A South London care home has been placed in special measures after a damning inspection that was partly sparked by the death of a resident.
The healthcare watchdog found people’s medicines were not always managed safely and staff were not always provided with the right training.
The Swallows, on Brownhill Road in Catford, is a care home that supports up to 33 people – some of whom are living with dementia.
The home has been downgraded to an overall ‘Inadequate’ rating following an inspection by the Care Quality Commission (CQC) in May and June of this year. The CQC said its inspection was carried out in part after it was alerted about an incident in which a person using the service died. The incident is subject to further investigation by the CQC as to whether any regulatory action should be taken.
No further details have been provided about this death.
Though this inspection did not examine the circumstances of the incident. information that was shared with the CQC about the incident raised potential concerns about the management of risk. The CQC said its most recent inspection was to examine those risks. The Swallows declined to comment.
During the assessment, CQC inspectors spoke with four people who used the service and one visiting relative. There were 27 people living at the service at the time of inspection. Inspectors also spoke with the registered manager and the provider’s operations manager, as well as eight staff members which included care staff, kitchen staff, domestic staff activities coordinators and maintenance.
The home manager, who runs the service, was not available during the on-site assessments. An Expert by Experience, which is a person with recent personal experience of using or caring for someone who uses services, spoke with 11 relatives by telephone to ask for their feedback on the care received by loved ones.
CQC inspectors said people spoke largely positively about the care and support their loved ones received, and said staff were kind, caring and empathetic; that staff communications with relatives was good, and the accessibility and responsiveness of management and staff was also good.
The CQC said while people it spoke with expressed they were generally happy with their care, its inspection found elements of care did not meet the expected standards. CQC inspectors found breaches of regulations relating to the need for consent, safe care and treatment, premises and equipment, staffing and good governance, and has told the care home it must make improvements and to complete an action plan which tells them about the improvements they are making.
They said risks to people were not always identified, assessed, documented and reviewed to ensure people’s safety and wellbeing. Inspectors said: “Mental capacity assessments were not always completed in line with the codes of practice, and premises and equipment was not always kept clean and safety checks were not completed in line with legislation and guidance.
“The provider did not always follow safe recruitment practices. There were no robust, clear and effective governance, management and accountability arrangements in place to oversee the service delivery and ensure people’s safety.”
The service was last inspected by the CQC in September 2019 and was rated Good in all areas however, ratings for being safe and well-led have been downgraded to Inadequate while the rating for ‘effective’ has gone down to Requires Improvement.
‘Caring’ and ‘responsive’ ratings have stayed the same and are still rated Good. The CQC has decided to place The Swallows in special measures, which means it will be re-inspected within six months to check progress has been made. When assessing how safe the service was, inspectors said the provider did not always work well with people to understand and manage risks.
They said: “Three people were at risk of falls. Their falls risk assessments were completed incorrectly and their care plans failed to detail the support people required to mobilise safely. There was no guidance for staff on the safe moving and handling of people and for the safe use of equipment where required. This placed people at risk of harm.”
When inspectors looked at how well-led the care home was, it said the provider did not always provide staff with the right training and ensure it was embedded into practice to deliver person-centred care or care that promoted the rights of individuals, particularly those living with dementia.
They also said: “Care plans and assessments were not always completed for individual areas of need and risk and sometimes contained conflicting and confusing information.
“For example, a person’s care plan documented that they had capacity to consent for staff to manage their medicines, however, their best interest’s assessment documented that the person lacked capacity to make this informed decision.” However when it came to caring and being responsive, the service was rated good in these areas.
Relatives told inspectors staff treated their loved ones with kindness and respect, and said the atmosphere within the service was relaxed and supportive.
Inspectors said: “Staff treated people as individuals. Relatives told us staff understood their loved ones and treated them as individuals. They said staff were able to manage and interact with people living with dementia. A relative told us, ‘The best thing about this place is the staff; they’re really kind and caring. They talk to my loved one and hold their hand. They style my loved one’s hair and are always looking to make sure they are safe.'”
On being responsive, inspectors said: “The provider helped people to plan for the future. People were cared for and supported at the end of their lives. Staff worked closely with health and social care professionals to ensure they knew how to provide dignified, comfortable and pain free care whenever possible.”
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