A Wiltshire care home ‘put people at significant risk of risk of harm’, a report claims.
Highfield Residential Home in Marlborough was rated “Inadequate” by the Care Quality Commission (CQC) after serious failings were found during an inspection in June.
The report, which was published on 14 August, told of how the service “put people at significant risk of harm and a decreased quality of life” due to a lack of meaningful audits and checks.
Numerous concerns were highlighted in the document, which rated the safety of the home and its leadership “Inadequate”. The general care of residents was rated “Requires improvement”.
The report said that due to out of date risk assessments “falls occurred regularly with little, or no action taken to mitigate future risk”.
Members of staff “did not know how to respond to protect people” in the event of a fire, with the potential consequences of fire within the home “assessed to be extreme”.
“We saw urgent actions stated in the home’s fire risk assessment dated June 2022 which had not been completed until a year later in June 2023, such as bolts on fire doors needing to be removed”, it said.
Inspectors found that the service was not working within the principles of the Mental Capacity Act 2005, which dictates when a person can be deprived of their liberty.
“Some staff raised concerns about the lack of training; one staff member told us they had worked at the service 3 years and had not received any training in safeguarding adults”, the report said.
It continued: “One staff member told us they raised a safeguarding concern which took 7 weeks to be actioned. We saw evidence of this during our inspection. This meant people were at risk of abuse.
“One staff member told us they were not offered further shifts at the service after they had raised safeguarding concerns.”
The CQC said that the service had breached Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (HSCA).
It said that due to the systems and processes not always being in place to ensure medicines were managed safely, the service breached Regulation 12 (Safe care and treatment) of the HSCA.
Inspectors did not see any evidence of community access on their visit to the Crosscrown-owned home, and heard concerns from one resident who claimed she had asked to go shopping but staff did not take her.
People were “left for long periods of time without interaction” from staff and the service “failed to support people using a person-centred approach”, leading to a breach Regulation 9 (Person-centred care) of the HSCA.
The report stated that inspectors observed “some positive interactions” and relatives of service users were “happy with the care provided”.
It said that staff “did not always talk about people respectfully”, adding that an inspector heard one employee describe someone as a “baby” as they just “eat, sleep and go to the toilet”.
Many concerns were raised about the management of the service, with the CQC report stating that staff were not trained in supporting people with end-of-life care and dementia.
“Three staff we spoke with confirmed they had not received training in these areas and records confirmed this. This placed service users at risk of being supported by staff who did not have training relevant to service users’ needs”, the investigation found.
Crosscrown Care Homes was approached for comment but did not respond prior to publication.
