A Holbeach residential home is putting people at risk due to poor management, unsafe medicine practices and a lack of infection prevention and control.
An inspector from the Care Quality Commission returned to the Nutten Stoven Residential Home in November after concerns were outlined in a report published in September.
The home can cater for up to 30 older people with a range of conditions, including dementia. There were 21 residents at the time of inspection.
“People were not protected by an effective safeguarding system. There was no process in place to record safeguarding concerns,” the most recent report says.
There was also concern over the use of ‘as and when’ pain relief.
“We observed one person experiencing significant pain during routine treatment from community nurses as staff had not administered prescribed pre-emptive pain relief,” the report says.
Medicine records were poorly managed at the Boston Road home, and not always completed while staff did not always know why residents were prescribed medication.
Admission assessments were not complete, and the inspectors were ‘not assured’ the provider was promoting safety through the layout and hygiene practices.
“There were no signs outside people’s bedrooms when they were self-isolating due to testing positive for COVID-19,” says the report.
“We were not assured that the provider was making sure infection outbreaks can be effectively prevented or managed,” adds the inspector.
While the provider was taking steps to employ more staff, there were gaps in the records, including in full employment histories. There was no registered manager at the time of the inspection.
There was also insufficient training with new members not completing mandatory areas such as health and safety or infection prevention and control.
There were also concerns that lawful authority was not always in place when residents were deprived of their liberty.
“One person was restricted to their bed through the use of bed rails, due to poor mobility. However, no capacity assessment of deprivation of liberty application had been completed,” the report says.
The overall rating of Inadequate was awarded the status in three of the five key areas. The other two require improvement.
The CQC has told the provider that it is in breach of two regulations and steps need to be taken to rectify the situation.
