The Care Quality Commission (CQC) has published a report rating the care delivered at The Old Village School Nursing Home in Bedfordshire as Inadequate across all areas.
Inspectors visiting the home found overwhelming systemic failures with the potential for serious harm to come to people who were vulnerable because of their dependence on others to meet their needs.
The home, run by Old Village Care Limited, was previously inspected in June this year when the regulator ordered swift action to bring about improvements after poor standards of care were identified.
• Insufficient number of suitably qualified, competent staff at all times to provide appropriate care and support to people with highly complex needs.
• Personalised risk assessments were not always sufficiently detailed or accurate. Staff did not know how to interpret them.
• Assistive technology designed to reduce the risk of harm to people was not always used when it was in place. People’s medicines were not managed, stored or administered safely.
• Staff did not always have time to ensure that people had drank sufficient fluids.
• Care plans had not been updated when people’s needs had changed.
When CQC inspectors returned to The Old Village School to carry out an unannounced inspection on the 3rd and 6th August they found the provider had failed to improve the quality of people’s care.
People said they did not always feel safe. One person told inspectors “the shortage of staff is terrible”. They said: “I was left in the garden for two to three hours with another person and not a soul came near us. The side door was closed because of the wind and this frightened the other person. It frightened me too. The other person was tapping on the window to come in. I was shouting for the nurse. Eventually someone came but by then the other person was crying and cold.”
Inspectors also found that staff did not have the skills to care for people living there. One person said: “I had my catheter changed here and they put the wrong dressing on it.” When the dressing was removed during a hospital visit it was found the skin beneath the dressing had blistered.
A visiting healthcare professional told inspectors one person who received continuous oxygen therapy had been found blue and in distress and the night nurse on duty had not taken the necessary steps to replace the empty oxygen cylinder. The healthcare professional visiting the home had to intervene to make the person safe.
The provider had not ensured that the service was caring and people’s dignity was often compromised as a result. One person told us: “I was left in an armchair from nine thirty in the morning until five or six or night without being moved. My bottom was killing me and I was dying to go to the toilet. They knew but forgot and would not let me go to the toilet and said I had to use a bed pan. It was too embarrassing for me.”
CQC inspectors found the leadership of the service was chaotic with directors of the company undermining attempts by the management team to introduce changes.
Old Village Care Limited was unable to work effectively with healthcare professionals who attended the home to review the care needs of people living there and had failed to ensure there were robust systems in place that worked to pick up shortfalls and improve the quality.
Commenting on the inspection report CQC’s Chief Inspector of Adult Social Care, Andrea Sutcliffe, said: “The shocking examples of care that my inspectors found at The Old Village School are absolutely appalling.
“Following a previous inspection of this service in June, the provider was set clear expectations for improvement and their attitude to doing something about it has been completely atrocious.
“In June, we had assurances from the provider that improvements would happen. But when we returned in August the situation was getting far worse, not better.
“This was not acceptable and it was essential for us to take further action so that people could be protected and kept safe.
“We worked closely with the local agencies who led and managed the process to move people to alternative accommodation. We know there have been some genuine concerns about the transfer arrangements and together we are looking at what lessons we can all learn from the closure process.
“This was not an action taken lightly as the last thing we want to do is move people from their homes if there is a possibility that the provider can turn the service around.
“I completely understand how distressing this upheaval was for the residents of The Old Village School and their families and I wish the provider had used the opportunity they were given to put things right.
“When providers fail in this way, we have to take action. People, and their families, deserve an awful lot better.”
A full copy of the latest inspection report is available to read on CQC’s website: http://www.cqc.org.uk/location/1-109157616