Care home near Chesterfield placed into special measures after inspectors brand it ‘unsafe’

The Care Quality Commission performed an inspection of Grove House care home on Moor Road, Ashover, in June this year.

Grove House is a residential care home, run by Peak Care Limited, providing accommodation and personal care for up to 31 older adults, some living with dementia. At the time of the inspection there were 22 people using the service.

CQC carried out an unannounced, focused inspection to look at how safe, effective and well-led the service was after receiving concerns about the leadership and management of the home.

Inspectors found that the service was not safe. Residents were not consistently protected from abuse and improper treatment as allegations of abuse were not always identified or referred appropriately.

People were also at risk of injury as a result of poor falls management. Risks to resident’s health and safety had not been sufficiently assessed or mitigated and care plans were not always in place to guide safe practice.

Lessons were not always learnt following incidents, and there was a risk that patients may not receive their medicines as prescribed because safe medicines practices were not followed.

Staff did not always use personal protective equipment (PPE) effectively to reduce the risk of infection.There were not enough staff employed to ensure the safe and effective running of the home and staff were not always deployed effectively.

Feedback about the quality of the food was poor and there was a risk that changes in people's weight may not be identified. Although people were helped to access support from external health professionals, care plans did not contain up-to-date information about their health needs.

Where people were unable to consent to aspects of their care, such as the use of movement sensors, their capacity to consent had not been assessed and there was no evidence that decisions made were in their best interests, or the least restrictive option.

Natalie Reed, the CQC’s head of inspection for adult social care, said: “During our inspection at Grove House, we found a home that wasn’t well-led, and the provider didn’t have sufficient oversight. This resulted in poor practices being allowed to develop and feedback from people wasn’t used to drive improvement.

“It was concerning that staff didn’t always have training in key areas. None of the staff had up-to-date training in falls management, which was worrying given the high number of falls that had taken place. Also, despite supporting several people with dementia, none of the staff had up-to-date training in this.

“People were at risk of injury as a result of poor falls management. Risks hadn’t been sufficiently assessed and care plans weren’t always in place to guide safe practice. Someone had fallen 18 times in the past six months, but there was no falls risk assessment and their care plan didn’t reflect the level of risk. Although a sensor mat had been implemented, we saw them alone in their room with the sensor mat tucked under the bed, which meant it wouldn’t be effective.”

Reed added that there were safeguarding issues at Grove House – with one resident leaving the premises unsupervised and another falling after being left unattended by staff.

She said: “The provider had failed to identify and refer safeguarding incidents. Although investigations had been carried out by the provider into concerns raised about poor practice, they hadn’t referred them to the local authority safeguarding adults’ team to investigate further. Also, the provider had failed to identify, investigate or refer other safeguarding incidents, such as someone who left the home unsupervised, and an incident where a person was left unattended by staff and fell.

“The provider has taken our concerns seriously and has an action plan in place to make improvements. They must address these as a matter of urgency to keep people safe. We will monitor them closely and return to check on progress to ensure improvements have been made and people are receiving safe care.”

Following the inspection, the overall rating for the service has dropped from good to inadequate. The ratings for being safe, effective and well-led have also declined from good to inadequate.

The service is now in special measures, which means it will be kept under review and re-inspected to check if sufficient improvements have been made.

READ THIS: Bodycam footage shows police breaking into hot car to free distressed dog stuck in high temperatures

D.A. Laird, the owner and director of Peak Care Ltd, said: “We acknowledge the CQC’s findings. We regret that our good reputation gained over 40 years has been tarnished by the vagaries of senior staff who have since been replaced by a new management team, the members of which are energised, dynamic and focused.

“We will continue to subscribe to transparency and investigation, and to this end we are happy to tell you that the CQC have expressed their satisfaction with our efforts made to date. We believe strongly in being ethical, honest and of good report, and this remains our objectives in spite of our present set-back.

“In our defence I wish to say that our staffing problems were largely due to the return of Covid-19 and its mutations. This significantly impacted upon me as the provider and upon my investment of personal time and involvement in the daily operations of the company. However, I am happy to tell you that we were judged as ‘good’ on caring and responsiveness, these qualities lie at the very heart of our operation.

“I assure you that I, the owner and director of Peak Care Ltd, will meet with all our residents and their significant others to explain the prevailing issues and to answer their questions and concerns.”