Chilterns Manor, a care home in Bourne End, has been rated ‘inadequate’ following an inspection by the Care Quality Commission.

Chilterns Manor is a residential care home that provides personal care and support for up to 22 older people and people with dementia.

Following the inspection, which took place in August, the CQC issued the provider with two warning notices. These reflected concerns about:

  • Unsafe management of medicines
  • Poor oversight of the service by the provider
  • Poor infection control practices
  • Poor record keeping.

The CQC also found that risks to people’s health and safety were not properly addressed at the service, particularly in relation to fire safety.

From ‘good’ to ‘inadequate’

The overall rating for the service has dropped from ‘good’ to ‘inadequate’. The ratings for two key criteria inspected, safe and well-led, have also dropped from ‘good’ to ‘inadequate’. The service is now in special measures.

Rebecca Bauers, CQC head of inspection, said:

We expect health and social care providers to guarantee people’s safety, dignity and independence. When we inspected Chilterns Manor, we were very concerned that the people who lived there, who called it home, weren’t safe.

It was very concerning to find that incidents were not being recorded or reported through the right channels to safeguard people. For example, injuries had been sustained from physical altercations between people. These hadn’t been referred to the local authority.

Daily notes stated an ambulance had been called in March this year due to someone being found with a head injury. There was no further information about this available at the home. The manager was unable to provide any details of what had happened or the extent of the injury.

We found a lack of oversight and good leadership at this service which has led to poor quality care for people in respect of care and support, which is unacceptable. We have told the provider that it must make significant, rapid and widespread improvements. We will continue to monitor them closely to ensure that these are made.

Further findings

The CQC’s inspectors also reported further concerns. Staff were unaware of the need for unexplained bruising to be investigated, and there was no process to refer such issues to the safeguarding team. Consequently, people were not safeguarded from the risk of abuse. Inspectors also reported to the service manager that some care workers interacted poorly or infrequently with residents.

Antipsychotic medicine had gone missing from the home. This had not been reported to the appropriate authorities. In addition, the manager and another member of staff were administering medicine by intramuscular injection, which was not allowed under the home’s terms and conditions of registration.

Inspectors had not received notifications about some events the provider was required to tell the CQC about, such as unexplained bruising, incidents between people resulting in injuries and an unexplained head injury. This placed people at risk of further harm and unsafe care.

There was some evidence of improvements being made when things went wrong. However, accident and incident records had not always been completed so it was not always possible to see if preventative measures were put in place where necessary.

The CQC’s full report on Chilterns Manor is available on its website.

Don’t forget – if you have experience of Chilterns Manor, you can rate and review the service here on our website.

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Published on 26 Oct, 2022 (updated 9 Nov, 2022)

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