Residents of a Wrexham care home were at risk of malnutrition, says a watchdog.
And because care plans were not followed, people did not receive the right care at the right time and were put at risk of harm because their needs were not explained to agency staff.
Following a visit to the Stansty House Care Home in Rhosddu, inspectors from the Care and Social Services Inspectorate for Wales (CSSIW) served three non-compliance notices on the owners, Minster Care Group.
The home is registered to accommodate 77 people, 28 of them needing nursing care and 24 with dementia.
In their newly-published report after their October visit, the inspectors commented: “The service is not currently meeting the needs of all people living in the home.
“Staffing issues have been a factor in the decline in the level of service, particularly to people with nursing care needs.
“The lack of leadership in the nursing unit is contributing to poor outcomes for people.”
Under the heading ‘Well-being’, the report states: “People unable to care for themselves independently are not always given the nutritional care they need.”
Files were not updated nor analysed by qualified staff and charts were poorly completed.
One individual for whom a dietician had prescribed a nutritional supplement three times a day received it only five times in two weeks – and none in the quantity prescribed.
Three residents at medium risk of malnutrition were supposed to be weighed monthly.
However one weighed 51.3kilograms in June, 50.kg in July, and there were no further records until October when the weight had dropped to 42.5kg.
The other two had not been weighed between January and August, by which time they had “incurred significant weight loss”.
The inspectors expressed concern about the risk of bed sores because air mattresses were at the wrong setting for the weights involved.
“The impact on people using the service is people are not as healthy as they could be and may be at risk of harm,” says the report.
Some people with ulcers had been admitted to hospital, but the CSSIW or local authority had not been informed about those incidents nor other issues including an injury sustained during manual handling by staff.
The inspectors say the care staff are “kind and caring and treat people with dignity and respect”.
Some of the problems were found to be due to lack of continuity of agency staff and poor quality handover sheets – so that they were unaware of people’s needs.
“People are at risk of harm as their individual care and medical needs are not always made clear to agency staff,” said the report. “This is a serious matter which results in poor outcome for people.”
A Stansty House spokesman said: “Immediate action was taken to address the shortcoming identified within the CSSIW’s report following its recent inspection.
“The issues identified relate mainly to documentation and communication between agency staff rather than the standard of care provided.
“It was recognised within the report that ‘care staff are kind and caring and treat people with dignity and respect’.
“A new unit manager has been appointed who has worked closely with our regional management team to improve procedures and communication.”
Extra permanent staff have been taken on to reduce reliance on agencies and the new team members have undergone ” rigorous” training on new procedures.
The spokesman added: “We continue to work closely with the local authority to ensure we are delivering the highest standard of care possible.
“The CSSIW has also been informed of the actions we have taken and we look forward to welcoming inspectors back in the near future.”
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