The Care Quality Commission (CQC) has told Gordon Lodge Rest Home in Westgate-on-Sea to make immediate improvements after an inspection in September sees them being rated as inadequate.
Gordon Lodge Rest Home, run by Fleming Care Homes Limited, is a residential care home that provides support for up to 33 older people.
This inspection was prompted to check on the progress of improvements they were told to make following enforcement action taken after our last inspection.
Following this inspection, Gordon Lodge Rest Home has dropped from requires improvement to being rated inadequate overall, as have the ratings for safe and well-led. The ratings for responsive, effective and caring were not inspected and retain their previous ratings of good.
The home has been placed in special measures, which means it will be kept under close review while improvements are made, and CQC is also using its regulatory powers further.
Serena Coleman, CQC deputy director of operations in the south, said:
“We were concerned to find a decline in the level of care being provided and the culture at Gordon Lodge Rest Home, which put people at an increased risk of coming to harm.
"The poor workplace culture directly affected the quality of care. Staff left their jobs due to lack of support and involvement in service improvements, leading to understaffing and inconsistent care. People living in the home felt unable to speak up about problems. This created an environment where neither staff nor residents felt empowered to highlight issues that needed addressing.
“People’s right to dignity and privacy wasn’t always respected. We were made aware of occasions when one resident would enter other people’s rooms while they were receiving care. Staff addressed this by locking the door of the person they were giving personal care to. However, no other action had been taken to manage the risks this resident posed to people at other times.
“We were told this risk had been removed because the person had since left the service and leaders advised hadn’t taken any further action. Instead, a healthcare professional had reported the incidents to the local authority safeguarding team.
"The service managed medicines poorly. Staff applied one resident's pain relief patch a day late, causing potential unnecessary pain, and failed to investigate or prevent future incidents.
“One person’s record detailed they should take a strong pain killer before they received treatment, but records showed this hadn’t been administered for several days. When we asked why staff said it had been stopped by health care professionals and they hadn’t updated the person’s care plan. This meant people were at risk of receiving medicines they were no longer prescribed.
“We have told Gordon Lodge Rest Home where we expect to see rapid and widespread improvements and it has been placed into special measures while these changes are made. We will return to re-inspect the home and won’t hesitate to use our regulatory powers further if people aren’t receiving the care they have a right to expect.”
Inspectors found:
- There were not always enough staff to meet people’s needs and keep them safe
- Leaders had not identified or addressed all infection control risks, such as broken furniture. Cleaning records had been recently introduced and staff noted when they had cleaned areas of the service, but this system had not been effective in improving the cleanliness of the home
- People were not always supported to move safely between services. One person’s relative said that their loved one had been waiting to see a health professional for several weeks
- Staff understood their responsibility to report safeguarding concerns but had not always taken action to protect people from the risk of abuse
- There was no formal process in place to induct agency staff. Agency staff said they were not introduced to people before they provided their care. Also, they supported people to get up, washed and dressed on their own without being told what people could do for themselves or what their preferences were. They had not been told about fire safety on arrival and said they were shown a fire exit later on in the shift.