Care home where resident died handed 'requires improvement' rating from watchdog (2024)

The death of a care home resident partly prompted a watchdog investigation into the Teesside facility, which found multiple breaches of the Health and Social Care Act.

Hawthorns Lodge Limited was visited by the Care Quality Commission (CQC) in an unannounced visit on January 24. The High Street, Loftus, Saltburn, venue was given an overall rating as ‘requires improvement’.

A report, published on April 6, outlined that the inspection was ‘prompted in part by notification of an incident following which a person using the service died’. The report adds: “This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circ*mstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.”

The CQC has deemed that in the areas of safe, responsive and well led, the home - which provides accommodation and personal care to up to 20 people in one purpose-built building - was rated as ‘requires improvement’. However, in the areas of effective and caring it was rated as ‘good’.

The overall ratings for the service, which had 16 people using the service at the time of the inspection, are ‘requires improvement’ under the questions of if the service is safe, responsive and well-led.

“We have identified breaches in relation to safe care and treatment, person-centred care and good governance at this inspection,” the report states. Hawthorns Lodge provides support to older people, including people who may live with dementia or a dementia related condition

In an overall summary of the inspection, the report states: “Care was task-centred rather than person-centred. Due to staff being busy they did not have time to spend with people. Throughout our observations some people sat silently or were not engaged or stimulated. There were limited activities and entertainment. A relative commented: "There is nothing to do, no entertainment, apart from at Christmas. Improvements were required to records to ensure people received safe and person-centred care. Risks were not always assessed and mitigated to keep people safe.”

Inspectors also deemed that improvements were needed to the environment to ensure it was ‘appropriately designed’ to meet people's needs, to keep people orientated as they moved around. Inspectors added: “Improvements were needed to give people control in their lives and involve them in decision making. People were not supported to have maximum choice and control of their lives and staff had not supported them in the least restrictive way possible and in their best interests; the policies and systems in the service had not supported this practice.”

CQC have made the following recommendations:

• Staffing levels and staff deployment to be kept under review.

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• Information should be made accessible to meet people's needs.

• Systems to communicate with relatives to be strengthened to ensure people and relatives are involved in the running of the home and to gather their feedback.

• Improvements to be made to people's dining experience.

• Improvements to be made to activities and outings to keep people engaged and occupied, as they choose.

Is the service safe?

Hawthorns Lodge was previously rated as ‘good’ under this key question. However, the rating was changed following its most recent inspection to ‘ requires improvement’. Inspectors explained that this meant ‘some aspects of the service were not always safe and there was limited assurance about safety’. There was an increased risk that people could be harmed, the report adds.

CQC inspectors stated that some improvements were needed to the management of risk to ensure people's safety. Hawthorns Lodge had a system of review of accidents and incidents, to prevent re-occurrence of incidents.

However, inspectors felt that there needed to be more ‘robust’ analysis, showing themes and trends, lessons learned and how reflections took place with staff. “Robust systems were not all in place to manage risks to people's safety,” the report states. “This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

The report also added that ‘medicines were not always managed safely’ and systems ‘were not robust enough to demonstrate the safe management of medicines’. This was deemed as a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspectors stated that ‘care was task-centred rather than person-centred’. “People were not offered opportunities to remain engaged or stimulated, throughout the day,” the report states. “Staff did not have time to spend with people other than when they provided support. More independent people sat on their own in the dining room at lunchtime, and staff were not available to provide prompts or encouragement to people eat their meal and to help provide a sociable dining experience.”

It was also noted that not all areas of the home were clean. The lounge carpet was ‘marked’, and some paintwork was ‘showing signs of wear and tear’. However, staff had received training in infection control practices and used personal protective equipment (PPE) effectively and safely.

Is the service responsive?

This key question was previously rated as ‘good’, however, it has now been changed to ‘requires improvement’ as ‘ people's needs were not always met’.

The report states: “Care records did not all reflect people's care and support requirements, with guidance so consistent and person-centred care was provided, but staff we spoke with knew people's needs. Social care plans were not in place developed with people, to help keep people socially active and occupied if they wished.

“Records did not provide guidance for all staff to provide safe, person-centred and consistent care to people. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

Is the service well-led?

Inspectors also rated this area as ‘requires improvement’ which was previously categorised as ‘good’. This meant the service management and leadership was ‘inconsistent’.

“Leaders and the culture they created did not always support the delivery of high-quality, person-centred care,” inspectors noted. They also stated that ‘the service was not always well-led’ and an ‘effective system to monitor the quality and safety of the service was not fully in place’.

Inspectors stated that they identified ‘shortfalls’ relating to person-centred care, the maintenance of records and good governance. The report adds: “The failure to ensure an effective system was in place to monitor the quality and safety of the service was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.”

Teesside Live has contacted Hawthorns Lodge Limited about the publicly available CQC report for a comment.

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