Care home ruled ‘inadequate’ after residents with dementia walked out

Highbury House Care Home
Highbury House Care Home
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A care home has been ordered to improve after inspectors found residents with dementia left the premises unnoticed, The Gazette can reveal.

Despite management at Highbury House Care Home, in Lytham Road, South Shore, telling inspectors from the Care Quality Commission (CQC) only one person had walked out – at least twice – records showed another had also slipped out, the watchdog said.

We were told by staff and a relative that one person with dementia had left the home unaccompanied and unnoticed a number of times

The elderly resident was found by paramedics in a back alley after falling over, while staff only realised another was gone when they were found by police, the CQC’s report said.

The home has now been placed in special measures after inspectors also said it smelled of urine and found walls and furniture in one bedroom stained with bodily fluids.

The CQC rated the home inadequate for ‘safety’, ‘effective service’ and being ‘well-led’, and requiring improvement for ‘responsiveness’ and ‘caring’, leading to an overall inadequate rating.

Blackpool Council says it will no longer place residents with the home until the situation improves.

Home bosses say steps have now been taken to improve, following the report while the manager at the time has left.

The CQC report states excrement was seen on one poorly resident’s catheter bag and bed as she waited to be moved to hospital, physical intervention was used without agreement or authorisation, and staffing levels were found to be unsafe.

Residents were also put at risk by excessively hot water, unrestricted first floor windows, an out-of-date gas safety certificate, and uncompleted legionella checks.

The CQC’s report, published this week, followed an unannounced visit to the home, which was caring for 28 people, last October.

It said: “We were told by staff and a relative that one person with dementia had left the home unaccompanied and unnoticed a number of times.

“We saw from records there were two occasions where the person had left. We saw an entry referring to this ‘happening too often’.

“We asked the manager how many people at risk, if alone outside, had left or tried to leave the home unnoticed. The manager told us this was the only person.

“However we were told another person had left the home unnoticed shortly before the inspection.

“We saw a brief report of this in the daily records. It stated the person had been found by paramedics in the back alley having fallen there.”

It added: “On one occasion staff did not realise one person had gone until they were informed the person had been found in the area by police.

“One member of staff said, ‘They were checked regularly but somehow got out through the fire exit. It was a blur really. I was that busy. Someone came and told us that [they were] out’.”

The incidents were not reported to the CQC, a breach of regulation. Five deaths at the home had also not been reported because the manager ‘forgot’.

Staff at the home took action within 48 hours of the CQC’s inspection to reduce water temperatures and install window restrictors.

The unpleasant odour and unclean and unhygienic equipment was rectified, and an extra member of staff was being hired, it added, while a gas inspection and legionella check had been scheduled.

People living at the home spoke with mixed views on their care, while several relatives said they were satisfied.

“However, this did not reflect our findings,” the CQC added.

“We saw staff unable to support people when they required assistance.

“On one occasion before lunchtime we saw people with dementia left unattended or with minimal supervision for 35 minutes.

“This left them at risk of harm. They were also unsupported to drink the drink they had been given.”

The food at the home was good, inspectors were told, with mealtimes ‘relaxed and pleasant’.

And staff were said to be ‘very caring and kind’, who respected residents’ privacy and treated them with dignity.

However, inspectors saw a member of staff taken a resident to the toilet before leaving the door ajar while they answered the front door.

Decor, which featured murals of ‘old Blackpool’, and old newsreels played on a TV in the hallway, helped people reminisce about earlier times, the report said, but there was no meaningful activity aimed at dementia patients.

The home, which met requirements at its last inspection in August 2014, has been given an overall rating of ‘inadequate’ and will be kept under review.

Another inspection will be carried out in the coming months to see if improvements have been made.

Home operator says changes mean report is ‘no longer accurate’

A spokesman for the home said:

“The wellbeing, safety and health of the residents we support are our top priorities.

“We were deeply disappointed by the outcome of the Care Quality Commission inspection in October 2015, and have been working tirelessly with all appropriate authorities to ensure we are delivering the high quality care we pride ourselves on and that residents deserve.

“Immediately following the inspection a detailed action plan was agreed with the CQC which we have been working to implement over the past four months. “The home is now being supported by a new and experienced Home Manager, and through a robust new recruitment process we have hired additional care staff. We have supported the staff team through a comprehensive re-training programme, and are working with residents and their loved ones to update care plans so they receive high quality personalised care. We are confident this report is no longer an accurate reflection of the care being delivered at the home, and look forward to demonstrating to the CQC the significant improvements we have made.”