Birkdale Residential Home in Oakengates was inspected by the Care Quality Commission due to concerns received about the ‘management of risk within the building’.
An inspection was carried out to find if the service was ‘safe’ and ‘well-led’ with both being graded ‘inadequate’.
At the time of the inspection there were 26 people using the care home, some of whom were living with dementia.
The inspector found that residents were at risk of preventable injury as the provider had ‘failed to ensure’ risks had been identified and mitigated. There was no evidence of anybody being harmed at the home due to the risks.
“People were at the risk of harm as the provider failed to ensure the physical environment was safe for people to live in,” found the inspector.
“Some wardrobes had not been secured to a fixed point and freely moved. They were a risk of toppling over. Heavy items were stored off the ground and at the risk of toppling. These issues put people at the risk of harm from crushing injuries.”
It was also found that substances which are hazardous to health were not stored securely and accessible for users with dementia.
“There were cleaning chemicals decanted into unlabelled bottles, nail varnishes and items marked as harmful, flammable and/or corrosive left accessible in communal areas,” the inspector added.
Some radiators had been left uncovered or with broken covers and several had a broken thermostat resulting in sharp point.
The provider had also ‘failed to complete’ adequate fire safety checks which included having holes in fire doors and additional locks on two fire exits.
Inspectors were also ‘not assured’ that the provider was promoting safety through hygiene practices.
“We saw visible dirt and debris on kitchen equipment, there was rust on radiators and radiator covers, there were broken tiles and evidence of water damage on walls,” found the inspector.
“There was food items and debris under the radiator covers and other evidence of poor cleaning. Food items were stored on the floor in the kitchen alongside mop buckets.”
Medicines were also found to not be safely stored or managed. The inspector found that two people were not given their medicated creams as prescribed.
“There were multiple locations throughout Birkdale Residential Home where toiletries had been left accessible to people, cleaning products had been decantated into unmarked bottles, medicines left in communal cupboard and cleaning products left on windowsills all of which was accessible to people living with dementia,” added the inspector.
“We have received assurances from third parties that actions are underway to address the most serious of our concerns.”
The CQC inspector was ‘assured’ that the provider was admitting people safely, was using personal protective equipment ‘effectively and safely’ and was responding to risks and signs of infection.
Users were found to be supported by enough staff who were available to ‘safely support them without any unreasonable delay’.
One relative told the inspector: “Staff are always there if you need them and are free to have a chat when you want.”
The inspector also found that people were safe from the risks of abuse and ill treatment. Another relative told them: “I don’t have any concerns about anything here. The staff are lovely and if I was worried, I would say something.”
Staff, and the management team, were found to follow best practice when assessing people’s capacity to make decisions and knew what to do to ensure any decisions made were in the best interests of the person concerned.
However, when assessing if the service was ‘well-led’ they found ‘widespread and significant shortfalls in service leadership’.
“Leaders and the culture they created did not assure the delivery of high-quality care,” the inspector found.
“The provider failed to ensure the learning from significant incidents were put into practice. The provider failed to demonstrate they understood legal requirements for appropriate environmental assessment or checks.
“The registered manager did not know about the risks resulting from legionella bacteria and had failed to ensure potential risks had been mitigated. The provider could not demonstrate they had commissioned a legionella risk assessment and could not demonstrate they had taken action to mitigate any potential for harm.”
Due to the overall rating of the service now being ‘inadequate’ the home has been placed into special measures.
The CQC said it will keep the service ‘under review’ and re-inspect within six months to check for significant improvements.