The Care Quality Commission (CQC) has dropped the rating of The Limes Care Home from requires improvement to inadequate and placed it in special measures to protect people, following an inspection in August and September.
The care home is run by Ask Care Homes LTD. It supports up to 28 older people, people living with dementia, or people living with physical disabilities, who don't require nursing care. There were 23 people living in the home during this inspection.
CQC carried out this inspection to follow up improvements to the management and safe recruitment of staff, which inspectors told leaders to make at a previous inspection. This inspection found improvements hadn’t been made and found new issues impacting people’s safety.
CQC has dropped the home’s ratings for safe, effective, and well-led from requires improvement to inadequate. CQC has dropped its ratings for caring and responsive from good to inadequate.
CQC has placed the service into special measures, meaning inspectors will closely monitor the service to keep people safe while urgent improvements are made. CQC has begun the process of taking further regulatory action to address the concerns, which Ask Care Homes LTD has the right to appeal.
Hazel Roberts, CQC deputy director of adult social care in the East of England, said:
“When we inspected The Limes Care Home, we were very concerned that leaders had not respected people’s rights to refuse care and hadn’t protected people from risks of abuse.
“Although we did receive mostly good feedback from people and their families who were able to provide it, they had a much more positive experience of care than people who were unable to advocate for themselves. Leaders need to do more to ensure poorer care isn’t normalised for people who were less able to give feedback.
“Staff had restrained some people who refused personal care and placed chairs in bedroom doorways to stop them leaving, but hadn’t assessed the risks of this or their mental capacity to make these decisions for themselves. This violated their human rights.
“Despite having safeguarding training, staff had failed to recognise safeguarding incidents that could put people at risk of abuse or neglect. One person told staff three times that they were in pain, and had unexplained bruises and other injuries, but staff hadn’t offered them pain relief or reported these.
“Because leaders hadn’t investigated these incidents or reported them to the local authority and CQC, they’d missed opportunities to learn and protect people from repeated mistakes.
“Most people able to give us feedback said staff were kind and understood them, and we saw examples of staff doing their best. But leaders failed to give their staff the training and oversight needed to protect everyone in their care.
“We’ve told the home’s management where they must make urgent changes and are closely monitoring to ensure people are kept safe while this happens. We’ve also taken further regulatory action due to our concerns, which the management has the right to appeal.”
Inspectors found:
- Leaders didn’t ensure people care plans were complete or up to date. This meant staff weren’t guided on how to support people’s individual needs or preferences.
- Staff didn't always communicate with people in ways they could understand, such as by using visual aids or reference objects.
- Leaders hadn’t ensured the environment was safe. Inspectors found fire risks, bedroom outlets hot enough to scald, and windows people could fall from.
- Despite health professionals recommending staff use a hoist, there was evidence of staff manually lifting people, which could be dangerous.
- The service didn’t always manage people’s medicines safely. Inspectors found expired and undated medicines in storage.
- Staff didn’t always respect people’s dignity. Inspectors saw staff discuss people’s health needs in front of others and also called someone a good boy.
- Some staff said leaders discriminated against them due to their race and gave examples. This is unacceptable, and undermined staff's ability to come together for the common purpose of people's care.
- Staff didn’t all feel safe to raise concerns to leaders or that they would be listened to, which could undermine people’s safety.