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Gloucestershire Business News

SPECIAL REPORT: Gloucestershire's care home failures

Today's Punchline survey of Gloucestershire's care homes reveals how nearly 15% of the county's nursing and residential facilities have failed to pass recent inspections.

Social care and health watchdogs the Care Quality Commission (CQC) have recently issued 27 notices to care homes throughout the county and told them they need to improve their practices after recent visits.

The safety enforcers also issued a stronger "inadequate" notice to a provider in Nailsworth which, as a result of special measures being re-issued in August, has now had all residents evacuated after local authorities stepped in.

Following an inadequate ruling earlier this year, inspectors paid an unannounced visit on June 8th to Aaron House, next door to Forest Green Rover's stadium in Nailsworth. They identified practices at the care home that remained unsafe and inadequately led.

At the time, the home was caring for four residents with a learning disability or an autistic spectrum disorder.

Factoring in mixed feedback from residents and their families, the report said: "People's individual risks were not always identified, assessed and mitigated. Staff were not given clear guidance or information on how to protect people from associated risks. People's medicines were not always managed safely. A robust system was not in place to ensure the provider had oversight of all incidents or accidents."

Further findings included: "Care was not always person-centred and did not always promote people's dignity, privacy and human rights," and while fire risks had been addressed, more measures were ruled necessary for preventing infection and legionella risks.

"A decision was taken by the local authority," the report added, "to move people out of Aaron House before we were able to share this feedback with the provider."

Elsewhere, findings on Gloucestershire Care Homes rated as 'needing improvement' included:

● Stinchcombe Manor care home, near Dursley, where a resident was able to leave the building and roamed unsupervised after a window restrictor was not in place.

● Gatwick House in Westbury-on-Severn, which provides for up to 14 people in a shared house and bungalow units. "There were no effective risk assessments in place in relation to water temperatures and how people were going to be protected from the risk of scalding," the inspection found, although it noted that remedial action was being taken.

● Charnwood House Nursing Home, in Gloucester's Barnwood Road, which showed care records had not been updated for two residents (though the home was removed from a previous special measures ruling).

● Queensbridge House in Cheltenham, which cares for a maximum of 27 people living with dementia, as well as younger people with complex health mental health needs, including some who had been through the criminal justic system. Inspectors noted "shortfalls in how people's risks were assessed, monitored, and managed which put people at significant risk of harm" and added that one person "had potentially been subjected to unlawful restraint". Fire risks were also identified and people "were at risk from falls from windows of height". On the understanding that no one was a suicide risk, the report added that ligature points had been removed when the service had started to support people with mental health needs. However, during a follow-up inspection "we observed numerous potential ligature risks throughout the environment and became aware the service supported people with significant histories of self-harm."

● Alison House, in Rudford, Gloucester, which looks after four childen and young people needing personal or nursing care. "The provider had not sufficiently assessed young people's capacity to consent or demonstrated effective oversight in this area," said the report. "This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

● Westgreen House, near Wotton-under-Edge, which was acquired in 2020 by Genie Care Homes and cares for 45 people, some with dementia. "Staff had not received sufficient or appropriate training, in line with best practice guidance, to safely support people with distressed behaviours. When one person's distressed behaviour escalated and put them and others at risk of harm, staff used medicines to calm the person. This intervention was not incorporated in the person's risk management records. This placed this person at risk of receiving inappropriate support." Measures to move another patient at risk from pressure ulcers were also inconsistent, while a pressure mat, which alarms if a patient falls out of bed, was recorded as activated but found under a bed, where it would not alert staff.

"Another person had been prescribed a blood thinner and there were no risk management records in place for the safe management of risks associated with this. This person had been assessed as high risk of falls and had fallen and bumped their head," inspectors found. They added: "The same applied for one person who was diabetic where risk management records did not reference potential risks associated with this condition."

In all, homes listed as needing improvement in and around Gloucester included: Alison House, Barbers Bridge; Saint Paul's Residential Home, Stroud Road, Charnwood House, Barnwood Road; Woodstock Nursing Home, North Upton Lane; Pine Tree Care Home Larchwood Drive; Chosen Court, Hucclecote Road; Brockworth House Care Centre, Mill Lane and King's Den, on Reservoir Road.

Cheltenham's care homes found lacking were Astell, Overton Park Road; Queensbridge House, Queen's Road and Bafford House, while Cirencester ranked in the list with Watermoor House and Stratton Court. Elsewhere, improvement was needed at Westgreen House, Kingswood; Henlow Court in Dursley; nearby Stinchcombe Manor; Highborder Lodge, in Leonard Stanley; Stroud's Winslow House in Springhill, and Northfield House, on Folly Lane (also in Stroud). Horsfall House, in Minchinhampton, was also given improvement orders.

As well as issuing cautions and imposing special measures, the CQC has the power to issue a document under section 31 of the Health and Social Care Act 2008, which can removes a home's registration with immediate effect.

However, the agency, which was established in 2009 as an independent, non-departmental public body of the Department of Health and Social Care, has been criticised for lacking muscle in the wake of the Pandemic and a current process which is seeing the body change its regulatory approach. 

This summer, Care Home Professional reported how a Freedom of Information request revealed that the CQC is completing almost two thirds fewer inspections of social care services than it was only four years ago.

It reported: "Announced inspections fell from a peak figure of 6,684 in the full year of 2019 to just 1,458 in January to May 2023. Unannounced inspection also appear to be decreasing. According to the FOI figures, 2,223 unannounced inspections were carried out in the first five months of 2023. In 2016, this reached a high of 19,586.

This makes a drop from a total of 26,270 inspections in the full year of 2019 to only 3,681 inspections in January to May 2023. When calculated on a pro rata basis, averaged out across all of 2023, this makes for a drop from 26,270 to 8,834 - a nearly 70% drop."

In terms of alerts raised, from January to May this year, there were more than 9,000 such announcements, raising concerns in the sector. In 2021, there were 21,886, while 2022 saw 23,116 alerts.

The framework for care homes failing to acquire an acceptable CQC rating is that they have have six months to make improvements. The CQC states, however, that it has stengthened its powers since April, including the introduction of a system that is no longer tied to set dates for inspections.

The CQC advises care homes in receipt of an inadequate rating: "After that, the inspector will return to see how you've improved. You may be given another six months to bring your service up to par, if you don't improve enough in the first six months."

● The CQC provided with specific data on all social care organisation services in Gloucestershire. The number of care home-related addresses registered as of September 8th was 201. Of these, 27 are currently in the 'requires improvement' catagory, while one was rated as 'inadequate'; Aaron House's website is now listed as 'reserved for future use' and the listed contact number is unobtainable.

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