A care home catering for 15 people with disabilities has been put in special measures.
Birchwood care home in Fullers Close, Chesham, had an unannounced inspection from the Care Quality Commission (CQC) in March.
It found that people were at risk of injury and choking.
Ambito Care, which looks after the care home, said it was committed to making improvements.
The care home provides accommodation and personal care for up to 15 people and was previously rated as requires improvement.
March's inspection was partly prompted after a 'scalding accident'.
In its report, published today (May 10), the health watchdog said risks to people were not mitigated.
It also highlighted safety failings in handling medication, staff training and record keeping.
"Fire drills were not taking place in line with the providers guidance on fire drills. This had the potential to put people at risk, as the service had not assured themselves people could be safely evacuated at night," the inspection revealed.
"Alongside, this a person's personal emergency evacuation plan (PEEP) indicated if there was a fire at night, staff were to ensure the person was safe and their bedroom door is closed. There was no indication if this agreement had been approved by the local fire service.
"Liquid medicines had a label on for date of opening and date of expiry. These were left blank. Therefore, no record was kept of the remaining balance of liquid medicines.
Some findings from the report also included:
- People's changing needs had not been reviewed to ensure the required staffing levels were provided.
- Up-to-date speech and language therapist guidance was not reflected in two people's care records.
- Some people were prescribed transdermal adhesive patches which are placed on the body to deliver a specific dose of medicine through the skin. Transdermal patch records weren’t in use to show where the patch was applied on the skin and the old patch removed after each administration.
- People's night-time personal emergency evacuation plan (PEEP's) indicated that some people required two staff to evacuate the building. The registered manager hadn’t considered how two staff plus a sleep-in staff member could safely evacuate people at night.
The care home will be closely monitored and has been asked to produce an action plan on how it is going to tackle points raised.
Ambito Care, which described the report as "bitterly disappointing" and said: "As the CQC acknowledged in its report we are working with them and other authorities in an honest and transparent way, and have made urgent and essential changes in order to address the feedback in the report."
Martyn Heginbotham, chief operating officer said: “We are bitterly disappointed that the service did not meet the standards we expect at this latest CQC inspection.
“The inspection team has praised the home for the proactive, speedy and open way in which these improvements have been made.
"Our priority remains ensuring that the individuals in our care at Birchwood continue to enjoy fulfilling lives in a safe and supportive environment. We are pleased to see the positive comments from the people we support and their families in the inspection report.
“The dedicated staff team will be given every support to enable them to provide the best possible outcomes for all at Birchwood in line with what we expect and aim to deliver at all of our services.
“We have already introduced changes to the leadership team, have accelerated a programme of refurbishment works, and have a clear action plan in place to ensure the required improvements to the environment are made quickly, effectively and sustainably.”
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