The Care Quality Commission (CQC) has downgraded the rating of Fitzwilliam Care Centre in Mablethorpe, Lincolnshire from requires improvement to inadequate and placed it into special measures to protect people following an inspection in October.
Fitzwilliam Care Centre, run by Mablethorpe Care Limited, is a residential care home which provides support to older people, people living with dementia, people with mental health conditions and people living with physical disabilities.
CQC carried out the inspection due to concerns received about the service and to follow up on actions raised at a previous inspection.
At the previous inspection in July, CQC found four breaches of the legal regulations relating to person centred care, safe care and treatment, management and safe staffing. The service remained in breach of these regulations. Further breaches were identified in relation to consent, safe environments, safeguarding and concerns raised around failure to report legally notifiable events to CQC and failure to comply with conditions of their registration.
CQC has rated Fitzwilliam Care Centre as inadequate for being safe, effective, caring, responsive and well-led, all down from requires improvement.
CQC has placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen.
CQC has also begun the process of taking regulatory action to address the concerns which Fitzwilliam Care Centre has the right to appeal.
Greg Rielly, CQC’s deputy director of adult social care for the East Midlands, said:
“When we inspected Fitzwilliam Care Centre, we found the service had deteriorated significantly since our last visit. People weren’t being kept safe due to poor leadership which was impacting on every aspect of the lives of people who called it home.
“People’s feedback on staff interactions depended on where they lived in the home. Older people who lived downstairs were generally satisfied, but we were saddened to learn that people who lived upstairs in the mental health units didn’t feel safe or supported due to the actions of other people living in the home and the small number of staff on hand when incidents occurred. Some people were working with their social workers to move to other places to live because of this.
“Staff lacked skills in mental health monitoring and were dismissive in care notes when dealing with people who expressed repeated feelings of self-harming behaviors and a desire to end their lives. Staff didn’t explore why they were expressing these concerns or how to identify triggers for risk behaviours.
“People were also worried about their medicines not being properly managed. During our checks, we found stock balance errors for 9 out of 15 people who might have been receiving the wrong doses, increasing their risk of ill health. One person had also run out of multiple medicines, posing a risk to their mental health. When staff raised the issue of medicines, they told us managers brushed their concerns under the carpet.
“Despite improvements to recruitment, staffing levels were still insufficient for safe care during outings or emergencies. Even the police had reported concerns to us about staff not being available to support people in distress in the local community, putting themselves and others at risk of harm.
“We have told leaders where we expect to see rapid and widespread improvements. We will return to check on their progress and have begun the process of using our regulatory powers further which Fitzwilliam Care Centre has the right to appeal.”
Inspectors found:
- Leaders didn’t ensure people’s care plans were person-centred or consistently accurate and failed to reflect people’s needs and how to support them.
- Staff didn’t consistently monitor people’s nutrition and hydration, putting vulnerable people at risk.
- Leaders didn’t support staff to assess or consider people’s sensory needs, such as to noise or light, so they didn’t have any strategies to help people cope.
- Staff had a mixed understanding of safeguarding and what abuse looked like. Leaders hadn’t ensured a number of incidents had been reported to CQC which they were legally required to do so to help it monitor people’s care.
- Leaders didn’t listen to concerns about safety and didn’t always investigate or report safety events. Lessons weren’t learnt to continually identify and embed good practice.
- Staff made sure the home was clean, but leaders didn’t ensure it was dementia-friendly. There were no signs or home design to support people to orientate themselves and prevent the risk of falls and distress. Leaders also didn’t use previous incidents to consider whether the home was safe for people.
- People said there was a lack of meaningful ways to spend their time, such as a timetable of activities, and staff didn’t encourage them to learn new skills to develop their independence.