Care home failings put residents at risk of harm

Home placed in special measures following damning report

A NEWBURY care home has been placed in special measures after a damning report revealed a host of failings which put residents at risk of harm.

Inspectors from the Care Quality Commission (CQC) rated Winchcombe Place inadequate and said it must improve within six months or face further action.

The unannounced inspection, which took place over two days in January, was in response to concerns regarding the safety and welfare of people living in the home.

Winchcombe Place, in Maple Crescent, is operated by Care UK.

The findings included:

. People were not safe and were at risk of avoidable harm

. Allegations of abuse incidents were not always reported in a timely manner to the CQC

. One person was highlighted as being at low risk of falls, despite them having a number of falls over a short period of time, some of which resulted in serious injuries and fractures

. A resident was left in dirty clothes all afternoon after spilling lunch down themselves

. One relative told inspectors they had found their family member lying in a wet bed fully-clothed in wet clothes and said his room was filthy and clearly had not been cleaned

. On one occasion staff had failed to identify that a person had not received medicine to support them with their anxiety for two weeks

. Care records and care plans were not always clear and had conflicting information

. People did not always feel well-supported, cared for or treated with dignity and respect

. One person at lunchtime, who was at high risk of malnutrition, was not encouraged by staff to eat their meal that was placed in front of them, despite there being significant concerns about their weight loss

. One resident lost 7.9kg in five months but was still waiting to be referred to a dietician when the inspection took place

. Complaints were not always logged or investigated properly

. Records of accidents and incidents lacked detail and action wasn’t always taken to prevent a reoccurence

. Risks associated with people’s mobility were not managed effectively, which exposed people to the risk of harm such as physical injury

. On Christmas Day last year, one resident had an unwitnessed fall and sustained a head injury which required hospital treatment

. Communal toilets with faeces on them for several hours before they were cleaned.

The report notes: “We have told the provider to take immediate action to address some of the concerns we found.

“Where necessary, another inspection will be conducted within a further six months.

“If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service.”

Inspectors also noted that there were widespread and significant shortfalls in service leadership.

“The registered manager of the home had left the service in December 2018, however was still registered with the Commission.

“Services registered with Care Quality Commission are supposed notify the organisation of significant events without delay.”

However, the report noted that the registered person had not always done so, meaning the CQC was unable to check that appropriate action had been taken to ensure people were safe.

Care UK’s regional director, Omar Taylor, said: “Care UK accepts that when CQC inspectors visited in January, elements of the service had fallen below the high standards we expect.

“Even before their inspection, internal audits had identified areas for improvement, including shortfalls in how the home team had been reporting to our regulators.

“Care UK has since brought in myself and two highly-experienced managers from other homes to help drive through a comprehensive improvement plan which focuses on things like better record keeping and care planning, as well as additional training for colleagues in areas such as infection control and medication management.

“We have already seen some very positive changes and I am confident we can sustain these to ensure residents receive the excellent level of care they deserve.”