A South Cumbrian care home has been placed in special measures by the health watchdog.
Inspectors from the Care Quality Commission visited Swarthdale Nursing Home in Ulverston following concerns about its management and staffing, plus the results of an inspection last year which found breaches of legal requirements and said it required improvement.
Initially, inspectors were only going to focus on safety and management in their most recent visit, but they said they found additional concerns and widened the scope of the inspection.
Inspectors identified six breaches in relation to safe care and treatment, person-centred care, need for consent, receiving and acting on complaints, staffing, and good governance.
They found that staff were committed and their interactions with residents were kind, caring and respectful, but the provider had not ensured people’s care plans
adequately reflected their preferences and actively involved them in making decisions about their care, treatment, and support.
Inspectors said: “People told us they did not like to bother the staff because they were so busy.”
The Rake Lane home cares for 23 people.
The 2022 inspection found that people were not safe at the home and not enough progress had been made since then for inspectors to be satisfied.
Among the issues identified were:
- Fire safety evacuation plans were not current
- Gas safety certification was not current
- Water temperatures were not regulated safely
- Legionella checks had not be carried out
- Paperwork regarding risk was poor
- Equipment, including beds, lifts and electrical equipment had not been checked
- The home’s safeguarding policy had not been updated since 2019
- Medicines were not managed safely
However, the report added: “The provider shared evidence of plans to address some of the risks following the inspection. We were sent confirmation of dates booked to assess asbestos, Legionella risk, and portable appliance testing.”
It said not all staff were trained on the electronic medicine administration system and added: “No controlled drugs audits had taken place since December 2022. We found an incident where controlled drugs had gone missing. This incident had not been appropriately recorded, reported, and investigated. We took action to ensure this was reported.”
Some staff were spotted handling medicines, food, and drinks without washing their hands or using hand sanitiser and staff were unclear about current COVID-19 guidance in relation to visitors entering the care home as neither the registered manager nor provider had provided them with updated best practice guidance, the report said.
Inspectors also found the effectiveness of people’s care required improvement as their needs were not always met and records were not kept up to date.
Staff told the inspectors they were not well supported by their manager and the inspectors said: “The provider had failed to ensure there were sufficiently skilled and supported staff to meet the needs of people.”
After the inspection, the home said it had begun to carry out staff appraisals and supported staff to access specific training, and it was being monitored.”
Inspectors noted that the home itself was clean and welcoming.
But they found that its management was inadequate. They said there were ‘widespread and significant shortfalls in service leadership’.
They added: “Staff informed us they did not have confidence concerns they escalated would be addressed and some staff gave us examples of concerns which had been escalated but not addressed by the provider or registered manager.”
The commission said it will now meet with the provider to discuss how it will make changes to make sure it improves it rating to at least good.
The report added: “We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress.
“We will continue to monitor information we receive about the service, which will help inform when we next inspect.”
