3 May 2012
During an inspection in response to concerns
We found that although some improvements had been made, such as purchasing new weighing scales and fortifying food there was still cause for concern. We have looked at the records of people's weight at each visit and again found that the records of their weight were inaccurate and that one person had lost a further large amount of weight. We saw that the arrangements for supporting people with their meals were not sufficient to ensure they received an adequate diet or fluids to protect them against the risks of inadequate nutrition or dehydration.
We also found that risks to people's health were not adequately addressed such as the management of epilepsy, and people continued to be at avoidable risk of pressure sores. We found people were at risk of unsafe and inappropriate care because of lack of information about changing needs, and lack of skill and equipment to safely move people.
We again found during this review that some people had unexplained injuries and that no investigation had been undertaken into the cause of the injuries. People were at risk of harm as there was not a system in place to identify and report suspected or actual abuse when needed.
We had been told of the provider's plans to replace furniture and furnishings to ensure the home is a comfortable and safe place to live. We saw during our visit of 3 May 2012 that although new beds, bed linen and towels had been purchased, people were still waiting for their bed linen to be changed.
There remained ongoing concern about the lack of sufficient hot water in people's rooms. There were a range of outstanding maintenance issues such as leaks to the roof which dated back for over a year, holes in flooring, poor condition of carpets, no working disinfector, and the new washing machine had not arrived. We found there was no ongoing monitoring and review taking place to ensure that the premises was satisfactorily maintained and risks to safety identified and managed.
We identified that there was a lack of suitable equipment being available to assist people. We have not been told of
the provider's plans to replace furniture and furnishings to ensure the home is a comfortable and safe place to live.
We saw that staffing levels had been increased since our previous visits in April 2012.
The provider had also agreed to Dudley Metropolitan Borough Council staff working in the service during the time the people with the most complex needs are assessed and moved to other placements. During our visits in May 2012 Summerfield had additional management, care and domestic staff from the local authority. However we found that the number and skills of staff were still not sufficient to effectively and consistently meet people's needs.
We found that a continued lack of appropriate systems to assess and monitor the quality of the service had resulted in the failure to protect people from the risks of inappropriate or unsafe care.
Dudley Metropolitan Borough Council has stopped funding for any new person who wished to live at Summerfield Care Home.
This report also followed up concerns identified on 5 and 23 April 2012 and the reader should also refer to these reports for further information.