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Archived: Ryecroft Private Residential Care Home Inadequate

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Inspection report

Date of Inspection: 11 December 2014
Date of Publication: 20 February 2015
Inspection Report published 20 February 2015 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Enforcement action taken

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 11 December 2014, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with commissioners of services.

Our judgement

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

We included this outcome area in our inspection, on the day of our inspection, as we had serious concerns about the quality and safety of the care provided to people who lived at the home. At the time of our visit, there were 14 people who lived at the home. A new manager had commenced in employment four days prior to our visit. This manager is not yet registered with the Care Quality Commission.

We spoke with two people who lived at the home, the three staff members, the new manager in post and the provider during our visit.

Staff we spoke with raised concerns with us, about the safety of the care that they were providing to one person at the home. We were told that the person had mobility problems but that the home had no moving and handling equipment to move the person safely. They said as a result they had to manually lift the person from the bed to the chair. One staff member told us that two staff had already “gone off work with bad backs”. This meant that the person had received inappropriate and unsafe care which placed both them and staff at significant risk of injury.

We spoke to the person concerned who told us “The people here are nice but they haven’t got the stuff to help me. I don’t want to be here. I can’t walk and haven’t got a wheelchair here. The staff lift me out of bed and into the chair. I get very frustrated; it’s hard on the staff”. We noted that the person was sat in a chair in their bedroom with no television, no radio and no means of accessing communal areas for company.

We looked at this person’s care records and found it contained little assessment information about the person’s needs and risks. It also contained no information relating to the person’s care as care plans and risks assessment were not completed. This meant staff had no guidance on what the person’s needs, risks and preferences were in the delivery of care.

We saw that a nurse had visited the person during November 2014 and documented concerns about the risks to both the person’s and staff health and safety. The nurse had documented that the manager would review the person’s care. One staff member we spoke with told us staff had raised concerns about the care of the person with “Everyone we can”.

We spoke to the provider about this. They told us that they had notified the Local Authority of the difficulties in caring for the person. We saw no evidence however in the person’s care file to demonstrate that any action had been taken. After our visit, we discussed our concerns with the Local Authority who had already raised a safeguarding alert in relation to this person after a recent Local Authority visit to the home.

We looked at two other care files as a result of our observations of care. These care files also contained limited, disjointed and conflicting information about people’s needs, risks and care.

For example, one person’s continence care plan described them as incontinent and requiring incontinence pads whereas the person’s risk assessment described them as continent. There was no guidance to staff on the type of incontinence, the incontinence pad to be used and the person’s preferences in relation to this type of personal care. The care plan simply stated “keep track of stock and re-order”.

We spoke with a person who lived at the home who we saw had not received their prescribed medication for an illness in a timely way. We spoke to the provider about this who acknowledged that the treatment prescribed by the doctor had not yet been obtained. This meant the provider had failed to meet the person’s individual needs which placed their health and welfare at risk. We asked the provider to obtain this medication without delay.

One person care file indicated that they had had multiple falls since April 2014. The person’s mobility care plan however made no reference to the person’s history of falls, the significant risk of further falls and offered no risk management guidelines to staff on