Torquay care home placed in special measures after inspection finds inadequate care

A care home in Torquay has been placed in special measures, after the Care Quality Commission downgraded its rating from good to inadequate.

Mr C's, run by Woodland Healthcare Limited, provides accommodation and personal care for up to 40 older people, including people living with dementia.

The CQC carried out the inspection in July, in response to concerns raised about the quality and safety of care and support being provided.

Inspectors found that care had deteriorated, and that the service was in breach of five regulations relating to person-centred care, staffing, safe care and treatment, safeguarding, and how the service was being managed.

The CQC rated Mr C's as inadequate for how safe, effective, responsive and well-led it is. Caring was rated as requires improvement.

The service has been placed in special measures, meaning it will be kept under close review by the CQC while improvements are made.

The CQC has also begun the process of taking regulatory action to address the concerns, which Mr C's has the right to appeal.

Stefan Kallee, the CQC's deputy director of adult social care in Cornwall, said inspectors found "a service where leadership and management had left people exposed to risks".

"A lift breakdown lasting five weeks impacted on people's lives. One wheelchair user missed a health appointment because they couldn't get out of the building, and another told us they didn't feel safe using the stairs," Mr Kallee said.

"A relative described their family member sleeping in a recliner chair in the lounge for days because they couldn't reach their bedroom. Leaders had not realised, or risk assessed, the impact this would have on people's lives," he said.

"We also found gaps in how people's day-to-day dignity was protected. One person's showers were restricted despite them wanting to wash daily, and there wasn't enough evidence the service had worked out how to support them properly," Mr Kallee said.

"Another person told us they'd lived at the home for months without their own clothes or belongings and didn't know if or when they'd ever return home," he said.

"Staffing was a problem too. Staff told us they were unsupported at weekends and, after asking for more support, were told to reduce staffing levels instead," Mr Kallee said.

"At the heart of all this was a leadership team who were not effectively managing the risks people were facing. Audits weren't picking up on serious issues with medicines, care planning and safety, and when concerns were raised by staff or relatives, they often went unresolved," he said.

"One relative told us they'd never been consulted about their family member's care, despite raising concerns about falls, diet and medicines," Mr Kallee said.

"It's important to say people told us the staff caring for them day to day were kind and knew them well, and that's clearly something to build on," he said.

"We've told leaders where they must make urgent and significant improvements, and we've placed the service into special measures so we can keep a close eye on people's safety while that happens," Mr Kallee said.

Inspectors found the service did not always identify when someone had been injured, including a case where two undated records showed bruising and skin tears on one person, but no safeguarding referral was made.

Staff did not always know how many carers trained to administer medicines were on shift overnight, leaving some night shifts without anyone qualified to do so safely.

The service did not always check medicines were being given safely, including a case where a medicine meant to be given only when needed was instead administered daily, without proper guidance for staff.

Staff did not always follow basic hygiene rules when giving out medicines, including an instance where the same pot was used for several different people without washing hands in between.

The service did not always track when people who could not move themselves were repositioned to prevent pressure sores, including a case where records showed this had not happened for more than 24 hours.

It also did not always record when people had gone without a bowel movement for a long time, including for a person receiving end-of-life care, meaning a health problem could have gone unnoticed.

The service did not always tell the CQC about serious incidents it was legally required to report, including a case where someone developed a severe pressure sore, and another where a person went missing and was later found lost and confused in the community.

In response, the senior management team at Mr C's said the feedback from the inspection "has been accepted and is being actively addressed".

"We are working very hard to rectify the issues found, and make the necessary improvements. As part of this process we have introduced a new management structure, strengthened the leadership and oversight and have already made a lot of positive progress to date," the team said.

"Moving forward we are committed to work closely with the CQC and the local authority in partnership to continue to improve the service and the quality for everyone who uses and relies on us at Mr C's."