Norfolk care home put into special measures amid concerns for patient safety
Staff were found not to be managing medicines safely - with one resident missing their medication for nine days in a row
Last updated 1st Nov 2024
Officials have put a care home in Norfolk into special measures - in an effort to protect the safety of those living there.
The Care Quality Commission (CQC) carried out an inspection of Ashill Lodge Care Home, near Watton, between May and July this year, after whistle-blowers raised concerns about staff training and responsiveness to people's needs.
The QC also wanted to check on the progress of improvements the home was told to make following warning notices around medication issued in a previous inspection.
Run by Ashill Lodge Care Limited, the care home provides accommodation and personal care to up to 35 older people, some of whom are living with dementia.
As well as the home’s overall rating dropping from requires improvement to inadequate overall, inspectors also dropped the home’s ratings for being safe, responsive and well-led.
The rating for how caring the service was dropped from good to requires improvement, while the CQC again rated the home as requiring improvement for being effective.
Inspectors also imposed conditions on the home, saying it must ask before admitting new residents to the home.
"Concerning"
Stuart Dunn, CQC deputy director of operations in the east of England, said: “It was concerning that standards of care being provided to people living at Ashill Lodge Care Home continued to fall below an acceptable level.
"Instead of using the findings from our previous inspection to make improvements, we found further decline which is why we took action around them admitting new residents and placed them into special measures to protect people.
He described some of what the CQC inspectors saw during their time at the home: “Staff didn’t always support people to eat and drink safely. For example, people who’d been given special diets to prevent choking, weren’t being fed foods with the right consistency to avoid this from happening.
"We saw other people who needed to sit upright to avoid choking, being left lying down in their beds to eat meals. Although leaders had provided recent training on this to staff, they couldn’t explain to CQC how they monitored people’s dietary needs. This is unacceptable, particularly for residents with dementia who need additional support.
“The home wasn’t safe or well-maintained"
“Leaders didn’t assess restrictive practices, which prevented people who are mobile from walking freely around the home. We have raised this to the service, and they have carried out an investigation.
“Staff didn’t manage medicines safely. For example, one person missed their medicine for nine days and staff hadn't followed the process to escalate to the GP immediately. Staff didn’t always document when topical creams had been applied meaning they couldn’t be assured that this had been carried out.
“The home wasn’t safe or well-maintained, with several dangerous hazards that posed significant risks to residents, especially those living with dementia. These included exposed wiring on electric bed handsets, and loose wires from sensor mats creating tripping hazards. While the service addressed these concerns after they were raised, it is unacceptable that they were allowed to persist for any length of time."
Stuart told us the CQC will continue to watch Ashill Lodge closely: “We have told leaders where we expect to see immediate and significant improvement and have imposed conditions on the provider’s registration to protect people. In the meantime, we’ll continue to monitor them closely to make sure people are safe while this happens and won’t hesitate to take further action if this doesn’t happen.”
Inspectors also found:
Staff weren’t offered specific training needed to meet individuals needs within the service, this includes Diabetes, Dysphagia and Stoma training.
The service was unable to provide evidence of how they monitor call bell response times. Call bell response times weren’t monitored, and people expressed frustration at the delays in getting assistance.
Safe recruitment practices weren't always followed, there were gaps in employment checks and inadequate risk assessments carried out.
Several areas of the home were visibly dirty and stained. Equipment used to transfer people was unclean despite being recorded as checked and cleaned.
Staffing levels weren't adequate, especially at night time to ensure people consistently receive adequate and safe care.
What has the Care Home said?
Ashill Lodge care home has been contacted for comment.