The Care Quality Commission (CQC) has rated Keegan’s Court Residential Care Home in Bishops Castle in Shropshire inadequate overall, following an inspection in July.
CQC carried out an unannounced focused inspection to look at how safe and well-led the service was after receiving concerns about the management of the home. Due to issues found during the inspection, inspectors also looked at how effective and caring the home was.
Following this inspection, the overall rating for the service has dropped from requires improvement to inadequate. The ratings for being safe and well-led have also declined from requires improvement to inadequate. Caring has gone from good to requires improvement and effective was inspected but not rated, and therefore remains rated as good.
Inspectors identified breaches in relation to keeping people safe, protecting people from abuse, failing to maintain people’s dignity, as well as ineffective systems and processes. The service is now in special measures which means it will be kept under review and re-inspected to check if sufficient improvements have been made.
Keegan’s Court Residential Care Home provides support with personal care for up to 19 older people, some living with dementia. There were 15 people using the service at the time of this inspection. Accommodation is provided in an adapted building providing 15 beds in the main building and two bungalows, each providing two beds.
Amanda Lyndon, CQC head of inspection for adult social care, said:
“When we visited Keegan’s Court Residential Care Home, we found a home that wasn’t well-led. Leaders and the culture they created didn’t provide high-quality care to people using the service.
“People weren’t safe as the environment wasn’t well maintained, and systems and processes weren’t effectively followed. There were fire exits blocked by furniture, and the cellar was heavily cluttered with combustible material. These issues put people at serious risk of harm in an emergency.
“The unlocked laundry area contained hazardous substances including chemicals identified as being corrosive. People were independently mobile within the home and had unrestricted access to the laundry area, putting them at risk of harm.
“Not all heavy wardrobes, or large pieces of equipment, were safely secured putting people at the risk of being crushed. Window restrictors weren’t in place on all windows or appropriately secured putting people at risk of falling out. Additionally, the pond area wasn’t safe for people to access. This area contained tripping hazards and an unsuitable cover over the water. This put people at the risk of drowning.
“People weren’t always treated with dignity and respect. Someone hadn’t been provided with toilet paper in their room. They had to use the torn pages of a magazine to clean themselves. Human waste was then left in the room for a period of at least 90 minutes which is totally unacceptable.
“We witnessed someone with capacity to make decisions for themselves, attempt to stand from their chair. A staff member instructed them, "You are not going anywhere." This was then repeated to them until inspectors made their presence known. The staff member then assisted the person. This interaction demonstrated a complete lack of respect and was completely undignified.
“Due to the number of serious issues found in this care home, it has been placed in special measures and we will return to check that urgent improvements have been made and embedded to reassure us that people are receiving the safe care they deserve. If we find this is not the case, we will not hesitate to further use our enforcement powers.”
Inspectors found the following during this inspection:
- People were not effectively protected from the risk of abuse and ill treatment. During our inspection we raised three separate safeguarding alerts with the local authority
- One of the bedrooms was being used by a member of staff to sleep in. This room contained personal items of property belonging to someone else. These items were mixed in with the staff members items. No one knew who the items belonged to or how long they had been in the room
- Confidential information was not secured and was accessible to those without authority
- People were not always protected from the risks of abuse. People did not always receive their medicines safely or as prescribed
- The provider did not effectively analyse significant incidents to learn from them and to make changes to improve people's safety. The providers infection prevention and control procedures were not effectively followed
- The provider did not have effective quality monitoring procedures in place to drive improvements in the care they provided. The management team did not have clearly defined roles and responsibilities
- People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible or in their best interests; the application of policies and systems in the service did not always support best practice
- The provider did not have effective systems in place to learn when things went wrong. For example, following a recent incident when someone went missing, they failed to review their systems to see if anything could be done differently.