Staff at a Spalding care home failed to spot abuse through neglect and inspectors made safeguarding alerts after visiting, says a recent report.
The Care Quality Commission report into Southernwood House, Matmore Gate, said one resident was ‘severely underweight’ and their nutritional intake record was incomplete.
The unannounced visit took place on July 21 but there had been no assessment of the resident’s malnutrition risk since February 2020.
They “had not been referred to a healthcare professional support with maintaining a healthy weight,” said the report, which was published last Thursday.
Inspectors noted that emotional needs were not assessed and lessons were not learnt when incidents happened.
“Following falls there was no review of a person’s mobility care plan. There was also no analysis of falls over time to see if there were any trends,” the report said.
“Following the inspection, we made safeguarding alerts for two people.”
“One person had recurrent bruises and skin tears. There was no record of any action being taken to investigate the causes,” the inspectors said.
The home caters for up to 28 people and provides personal care to others living in their own home.
“We received concerns in relation to the management of medicines, infection control, staffing levels and the management of the service,” said the report.
“People were at risk of abuse and not having their rights protected.”
Inspectors took account of the ‘exceptional circumstances arising as a result of the COVID-19 pandemic’ when considering enforcement action.
The home requires improvement in the areas of being well-led, being safe and overall. Enforcement action requires the home to improve management of medicines, infection control and risk. Also to improve in the safeguarding and protection of people’s rights. It also has to improve quality monitoring.
“The provider responded immediately during and after the inspection. They said they would ensure staff received further training,” said the report.
Inspectors also mentioned staff wearing masks under their chins and not replacing them after breaks.
The lack of systems meant it was also not possible to assess if residents were receiving their medicines safely.
But there were enough staff for the number of residents at the time and inspectors heard that they were kind and caring.
Care calls to people in their own homes were ‘completed in timely fashion.’
