Ipswich care home placed into special measures
Inspectors said those living at the home weren’t always getting safe, person-centred, and compassionate care
A care home in Ipswich has been placed into special measures, after whistleblowers raised concerns about a number of issues, including end-of-life care.
Inspectors from the Care Quality Commission (CQC) have dropped the rating for Handford House Care Home, which provides accommodation and care for adults living with dementia and/or with a physical disability, from good to inadequate, following an inspection in July.
The CQC says the inspection was prompted after whistleblowers and health professionals contacted the organisation with concerns about end-of-life care, staffing levels, hygiene practices, and the overall safety and quality of people’s care in the home.
The ratings
The home’s overall rating has dropped from good to inadequate.
It's also now rated inadequate for being safe and well-led.
The ratings for effective, caring, and responsive have also been dropped from good to requires improvement.
As a result, the CQC has placed the home into special measures, meaning it will be kept under review and closely monitored to ensure people are kept safe.
The CQC has also proposed taking further regulatory action, which the service has the right to appeal.
“There weren’t enough staff to care for people properly"
Hazel Roberts, CQC deputy director of operations in the East of England, said: “We were concerned to find people at Handford House weren’t always getting safe, person-centred, and compassionate care.
"This was because there weren’t enough staff with the right training to meet people’s needs. Leaders had also failed to act on problems quickly to protect people.
“There weren’t enough staff to care for people properly, and people living at the home and their family told us they’d waited up to half an hour for staff to answer call bells on multiple occasions.
"These delays placed people at risk of harm, particularly those needing urgent assistance. Some relatives said they’d had to step in to carry out their family member’s personal care because of this and one person had stopped asking staff for help with showers entirely, impacting their dignity.
“People living in the home shared mixed feelings about staff. While some told us some staff were kind, others said they were disrespectful or didn’t speak to them.
"We saw staff didn’t always acknowledge people they were caring for and were often focused on getting tasks done instead of listening to people’s individual needs."
"Risking people’s health"
She also explained inspectors noted the home appeared dirty: “We saw the home wasn’t always kept clean, with visibly dirty bathrooms.
"People told us the floors were often sticky, and one relative had raised concerns about soiled continence pads being left on the floor. There were also outbreaks of two bacterial infections, MRSA and Strep, in the home during our inspection, risking people’s health.
"Outside health professionals were supporting the home to control these outbreaks but had previously found issues with the home’s hygiene practices, such as hand washing.
“Leaders weren’t consistently ensuring the home’s environment was safe. Inspectors found a handrail coming away from the wall and a bookcase which hadn’t been secured to ensure it didn’t fall.
"Leaders did act on these immediately when it was raised by our inspectors, but they should be identifying and acting on these issues themselves."
Ms Roberts mentioned they'd also spoken to residents' families: “Relatives had raised multiple safeguarding concerns, including around other residents being allowed to enter their family members’ bedrooms without permission and leaders not informing a relative when a resident had fallen. The local authority was carrying out multiple safeguarding enquiries and had temporarily stopped new placements in the home.
“Following visits by outside organisations, leaders had begun making improvements in many areas, but these weren’t fully implemented yet.
“We’ve placed the service in special measures and will monitor it closely, including through further inspections, to make sure these improvements are made quickly and people are kept safe. We’ve also proposed taking further regulatory action to protect people, which the service has the right to appeal.”
More details
Inspectors also found:
• Staff didn’t always involve people and their families in planning their care. Many care records were unclear or generic and had little information on people’s preferences or personal history to guide staff.
• People told inspectors there were few opportunities for social engagement or activities. Some relatives said they’d found their family members sitting in their bedrooms with the curtains closed and lights off.
• People’s appearance and personal belongings weren’t always looked after in respectful ways, with some relatives saying they’d found their family members’ wearing other people’s clothes or with personal items such as their spectacles missing.
• Leaders lacked oversight of significant gaps in staff training, including in safeguarding and how to care for people living with dementia or people with limited capacity to make decisions about their own care.
• The service hadn’t always recorded mental capacity assessments or best interest decisions as legally required for people that needed them. This meant leaders could not ensure staff were supporting people in ways which still maximised their choices and respected their rights.
• People’s medications were not always managed safely. Some people hadn’t always received their prescriptions or pain relief in a timely way and one staff member said they’d been asked to administer medications without training.
• Inspectors found several people’s care records didn’t include their end-of-life care decisions. Some relatives said they were distressed by the standard of end-of-life care and hadn’t always been listened to. Leaders said they planned to review end-of-life care records.
• People weren’t always supported to reposition regularly and health professionals had found improvements were needed to prevent skin injuries. Leaders were working with a tissue viability nurse to improve this.
• Inspectors found people were being served food and drink from containers that weren’t being cleaned regularly. People and their relatives had raised concerns about food being poor quality or bland.
There were some positives though:
• Leaders had recently introduced a ‘resident of the day’ system in which they asked for feedback each day from a person in the service and their relatives. One relative told inspectors they felt better about the service after having one of these discussions.
• People’s bedrooms were personalised with items that reflected their individuality, including photos and memorabilia.
We've contacted Healthcare Homes Limited, which runs Handford House Care Home, for comment.