Damning report of care home where great-gran allegedly suffered fatal assault says it still requires improvement

A Dunstable care home where a great-grandmother was allegedly fatally assaulted has been criticised in a damning report by the Care Quality Commission.

An inspection of Ridgeway Lodge Care Home, in Brandreth Avenue, was prompted following the death of Sheila Hartman, 88, who was allegedly attacked by a fellow resident and died shortly after at the home (run by care provider HC-One) on October 2.

An inquest into her death was opened on November 2 and adjourned to February.

The incident being investigated by the CQC will determine whether regulatory action should be taken. And while the inspection on October 13 did not examine the circumstances of the incident it raised concerns about the management of risk in dementia care and staffing levels.

The CQC report identified breaches in relation to safety management, staffing, person centred care and leadership of the home and will request an action plan to improve the standards of quality and safety. Concerns included:

> The service was not always safe.

> The service was not always effective.

> The service was not always caring.

> The service was not always responsive.

> The service was not always well-led.

And it was the second time in a row that the care home was found to be ‘requires improvement’ – with it previously receiving the rating in March 2020.

The report states: “The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

“We have identified breaches in relation to safety management, staffing, person centred care and the leadership of the home.

“We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.”

A spokesperson for Ridgeway Lodge said: "The wellbeing and safety of our residents remains our top priority, and we therefore take all feedback from the Care Quality Commission (CQC) very seriously. We are pleased that the CQC have recognised the steps we have taken around increasing staffing levels and note the positive feedback from residents and relatives.

“However, we recognise there are further improvements needed to meet the high standards our residents and their loved ones rightfully expect and deserve. We acknowledge the report highlights instances where we have fallen short of these standards. Since the CQC’s inspection in October, we have begun taking actions and embedding new practices to specifically address these shortfalls.

“We continue to work closely with the local authority and the CQC to progress our improvement plan, and to make sure residents consistently receive the right support. Everyone working at Ridgeway Lodge is determined to deliver kind care and achieve the best outcomes for our residents.”

The report found issues with how the registered manager, provider, and staff supported people who lived with dementia and who expressed forms of distress. Staff training, knowledge and skills in this area were limited and people did not have meaningful reviews of their care.

There was also a lack of dementia expertise and a lack of stimulation and access to safe spaces outside.

It also highlighted that risks associated with dementia were not always explored and captured in risk assessments and care plans.

And when people needed sensor equipment to reduce the risks of falls, equipment was not always working or positioned correctly.

There were staff shortages at night and poor processes to guide staff about what to do if there was reduced staffing. When evening shifts operated with fewer staff, managers did not investigate to look at what went wrong.

Meanwhile, staff did not have effective training and competency checks in place. Key training such as dementia training was not embedded into staff practice and people's social experience living at the home was not always personalised. Staff did not routinely chat and spend time with people – their interactions were task-focused.

The report added that managers and the provider did not always investigate events when needed to learn lessons from these. Audits and reviews into people's social experiences at the home were limited.

But the report also found that people spoke with confidence about feeling safe at the home, though their relatives were less confident.

People received health input from a GP or nurse as needed. They received effective care in terms skin management, and management of medicines, and were supported to have choices and some control of their lives – with staff supporting them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.