The Care Quality Commission (CQC) has rated a Bedfordshire care home inadequate and placed it in special measures.
CQC inspected Chiltern View, in Dunstable, after reviewing information it held about the service, and following concerns raised by local environmental health and fire safety officers.
The inspection found the home, which can care for up to 36 older people including those living with dementia, was not providing standards of care people have a right to expect.
In addition to rating it inadequate overall following the inspection, CQC rated the home inadequate for being safe, effective, caring, responsive to people’s needs and well-led.
The service, which is provided by Benslow Management Company Limited, was previously rated requires improvement overall.
Due to the poor care inspectors found, CQC placed the service in special measures. This means it is being kept under close monitoring and it will be subject to further enforcement action if improvement is not made.
To protect people from the risk of avoidable harm, CQC also placed conditions on the provider of the service’s registration, restricting it from admitting new people to the home and requiring its leaders to take specific actions to reduce risks to people.
Louise Broddle, CQC head of inspection for adult social care, said:
“Standards of care at Chiltern View put people using the service at risk of harm. This is unacceptable.
“People’s medicines weren’t well managed, and there weren’t sufficient staff at all times to administer medication. This meant senior staff had to be called to the service during the night when people needed medication, including for pain relief, causing people to experience delays.
“We also found people’s mealtimes and diets were badly managed, placing them at risk of avoidable harm.
“One person, who was at high risk of weight loss, had lunch at 1.28pm and was offered their final meal for the day, of which they ate only a little, just two hours later. They were then not offered anything else until breakfast the next day, after 10 am.
“A second person, who had lost significant weight over the preceding year, frequently went 18 hours between the last meal of the day and breakfast the following morning.
“Behind the issues we identified was a lack of good leadership. Leaders had failed to ensure the home was adequately staffed and that good policies to support people’s health and wellbeing were followed.
“We are keeping Chiltern View under close review and we will not hesitate to take further action if we are not assured it has made significant improvement.”
The inspection found:
- The service was not well-led as effective quality monitoring systems to identify and address shortfalls were not used.
- People were not protected from harm and lessons were not learnt when things went wrong.
- People at risk of pressure damage to their skin did not receive appropriate support to reduce the risk of new or worsening injury.
- People were not protected from the risk of malnourishment or dehydration.
- Medicines were not managed safely.
- The service was not clean, and appropriate measures to protect people from the spread of infection were not followed.
- The premises had not been designed or maintained to meet the needs of people living there.
- There were not enough staff to meet people's care and support needs. A high number of agency workers were used, some of whom lacked the required skills and experience and were unfamiliar with people’s needs. Although permanent staff provided better care, they were extremely busy and lacked time to provide good quality outcomes for people.
- People did not receive timely care and were left for long periods without interaction or support from staff. People, particularly those cared for in their bedrooms, were left isolated with no stimulation. Many staff did not engage with people or initiate conversation, and no opportunities for meaningful occupation were offered to people.
- People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible.
- People were not always treated with dignity and respect.
- People, or their relatives where appropriate, did not always feel supported to be involved in making decisions about their care.
However:
- Following the inspection and the urgent action CQC took, the provider of the service increased the number of staff on shift and took steps to ensure every shift was supported by permanent staff alongside agency staff.
- The provider of the service also took steps to ensure there was a member of staff on every shift who was assessed as competent to administer medicines.