A Cornwall care home being investigated after a resident died has been placed in special measures because it can't protect people. St Petroc's Care Home in Bodmin was rated as inadequate by inspectors from the Care Quality Commission (CQC) following a visit in September last year.
The inspection was prompted 'in part' due to an incident following which a person using the service died. The information shared with the government body about the incident indicated potential concerns about how they were managing the risks associated with unplanned restraint, the CQC said.
The incident which occurred is subject to further investigation by the CQC as to whether any further regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident, the CQC said. Following the inspection, CQC has served four warning notices to St Petroc to focus their attention on making rapid and widespread improvements around safe care and treatment, consent to care, safeguarding, and the management of the service.
The service’s overall rating has dropped from good to inadequate as have the ratings for safe and well-led. The ratings for effective, caring and responsive were not reviewed in this inspection and remain rated as good.
The service has also been placed in special measures, which means it will be kept under close review by CQC to keep people safe and it will continue to monitor to check sufficient improvements are being made. If CQC doesn’t see rapid and widespread improvements, CQC may use its regulatory powers further.
St Petroc's Care Home, which is run by Stonehaven (Healthcare) Ltd, provides personal care to up to 30 people and residential care to older people who may have a physical disability. Stonehaven said it "was extremely concerned and bitterly disappointed that these standards have slipped" when it has always been "proud that standards have been high at the care home".
Catherine Campbell, CQC deputy director of operations in the south, said: "When we inspected St Petroc's Care Home, we found it did not have strong leadership. This was exposing people to a risk of abuse and harm because they didn’t ensure staff had the skills and training necessary to meet the needs of people living there.
"Residents told inspectors they saw staff bullying others in communal areas. Vulnerable people were relying on all staff members to act as their advocates, to help them live their best lives, and it is unacceptable the people they relied on were treating them this way.
“I want to thank the staff who came forward to tell us they felt colleagues were minimising and mis-recording injuries in service records. In one case, a staff member incorrectly logged a significant incident where their colleague injured someone twice as unexplained. This is particularly important as leaders had allowed a closed culture to develop and staff who did raise concerns were treated poorly by their colleagues and manager. It is hard to make a stand, and we want to acknowledge their bravery."
She added: "Staff who witnessed abuse had reported their concerns to leaders, but these concerns had not been investigated and prior to our inspection action had not been taken to protect vulnerable individuals. In addition, staff described incidents where their colleagues discriminated against a visually impaired person by silently walking away when they asked for help.
“We also found staff had subjected people to restrictive practices by delivering personal care without consent. Staff involved in these incidents told us it had been in the person’s best interest but there was no documentation or guidance that supported this approach.
“Following these and further allegations made to us through the inspection, we made safeguarding alerts to the local authority about the quality of care provided to seven people living there and shared details of these allegations with the owner, Stonehaven (Healthcare) Ltd. Shortly after the inspection the registered manager left the service.
Ms Campbell said the CAC has told leaders at St Petroc's Care Home and Stonehaven they expect to see "rapid and widespread improvements".
She said inspectors will return to check on any progress made, adding: "We won’t hesitate to take use our regulatory powers further if people are not receiving the care they have a right to expect."
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What the inspection of the Cornwall care home found:
- Care wasn’t private or dignified, with inspectors observing staff members providing personal care in bathrooms with the door open. Inspectors immediately highlighted this to the registered manager and subsequently informed the service’s directors
- Staff had no confidence that concerns would be investigated. Staff described how they had been punished and discriminated against by other staff and the registered manager
- The home consisted of three distinct areas and at night only two staff were on duty to support the 23 people living in the service. This impacted on staff availability and response times while meeting these individual’s needs
- Staff and people living in the service described incidents of conflict that had repeatedly occurred between the registered manager and the previous deputy manager in communal areas of the home
- The service used cut up old towels, with frayed edges as flannels during personal care. The manager didn’t like this, but no action had been taken to improve the quality of flannels, prior to the inspection
- Risk assessments and people’s care plans were not accurate or detailed enough to ensure safe and effective care
- Staff training was not completed at a satisfactory level across the service
- People didn’t feel involved in their care planning
- People’s dignity was not always maintained
Bosses at Stonehaven, which has owned St Petroc’s since November 2003, said: "Immediate action was taken to address the CQC's concerns, to ensure that all residents were safe, to implement a more open culture to enable our care team members to confidently discuss and report any future concerns and to ensure that improvements were being identified and addressed promptly.
"Stonehaven (Healthcare) Ltd have always been proud that standards have been high at the care home and were extremely concerned and bitterly disappointed that these standards had slipped."
A spokesperson for the firm added: "Following the inspection, for the benefit of residents and team members, immediate staff changes were made and new processes and procedures were introduced to provide greater insight with regards to the care being provided in the home. These improvements have been made working alongside the Cornwall Council Safeguarding and Quality Assurance teams and other visiting professionals, all of whom have acknowledged the improvements made at the care home.
"We have made significant improvements at St Petroc’s and look forward to the CQC visiting to conduct their next inspection. We look forward to the CQC inspector seeing these positive changes and meeting the new Care Home Manager together with her caring and dedicated team.
"Stonehaven will continue to work closely with the CQC and Cornwall Council to ensure that these renewed standards are maintained allowing us to provide a high level of care to our residents now and into the future."
Nathan Stone, director of services development and HR at Stonehaven, added: "We’ve worked with the care team at St Petroc’s to implement a significant number of changes to our working practices. We now have a new care home manager in place who is providing strong, focussed and person-centred leadership whilst championing an open and supportive culture within which our care team members are able to flourish."
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