The Care Quality Commission (CQC) has rated Roop Cottage Residential Home in Pontefract, West Yorkshire, inadequate, and placed it in special measures to protect people following an inspection in November and December.
Roop Cottage, run by SNSB Limited, provides residential care for up to 35 people.
The inspection was prompted due to concerns received about people being unkempt and remaining in their bedrooms, poor management of choke risks, dietary needs, weight loss, diabetes, pressure care, privacy, dignity and cleanliness of the environment.
Following the inspection, the overall rating for the home as well as safe, caring, effective, and responsive have all declined from requires improvement to inadequate. Well-led was again rated as inadequate.
CQC has taken further enforcement action, which will be reported on when we are legally able to do so. Roop Cottage has also been placed into special measures. This means CQC is closely monitoring it to ensure people are being kept safe, and it will be assessed to see whether improvements have been made.
Sheila Grant, CQC deputy director of operations in the north, said:
"When we inspected Roop Cottage, we found a disorganised and unsafe service, where a lack of strong leadership was impacting people’s care and placing them at risk of harm. We took immediate enforcement action to ensure improvements are made so people can be cared for safely and appropriately.
"Concerns raised at previous inspections hadn’t been acted upon and there was very little evidence to show the service was learning when things went wrong. For example, leaders repeatedly accepted new people into the home without assessing risk, even though a serious incident had occurred with someone who was admitted without an assessment of the risks to themselves or others.
“This is a place people call home and being kept clean and hygienic is a basic care need that people should be able to expect as an absolute minimum. However, we saw some people looking unkempt with dirty fingernails and mouths, and unbrushed teeth which placed them at risk of infection.
“It was upsetting that some people who were unable to communicate verbally weren’t having their basic needs met. Two people who were unable to speak with us had very dry mouths and one person was chewing their hand, which staff said was a sign they may be thirsty or hungry.
“We raised concerns at previous inspections around people not being given choice about where or how they wanted to spend the day. We continued to see people in bed or sitting in their rooms, even when their preference was to be in communal areas.
“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:
- Support for people around waking times, drinks and mealtimes wasn’t person-centred and didn’t respect people's preferences and wishes
- People weren’t fully supported to express their views and be involved in decisions affecting their care
- Leaders were not able to identify a service improvement plan or action plan from concerns raised at previous inspections
- People weren’t weighed consistently, and records were poor. Where there were recorded weight losses, no action had been taken to follow up on this
- There was insufficient oversight, such as of accidents and incidents, to identify where lessons could be learned
- Safe recruitment procedures weren’t robustly followed
- Some equipment wasn’t thoroughly cleaned and there was a build-up of dirt and stains on furniture, and around taps in bathrooms
- Assessments and care plans lacked detail for some people.
The report will be published on CQC’s website in the next few days.