Archived: Purbeck House Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

At this assessment we reviewed all the quality statements for this key question. We found the service was in breach of legal regulation in relation to person-centred care and the failure to comply with the principals of the Mental Capacity Act 2005.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Detailed assessments of people’s needs were not completed prior to or on admission to the service. Without these assessments the provider could not develop detailed and specific care plans and risk assessments or ensure staff had the skills and understanding to help ensure people would be provided with effective, safe or appropriate care to meet their specific needs.

Care plans reviewed during our assessment lacked important information about people’s specific needs and inaccuracies and omissions were found in essential care documentation. For example, care plans failed to include vital information on how to keep people safe and lacked information about their preferences and wishes. This meant staff did not have access to person centred information about people which negatively impacted the care they received.

Although it was noted people’s care records were reviewed frequently, we found a number of care plans stated comments such as ‘the plan still needs developing’ and ‘These are not yet known in full’ under the wishes and preferences section of part of a specific plan. These comments were in records for some people who had lived at the home for a number of years, yet there was no evidence to demonstrate action had been taken to gather this information and understand people’s needs and wishes in detail.

The provider failed to evidence that people were involved in contributing to their care needs assessments or developing plans around their care. People's assessments did not always reflect the complexity of their needs, and so did not support staff to meet these needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Recognised tools for assessing risk of malnutrition were not used effectively to identify and monitor risk. For example, we identified some people’s Malnutrition Universal Screening Tool (MUST) scores would require weight monitoring weekly however, they were being weighed monthly. This meant unexplained weight loss would go undetected causing delays in action or referrals to external professionals if required.

During our inspection we identified that the provider failed to monitor people’s hydration needs, which meant that people were placed at increased risk of dehydration. On the last day of our visit the provider had put fluid charts in place. However, these were not effective and did not include the actions to take when a person’s fluid intake was inadequate. People who had reduced fluid intakes did not have hydration risk assessments to provide guidance to staff about the risks of dehydration.

Clinical assessments showed significant gaps. For example, we found minimal evidence of appropriate care planning for specific medical needs, like diabetes and constipation which is not in line with best practice guidance. This placed people at risk of significant harm.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

There was a lack of evidence to demonstrate that people who were unable to attend external appointments accessed the services they required. Further, there was limited information within records to demonstrate how services worked together. For example, from the lack of detail in care records it was difficult to confirm if people had access to dentists or opticians as required. When this was discussed with staff, they were unable to describe how support from these services would be provided. Some of the care plans we reviewed, briefly referred to a chiropodist coming to the service. However, there was no information regarding the frequency of these visits especially when people had a health condition such as diabetes that could impact on their health and wellbeing.

The provider failed to work with other services such as the GP (General practitioner) and district nurses to review people’s health needs. Arrangements were in place which allowed the service to have weekly involvement with the local GP practice to discuss changes in people’s health and request advice and support. However, we received mixed views from professionals about timely and effective teamwork. For example, a mental health professional described how they had a positive working relationship with the provider and described them as, “so receptive; they will keep us updated and informed about [persons] condition and wellbeing. They are very proactive.” However, another healthcare professional told us there has been “delays in staff reporting issues, which can suggest to me more staff training may be needed, for example, I noticed that one patient had a UTI which was obvious because of the offensive smell when visiting the home about a different issue. This had not been raised to me.”

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Although some people's health needs were identified, such as those who had diabetes, there was little information about what could be done to best support them to manage this through their lifestyle, such as diet and activity. People did not have goals related to their health, such as target weights if they were over or under weight.

During the inspection we observed that the dining experience was rushed, impersonal, and staff did not engage with people in a meaningful way. People were not supported or encouraged to eat healthy balanced diets which met their specific needs, such as diabetes or food at the appropriate consistency. Of the menus reviewed we noted meals often lacked variety and there was limited choice. For example, this included but was not limited to, for one day the food choices were faggots, potatoes and vegetables or sausage, mash potato and baked beans. On another day the choices were beef mince and dumplings or cottage pie. The menus had not been updated since May 2024, therefore we could not be assured changes in weather temperature had been considered.

There was a lack of meaningful activities provided to people to engage them. People, particularly those with a cognitive impairment, were observed sitting in silence for extended periods with little interaction or stimulation. People and relatives confirmed there was little for people to do. A relative said, “I have never known activities to happen.” A visiting health care professional told us, “There is not enough for people to do.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

At the time of our inspection the management team and staff lacked knowledge and understanding of people’s past and current medical needs. Without this information the management team and staff could not be aware of what and how to monitor people’s needs and conditions to help ensure effective care and treatment. Therefore, the provider failed to assure themselves that outcomes for people were positive and consistent. Further, the management team and staff failed to meet both clinical expectations and the expectations of people.

There were no systems to ensure routine monitoring of people’s care and treatment. For example, periods of constipation and potential dehydration had not been identified, which meant no action had been taken to address these risks. Where injury, incidents, accidents or falls had occurred no records were in place which demonstrated immediate and short-term monitoring was completed such as head injury monitoring following unwitnessed falls or increased monitoring and oversight for specific conditions. This meant people did not receive safe, person centred care.

We found people’s care records had not been appropriately updated following changes in people’s conditions, abilities and needs and these records failed to give staff the clear and up to date information they needed to provide effective high-quality care.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider failed to ensure the correct procedure was followed in relation to the Mental Capacity Act 2005 (MCA). On reviewing people’s care records, we found multiple examples where the provider had failed to ensure they acted in accordance with the legal requirements. For example, mental capacity assessments had not been carried out when specific decisions needed to be made. This included decisions related to people’s accommodation for the purpose of 24-hour care and supervision, decisions related to how their care was planned for and delivered, receiving regular welfare checks and having photographs taken.

Furthermore, decisions which involved restrictive measures, such as movement sensors, had not prompted an assessment of the person’s capacity to consent, where appropriate. There was no evidence of how a decision had been made, or whether the decision was in the person’s best interests. Therefore, we could not be assured people’s consent was gained appropriately and decisions made on their behalf was done so in accordance with the requirements of the Mental Capacity Act 2005.