The Care Quality Commission has published a full report of the inspection which led to the closure of Horncastle House Care home at Sharpthorne, East Grinstead.
The report reveals that residents were at risk of serious harm - or even death - when inspectors carried out an unannounced inspection on 13 September. At the time, inspectors had to intervene to keep people safe.
As a result of the concerns, CQC used its urgent enforcement powers to remove the location from the Care register, while notifying the local authority and NHS of its serious concerns.
Shortly after CQC issued its enforcement notice, the care provider Sussex Heath Care withdrew staff support effectively leaving the authorities with no alternative but to move the residents out that night.
Debbie Ivanova, CQC’s Deputy Chief Inspector of Adult Social Care, said:
"The standard of care that we found on our inspection left us in no doubt that some people living at Horncastle House were in danger of choking if we did not act quickly to protect them. People were being exposed to immediate risk of serious harm or death because of the poor practice.
"In the circumstances we had no choice but to take urgent action, while at the same time working with colleagues from the local authority and the NHS to keep people safe.
"During an emergency closure, people do need to move but we recommend it is done in a planned and measured way. In this case the provider took the decision to withdraw their staff. That decision meant that the local authority had no alternative but to move people out that night, adding unnecessarily to the stress and worry for the families and for those involved."
At its last inspection in August 2018, Horncastle House had been rated as Inadequate overall. At the time the provider had given assurances that it would take immediate action.
But on 13 September, following concerns that had been raised by a relative, inspectors found that known risks to people had increased rather than reduced.
The service was unsafe for the people living there, because risks from choking, lack of access to their call bell, from falls, poor hydration management, improper use of pressure-relieving equipment and the environment had not been remedied since the last inspection.
There were not enough experienced and competent staff deployed to meet people's needs, with a heavy reliance on agency staff who did not know people well. Staff practice was observed to be poor but had been unchallenged by managers or the provider.
Information and records about people's care needs were dangerously inaccurate and conflicting, making them unworkable as guidance to staff.
The provider blamed the staff for letting them down - but did not properly take account of the provider's responsibility to ensure that people received safe and appropriate care.
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