RESIDENTS living in a care home were placed 'at risk' of avoidable harm after an inspection found medicines were not always used correctly and background checks on staff were not always completed.

Burbank Mews in Hartlepool, which provides care for up to 12 people with learning disabilities and autism, was downgraded by the Care Quality Commission (CQC) after several failings were identified during a recent inspection.

Described as a 'care home', which up until its last inspection had been rated good in 2018, the site was downgraded to inadequate following an unannounced inspection in February, this year.

A report into the CQC’s findings published in April, revealed eight residents were living there at the time when inspectors identified concerns which breached the Health and Social Care Act.

The report said: "The inspection was prompted in part due to concerns we received about the increase of safeguarding incidents, the quality of care records, excessive use of agency staff and staff training not being up to date."

Among concerns, the report found the care home had been in breach of the Health and Social Care Act after the handling and administering of medicines was 'not always' managed safely.

'At risk of harm'

It said: "Medicines were not always managed safely. For example, where medicine was prescribed for distressed behaviour, one person's care plan stated it was 'used to calm down when highly agitated' with no explanation what that looked like for that person.

"Staff did not always record the reason they had given 'when required' medicines, or the outcome for the person, to show whether the medicines had been effective."

In one case, one resident's medicine guidance differed from what was actually on the medicine administration record – and in another, one person was given their medicine after 45 minutes rather than the one hour required – placing that person 'at risk of harm.'

The report went on to identify problems with some members of staff, where inspectors found some did not 'regard' the people in their care as 'equals.'

The report said that while most staff were "caring and respectful," some staff spent a large amount of time in the office when there was no 'apparent need,' casting doubt over whether staff were engaging with residents in the way they should.

'High turnover of staff'

When looking into how staff were recruited, inspectors found staff files did not contain their full employment history, records of interviews had not been completed fully and the appropriate number of references had not always been checked.

The report said: "This meant adequate background checks had not been carried out to ensure staff were safe to work with vulnerable adults. Disclosure and Barring Service Checks had been carried out but these had not been recorded accurately."

While there were enough staff to meet people's needs, inspectors discovered there had been a recent high turnover of staff, although a reliance on agency staff had 'decreased'.

Meanwhile, inspectors said staff had been told to only record 'serious incidents,' meaning the CQC could not be sure that all incidents had been appropriately recorded.

It said: "For example, whilst daily notes gave the impression someone had had a good day - incident records documented they had had extended periods of distressed behaviour.

"This meant it was difficult for both staff within the service and external professionals to gain an accurate picture of people's needs and whether interventions were working."

What the care home have said

In response to the findings, a spokesperson for MyLife Supported Living Ltd - which runs the care home - said a new management team had been brought in.

They said: "The wellbeing of our service users is of paramount importance to us. For every person in our care we strive to create an environment where we support the independence which enables individuals to flourish.

"Following the inspection, MyLife Supported Living Ltd immediately responded to the concerns raised.

"A new management team, including a new Registered Manager, has been hired and a new staffing structure has been established, which includes improved training and support systems across the service.

"A new outcome-based care planning system has been implemented, ensuring that the individuals living at Burbank Mews are fully supported to live in a safe, effective, caring and responsive environment led by trained staff who respect their views and listen to their wishes.

"As well as safely managing the service during the ongoing COVID-19 crisis, the management team at Burbank Mews met all of the actions within the CQC report by the specified deadline of 30th April.

"The CQC have been involved in all progress made at Burbank Mews and have been regularly updated by our senior management team.

"The team at Burbank Mews continue to engage with service users and their families, carrying their full support as we deliver these changes."