The Care Quality Commission (CQC) has rated The Chimes Residential Home as inadequate and placed it into special measures to protect people, following an inspection across July and August.
The Chimes Residential Home, run by Sonic Gold Limited, is residential care home providing support to older people living with dementia, mental health conditions, physical disabilities and sensory impairments.
During this inspection, CQC found The Chimes to be in breach of three regulations relating to how it was being managed, safe care and treatment, and safeguarding.
As well as the overall rating, CQC has downgraded the ratings for safe and well-led from requires improvement to inadequate. The ratings for effective and caring have been downgraded from good to inadequate. The rating for responsive has been downgraded from good to requires improvement.
The service has been placed in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made. CQC has also begun the process of taking regulatory action to address the concerns, which Sonic Gold Limited has the right to appeal.
Amanda Lyndon, CQC deputy director of Adult Social Care in the West Midlands, said:
“When we inspected The Chimes, we found poor leadership had created a culture of apathy, which filtered down to how some staff were treating people living at the home, resulting in them coming to harm and experiencing neglect.
“Leaders had created an environment where people didn’t see the point of reporting concerns, one person living at the home told us nobody listened or cared. Staff also described speaking up as pointless and told us there was a culture of fear where managers shouted at them. Not listening to or acting on feedback meant leaders didn’t create any opportunities for improvement to take place.
“It was also very concerning that the service didn’t record or learn from safeguarding incidents. One person showed us bruising on both arms, believed to be caused by staff, but management couldn’t provide us with any documentation of this incident. Another person had multiple injuries, including to the head and face recorded, but there was no evidence they were properly reviewed to understand how it had happened to prevent it from happening again.
“There was one case of a serious incident involving someone who demonstrated self-harm and suicidal thoughts. The incident wasn’t escalated or properly investigated, leaving other staff and management unaware. This resulted in environmental ligature risks remaining present in that person’s room, putting them in grave danger.
“Risks were not properly assessed when making decisions on people’s care. Some people with alcohol dependency were supported to consume alcohol daily without professional review or sufficient monitoring.
“The apathy we saw was also reflected in the visibly deteriorating environment at the home. We saw damaged radiators, stained walls, exposed electrical sockets, and rooms in need of redecoration.
“We have been clear with leaders that we expect immediate and substantial improvements. We are continuing to closely monitor the home to ensure people are kept safe and have proposed taking further regulatory action which the service has the right to appeal.”
Inspectors found:
- The service did not ensure there was enough staff to provide the required level of care. When staff raised these concerns with management, they were not acted upon.
- People and relatives told us they had not been involved in developing or reviewing their care plans.
- Leaders didn’t ensure staff received training designed to help safe deescalation of aggression. Staff said they didn’t feel safe as a result.
- Staff didn’t support people to consider and record their wishes regarding their care, treatment, spiritual needs, cultural preferences or other matters important to them at the end of their lives.
- Staff only interacted and engaged with people on a limited basis. Staff were primarily task-focused, with few opportunities for meaningful conversation, reassurance or personalised support.
- The Chimes didn’t provide people with timely support, with significant delays reported by people as being up to an hour or even the entire night.
- Staff did not administer medicines safely. Medicines labelled ‘do not crush or chew’ were crushed and medicines were continued even after changes in people’s health should’ve necessitated a review.