Buxton care home in special measures issued CQC warning notice over safety

As previously reported, Haddon Hall Care Home, on London Road, was put into special measures last October over what CQC inspectors saw as an inadequate response to problems first identified in January 2022.

A further unannounced inspection was carried out in June 2023 and the conclusions of the report published this month found that the home’s 61 residents were “at risk of avoidable harm” and that Porthaven Care Homes Limited was in breach of regulations.

Furthermore inspectors noted “there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”

“We found no evidence that people had been harmed, however, systems were either not in place or robust enough to demonstrate governance was effectively managed.”

Care homes in special measures are usually afforded a 12-month window in which to address their failings, a period which began with last October’s inspection, so further enforcement action by the CQC may follow soon. Inspectors will typically follow up within three months of a warning notice.

The October 2022 inspection had resulted in the CQC issuing Porthaven with a notice to cancel the professional registration of the manager in charge at the time.

Porthaven is required to have a registered manager to oversee the delivery of regulated activities, but when inspectors returned to Haddon Hall in June there was no registered manager in post at the home.

A new manager who had been in post for three months told inspectors they intended to submit an application to register. The Buxton Advertiser understands that process is still ongoing.

In their latest visit, inspectors also spoke to service users and relatives, professional partners, staff and company management, as well as reviewing documents, and concluded the home was still failing to meet three legal requirements laid down by the Health and Social Care Act 2008 and subsequent rules in force since 2014.

The report describes how Porthaven had failed to ensure that staffing levels were adequate to meet people's needs, and that management and governance processes were not being used effectively to assess, monitor and mitigate risks to the health, safety and welfare of residents.

Specific examples include care plans with insufficient information about individual residents, incomplete records of their fluid intake and physical movement, and of actions taken after residents had fallen, and that “mental capacity assessments and best interest decisions were not always completed for all aspects people's care.”

The report adds: “Assessments of people’s needs had been carried prior to people using the service, however care had not always been delivered in line with people’s choice and preference.”

One person’s care records stated they would like to shower daily, however their care records showed they had only six showers in a 23-day period.

The report also contains statements from residents’ relatives such as “They are short staffed and [staff] are rushed off their feet,” and “I asked if [person] could have a bath, staff told me they don't have the time.”

Inspectors heard from employees who were positive about training and confident they could deliver effective care, but that staffing shortages left them having to cut breaks short and stay beyond the end of their shifts to keep up with the workload.

Employees are said to have continued raising concerns with Porthaven over staffing levels, and that they felt the provider had not taken enough action to address the situation.

Despite the pressure on the service, inspectors did note that the management of some key safety procedures such as administering medicines, safeguarding and infection control did appear to be running effectively.

One relative told inspectors, “On the medical side I feel confident, they are pretty attentive and when required have taken [person] to hospital.”

It also appears that Porthave is responding to the issues identified as the report notes: “During our inspection, the provider took immediate actions to mitigate the risks we identified, this included increasing staffing levels and introducing new monitoring systems for daily recording charts. The provider also commissioned a management consultant and temporarily paused new admissions to support the improvements required.”

A spokesperson for the company said: “We are dedicated to providing our residents with high quality care that meets their needs, and we always take feedback from the Care Quality Commission very seriously. Since the CQC inspectors last visited our home in June, we have already made a number of changes and improvements at the home.

“We appointed a new home manager at the end of March, who is embedding the changes we are continuing to make at the home. Under their leadership, we have made improvements to our systems and processes which address the outstanding areas for improvement identified in the CQC report.”

They added: “We are pleased that the CQC acknowledged that we took immediate action to address staffing levels on the day of their visit and they noted improvements in our record keeping. Relatives and staff spoke positively about the home manager.

“We continue to build on the progress we have made since the CQC inspectors visited us in June and look forward to welcoming them into our home again at their next inspection.”

To read the latest inspection report in full, go to https://tinyurl.com/4p8a8e88.

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