Residents are ‘not safe’ at Corby care home Willow Brook House say inspectors, as it’s placed into special measures
Vulnerable residents at a short-staffed Corby specialist mental health care home were ‘not safe’ after they missed vital medication and appointments, had access to dangerous substances left in communal areas and had calls for help unanswered for an hour.
The Care Quality Commission (CQC) found seven legislation breaches at Willow Brook House in Corby Old Village during an unannounced inspection called because of safeguarding and staffing concerns. They highlighted a range of issues including communication difficulties between residents and workers.
But the owner, St Matthews Healthcare, has responded by hitting back at the independent regulator, claiming that ‘wholly unacceptable’ and derogatory comments were made about a member of staff from an ethnic minority and questioning the CQC’s ‘corporate culture’.
At the time of the inspection there were 36 adults living at Willow Brook House, all with severe, enduring mental illness with complex needs.
The home is run by St Matthews Limited, trading as St Matthews Healthcare, which runs ten hospitals and care facilities – mostly in Northamptonshire.
CQC Inspectors rated the home as ‘inadequate’ said residents were ‘not safe and at risk of avoidable harm,’ and told the owners they must take immediate action to improve before a reinspection. The home will remain in special measures until then.
St Matthews say they have already made major changes at the home.
When inspectors visited in May, they found there was no registered manager at Willow Brook House, a high number of staff vacancies and the majority of care posts filled by short-term agency workers.
Despite this, St Matthews continued to admit people with complex mental and physical health needs without the resources to manage their care.
One relative told inspectors they were worried for the safety of their relative. They said: "Other residents are fighting, there are no staff to intervene, there are no regular staff."
The inspectors found people were at risk of witnessing aggression, and said that the provider had not employed key staff such as assistant psychologists or deployed occupational therapists.
They said the home was ‘crowded and noisy with many incidents of verbal and physical aggression’.
People did not have all their risks assessed or have care plans.
Residents were not always protected from the risks of scalding, choking or harm associated with the misuse of cleaning fluids as they had access to hot urns, kettles, powdered drinks thickener and cleaning liquids in the dining areas and false teeth cleaning tablets in bedrooms.
The inspection report added: “People did not always get the response they needed from staff. One person living in the birch unit said, ‘Occasionally I ring my bell to help get me up. I can wait minutes or an hour sometimes. They come in and cancel my call and don't come back.’”
In one four-week period, 15 people had missed 167 doses of their prescribed medicine as staff had recorded they were out of stock. This included medicines for the treatment of psychosis, depression, heart conditions, epilepsy, and pain.
Morning medicine rounds took more than four hours meaning doses were missed and appointment letters were left unopened, leaving residents’ health at risk of deterioration.
Staff gave people the wrong texture of food, placing them at increased risk of aspiration and choking.
Residents were said in the report to be at risk of dehydration and there was a lack of oversight of people's fluid intake.
The inspection team saw that people did not always have access to adequate fluids, with one person given a jug of juice but no glass to drink from.
People living with diabetes were not offered alternatives to puddings with sugar in. One person told inspectors: “I'm diabetic type 2, they offer me sweets I shouldn't have."
All clocks in the home were set to 12 o’clock, potentially causing dementia patients to be disorientated.
There were no activities put on, and one resident who communicated using Makaton was at risk of isolation because none of the staff knew the sign language. Another, who had a strong London accent and used colloquialisms, was not understood by staff as they had been given no support to increase their understanding.
Following the visit in May, the home was issued with four warning notices.
Craig Howarth, CQC deputy director of operations in the Midlands, said inspectors had discovered ‘poor leadership’ adding: “Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found here.
Noting staffing issues and an absence of ‘key staff’, Mr Howarth added: “The provider continued to admit people with complex mental and physical health needs without the resources to manage their care or meet their needs.
“Additionally, staff didn’t keep up to date records when people became unwell. This meant people were at risk as staff were unaware of their condition and any necessary healthcare needs they may have.
“During the inspection, we also found unopened medical appointment letters which is totally unacceptable because it indicates that people weren’t always attending their appointments and putting their health at risk. Leaders must action this as a priority as everyone at Willow Brook House must have the opportunity to attend their medical appointments so they can receive the appropriate care and treatment they need.
"If sufficient progress hasn’t been made, we won’t hesitate to take further action to ensure people’s safety and well-being.”
The home was formerly used as a residential home for the elderly but shut its doors during the pandemic, with 35 residents including many with dementia, moving out after the home was sold to St Matthews Healthcare.
A spokesperson for Willow Brook House said: “Our absolute priority is making sure the people that live with us receive the high standard of care and support they deserve. In the three months since the inspection, we have worked hard to make sure the home is meeting the standard we and the people we support expect.
They said they’d employed 12 new staff and had revisited training as well as reviewing every residents’ care plan.
They added: “We have had multiple monitoring visits from our local authority and NHS partners, and we have commissioned our own independent inspection, with feedback routinely suggesting the home is performing significantly better than the CQC report suggests.
“Notwithstanding our commitment to continual improvement, we have separately raised several serious complaints about wholly unacceptable comments made by the inspection team. This included the use of offensive and derogatory language when referring to colleagues from an ethnic minority background.
“We believe this significantly undermines the accuracy of the inspection report and some of its findings and calls into question the preconceptions of the inspection team. More concerningly, despite raising a formal complaint in June – and writing to our local MP, the Government, and the CQC’s CEO – the CQC has not treated the matter with the seriousness it deserves and has yet to launch an investigation.
“There is an appropriate balance to be struck between a thorough and detailed inspection, whilst treating frontline health and care workers with the professionalism and respect they deserve. Our experience suggests serious questions need to be asked about the CQC’s corporate culture as a regulator covering a sector where nearly 40 per cent of the workforce is from an ethnic minority or non-British background.”
Following the comments from Willow Brook House, the CQC issued a second statement last night (Thursday) that said: “We expect providers to support staff to communicate with people using services in a way which enables them to be free from distress. At Willow Brook we found this wasn’t always the case and some people were showing signs of distress because they were having difficulty communicating their needs to staff.
“These communication difficulties were having a detrimental impact on people’s health and wellbeing and is important information which should be included in the report and is an accurate reflection of what was found during the inspection.
“CQC looked at all the evidence regarding this inspection and were satisfied the report is accurate and should be published in line with usual processes. CQC have a legal obligation to share this information with people, so they are informed about the poor standard of care this service is providing.
“Following the inspection, St Matthews Healthcare, submitted a complaint to CQC on 26 June about elements of the inspection process. CQC have requested further information from St Matthews Healthcare to understand the scope of the complaint. CQC received confirmation on the scope from St Matthews Healthcare yesterday (Thursday, August 10) so is now able to begin the investigation.”