Care home told to improve after residents found with unexplained bruising
PUBLISHED: 13:22 12 March 2018
Danny Loo Photography 2018
A care home has been told it ‘requires improvement’ after inspectors found some residents with unexplained skin tears and bruises.
The Care Quality Commission (CQC) published its latest inspection report on Monread Lodge in Woolmer Green on February 28.
After four unannounced visits between September 25 and October 9 last year, the concluded that the provider “requires improvement” across all five measures, and that it is not consistently safe, effective, responsive, or well led.
It was in breach of four different regulations of the 2008 Health and Social Care Act (HSCA).
The CQC found examples of residents, who are not always capable of saying what has happened to them, having unexplained skin tears and bruises.
Not all of the injuries had been properly investigated or reported to external safeguarding authorities.
Staff said they may have been as a result of less well-trained agency staff, and the use of a type of bed hoist that they were unfamiliar with.
Monread Lodge’s management bought new bed hoists as soon as they were informed by the CQC, and has stopped using agency staff.
While staff have a good knowledge of individuals’ risk factors and care plans were much more up-to-date than before, some of them were inconsistent or incomplete.
The home is in the process of improving care plans, focusing on the most complex cases first.
One resident, who was returning from hospital after a fall, was not assessed on returning to the home.*
As a result, they were then injured a second time in another fall.
In another episode, a staff member withdrew a resident’s pain medication on their own judgement without consulting or notifying a GP, relatives or management, even though the resident was unable to communicate their own experience of pain.
Consent forms, which are signed on behalf of residents who are not fully able to make their own decisions, were not always signed off by people with the legal authority.
Nonetheless, the words of one resident echoed the CQC’s finding that overall, staff clearly show care and respect for their dignity, saying: “They are very respectful.”
In other measures, such as nutrition, there were concerns coming from the fact that on the day of the inspection the chef on duty had no awareness of any residents’ dietary needs, leading to one resident being given ingredients to which they were intolerant.
Residents were not weighed frequently enough and were often given dietary supplements close to mealtimes, which can affect the appetite.
Furniture and carpets were dirty and smelly, despite the previous inspection in May 2017 ordering the care home to replace them before the next inspection.
By September, the care home had got as far as making a purchase order.
Despite the problems, report acknowledged that many of the CQC’s previous recommendations had been put in place or were in a long-term process of improvement.
With increased in-house staffing, better administering of medicine, and new management, there is a sense that things are being turned around.
The interim manager was transparent about many of the issue, saying: “We are starting the fundamental basics of care and dignity all over again.”
One family member also acknowledged the changes: “Feeling listened to, valued, and that our views matter, that is a long way off, but I feel confident it is coming.”
A staff member added: “Morale is low, but we see the progress.”
Since the inspection, the home has brought in a new manager, Maggie Wallbridge, who has previously worked with the CQC as an inspector.
Monread Lodge is part of the Maria Mallaband Care Group, which has 83 homes across the UK, Northern Ireland and the Channel Islands.
Vicky Craddock, operations manager of the group, did not respond to specific enquiries about how Monread Lodge would ensure it was not in breach of regulations in future.
She said: “Senior managers are supporting staff at Monread Lodge following the last CQC inspection, which took place in September 2017, in order to ensure that the necessary improvements are made and sustained.
“We are confident that we have made the necessary improvements and look forward to demonstrating this when CQC next visit.”
*Respondents to CQC reports are kept anonymous.