A Blackpool care home has been slammed by watchdogs after a recent inspection uncovered multiple failings which put residents at risk.
Ambassador Care Home is a residential care home providing personal care to 31 people who may be living with dementia and after a recent inspection carried out by the Care Quality Commission (CQC), staff were found to be in breach of regulations.
The recent inspection was carried out after the CQC received concerns in relation to the management of medicines, infection prevention and control,nutrition, risk and staffing.
They also received concerns on how people were supported to maintain their dignity.
During the inspection, which focussed only on the caring, safe and well-led aspects, it was discovered that the administration of medicines proved to be a major issue for staff at this home with a lack of adequate management causing further problems.
In an report published on Christmas Day, CQC inspectors said that staff didn’t always know how or when to administer medicines to the residents correctly as one person who was in need of eye drops was not safely given them.
People missed some doses of their prescribed medicines because there was no stock available in the home for them while a resident was not given one of their tablets for over three weeks because staff had not checked their medicines carefully on admission to the home.
Access to risk assessments- tailored to each resident weren’t available for staff and inspectors to see which put vulnerable residents at risk of harm.
The report states: “On the three days of the inspection we were unable to access the electronic system to review people’s weight management.
“We spoke with two agency staff members who told us they did not know if people needed help to eat as they could not access the electronic system. They had not been informed of the help people needed.
“An agency staff showed us the documentation they had been given- there was no accurate information in relation to a person’s abilities and the record did not contain the name, or any information of the person.”
Fire risk assessments were also not up to standards as the provider hadn’t ensured the safety of the home- several fire doors within the home did not shut properly, posing a risk that if a fire occurred, it would not be contained.
As well as risk assessments, the lack of effective management lead to further failings as during the inspection its was found that audits were not properly carried out.
The CQC report outlines: “The provider failed to have oversight and management of the service to protect people from harm. Audits of falls were carried out. One entry recorded, “A pattern of falls appears to be in their own bedroom between checks.”
“We reviewed the accident and incident records and saw records which showed some people were having falls and/or sustaining injuries. There was no action to show how this risk was to be managed and lessons learned shared.”
Documentation to guide staff and information to support other health professionals make clinical decisions was not always available.
Inspectors from the CQC said: “We were informed a new electronic care record system was being introduced and the existing electronic care record system was unavailable.
“On all three days of the inspection, electronic care records and risk assessments from the existing electronic care records system were not available at the home.
“The new system did not contain sufficient information to enable staff to give the care people needed. For example, one person required a mobility aid.
“The record viewed did not explain the abilities of the person or the person-centred help they needed. We were told there were no paper care plans to support staff knowledge and understanding.”
Serious hygiene issues were also discovered during this inspection- some beds, had urine marks on the bedding and other stains.
Equipment was also found to be in a questionable state as commodes had a build-up of dust and matter on them, a sensor mat was dirty and there were faeces dried on the side of a toilet.
Prevention and infection control didn’t meet the standard requirements as the CQC found a lack of assurance in the provider effectively using PPE- a staff member did not wear a mask when working and said they had one in their pocket.
Recruitment was also in question as agency staff had been provided to help people; however, they did not know the help and support people needed.
The report states: “We observed one person being pushed across the lounge by another person who lived at the home, an agency staff intervened to prevent the risk of harm.
“The staff member said to us, “I don’t know anything about anyone, I don’t know how to help.”
“Two agency staff told us they had not received an induction to the home. They said they had received no information about people and had not had a tour of the home to familiarise themselves with the layout.
“We asked an agency staff member what they would do if there was a fire, or the fire alarm sounded. They said,”I’d run around like a headless chicken because I don’t know anything.”
Another failing found in the running of this care home was the care aspect given to residents as the provider did not consistently ensure people’s privacy and dignity were maintained.
The CQC report states: “On three separate occasions we saw a person in communal areas and their continence aid was on view. We raised this with staff to support the person’s dignity.
“The downstairs bathroom contained a whiteboard with people’s names on and ‘bathing routine’. This practice did not promote people’s individuality and shared personal information about them.
“The downstairs bathroom door had a lock that could not be locked. We saw this bathroom was in use by people who used the service. There was also a toilet in use with no handle and lock.”
With the current strains of the pandemic adding to the pressures in care homes, the CQC ensured this was taken in to account during the inspection.
It states in the report: We are mindful of the impact of the COVID-19 pandemic on our regulatory function.
“This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
“We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified breaches in relation to the safe management of medicines, record keeping and good governance.”
LancsLive contacted the care home for a comment.