The Care Quality Commission (CQC) has taken action to protect people living at Teignbridge House Care Home Limited in Teignmouth, Devon, after an inspection in June sees the home rated as inadequate and placed into special measures.
Teignbridge House Care Home Limited is a residential care home providing personal care to up to 24 older people some living with dementia. This also includes people staying for intermediary care, to either prevent a hospital stay or help them transition back to living independently at home.
An unannounced comprehensive inspection was carried out due to information CQC held about this service and to follow up on actions inspectors had told the provider to take at previous inspections. This was originally a focused inspection, however, due to the serious concerns that inspectors found when they visited the home, this was expanded to a full inspection.
Following the inspection, the overall rating for the service has deteriorated from requires improvement to inadequate, as did the ratings for safe and well-led. How effective the service is has dropped from good to inadequate and the ratings for how caring and responsive have dropped from good to requires improvement.
CQC have taken further enforcement action, which will be reported on when legally able to do so. In the meantime, Teignbridge House Care Home Limited has now been placed into special measures. This means CQC is closely monitoring it to ensure people are being kept safe, and it will be inspected again to assess whether improvements have been made.
Cath Campbell, CQC deputy director of operations in the south of England, said:
“Despite CQC telling Teignbridge House Care Home Limited where it needs to improve, it is unable to make rapid changes or sustain them. This has led to their rating stalling at requires improvement since 2019 as we find improvements in some areas and then a decline in others. This is not acceptable for the people living at Teignbridge, who deserve more, and after finding serious decline at this inspection, is why we have placed the home into special measures and started the process of taking further action to protect people.
“Teignbridge weren’t protecting people from the risk of abuse, especially from staff members. We followed up on concerns about one person’s well-being after they were affected by the actions of one staff member. We were so concerned we made a safeguarding alert to the local authority and raised it with the provider who hadn’t done so, or even addressed the allegations with the staff member involved. This is unacceptable. This wasn’t the only safeguarding alert we had to make at this inspection.
“People weren’t being supported to live dignified lives. One person told us they were unhappy with their appearance, which we saw had been neglected. It was also more concerning that this person was reliant on staff to advocate for them because they were living with dementia and had few visits from family or friends. There was no record of their GP being contacted for advice on how to look after this person’s health, so we made an individual safeguarding alert to the local authority.
“After the inspection we fed back our findings to the provider who was also the registered manager. They took the decision to step down and engage a new person to run the service. The provider also contacted the local authority’s quality assurance and improvement team for advice as they recognised they needed support, and have employed a consultant to help them make improvements.
“We will return to check on the progress of improvements we’ve told them to make, and we will be closely monitoring this service along with the local authority, to ensure people’s safety while we take further enforcement action.”
Inspectors found:
- Safeguarding concerns were not always being reported externally, this meant the service was failing to protect people from abuse
- There were poor management systems and oversight of care. This meant the risks of malnutrition, dehydration, lack of mental and emotional stimulation, poor infection control, staff training and environmental risks had not been identified or addressed
- A yellow waste bag containing used incontinence pads had been left open on a stair well. This was pointed out to the provider, but they did not close it or find a staff member to remove it. This put people at risk of catching and spreading infections
- Not all staff were recruited appropriately. Inspectors found gaps in staff employment histories and there was a poor choice of references. Steps had not been taken to ensure all staff were suitable to work in a care home
- Care plans for people living with dementia did not contain records of best interest decisions or mental capacity assessments
- The service didn’t have an effective admission system, meaning the management team couldn’t make sure they could meet the needs of people moving to the service. Particularly those who needed extra assistance to move using equipment or had additional care needs.