A Cumbrian care home has been placed into special measures by the health watchdog because its services are inadequate.
Holmewood Residential Care Home in Cockermouth was visited by Care Quality Commission inspectors in July and August last year and the watchdog has published its report this month.
At the time of the inspection, 22 people lived at the Lamplugh Road home.
Inspectors asked for GP visits for four people they were concerned had experienced – or were at risk of – neglect.
The report added: “On occasions, people were crying as they had not received assistance they needed.”
The report also found:
- People were at significant risk of harm as safety was not prioritised
- People were not safeguarded against the risk of abuse
- Health and safety risks were not always identified or managed
- There were not sufficient members of staff
- Staff did not always have the correct knowledge or skills to provide care
- People were not involved in planning their end of life care – including one person who receiving end of life care
- The premises were not suitable for people’s needs
- There was a lack of a relationship with local GPs
- There was poor infection prevention
- People were not treated with dignity or respect
- Care was delivered to help staff speed and efficiency, rather than the person’s needs
Inspectors said the service was not safe – rating it as inadequate.
They said while they found no evidence that people had been harmed. But because the provider failed to assess and mitigate risks to people, it placed people at risk of harm.
It highlighted that the call bell system was not fit for purpose – staff used walkie talkies to communicate and that was not effective.
The report said: “Inspectors were having to tell staff which buzzers were activated to enable them to respond. Some people had stopped pressing their call bells as requests for assistance were not always answered.”
The home has told the commission it would arrange for the call bell system to be replaced.
The commission will keep the home under review and will reinspect within six months. If there is no improvement, the commission can take enforcement action.
The report added: “People were at risk from their health conditions not being managed, injuries and unsafe end of life care. We requested a GP visit for three people during day two of the inspection and made safeguarding referrals.”
Inspectors said staff could be unkind, dismissive and lack compassion at times.
They said: “We observed one person sat with their bedroom door open while their call bell was buzzing, care staff walked past the person’s room and ignored them. Another person said, “They [care staff] say to me ‘you do know there are 26 people and only two of us don’t you?’
“People experienced discomfort and distress as their requests for assistance from care staff were not answered in a timely way or reassurance provided. At times people were seen crying or making distressed sounds as they were in discomfort and wanted support. One person said, ‘They [care staff] get a bit fed up
with me because I press my buzzer.’
“People’s care and support was organised for staff convenience. For example, people were given meals in their bedrooms as this was easier for staff to manage.
“People were encouraged to go to bed early as part of an established, institutionalised routine.
“Most people were in their bedrooms by 4pm, ate their tea at 4.30pm and then changing into their nightwear.
“People remained in their rooms until the following morning. One staff member was observed persuading a new person to go to bed early, when the person did not want to.”
Inspectors said that following their feedback, a provider representative spoke with people to look at their preferences and changes needed at the home to accommodate these.
However, the report added: “The registered manager was not always open or accepting of the issues found during the inspection. For example, they told us people chose to go to their bedrooms at 4pm. We observed staff encouraging this practice.”
Churchlake Holdings Limited, the parent company of Lakeland Care, entered administration in 2022.
Holmewood is being overseen by administrators Kroll Advisory and Cornerstone Care Solutions.
Phil Dakin, joint administrator at Kroll, told the BBC: “We acknowledge there were some shortfalls with regards to the state of the home at the time of the inspection, however we feel strongly that the details in this report are misleading and we have raised this directly with CQC.
“The report contains a number of inaccuracies and fails to highlight much of the positive evidence provided about the care given to the residents.
“We take any allegations of inadequate service very seriously and feel that we have sufficiently addressed the relevant concerns raised by the regulator.
“We are extremely disappointed that CQC has not sought to engage directly with us further, formally acknowledge our complaints or come out to re-inspect the services.
“The inspection took place in July last year, further evidencing the inefficacy of the regulator in dealing with matters as serious as this.”
