Two residents died between the start and end of an unannounced care home inspection in Hove, which was triggered by whistleblowers.
The registered manager walked out on the second day of the three-day inspection by the Care Quality Commission (CQC), the official government watchdog.
Now a report by the CQC says that the Bon Accord nursing home, in Church Road, Hove, has been rated inadequate and placed in “special measures”.
The report said: “The inspection took place on (Monday) 6, (Tuesday) 7 and (Wednesday) 15 February 2017.
“The inspection was brought forward due to information of concern that we had received from relatives, the local authority (Brighton and Hove City Council) and the (Brighton and Hove) Clinical Commissioning group (CCG) due to information of concern.
“The first and third days of inspection were unannounced which meant that the provider, registered manager and staff were not expecting us.
“Bon Accord is a nursing home providing accommodation for people who are living with dementia and who require support with their nursing and personal care needs.
“On the first day of our inspection there were 31 people living in the home. On the second day of our inspection there were 30 and on the third day of our inspection there were 29 people living in the home. This was due to deaths that had occurred.
“The home is owned by Four Seasons (No 9) Limited, which is part of a large, privately owned, national corporate provider called Four Seasons.
“The management team consisted of a registered manager and senior care assistants. On the second day of inspection the registered manager resigned with immediate effect.
“The overall rating for Bon Accord is ‘inadequate’ and the service is therefore in ‘special measures’.
“Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.
“The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
“If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service.
“There were systematic failings, poor leadership and management and ineffective governance that meant that people did not always receive good quality, safe care.
“Quality assurance processes, while sometimes recognising that there had been inadequate care, were not robust and had failed to adequately improve the care that people received.
“There had been ongoing, longstanding issues with regard to people’s access to medicines that had not been suitably managed or improved.
“The registered manager, who was new in post, was not suitably supported to ensure that they were able to assess, monitor and improve the care people received.
“The provider had failed to ensure that people received a good-quality service that they had a right to expect.
“There was low staff morale, staff were unhappy and felt unsupported and this was embedded in most staff’s practice and in the culture of the home.
“People were at risk of social isolation and were not adequately monitored to ensure their safety, nor did they have access to call bells to enable them to summon assistance when needed.
“People did not receive safe care and … people had consistently not had their prescribed medicines for several days and this had a direct, negative impact on their health and wellbeing.
“People did not always receive support to access healthcare that was responsive to their needs.
“A relative told us, ‘We weren’t happy. X had a high temperature for a few days and they were coughing when they were drinking. Eventually my relative had to insist that they call the doctor which they did and X had got a chest infection and was given penicillin. They hadn’t picked up on it and in the end X had to go to hospital and was diagnosed with pneumonia.’
“Some people had lost significant amounts of weight. While this had been monitored, it was not apparent what action had been taken in response.
“Food and fluid charts lacked detail to identify if people had been continually refusing food and not all people had access to supplements or fortified food to increase their calorie intake.
“Not all people received appropriate support to eat and drink. A relative told us, ‘I’m not confident that they would give X the attention they need to make sure they eat properly so I come in every day to feed them and make sure they have fluids too’.
“People were not always assisted to move and position in a safe manner. People were not always protected from harm and abuse.
“Some people, who were living with dementia, sometimes displayed behaviour that challenged others.
“Observations of staff practice when assisting people during times of distress, as well as records, raised concerns with regard to the use of restraint.
“Staff had not received training in how to deal with such situations and as a result asked a CQC inspector of the correct way to do this.
“There was a lack of understanding with regard to circumstances that could be constituted as abuse.
“The registered manager had failed to identify these and medication errors as safeguarding incidents and had not always reported the incidents to the local authority for consideration under safeguarding guidance.
“There were no meaningful activities for people to participate in and people spent their time in their beds or armchairs, sleeping or walking around the home looking for something to occupy their time.
“Some people were socially isolated in their rooms. One person, whose room was on the upper floor of the home, and who had no access to a call bell, was continually crying and calling for help and was showing signs of apparent anxiety.
“People were not always treated with dignity and their privacy was not always maintained. Most staff treated people with respect. However, observations of some staff’s practices demonstrated that they did not maintain people’s privacy when discussing sensitive information.
“Observations showed staff discussing people’s confidential healthcare needs as well as organisational information in front of other people and relatives.
“Staffing levels were not effective during peak periods and when people required assistance from staff they were not always available.
“A significant amount of staff had left and there had been an influx of new care and nursing staff.
“Existing staff told us that new staff often lacked the skills and experience required to enable them to carry out their roles and that their inductions into their roles were not effective.
“Some staff held roles which enabled them to carry out certain nursing tasks. However, there were concerns, due to the high levels of agency registered nurses used, that these staff were often unsupervised and not adequately supported.
“Due to the level of concerns with regard to people’s safety, subsequent to the inspection safeguarding alerts were raised with the local authority.”