Chilterns Manor in Bourne End, Buckinghamshire has seen its overall rating drop from good to inadequate, following an inspection by the Care Quality Commission (CQC) in August.
Chilterns Manor is a residential care home that provides personal care and support for up to 22 older people and people with dementia.
Following the inspection, CQC issued the provider of Chilterns Manor with two warning notices in response to concerns about unsafe management of medicines, poor oversight of the service by the provider, poor infection control practices and poor record keeping. Additionally, risks to people’s health and safety were inadequately addressed at the service, particularly around fire safety.
The overall rating for the service has dropped from good to inadequate. The ratings for safe and well-led, have also dropped from good to inadequate. The service is now in special measures.
Rebecca Bauers, CQC head of inspection, said:
“We expect health and social care providers to guarantee people’s safety, dignity, and independence. When we inspected Chilterns Manor, we were very concerned that the people who lived there who called it home weren’t safe.
“It was very concerning to find that incidents were not being recorded or reported through the right channels to safeguard people. For example, injuries had been sustained from physical altercations between people. These hadn’t been referred to the local authority. A family member told us their relative had some bruising from an altercation with another person living at the service, and the provider hadn’t noted this down anywhere in their care plan.
“Daily notes stated an ambulance had been called in March this year due to someone being found with a head injury. There was no further information about this available at the home, no accident or incident form was completed, and no safeguarding referral was made. The manager was unable to provide any details of what had happened or the extent of the injury.
“We found staff didn’t consistently have oversight of good hygiene practices to prevent the spread of infection. Records didn’t show any training on infection control or the correct use of personal protective equipment.
“We found a lack of oversight and good leadership at this service which has led poor quality care for people in respect of care and support which is unacceptable.
“We have told the provider that it must make significant, rapid and widespread improvements and we will continue to monitor them closely to ensure that these are made.”
Inspectors found the following:
- Staff weren’t aware of the need for unexplained bruising to be investigated. There were instances when handover records and care notes described where bruising was found. When asked what action was taken in these instances inspectors were told it was noted on the computer system. The manager said no other action was taken. There was no process to refer to the safeguarding team so that people were not safeguarded from the risk of abuse
- From the first day of the visit, inspectors reported to the manager poor or few interactions by some care workers. For example, one person was being assisted by a care worker to come downstairs. The only time the member of staff spoke with them was to say "Sit" when they got to the stairlift and "Wait, wait" when they reached the bottom
- There was some evidence of improvements being made when things went wrong. However, accident and incident records had not always been completed so it was not always possible to see if preventative measures were put in place, where necessary
- Inspectors had not received notifications about some events the provider was required to tell CQC about, such as unexplained bruising, incidents between people resulting in injuries and an unexplained head injury. This placed people at risk of further harm and unsafe care
- Antipsychotic medicine had gone missing from the home. This had not been reported to the appropriate authorities. The manager and another senior member of staff were administering medicine by intramuscular injection, which was not permissible under the home’s conditions of registration
- Staff were not alert to fire safety risks. A fire escape door and evacuation route were obstructed. Additionally, a bedroom door was found to be propped open with a portable heater. The manager was informed about this on the first day of the inspection and it was still being propped open on the second day until the maintenance person was able to repair it. Staff had not considered the need to remove the heater and keep the door closed.