Private Cradley Heath care home in special measures over residents' pressure sores

Such was the scale of concern, inspectors raised safeguarding issues with Sandwell Council.

Trinity House care centre, based in Cradley Heath, received an inadequate rating by the Care Quality Commission (CQC) after inspectors found multiple failings, including a broken television in the only remaining communal space.

The care home had provided “no meaningful programme of activities” for residents to engage in, according to inspectors, with its garden in a “state of disrepair” with multiple hazards to people’s health and safety.

The inspectors discovered five people living in the home with pressure sores. Inspectors noted risk assessments and care plans had “not been developed” to help and mitigate residents with pressure sores.

It noted: “We were not assured staff had liaised effectively with the tissue viability nurse. Where advice had been sought from them, care plans had not been developed to reflect the advice given. Furthermore, the advice given by the tissue viability nurse was not always followed by staff.

The inspectors also raised a safeguarding concern to Sandwell Council for four residents, regarding the care they received from Trinity House. Three Deprivation of Liberty Safeguards (DoLS) were discovered to have expired and not reapplied for.

“This meant some people who were unable to consent to their care may be being deprived of their liberty without authorisation from the local authority,” the report added.

Inspectors noted staff treated residents with “kindness and compassion”, with one resident adding: “I love it here; I hope I can stay forever.”

Another person’s relative told inspectors: “The staff like him there; they have a good rapport with him.”

But the report said several incidents involving accidents, administration of medicine, and nutrition, were not recorded by care management. Agency nursing staff supported the majority of staff at Trinity House as the care home had limited numbers of permanent nursing staff, it said.

Inspectors noted agency staff lacked a “clear understanding” of people’s risks, care needs and preferences. In one incident, handwritten notes were used to inform a resident’s care needs. When inspectors asked the agency nurse about the medicine prescribed, they were “unable” to provide or find any information related to the resident’s medicines or care records, as this had not been handed over.

Inspectors saw entries in one person’s care records indicating they had fallen on five occasions. When reviewing the provider’s incident log, only one of these falls had been reported. No risk assessments had been completed for two people at risk of falls.

A further person had bed rails in place which had caused an injury, according to inspectors.

“No bed rails risk assessment had been developed either prior to or following this incident. Furthermore, the incident had not been reported, meaning the provider had not investigated the event or made changes to reduce the risk of future harm”, the report added.

Medicines were not stored correctly, with temperatures not recorded daily, according to the report. While no evidence was found that people were harmed, inspectors noted systems were either “not in place or robust enough” to keep residents safe.

Trinity House had previously operated in-house under the company Trinity House Care Centre Limited. At its last inspection, it received a "requires improvement" rating.

The care home was re-registered under a new provider, Rehability UK Residential Limited, in April 2020 – almost two years between its registration and inspection.

Rehability UK Residential Limited, a private care company with headquarters in Coventry, employs around 1,000 people. Its website lists care homes based as far as Essex and Dorset.

Inspectors noted residents were “not always encouraged to be as independent as possible”, despite Rehability UK Residential Limited's own website declaring it supports residents to live their best possible life. “They are at the heart of all we do”, says the website.

Cristina Pashmi, managing director of Rehability UK, said: “​​Rehability UK takes the findings of CQC extremely seriously and I have been directly involved in working intensively with the Trinity House management, CQC and the local authority to provide assurances that Trinity House is a safe and caring place for all of our residents.

“We have also provided assurances to our residents and families, who have kept informed of the findings and actions we have taken along the way.

“We have delivered comprehensive action plans for both CQC and the local authority and facilitated regular visits by the local authority which have now been scaled back in response to significant improvements made over the last couple of months. We will continue to monitor the performance of Trinity House to ensure it meets our high standards.“

A spokesperson for Sandwell Council said: “We are working  collaboratively and regularly with all partners including Trinity House to ensure that people are safe within the home.

“We have held meetings under our safeguarding policy and procedures and have implemented safe and well checks and reviews of people living there. We also worked closely with the Care Quality Commission (CQC) in relation to the service and the sharing of information.

“Officers in the council have worked extensively to ensure that people are safeguarded and that our Quality and Safety Team monitors the care we commission. A review had been completed prior to the CQC inspection and the home was already working on some improvements.”