Lincolnshire care home in special measures, inspectors find ‘risk of injury’

A care home in Sleaford has been placed into special measures after being given an overall rating of ‘inadequate’ by the Care Quality Commission (CQC), but it says action has already been taken to rectify the issues.

Oakdene Care Home on Eastgate in Sleaford provides personal and nursing care for up to 35 people. At the time of the inspection there were 29 people using the service.

CQC inspected the care home on January 9 and 12, 2023. It was rated as ‘inadequate’ for how safe, effective, and well-led is, but as ‘good’ for being caring and responsive. In terms of whether the service is effective, CQC said there were “widespread and significant shortfalls in people’s care, support and outcomes.”

The care home, which was previously rated as ‘good’, said it has made “immediate, significant changes to rectify the issues raised by CQC” and is looking forward to the “return inspection in the near future”.

CQC published their findings in a report on February 20 which said that people did not receive safe care “because care staff did not have enough written guidance or training to complete their role safely” – read the full report here.

CQC said there was “poor oversight of the service” and “when risks were raised, there had been a failure to take timely and effective action”.

It was also noted that “concerns with the environment were not managed safely”. The emergency buzzer system could not always be heard, so did not allow a timely response from staff, while people were at risk from getting trapped in bed rails.

Hoist slings, used to lift people to aid moving to a new position, were damaged, which CQC said “risked causing injury”. Topical creams were not stored or recorded appropriately and the report says that staff did not always record why ‘as ‘needed’ medicines were given.

People’s care plans and risk assessments were not kept up to date to keep them safe from harm. CQC gave an example of a person who was known to smoke alone and said: “We saw they had burn marks on their clothing and wore highly flammable body cream” and “appropriate action had not been taken to ensure they were kept safe from the risk of burning themselves.”

Incidents were not reviewed to ensure care was improved, CQC added. It saw records which showed one person had fallen from their bed multiple times, but action had not been taken to reduce this risk of them falling.

CQC said it was “particularly concerned” about the sluice room, a closed room specifically designed for the disposal of human waste products. “We observed that unclean urien bottles and bed pans were being stored in the sluice room and the shelf underneath was dirty,” it said.

CQC’s report also stated that the home was not always clean, and staff did not use nationally recognised risk assessments effectively. Audits were also not always carried out by the provider to ensure care was of good quality.

It added that “people were not supported to have maximum choice and control of their lives”, while the policies and systems in the service “did not support more effective practice”.

However, it was also noted that a new manager had been employed but had only been in position for a week, so “their work was not yet embedded at the service.” At the time of the inspection the registered manager had left employment a week before so there wasn’t one in place when CQC visited.

CQC said the inspection had been prompted “in part due to concerns received about staff training, unsafe moving and handling, bed rails and cleanliness.”

It added that the local authority had also completed an audit in November 2022 and identified some concerns about safety at the care home, so a decision was made for CQC to inspect and examine those risks.

After the inspection, CQC said it had identified breaches in relation to consent, safe care and treatment and good governance. In the report, CQC added that it will request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

A spokesperson for the care home told The Lincolnite: “While we are disappointed by the outcome of the inspection, we are always looking for ways to improve the service we provide and we take on board the comments made in the report.

“With our new management team now in place, we have made immediate, significant changes to rectify the issues raised by CQC and we look forward to the return inspection in the near future.

“Longer term we are confident this process will make Oakdene stronger as a whole. We hope that all of our residents, staff and their families are reassured by the positive changes that we have made and we would like to thank them all for their ongoing support.”

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