Inconsistent risk management and leadership sees Burton’s Homefield Grange care home downgraded to ‘requires improvement’ by CQC

NOT always managing risks to residents and inconsistent leadership were key reasons a Burton care home was rated ‘requires improvement’ by health watchdog the Care Quality Commission.

Homefield Grange in Salisbury Road, which provides personal and nursing care for up to 64 older people, some of whom live with dementia, was visited by inspectors on 23rd and 24th March.

They ordered improvements be made to the service’s safety and leadership, although its effectiveness was rated ‘good’.

The overall rating was a downgrade from the ‘good’ awarded in December 2021 after a previous inspection.

CQC’s latest unannounced visit was prompted by alerts concerning the risks of eating and drinking and medicines and management.

Focused purely on whether the home was safe, effective and well led, it found it did not always safely manage risks of malnutrition, dehydration and swallowing.

Inspectors found people were at an increased risk of being harmed, with systems and processes to protect them not always operating effectively. However, there was no evidence anyone had been harmed.

“We reviewed two people who had been assessed as at high risk of malnutrition and dehydration and records showed they had lost weight,” the report said.

“Their care plans did not include actions to instruct staff how to improve nutrition and hydration and prevent weight loss such as food and fluid monitoring, high calorie snacks, frequency of weighing or a referral to a dietician.

“One person had been assessed as a high risk of choking and required a pureed diet.

“The person was living with dementia and unaware of their choking risk.”

But it continued: “The person had food placed within easy reach on their bedside table that did not reflect their safe swallowing plan and placed them at risk of avoidable harm.”

Protocols were not always in place for managing prescribed medicines, said inspectors, and some poorly maintained equipment was said to have compromised infection control.

Residents said they felt safe and had confidence in the staff, and the staff themselves also told how they felt supported by their colleagues and seniors, with good communication.

The inspectors were assured the home was preventing visitors from catching and spreading infections, with safe and effective PPE use.

But Homefield’s service management and leadership dropped from ‘good’ to ‘requires improvement’ as inspectors found it inconsistent.

“Leaders and the culture they created did not always support the delivery of high-quality, person-centred care,” the report said.

It continued: “We found no evidence that people had been harmed, however systems were not in place or robust enough to demonstrate risks to people were effectively managed or that regulatory requirements were being met.

“This placed people at risk of harm.”

Homefield was found to be in breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (regulated activities) Regulations 2014.

Its effectiveness retained a ‘good’ rating, with staff found to have worked closely with other agencies to ensure people had good health outcomes.

These included GPs, physiotherapists and speech and language therapists.

A Homefield Grange spokesperson said: “We take feedback from the CQC extremely seriously.

“We are pleased that the home continues to be rated ‘good’ in the caring, effective and responsive categories. Residents told the CQC that they felt safe and had confidence in our staff team.

“Following the inspection in March, we have put in place an immediate action plan to address the areas identified as requiring improvement.

“Our absolute priority is to ensure residents are happy, healthy and safe and we look forward to demonstrating improvements at the home when it is next inspected in the near future.”