The Care Quality Commission (CQC) has rated Caradoc House Residential Care Home in Church Stretton, Shropshire, inadequate following an inspection in August.
Caradoc House Residential Care Home provides personal and nursing care for up to 11 people. The service supports older people, including people living with dementia. At the time of the inspection there were 10 people using the service.
CQC carried out an unannounced focused inspection of the service to follow up on concerns about how the home was currently being managed.
Following this inspection, the overall rating for the service has dropped from requires improvement to inadequate. How safe and how well led the service is has dropped from requires improvement to inadequate and how caring the service is, has dropped from good to requires improvement.
CQC have also placed Caradoc House in special measures, which means it will be closely monitored and re-inspected to assess whether improvements have been made. If sufficient improvements are not made, CQC will not hesitate to take further action.
Amanda Lyndon, CQC head of inspection for adult social care, said:
“When we inspected Caradoc House Residential Care Home, we were disappointed to find the service wasn’t well led, and the provider wasn’t giving good direction to staff regarding the running of the home.
“Our inspector found some medication kept in a carrier bag in the conservatory. Other prescribed medication was kept in the laundry area. This unsafe storage of medicines put people at risk of harm as they might accidentally, or intentionally eat them.
“There weren’t enough staff with the right skills and training, and only one staff member was working at the home during the night. This staff member wasn’t trained to help people take their medicines which created a delay in people accessing them.
“Lessons weren’t learnt at Caradoc house when things went wrong. The provider didn’t have effective systems in place to look at incident and accident records to identify any trends or patterns to prevent them from happening again.
“It’s completely unacceptable for people to be living in these conditions. Our priority is for the safety of people using the service, and we have told the provider to make improvements as a matter of urgency. We will continue to monitor the service closely and if the required improvements aren’t made, we’ll consider taking further action which could lead to closure of the service.”
Inspectors found the following during this inspection:
- People were expected to eat their meals at tables with broken curtain poles and confidential information on them. This was not a dignified dining experience and did not value the person living in the service
- The registered manager was observed entering a person's room without seeking their permission. The staff member moved an item of furniture in the room but ignored the person. It was not until the person said, "hello" that the staff member acknowledged them. The same staff member was observed entering another person's room again with them present and again without announcing themselves. This demonstrated a complete lack of respect for the people living in the service or their privacy
- The provider had failed to ensure windows had the correct restrictors in place putting people at risk of harm from a fall from height. People accessed areas where large wardrobes, ladders, used doors and wooden pallets were not secured safely this placed people at risk of harm from being crushed
- Inspectors found bleach, weed killer, cleaning chemicals and building materials were left unsecured throughout the premises. People were independently mobile, including those living with dementia. This put people at the risk of accidentally or intentionally eating harmful substances
- The registered manager also failed to identify and manage the risks from hazardous substances, breaches in confidentiality, multiple trip hazards and risks from being crushed. They did not check medicines were administered safely or stocks matched the medicines given. The provider had not identified or acted to rectify these concerns. These issues put people at the risk of harm from receiving unsafe care in the home
- People were not protected from the risk of abuse and ill treatment. The provider did not know who was in the building at any given time or if staff living in the building brought in visitors. One staff member told said, "I have no idea who is in the building at any time. They just let themselves in and walk through here like they own the place. Recently a midwife turned up and we didn't even know there was a baby living in the building. We just don't know who is in here." This put people at risk of abuse as the provider did not know those accessing or staying at the home
- The registered manager failed to report significant events to the Care Quality Commission. For example, there was evidence an abusive act had been reported by staff to the management team. However, the management team had not passed this onto the CQC.