Shottendane Nursing Home in Margate has been told to make improvements after its overall rating dropped from good to inadequate, following an inspection by the Care Quality Commission (CQC) in February.
Shottendane Nursing Home supports up to 38 people with nursing needs, including people with dementia, and those who need end of life care. At the time of the inspection the service was supporting 36 people.
CQC carried out an unannounced focused inspection to look at how safe and well-led the service was after receiving concerns relating to safeguarding and people’s nursing care needs. Following the inspection, the overall rating for the service dropped from good to inadequate. Safe and well-led also dropped from good to inadequate. Effective, caring and responsive were not rated on this occasion.
The service is now in special measures, which means it will be closely monitored and re-inspected within six months to check improvements have been made.
Hazel Roberts, CQC’s head of adult social care inspection, said: “When we inspected Shottendane Nursing Home, we were very concerned about how poorly COVID-19 was being managed as the home wasn’t following government guidance to keep people safe. They admitted new people into the home without considering the risk to them, and some people who were COVID-19 positive had signs on their doors to indicate they were infected, but others didn’t.
“Personal protective equipment (PPE), such as masks, gloves and aprons, had been discarded in general bins which anyone could access, rather than being labelled as offensive wate, some staff weren’t wearing masks or wearing them incorrectly, and nothing was done when we raised this.
“Relatives told us they had been prevented from visiting the home, or had time restrictions placed on their visits, which again, was not in line with government guidance.
“We found thickening powder had been left in people’s rooms by staff. This is used to make fluids thicker so people with swallowing difficulties can drink safely, but if swallowed without fluid, people could be at risk of choking. This was a particular concern for those with dementia.
“And we also found a number of other environmental risks. Two first floor rooms didn’t have window restrictors in place, but the rooms were left unlocked, putting people at risk of falling out of the window. People had access to a large garden with a pond in it, but there was no fence or barrier in place to prevent people from falling in and drowning.
“We were told by relatives that staff were kind and caring, however, they all said that the service was understaffed, and people were left to sit in their rooms all day with little engagement from staff.
“When we raised issues with the management team, they took some action, for example completing an infection control audit, and an audit on all window restrictors, however, further improvements are needed. Our priority is for the safety of people living in the home and the quality of care they receive, and we will continue to monitor the service closely.”
CQC found the following during this inspection:
Oversight and governance systems were ineffective. Some issues had been identified in audits as needing action, however there was no information on what action was taken to address shortfalls.
There were not enough staff; this included nursing, care workers and activity staff and staff were not always recruited safely. The provider also failed to ensure staff training was complete and up to date.
People were not protected from the risk of the spread of infection. Staff did not wear or change their personal protective equipment (PPE) in line with government guidance. The provider did not follow government guidance in relation to visiting or admitting new people into the service.
Risks to people were not always assessed and mitigated. Risk assessments did not contain sufficient information on how to address health risks. Risks relating to thickening powders had not been assessed or mitigated. Environmental risks such as broken window restrictors had not been identified.
Some staff lacked understanding of safeguarding principles. When incidents occurred, they were not always documented, and action taken to reduce similar incidents re-occurring.
Medicines were not managed safely; there was a lack of guidance to inform staff about some people’s medicines, or to help staff assess when people who were unable to vocalise verbally were in pain.
Care plans were basic, and in some cases, did not contain sufficient information on action to take to reduce risks.
There was a lack of learning from incidents and oversight of accidents and incidents was not robust. There was no system in place to review accidents and incidents and incidents reoccurred.
Relatives said they felt well informed about the care their loved ones received, however they had not been kept up to date in other matters. For example, when the registered manager left the home, relatives were not informed until the following month. Communication regarding visiting had not been clear, and some relatives were unaware if they could visit their loved ones.
The report will be published on the website in the next few days.