and listen and act on their concerns and it’s unacceptable that those they relied on were treating them this way.
Staff didn’t always give people the opportunity to make informed choices about their care. People’s consent wasn’t always sought before care and treatment was delivered and some staff made little effort to communicate with people and made decisions for them. Care plans included people’s likes and dislikes as well as their interests, but these preferences weren’t always taken into account.
In addition, leaders hadn’t ensured there were enough staff or that they had the right skills to meet people’s needs. We saw several instances of poor staff practice, such as staff failing to respond to people’s requests for help, not supporting people appropriately when they were distressed, and walking away from people when they needed further help. Call bells were heard ringing for 20 minutes before staff responded.
Following the inspection, we issued three warning notices which told leaders where we expect to see rapid and widespread improvements. We will continue to monitor the home closely to keep people safe during this time and will return to check on the progress of improvements.
Inspectors found:
- People’s individual risks weren’t always managed safely. One person at risk of choking did not always receive appropriate food, however leaders took steps to address this after inspectors raised this concern.
- Medicines weren’t always managed well and people didn’t always receive them as prescribed.
- Leaders didn’t have good systems and processes in place to manage safety risks or make improvements. The registered manager told inspectors they believed they were not allowed to audit all areas of the home because they lacked clinical training. They had also failed to act on improvements raised by CQC at previous inspections or by external agencies including the local authority safeguarding team or health and social care professionals.
- Staff hadn’t received all the training they needed to ensure people were safe and to support their individual needs. In addition, mandatory training hadn’t always been completed.
- Infection prevention and control measures were inconsistent. Cleaning records hadn’t always been completed, protective clothing staff used was out of date and guidance for staff was unclear.
- Feedback from relatives about the home was mixed. One relative told inspectors the home had transformed their loved one’s life, while another said they were worried every day about their relative because staff weren’t providing them with the care they needed.
The report will be published on the CQC website in the coming days.