The Care Quality Commission (CQC) has rated Grove House, Ashover, in Chesterfield inadequate overall, following an inspection in June.
Grove House is a residential care home, run by Peak Care Limited, providing accommodation and personal care for up to 31 older adults, some living with dementia. At the time of the inspection there were 22 people using the service.
CQC carried out an unannounced focused inspection to look at how safe, effective and well-led the service was after receiving concerns about leadership and management of the home.
Following the inspection, the overall rating for the service has dropped from good to inadequate. The ratings for being safe, effective and well-led have also declined from good to inadequate.
The service is now in special measures which means it will be kept under review and re-inspected to check if sufficient improvements have been made.
Natalie Reed, CQC head of inspection for adult social care, said:
“During our inspection at Grove House, we found a home that wasn’t well-led, and the provider didn’t have sufficient oversight. This resulted in poor practices being allowed to develop and feedback from people wasn’t used to drive improvement.
“It was concerning that staff didn’t always have training in key areas. None of the staff had up to date training in falls management, this was worrying given the high number of falls that had taken place. Also, despite supporting several people with dementia, none of the staff had up to date training in this.
“People were at risk of injury as a result of poor falls management. Risks hadn’t been sufficiently assessed and care plans weren’t always in place to guide safe practice. Someone had fallen 18 times in the past six months, there was no falls risk assessment and their care plan didn’t reflect the level of risk. Although a sensor mat had been implemented, we saw them alone in their room with the sensor mat tucked under the bed, which meant it wouldn’t be effective.
“The provider had failed to identify and refer safeguarding incidents. Although investigations had been carried out by the provider into concerns raised about poor practice, they hadn’t referred them to the local authority safeguarding adults’ team to investigate further. Also, the provider had failed to identify, investigate or refer other safeguarding incidents, such as someone who left the home unsupervised, and an incident where a person was left unattended by staff and fell.
“The provider has taken our concerns seriously and has an action plan in place to make improvements. They must address these as a matter of urgency to keep people safe. We will monitor them closely and return to check on progress to ensure improvements have been made and people are receiving safe care.”
Inspectors found the following during this inspection:
- The service was not safe. People were not consistently protected from abuse and improper treatment as allegations of abuse were not always identified or referred appropriately
- People were at risk of injury as a result of poor falls management. Risks to people's health and safety had not been sufficiently assessed or mitigated and care plans were not always in place to guide safe practice
- Lessons were not always learnt following incidents
- There was a risk people may not receive their medicines as prescribed because safe medicines practices were not followed
- Staff did not always use personal protective equipment (PPE) effectively to reduce the risk of infection
- There were not enough staff employed to ensure the safe and effective running of the home and staff were not always deployed effectively
- Feedback about the quality of the food was poor and there was a risk that changes in people's weight may not be identified. Although people were supported to access support from external health professionals, care plans did not contain up to date information about their health needs
- Where people were unable to consent to aspects of their care, such as the use of movement sensors, their capacity to consent had not been assessed and there was no evidence that decisions made were in their best interests or the least restrictive option.