Wood Hill Lodge: CQC takes action at “inadequate” Sheffield care home where patient beds were stained with faeces

The Care Quality Commission (CQC) has dropped the rating for Wood Hill Lodge care home in Sheffield to "inadequate" overall, and in terms of being safe and well-led, which puts it in special measures.

The Burngreave home, run by Portland Care 4 Limited, cares for adults living with physical disabilities and mental health issues, including older adults living with dementia. 

The CQC, which is responsible for regulating health and social care providers across the UK, found it “remained in breach of regulations” in a targeted inspection on October 10.

This comes after an unannounced inspection in August which was prompted by “concerns received about risk management, governance, and oversight”.

The CQC has made two safeguarding referrals to the council based on issues which had not been picked up by staff or management, the recent report states.

It is now “taking regulatory action to protect people and will report on this when legally able to do so”. 

The report states: “The provider had a system in place to safeguard people from the risk of abuse. Staff we spoke with were knowledgeable about safeguarding procedures.

“However, staff told us they would report to the local authority or CQC as they were not confident the management would respond appropriately”

Jenny Wilkes, CQC deputy director of operations in the north, said: “We were disappointed to find people weren’t always being supported to live in a safe and dignified way and leaders hadn’t ensured staff knew how to meet people’s specific needs, including those people living with dementia.

“There were chairs that people were sat in stained with urine, unclean mattresses and bedding stained with faeces.

“We found the environment was in a poor state of repair and bedrooms had broken furniture. For example, there were chest of drawers broken, no fronts on drawers, or the drawers had collapsed.”

The report states medication systems were not managed safely, and as well as missing medications, some people had been given the incorrect dose, putting them at risk of harm.

“One person missed daily doses of their laxative for ten days and another person was unable to have 14 doses of their anxiety medicine and they experienced severe anxiety,” added Ms Wilkes.

The report adds one person was given doses of paracetamol too close together, and medicines that must be given on an empty stomach were given at mealtimes which risked their effectiveness.

Recorded fridge temperatures showed that insulin had been stored above the recommended temperature for three days, meaning it may not work properly.

The report adds: “One person was given incorrect doses of their insulin placing their health at risk of harm …  One person was placed at significant risk of aspiration pneumonia because staff had not thickened their fluid properly and it was too thin for them to drink safely.

“We found no evidence that people were harmed at the time of the inspection because the harm is not always immediate. However, people were placed at increased risk of harm by unsafe management of medicines”

The inspection found that staff referred to service users as ‘walkers’ and ‘wheelchairs’, language which Ms Wilkes calls “derogatory”. This was not picked up by service managers, according to the report.

People were sat in the same chair or wheelchair all day with no change of environment or social stimulation, the CQC report states, with one person saying “I am bored, nothing to do”.

The report notes an activity coordinator who was “passionate about providing positive outcomes for people” but “limited in what they could do with budget and staff to support with outings”.

The CQC received mixed feedback about management, with one person describing it as “good, well run, lovely”, and others saying it was poor or they did not know who the manager was.

The report states: “It was not clear how the provider engaged with staff to obtain their feedback and ascertain any support or training requirements. 

“Staff had received supervisions since our last inspection … However, staff told us this was not an effective supervision and they had just been given pieces of paper to sign. 

There was no recorded evidence of regular staff meetings taking place, and staff told inspectors they “did not feel supported”, the report states.

“Not enough improvement” had been made in the key questions of leadership and safety since August, and the provider remained in breach of Health and Social Care Act regulations (17(2), 12 and 9), the report finds.

Ms Wilkes said: “We’ll continue to monitor the service closely to ensure improvements are made and won’t hesitate to take further action if we’re not assured people are receiving safe and dignified care.” 

The service will be kept under review and be re-inspected within six months to check for ‘significant improvements’.

If the provider has not made enough improvement within this timeframe, and any rating remains ‘inadequate’, the CQC will start the process of preventing the provider from operating this service.

This inspection did not rate how effective, caring and responsive the service was, so these categories remain rated ‘good’.

A spokesperson for Portland Care 4 said: “We appreciate that some of the report’s findings may be concerning to our residents and their families, friends and carers. We are keen to provide reassurance and will continue to provide an open and transparent dialogue regarding the care provided.

“We do not believe that the recent report is a fair and balanced representation of the service provided at Wood Hill Lodge and does not reflect the lived experience of our residents.

"However, regardless of our concerns about the process, everyone can be reassured that the ongoing safety, wellbeing and care of our residents is our top priority. We are working hard to address any issues to ensure that this home is swiftly returned to a thriving nursing home environment for our residents.”

Portland Care 4 will be making a formal representation in due course and is unable to make any further comment until this process is concluded.