Woolton Hill care home placed into special measures after damning report highlighted serious failings

Enbridge House Care Home in Woolton Hill has been placed into special measures after a damning report highlighted serious failings that put residents at risk of harm.

Inspectors from the Care Quality Commission (CQC) found that medicines were poorly managed, staff had not been trained properly and wounds were not correctly identified, treated or reported.

The report also noted that some people had experience significant, unintentional weight loss – with one resident losing 26kg in 15 months.

Again, it said this was not appropriately identified or reported.

In all, the care home – which provides personal care for up to 17 people aged 65 and over – was rated as inadequate in three of the five inspection categories, safe, effective and well-led.

The other two categories – caring and responsive – were deemed to require improvement.

The report was published last week following inspections on three separate dates in July.

Among its other findings were that people were not safe in the service and that there were serious concerns about the care of people's skin.

The report said: “Skin and wound care was poorly and inappropriately managed. For example, one person had 12 wounds.

“We saw records that suggested some wounds were approximately a year old and the community nurses confirmed this in their assessment of people's wounds.

“People should have been referred to the community nurses for treatment, but the service had been inappropriately treating the wounds.”

It added that the registered manager “did not understand that certain types of wounds could be a sign of neglect and required reporting to the local authority and the commission”.

The report said this had exposed people to harm, adding: "The attitude within the service was that pressure ulcers and weight loss were an inevitable part of aging.

“This was inappropriate and not evidence based.”

The provider had not involved external healthcare professionals appropriately to support people safely, it concluded.

The report went on to say: “There were health and safety risks in the service. The provider lacked understanding of safeguarding processes.

“They were providing treatment that had not been agreed with healthcare professionals and were making decisions without appropriate consultation with the GP or community nurses.

“People were not appropriately involved in decisions about their care. Care records were not person-centred or appropriately detailed and sometimes were out of date.”

In addition to this, inspectors observed that: “Decisions around end-of-life care planning were not appropriately documented.”

The report highlighted that there had been “serious failings in the governance of the service that led to a closed and complacent culture within the home”.

It went on to say: “The registered manager told us, 'Over the last 18 months, I hold my hands up. We didn't use our outside resources as much as we should'."

The report also expressed serious concerns about training.

It said: “Fewer than half the staff had safeguarding training at the start of the inspection.

“Neither the provider, registered manager or care manager had safeguarding training and had very little training overall.

“The staff member who had been treating wounds did not have any recent training in wound management. Very few staff had training in food hygiene.

“Given the concerns found in the inspection, this placed people at significant risk of harm as staff were not suitably trained to carry out their duties.”

The report also said that staff were constantly interrupted when they were giving medicines to people.

This, it added, meant people were left to take it themselves unsupervised and without appropriate risk assessment.