Suffolk care home rated 'inadequate' and placed into special measures
People in the home told inspectors they didn’t feel safe and described other people being physically aggressive
A care home in Suffolk's been rated as inadequate and placed into special measures, following an inspection by the Care Quality Commission (CQC).
Inspectors visited the Limes Retirement Home in Eye in May and July last year, after people expressed concern about people’s safety and the quality of care in the home, which provides specialist care for people with Alzheimer’s and dementia.
As well as the home’s overall rating dropping from good to inadequate, so have the ratings for safe, effective, caring, and responsive.
The home’s rating for well-led dropped from good to requires improvement.
As a result of the inspection, the CQC has imposed conditions on the home to focus its attention on the areas where it says 'significant and immediate improvements are needed'.
These conditions prevent the home from admitting new residents, require leaders to take immediate action to improve people’s safety, and require the home to send monthly reports to the CQC detailing progress.
"Deeply concerned"
Hazel Roberts, CQC deputy director of operations in the east of England, said: “During our inspection, we were deeply concerned to find the needs of people living with dementia weren’t understood, putting their safety and wellbeing at serious risk. Leaders had very little oversight of people’s care and had failed to respond when things went wrong.
“People in the home told inspectors they didn’t feel safe and described other people coming into their room, being physically aggressive or exposing themselves.
"It was concerning that staff hadn’t been trained to support people with dementia or mental health needs whose behaviours caused risks to themselves or others, and we found incidents of assaults, exposure, urinating and unwanted physical contact between people living at the home.
“Staff had also recorded people falling 52 times in the six weeks before our inspection, and inspectors found more falls which hadn’t been recorded.
“These incidents represented serious risks to people’s health and safety, however inspectors found the registered manager didn’t know about them.
"As a result, they’d taken no action to investigate these incidents or protect people in future and hadn’t reported them to the local authority or CQC for external oversight. During this inspection we raised an organisational safeguarding alert to the local authority."
"During our inspection we saw people who were visibly distressed"
Ms Roberts continued, saying staff experience was lacking: “While many staff were well-intentioned, leaders didn’t make sure they had the training to care for people with dementia.
"There also weren’t enough staff to meet people’s needs, meaning people were often left alone. During our inspection we saw people who were visibly distressed, anxious, and left in unsafe ways with staff unavailable to support them.
“The service also hadn’t always fully assessed people’s needs to make sure the home could meet them. One person’s wheelchair didn’t fit through the doorways or corridors, meaning they weren’t able to take a bath or shower, impacting their dignity and wellbeing.
“We’ve imposed urgent conditions on the home’s registration to protect people and focus leaders’ attention on making immediate improvements. We’ll continue to monitor the home, and won’t hesitate to take further action if we’re not assured people are being cared for safely.”
What else did inspectors find?
- The home environment was unsafe. Frail and immobile people were living in small rooms with uneven floors. The environment was poorly maintained and the home’s kitchen was not clean, including equipment used for food.
- The service had only one bathroom and one wetroom for up to 26 people. One person was frequently urinating in common spaces but staff hadn’t made a plan to respond to this.
- Staff had not received fire evacuation training and said they didn’t know how they could evacuate people with mobility needs on the first floor.
- Many people were left alone by staff for long periods, meaning other residents had to call for help when people were at risk. Staff often found people on the floor, having fallen with no staff around to help.
- People were left sitting for very long periods of time, which can increase their risk of falling. One person who had fallen eight times in eight weeks was left in a hard chair from 4pm until 9:50pm, and inspectors had to intervene when staff tried to get them up in an unsafe way.
- People’s care plans were incomplete and made without input from them or people caring for them. Staff said they rarely looked at these plans, meaning they weren’t guided on people’s
- individual needs, preferences, or risks.
- Staff didn’t always consider people’s consent or mental capacity in their care, so couldn’t ensure their rights and independence were always protected.
- Staff didn’t always understand how to meaningfully engage with people living with dementia or
- support daily activities for their wellbeing. However, some people and relatives gave positive feedback about events held at the home.
- Staff did not have the skills and confidence to help people plan how they wished to be cared for at the end stage of their life.
- Staff didn’t always ensure people received their medications safely or as prescribed.
What do bosses at the Limes Retirement Home say?
We've contacted bosses at the Limes Retirement Home for comment but are yet to hear back from them.