Inspectors find people still at risk amid 'catalogue of errors' at Buxton care home

A Buxton care home has again been ordered to make urgent improvements after inspectors found it had failed to address the alarming safety flaws for which it was put in special measures.

By Ed Dingwall
Thursday, 19th May 2022, 11:19 am

The Care Quality Commission (CQC) has kept the Branksome, on St John’s Road, under review since an inspection in October where residents were found to be at risk of malnutrition and unexplained injuries.

In a report published last week, inspectors say when they visited in March the home was still inadequate in terms of safety, effectiveness, responsiveness and leadership, and required improvement for care.

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The Branksome care home has failed to address critical safety risks first identified by CQC inspectors in October.

Natalie Reed, head of adult social care inspection, said: “We found a service that wasn’t providing safe care for the people living there. Staff had limited understanding of how to support people in a way which upholds their dignity, choices and human rights.

“We found a catalogue of errors, each putting people in harm’s way. Staff didn’t support people at risk of choking to eat or drink, putting them at serious risk. Also, people had unexplained injuries, such as cuts or bruising, but nobody was aware how these happened, and nothing was done to investigate these or make the local safeguarding team aware so they could carry out an independent review to keep people safe.”

She added: “Sadly, this was just the tip of the iceberg, yet some people living there had come to regard this poor standard of care as acceptable. When relatives complained about the service, they were either ignored, or no apology was given.

“We have told the provider they must make urgent improvements to the service and if we are not satisfied sufficient improvements have been made, we will not hesitate to use our legal powers to ensure people are safe.”

The report lists a series of shocking discoveries, such as the absence of medication for a person who had been prescribed a controlled drug for pain relief, to be given whenever they needed it – one of numerous instances when professional healthcare guidance had not been followed.

The majority of staff were found to be kind and caring, however, inspectors recorded instances when some were not. During one mealtime an employee walked up behind a person and, without warning, tried to move them in their seat to sit up straight. The person appeared shocked and upset, but there was no apology.

The home had also neglected to carry out recommended changes to signage around the home, such as menus and activity plans, which were not easy to understand for anyone with sensory loss. Staff also still did not have reliable access to information on residents’ cultural beliefs to ensure appropriate support.

The service will remain in special measures, closely monitored and re-inspected within six months. If sufficient improvements are not made within that time, CQC will take further action.

A spokesperson for the home’s owner Four Seasons said: “We deeply regret that the home remains below the standards that we and the CQC expect and have been working since the inspection in March to support everyone in the home.

“The safety and wellbeing of our residents and colleagues are our main priority. We're taking urgent action to rectify the situation and providing the CQC with weekly progress reports.”

To read the full report, go to

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