Pinford End House Nursing Home, near Bury St Edmunds, is placed into special measures by Care Quality Commission to protect people
A care home has been placed in special measures after inspectors found people were at risk of harm.
Pinford End House Nursing Home, at Hawstead, near Bury St Edmunds, has been rated ‘inadequate’ overall in a scathing report by watchdog the Care Quality Commission (CQC).
According to one member of staff, ‘leaders were more focused on money than people’s care’, commented Catriona Eglinton, CQC deputy director of operations.
At the last inspection, which rated the nursing home ‘requires improvement’ (published February 2023), the provider completed an action plan to show what they would do and by when to improve.
However, at the latest inspection, with visits over five days in September, the provider remained in breach of regulations.
The CQC said this inspection was prompted in part due to concerns received by the regulator about safe care and treatment, safeguarding, infection prevention and control, safe medicines management and good governance.
“We found evidence during this inspection that people were at risk of harm from these concerns,” the inspection report said.
The CQC rated the home, which specialises in care for people at the end of their lives, inadequate and placed it in special measures, which means it will be kept under close review by the watchdog to keep people safe and monitored to check sufficient improvements have been made.
Mrs Eglinton said there were ‘significant shortfalls’ in leadership, medicines were poorly managed - mentioning one person hadn’t received their medication – and the provider failed to provide accurate reporting and risk assessments when people required personalised care.
She also said some people spent long periods of time in sedentary positions, with gaps in records showing they hadn’t been helped to move in up to nine hours.
The inspection report says the CQC wrote to the provider during the inspection due to its serious concerns of people receiving poor quality care and requested an urgent action plan.
“The provider told us they had not been aware of the significant failings at the service and risks posed to people's safety and wellbeing,” the report said.
The CQC report says it identified breaches in relation to safeguarding people from abuse, safe care and treatment, medicines management, safeguarding, staffing, person-centred care and governance at this inspection.
In terms of staffing, at night the CQC found that there was one nurse and three care staff to support 35 people.
Mrs Eglinton said: “When we inspected Pinford End House Nursing Home, we found there were significant shortfalls in service leadership and leaders had created a culture which didn’t ensure people received high-quality care. Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found here.
“We found leaders didn’t manage staff well and when talking to inspectors about their experiences of working at the service, some staff were visibly upset. They told us there wasn’t regular supervision or staff meetings. They also told us staff morale was low and the atmosphere was unpleasant as, according to one member of staff, leaders were more focused on money than people’s care.
"Inspectors found that medicines were managed poorly. For example, one person needed their medication administered in a particular way, but this wasn’t put in place and therefore, they hadn’t received their medication, putting them at risk of harm. The registered manager said the delays were due to a lack of signed paperwork.
“We found the provider failed to provide accurate reporting and risk assessments when people required personalised care. For example, there were ineffective risk assessment plans and guidance for people at risk of choking, so, staff weren’t sure what actions to take to keep people safe from harm.
“Also, some people spent long periods of time in sedentary positions without being helped to move. This put people at increased risk of harm and skin breakdown. We found there were gaps in records showing they hadn’t been helped to move in up to nine hours.
“We have reported our findings to the provider, and they know what they must address. We will monitor the service to ensure people are receiving safe care. If sufficient progress hasn’t been made, we will not hesitate to take action to ensure people’s safety and wellbeing.”
The provider had taken ownership of the service in 2022.
The service provides personal, nursing and end-of-life care. At the time of this inspection there were 35 people using the service.
The report said: “Staff told us, ‘Morale is very low, it has hit rock bottom’.
“And, ‘The atmosphere here since the new owners took over is horrible. The focus is on money and not the care of the residents. I have always been proud to work here, we always had a good reputation, but not anymore’.
“One staff member said, ‘The manager is very good, very caring but they can't do it all. They try to do it all themselves but needs help’.”
Following this inspection, the service was rated inadequate for whether it is safe, effective and well-led, while it was judged to require improvement for whether it is caring and responsive.
The report said feedback from people using the service and their relatives was inconsistent and while the CQC received some positive comments about the levels of support and quality of care, it also heard concerns about areas such as inadequate staffing, declining quality of food and the provider’s inadequate response to complaints.
Inspectors found:
•The provider's governance systems and audit processes continued not to be robust enough to ensure shortfalls were identified and addressed;
•The provider had failed to take action in response to fire safety concerns highlighted following external fire inspection visits;
•Fire safety procedures were unclear, and staff including agency nurses with overall responsibility for the safety of the building did not have access to the training and information they needed to respond in an emergency;
•The provider did not always respond to safeguarding concerns in line with their own policy and local protocols;
•When events including safeguarding incidents had occurred, records did not evidence what action had been taken. There was no evidence lessons were learnt when things went wrong;
•The safety of people at risk of choking, inadequate food and fluid intake and those at risk of acquiring pressure wounds had not been effectively monitored to ensure their safety and wellbeing;
•Regular checks continued not to be carried out on medical devices, such as suction machines to ensure they remained in good working order for when needed in an emergency. There were insufficient trained or supervised staff to safely meet the needs of people. People told us there was not always enough staff to meet their needs;
•Infection control procedures were not always followed to ensure the spread of infection was reduced;
•A number of bathrooms were being used to store equipment such as trolleys, hoists, discarded hoist slings, towels, continence equipment and boxes. Staff told the CQC this prevented them from access to these rooms to support people with bathing;
•People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The report will be published on the CQC website in the next few days.
The website for the care home says it is family owned, ‘offering quality care for the elderly’, and was established in 1987.
SuffolkNews approached Pinford End House Nursing Home for comment.
