A care home has been told that it requires improvement after a resident lost 12kg in weight in 18 months.
Twin Oaks in Windermere was inspected by the Care Quality Commission after concerns were raised about the treatment of a resident and management oversight of the service.
The care regulator investigated whether the care home was safe and well-led and published its findings two weeks ago.
Inspectors said the provider had not ensured people’s nutritional risks had been properly assessed and risks mitigated. One person lost 12kg in under 18 months, with the last recorded weight taken over three months prior to the inspection.
Another person, who had been identified as having had consistent weight loss, did not have a nutritional risk assessment completed and the CQC found no evidence they had been referred to health professionals.
A third person with a history of weight loss prior to admission did not have their weight recorded in their care records.
Twin Oaks is a residential care home registered to accommodate up to seven people in need of personal care. Accommodation is provided over two floors with single rooms, all with en suite facilities. On the days of the inspection, there were six people living at the home.
Other key findings
- Care planning and risk assessing were inconsistent. Some records had not been updated and some were incomplete. They did not always provide a reliable and accurate record to guide staff.
- There were a limited amount of environmental checks at the home and none of these were documented. Additional checks were also required around fire safety.
- In some areas, management and provider oversight and responsibility were poor. The registered manager had purposefully completed care records in advance of the care being provided. This could mislead someone reviewing these records and in particular health care professionals.
- The provider’s systems and processes for the oversight, quality monitoring and safety of the service had been ineffective in anticipating and addressing concerns found during the inspection. This placed people at risk of harm.
- Breaches of regulations were found by inspectors in the area of oversight of the systems used to oversee the quality and safe running of the home, recruitment issues, fire safety concerns and safe care planning and risk assessments
- Recruitment processes were not effective at ensuring staff members were always suitable for working with vulnerable people.
- Some essential safety checks had not been made.
- Some improvements were required with medicines storage. The service needs to make sure medicines are stored consistent with the manufacturer’s guidelines. People did, however, receive medicines as prescribed by their health care professionals.
- Infection, Prevention and Control (IPC) processes were appropriate and inspectors were assured about the service’s ability to mitigate the transmission of infections.
- Staff were competent with safeguarding processes and knew how to protect people from abuse. Relatives said their loved ones felt safe in the home and were trusting of staff and management. Inspectors observed good practices and interactions between staff and people during the inspection. The service’s safeguarding processes were robust.
- Staff supported people to have access to health professionals and specialist support and the service worked well with external professionals.
- The provider and registered manager acted during and immediately after the inspection to address the risks found. This included improved monitoring, checks and reviews.
In the last inspection where the service was rated, the home was deemed to be good in all areas.
A spokeswoman for the home said she would not be responding to the report as the Twin Oaks would be “legally challenging the whole thing”.
