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CQC rates Tyne and Wear care home 'inadequate' after finding drug and choke risks


A care home in Tyne and Wear that was found to have left residents at risk of choking, without adequate access to drinks, and receiving medicines in the wrong way has been told by the regulator it has failed to make enough improvements to be removed from the “special measures” regime.

The Care Quality Commission last visited Windsor Care Home in June 2016 and found a series of problems including infection risks, incidents not being reported, and people’s hydration and nutrition needs not being managed safely.

“We also found gaps in the records we looked at where staff had not signed for the administration of medicines”

CQC report 

The latest inspection in October revealed the organisation, which has 50 residents and employs nurses and care workers, was continuing to breach six of the CQC’s care regulations. These included a lack of risk assessments about potential choking for people who had swallowing difficulties.

On the day of the visit, inspectors saw a resident choke after they were given the wrong texture food and in a different case found staff had given the wrong advice to family members about the consistency of food required for their relative.

Poorly recorded food and fluid charts were also noted and inspectors found gaps of over four hours, with no information about whether drinks had been provided to some residents.

“There were no target amounts set out in care plans or on fluid charts, so it was not possible to know whether each person had had the right daily amount of fluid they needed,” said the CQC in its report on the organisation.

During tea rounds, inspectors saw no snacks were offered and alternative drinks were not available, while during meal times no juice or water was served or offered.

“There was no evidence in the training files of the seven nurses of their assessed competency for areas such as catheter care and tube feeding”

CQC report 

Meanwhile, inspectors found medicine records had not been completed correctly – which meant residents were at risk of drug errors – and stocks were not properly recorded.

“We also found gaps in the records we looked at where staff had not signed for the administration of medicines. It was, therefore, not always possible to confirm if staff gave people their medicines as prescribed,” said the CQC’s report.

Inspectors checked a sample of medicines against records for 12 people and found 10 – including oral drugs, inhalers and nutritional supplements – did not match up, while five medicines for a handful of people were not available at the home.

As a result, the CQC said it could not be certain people were having their medication administered correctly, and also concluded that the system for ordering prescribed medication was failing.

Other ongoing problems included “significant gaps” in training for care staff and competency checks of nurses.

“Failing to learn and act on the previous inspection findings is not good enough”

Debbie Westhead

Although the home had improved its training for workers since the last inspection, the CQC’s report said: “There was no evidence in the training files of the seven nurses of their assessed competency for areas such as catheter care and tube feeding.

“Only two nurses had attended a pressure ulcer management and prevention session, and a training session around epilepsy. Documents for medicine competencies of nurses had not yet been completed,” added the report.

However, since the last inspection, over two-thirds of the senior care workers and other care staff had attended training about the Mental Capacity Act and Deprivation of Liberty Safeguards regulations.

Since its last visit, the CQC also found staffing had improved. It noted that, due to the number of people with very complex nursing needs having reduced and others moving on to other services, staffing levels were now in line with local authority commissioners’ requests.

“This inspection found that there was not enough improvement to take the provider out of special measures”

Debbie Westhead

In addition, at the time of the regulator’s latest inspection a new manager had been in post for three weeks, whom staff said was open and approachable.

However, overall the regulator said the care home was providing an “inadequate” service and therefore should remain in the special measures support scheme for struggling health and care providers.

Debbie Westhead, CQC deputy chief inspector for adult social care in the North, said the care provided at Windsor Care Home was “unsatisfactory” and that the regulator was continuing to work with South Tyneside Council to ensure people living at the home were not at undue risk.

“Breaches from the last inspection had still not been rectified, including medicines still not being managed in a safe way. Failing to learn and act on the previous inspection findings is not good enough,” she said.

“This inspection found that there was not enough improvement to take the provider out of special measures. [The] CQC is now considering the appropriate regulatory response to resolve the problems we found,” she added.

A spokeswoman for Windsor Care Home said the organisation working closely with the South Tyneside Council and the CQC to make the required improvements to the service.

”Since this inspection report is from October, there has been continuous progression within the service from the feedback we have received.

”The welfare of our residents as always remains the focus, and ensuring they receive the best care possible is paramount to our actions. We will continue to work to ensure this is maintained going forward,” she added.



Readers' comments (4)

  • Good for the CQC.

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  • When are the CQC inspectors going to talk to staff OFF THE RECORD or listen to them when they report anonymously. Another very good source of information are the agency nurses.
    Agency RNs see the worst of care homes & refuse to go back to them. Most do what they can while they are there but have found that if they report, their shifts dwindle.
    CQC have a long way to go to get the trust of care home staff to the extent that they will speak openly to them, knowing that there will be no feedback to employers and managers.

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  • I absolutely agree with the above statement, CQC have to start speaking to the front line staff instead of listening to the lies, and cover ups the managers of the homes provide

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  • The Care Inspectorate (the Scottish version of the CQC) in Scotland have a telephone helpline where anonymous reports can be received. I can only assume that English and Welsh government does not really want to know what is actually going on.

    But anyway as far as I can see, the CQC is almost entirely judging by records kept by the homes, records which may or may not be true.

    I appreciate the CQC are only permitted to judge upon what they see with their own eyes on their visits and I also appreciate that the CQC is not allotted funding for enough manpower hours to have inspectors physically present in a home for long enough so that they can actually see what is and is not happening.

    Their answer to that seems to be "Experts by Experience" - volunteers with an interest in standards in residential and nursing homes who accompany the CQC inspectors on their visits but I have NEVER seen any adverts aimed at recruitment of these volunteers.

    The best resolution would be more inspectors and funded manpower hours so that they could turn up unannounced when adverse reports had been received and just sit and see who doesn't get pressure relief when they should, etc.

    If anyone out there knows anyone who might become a useful volunteer, then they could let them know about it. Like now! Or if CQC recruitment flyers are available, perhaps they could distribute them?

    The CQC have to be impartial and as I understand it cannot base reports alone on what staff tell them but have to have seen it for themselves, hence the unfortunate dependence on records kept by the homes.

    To Nursing Times I would say this - it is not enough to say "care home." Laws and systems for residential care homes and nursing care homes are different and so which type of home a report is based on needs full identification every time.

    Failure to do so means that we cannot see where Local Authorities may be detaining service users in residential care homes (even though they could be suffering avoidable harm because they really need to be receiving nursing care) in order to use the fees from the self-funding residents to assist funding of those residents who are due to be funded entirely by the LA.

    The knock-on effect of this state of affairs is an inappropriate reduction of costs to NHS authorities, feathers in the caps of the unregulated NHS Senior Managers for keeping costs down, and bully cultures making everyones' lives miserable - service users, their relatives and friends and decent staff who could well find themselves witch hunted out of employment or persecuted as whistleblowers.

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