The previous year, police launched an investigation after three of the home’s residents were hospitalised with “diabetes-related problems”.
Two of the patients subsequently died, but the police inquiry was dropped after officers failed to find evidence of “any relevant criminal offences”.
This unannounced inspection may well still concern many concerned parties as to standards at the home
The report states:
CQC previously inspected Partridge Care Centre on 07 January 2013 and found the provider had failed to plan and deliver care in such a way as to meet people’s individual needs and ensure their safety and welfare.
A spokesperson said: “We judged this had a moderate impact on people living there and we required the provider to make improvements. The provider wrote to us setting out their action plan which stated that they would be compliant by 31 March 2013 or sooner.
“When we inspected the home again on 16 May 2013 we found the provider was still not compliant. This was because there was a delay in supporting people living in the Mallard units with their personal care requirements. This adversely affected other aspects of care such as providing people with breakfast or medication.
“We saw that people were not protected against the risks of receiving care and support that was unsafe because care plans for pressure ulcers were not in place.
The report goes on to make the following observations:
1.The provider did not have an effective system to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. This was because audits had failed to identify that there were shortfalls in the standards of care delivered on the Mallard units.
2. People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.
3. We have asked the provider to send us a report by 24 July 2013, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.
4. We have taken enforcement action against Partridge Care Centre to protect the health, safety and welfare of people using this service.
5.People did not experience care, treatment and support that met their needs and protected their rights.
When we previously inspected Partridge Care Centre on 07 January 2013 we found that the provider was not compliant with this standard. This was because the provider had failed to plan and deliver care in such a way as to meet people’s individual needs and ensure their safety and welfare.
In particular, we noted that people who had been recently admitted to the home were not adequately assessed. Up to date information about risks that might affect their health and wellbeing was not present in their care plans. This meant that people did not experience care and treatment that met their needs.
We had also noted that people who lost weight were not monitored effectively, either because their records were not properly completed or because no action had been taken to address the weight loss.
We inspected the home again on 16 May 2013 and carried out observations in the Mallard and the Kingfisher Units and interviewed people and staff. We found a disparity in the standards of care and treatment between both units. For instance, on the Kingfisher 2 unit we saw that the people who live there had awoken and had been supported with their personal needs, such as washing, dressing and having breakfast by mid-morning. We also observed that there was frequent and friendly interaction between staff and people.
On the Mallard 2 unit we saw that one person was still being supported in this way at 12.10pm. Furthermore, some people did not receive their breakfast until after 11am. We saw one person for example, sitting unattended, with a cooked breakfast in front of them and not eating it. After around 25 minutes a staff member came and helped the person to eat by which time the food was cold.
We saw that the delay in people being supported with their morning routines and with their breakfast had an impact on the administration of medication. We noted that the morning medication round was still being carried out at 11.15am despite having started at 8.30am.
We also saw that there was no meaningful activity provision and no interaction with the people living on either the Mallard 1 unit or the Mallard 2 unit. A staff member said, “We can’t spend time with the residents. There’s no activities; no communication.” This meant that people living with dementia were not supported to be engaged with life enriching experiences.
We found that people who were at risk of developing pressure ulcers or from poor nutritional intake were not receiving care that ensured their safety and welfare. For example, we saw that one person who was at risk of developing a pressure sore was sitting on a chair without a pressure relieving cushion. The person had also not experienced a positional change for over five hours.
Another person who was being cared for in bed and who already had a developed pressure ulcer had been living at the home for over six days without having their care planned to manage the pressure ulcer. This meant that care and treatment was not planned in a way that ensured people’s safety and welfare.
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