Nursing home receives special measures, shock report says people with dementia are “at risk”

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A Coventry nursing home has been criticized by inspectors – saying it puts seniors at risk.

Jardine Crescent’s Hawthorne House has been the subject of special measures after a report by the Care Quality Commission deemed it inadequate.

In the report, released earlier this month, the CQC found that people at home, caring for people with dementia and physical disabilities, were unsafe and at risk of avoidable harm.

Hawthorne House was found to be inadequate overall and inadequate in terms of safety and good management, when it was deemed necessary to improve its efficiency, caring and responsiveness.

A spokesperson for its parent company said it had made a series of improvements since the inspection.



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Inspectors found that “unexplained bruises” were not investigated consistently and that accidents were not investigated in a consistent manner to protect people from preventable damage.

One person had seven falls in February of this year, which were not investigated.

The nursing home said that since the inspection, a new director had been appointed and that a number of other improvements and guarantees had been implemented.



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The inspectors found no evidence that anyone had been injured, but found that they were not protected from the risk of potential harm. The supplier responded to the findings of the inspections “immediately during and after the inspection,” the report said.

Other criticisms have been made:

  • A person who has lived at home since 2017 did not have equipment to protect him from the risk of sore skin
  • Drugs were not safely managed and controlled drugs were not safely monitored
  • Systems failed to make sure people had their medications as prescribed
  • People may not get the care they need, when they need it

There were also staffing issues. Residents and families told inspectors that there were not always enough staff available, and the staff themselves indicated that they had expressed concerns.

The report added, “The inspectors saw that the staff were task-oriented and sometimes quick to deal with people because they did not have time to support them.”

Again, the supplier responded quickly and agreed to review the staffing levels.

Hawthorne House is a residential nursing home which, at the time of the inspection, provided personal and nursing care to 92 people. The service can support up to 102 people.

What did the nursing home say?

Kelly Mulhern, director of nursing at St Matthews Healthcare, said the inspection took place in March and since then major changes have taken place. These include:

  • A new manager
  • Review of all staffing arrangements
  • Staff training
  • Subsequent recruitment
  • Revised nursing structure
  • Quality improvement monitoring
  • Strengthening of the governance system.
  • New roles created to support the delivery of care.
  • Communication strategies examined.
  • Strengthening relationships with stakeholders.
  • Clear action plans have been developed and an improvement plan must be completed within six months, ready for review.

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