Bingley care home Duchess Gardens Care Centre 'inadequate'

The Care Quality Commission (CQC) visited Duchess Gardens Care Home, on Lady Lane in Bingley, on three dates in March.

Inspectors found the home, rated ‘inadequate’ for its last three consecutive inspections, remained in breach of regulations.  

Duchess Gardens Care Centre in Bingley

“Some of the concerns we found at this inspection related to issues found at our previous inspection, meaning action needed to achieve the necessary improvements had not been taken,” said a report.

People at 'risk of harm'

Inspectors said people were “at risk of harm”.

The report said: “We reviewed 12 people's care plans and risk assessments and found shortfalls in them all.

“Risks relating to people's skin integrity, wound management, mobility, nutrition and hydration, choking risks and catheter care were not assessed or monitored effectively.

“One person had sustained a skin tear on their leg and despite care workers reporting this to clinical staff, no medical review or treatment was provided for up to two weeks following the injury.”

It added: “We observed multiple occasions when call bells were out of reach for people to use when in their bedrooms, and also observed some rooms where no call bells were available.

“This meant these people were unable to summon help should they need it and had no access to call staff in an emergency.”

Unclean areas and unexplained injuries 

Inspectors said many areas of the home appeared unclean, with stains on bedroom walls and dirty floors.

The report said high touch point areas were not clean, which meant there was an increased risk of infection transmission.

It also detailed how inspectors identified reports of people having injuries, but the cause was unknown.

“There was no evidence of a follow-up investigation or a referral to the relevant safeguarding authority,” it said.

“Unexplained injuries were not investigated to establish if there were signs of abuse. This meant we were not assured people were protected from the risk of injury or harm from abuse.”

“We found evidence staff were not recognising or reporting safeguarding incidents.

“We observed one person who had a large bruise on the palm of their hand and was wincing in pain. Staff had not noticed this and therefore failed to document and report this injury.

“This meant there was a delay in investigating how the injury occurred and managing the person's pain and discomfort.

“We found examples of accidents and incidents that had either not been reported to CQC or the local safeguarding authority despite accident forms being completed.

“This meant there was no monitoring or oversight from external bodies. We have made referrals to the local safeguarding authority.”

'Significant shortfalls' found

Inspectors said safe recruitment practices were not followed and agency workers had cared for the home’s most vulnerable people “despite not being given any background information on the person's needs or choking risks”.

The watchdog also found people’s privacy and dignity were not always respected.

Inspectors said they saw food being put near people on tables, but there was no effort to ensure they could reach meals comfortably.

“One person was sat in a chair and their meal was placed on an overbed table and pushed towards them,” said the report.

“This person could not reach the meal properly as the table was not placed close enough. The person attempted to eat the food with their fingers, no assistance was provided. A small amount of food was eaten, and the plate was then removed by staff.

“People requesting support were not always given this in a timely or responsive manner.

“One person had asked for staff to take them to the toilet, this person waited over 30 minutes for carers to arrive and support with this.”

“Another person was complaining of being in pain and requested pain relief.

“Care staff acknowledged the person's pain and informed them they would let the nurse know. This person had not received any pain relief or was seen by the nurse for over an hour after they requested it.”

The report said “significant shortfalls” had been identified at the last three inspections.

“We found continued breaches of regulations relating to the management of risk, and good governance,” it said.

“We also found new regulatory breaches relating to safe environments, medicines, the safe recruitment of staff, privacy and dignity, safeguarding and infection prevention and control.”

Qualia Care, which runs the home, was contacted for comment but did not respond.