Patients were put at risk at a care home that has been deemed inadequate and placed into special measures.
Avalon Care Home on Duke Street in Southport has been strongly criticised in a report by the Care Quality Comission, which found the home in breach of health and social care act regulations.
The breach related to the way the Sefton home treated consent for some of the patients, which was deemed at times not in accordance with the Mental Capacity Act.
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Some patients had been deprived of their liberty without the appropriate paperwork in place, which left vulnerable residents at risk of harm, according to the report.
The report was released today following an unannounced inspection carried out in August. The inspection came about “in part due to concerns received about infection control, record keeping and timely requests for medical input.”
Inspectors found that while some family members spoken to had praise for the home and said they felt relatives got “safe care” and it was a “good home”, there were several areas of serious concern with safety and management.
In particular, inspectors said there were issues around deprivation of liberty for some of the home’s 23 residents, who have issues ranging from dementia to learning disabilities, autism, mental health needs and physical disabilities.
In one case, a patient who was struggling to swallow food was not recognised as at risk of choking, meaning specialist assessments were not carried out and the individual was left at risk.
On other occasions, bed rails were used without appropriate risk assessments or referrals to ensure correct equipment, leading to “minor skin tear” injuries for some residents.
Staff also failed to document actions taken following a fall, which meant that inspectors were “not assured” staff knew how to recognise and act on injuries following such incidents.
Medication was also found “frozen” in a malfunctioning medicine fridge at the home.
Infection control was identified as a concern, with personal items being left in communal bathroom cupboards that could risk the spread of infections.
The home had stopped using PPE in July 2022 without a proper risk assessment although after a recent covid outbreak, staff had started to wear masks again just before the CQC inspection, according to the report.
Concerns were raised by inspectors about the management of medicine, and area that required improvement at the previous inspection and had since deteriorated, leaving the home in breach of regulations.
Among issues identified included inspectors finding frozen medicine in a medicine fridge that was malfunctioning. ‘As and when’ medication also appeared to be getting given to residents on a regular basis.
The use of ‘covert measures’ to give medicine to some residents by slipping it into their food was also identified as problematic. According to inspectors this was done in a way that could not guarantee patient safety as a pharmacist had not been consulted to check it was safe beforehand.
While incident forms were filled in, inspectors found “actions taken were not recorded and ‘lessons learned’ boxes were left blank” meaning incomplete records and “missed opportunities” to improve practices.
The management of the service was also deemed inadequate, with failings to understand risk, requirements and performance as well as issues around staff training and development being identified in the report.
One management failing identified was around storage of ‘do not resuscitate forms’ which were not easily accessible in a downstairs cupboard. Inspectors said this could have led to staff being unsure what to do when a particular patient’s heart stopped beating.
Rating the service as inadequate overall, the report added: “The provider did not have a robust system to monitor incidents, meaning there was a risk some incidents may not be reported.”
As the home is now in special measures, if improvements are not made, the watchdog could order the suspension of activities at the home or even its closure.
The registered manager of Avalon Care Home, Ann Jones, told the ECHO she was “disappointed” with, but accepted the CQC findings and was putting measures in place to bring about improvements.
Ms Jones said: “Avalon care home are disappointed with the recent CQC findings and are working with the relevant parties recommended by the CQC to make the required improvements.
“We have also taken on a private consultant to support us with these changes. Avalon has always prided itself in providing the highest quality of care for everyone who lives here and we do acknowledge that we need to make some improvements to get back our high standards that we strive for.
“We thank the CQC for highlighting these areas within our paperwork and the structure and are grateful for the support they are providing.”
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