Bindon Residential Home

⚠ Failure to prevent avoidable harm or risk of harm, including issues with falls risk management, pressure relieving equipment, repositioning, blood sugar monitoring, failure to protect people from the risk of infection due to an unclean and malodorous environment, insufficient housekeeping staff, soiled facilities, overflowing clinical waste, staff not always having …

⚠ Failure to effectively employ a sufficient number of suitably qualified and skilled staff to meet people's needs and ensure cleanliness, leading to delayed personal care, lack of monitoring for challenging behaviours, staff undertaking multiple duties, and failure to ensure staff were suitably trained and effectively supervised, with a lack of …

⚠ Failure to operate robust recruitment procedures, including not consistently obtaining references and DBS checks for agency staff, leading to a person with concerning information in their DBS check having access to vulnerable people.

⚠ Failure to maintain premises to a safe standard, including fire safety issues (fire doors not closing, overdue checks, old extinguishers), unmaintained equipment (low beds, inappropriate chairs, unserviced hoist slings), lack of hot water, trip hazards, exposed hot pipes, water temperatures above recommended levels, and failure to ensure the decoration and …

⚠ Failure to ensure people had sufficient amounts to eat and drink and to maintain a balanced diet, including delayed GP referrals for weight loss, un-reordered nutritional supplements, inconsistent weight monitoring, and poorly completed food and fluid charts.

⚠ Lack of understanding in providing considerate and dignified care, evidenced by poor personal care (dirty, mismatched clothes, long dirty nails, poor mouth care), staff discussing care needs in communal areas, and failure to protect a person from unwanted visitors.

⚠ Lack of person-centred care, with care records not always reflecting needs and preferences, contradictory information, overdue reviews, limited behaviour plans, poor communication of needs to staff, brief and repetitive daily intervention records, and a lack of stimulation and occupation for people.

⚠ Failure to monitor themes from complaints and make improvements, leading to people feeling unheard and necessary improvements not being addressed, with themes from complaints (lack of staff, person-centred care, cleanliness) still evident.

⚠ Widespread and significant shortfalls in governance and failure to implement improvements, including insufficient oversight, ineffective systems for identifying shortfalls, lack of needs analysis for staffing, unsafe recruitment, delayed action on weight loss, inaccurate record keeping, ineffective complaints and communication systems, inadequate assessment and planning for management and staff turnover, lack …