Soiled bed sheets and unexplained bruising among failings found at Leicestershire care home

A dementia patient told inspectors they only had one shower every six weeks at a county care home.

Scalding hot water, residents sleeping on soiled sheets, and unexplained bruising and grazes were also found when inspectors from the Care Quality Commission visited Quorn Orchards Care Home, in School Lane.

There was evidence that incidents and altercations between service users were happening on a daily basis, at the home which had 29 residents at the time of the inspection.

Inspectors raised safeguarding alerts with the local authority because of some of the things they witnessed.

The unplanned inspection took place in October 2018 and the report was published this month.

‘Unexplained bruising’

Accident and incident records looked at by inspectors said that seven residents had unexplained bruising, skin tears and grazing in the ten weeks before the inspection.

People living at the home were subject to abuse from fellow residents who had behaviour challenges.

The registered manager was aware of the incidents but had not raised safeguarding alerts with the local authority leading to inspectors calling them in.

There were not enough staff to meet people’s needs. One staff member said: “Staffing is ok until we have an incident, then there are not enough of us to give everyone the care they need.”

Records showed that there had been 11 unwitnessed falls in communal areas since July 2018. The CQC said that there were not enough staff to support people moving around safely.

‘Shower every six weeks’

A resident told inspectors that they would like to bathe more often. “I am helped to shower every six weeks. I have a strip wash most days, it depends if there are enough staff,” they said.

Inspectors were so concerned about the lack of staff that they raised a safeguarding alert.

As a result, one person was moved to another care home the day after the inspection.

Most people spent their day in the communal areas. One resident spent all day, most days, sat in a room on their own with no TV, radio or interaction with others.

A relative told inspectors: “Staff have no time to spare, they sometimes leave the lounges with no staff and let the ‘wanderers’ get on with it.”

Patients had not been given the opportunity to talk about end of life care.

‘Scalding risks’

The care provider had failed to follow recommendations made by the fire service. Items were stored in the boiler room and under the stairs which could pose a fire risk. Weekly tests were not carried out. The provider said that the maintenance person had been present.

Water temperatures were tested and were found to be a scalding risk at 44 degrees centigrade. The Health and Safety Executive state that hot water measuring 44 degrees or higher causes an increased risk of serious injury or fatality.

The provider took action on the day of the inspection to ensure the temperature was lowered.

A stair gate at the top of the stairs opened both ways meaning there was no protection and residents had access to steep stairs. A secure gate was installed after the visit.

There was also a risk of infection from chipped cups and plates.

Beds were not changed when soiled. The report states: “We observed two people’s beds had been made but had unpleasant smells. These beds had soiled sheets.”

‘Confusing environment’

The environment was not dementia friendly. Paper signs stuck next to bedroom doors did not correspond with metal numbers mounted on them. In one communal area the television was on mute with the radio playing in the background. Both things could confuse people with dementia.

A bathroom had been upgraded to a wet room but was not in use as it was being used as a store room.

Kitchen and care staff did not have access to people’s dietary needs. This put people at risk of choking.

The cook told inspectors that the provider amended her food orders limiting meal options.

‘Fantastic staff’

Relatives told inspectors staff were ‘fantastic’ and that they knew their loved ones well.

Inspectors said that residents were supported in maintaining relationships with people who are important to them.

Birthdays were celebrated and staff respected residents’ dignity and privacy.

The provider was criticised by the CQC for not reporting incidents in the correct way.

The report states: “The registered manager did not understand their responsibility of reporting incidents to CQC.

“The registered manager had not made the appropriate notifications to CQC regarding incidents of people incurring unexplained injuries or verbal and physical abuse by people using the service.”

A spokesperson for the home said: “We have addressed the concerns raised by the CQC. “Improvements have been made. We look forward to their next visit.”