The Care Quality Commission (CQC) has taken urgent action to protect people at Little Oyster Residential Home, Minster-on-Sea, following an inspection in July that highlighted serious failings in the standard of care being delivered.
At a previous inspection in April, there was positive progress in the quality of care being delivered, but in the months following, CQC was contacted by several whistle-blowers and had serious concerns about people’s safety, staffing and management of the home which prompted the recent inspection in July.
Following the inspection, CQC issued urgent and immediate conditions on the provider’s registration, preventing it from admitting residents to the home, including respite admissions or returning residents.
The service was previously rated as good but is now rated inadequate overall; it was rated inadequate for being safe, effective and well-led and requires improvement for being caring, and responsive.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people, said:
“We returned to Little Oyster Residential Home because, despite seeing some small improvements at our previous inspection, we were very concerned by new information we received from whistleblowers and others, who expressed their concerns regarding the service. I would like to thank these people for coming forward, as I am aware it can be difficult to speak up, but it has allowed us to intervene to make things better for people.
“Make no mistake, this was not a pleasant place to live for the people who called it home. When we inspected, some people asked us for help to contact their social worker to move them elsewhere because they were so deeply unhappy. Some people told us they were frightened, and that they didn’t feel safe. Nobody should feel like this in their own home.
“Low staffing levels impacted on every area of the care being delivered at Little Oyster. Staff didn’t have enough time to meet even the most basic of people’s needs as the report clearly shows.
“Leaders at this service did not create an environment where staff felt empowered to raise concerns, and a lack of good processes, especially around safeguarding referrals, meant people were not protected from harm and abuse.
“We have placed urgent conditions on Little Oyster’s registration to protect people, and other local stakeholders are working with the service to ensure people’s safety.
“We will continue to monitor them and expect to see rapid and significant improvements at this service and won’t hesitate to take further enforcement action if this doesn’t happen.”
Inspectors found the following issues at the service:
- The systems in place to audit the quality of the service were not robust or sufficient to alert the provider to concerns and issues. People were at risk because the provider had not acted to ensure they had enough oversight of the service
- This included staffing. Inspectors were not assured enough staff were deployed to meet people's needs. The acting manager was unsure of which staff were working and which staff were off
- People's cultural needs were not always respected with one person telling inspectors about the impact of staff treating them differently because of the country they were born in
- Risk assessments and care plans had not improved. They did not provide clear guidance to staff about how to meet people's needs safely, or with current information about people's prescribed medicines, meaning inaccurate information could be given to healthcare professionals
- There was a build-up of items in storage which could be a fire hazard. Fire drills had not taken place since November last year, and a significant number of staff had not attended them. One resident was locked in their flat each night without any means of escape in the event of a fire
- People were not supported to access medical appointments to ensure their health needs were met. Some people who had frequently fallen had not been referred to medical professionals for further assessment or treatment
- Some call bells were muted or switched off without staff attending to the call, one person said they had used their personal telephone to request help
- Thickening agents prescribed for people who had swallowing difficulties were not always measured accurately, which posed a choking risk to people. People’s choking risk assessment stated staff were trained in de-choking, but this was not on the list of training that staff were supposed to complete
- There was no dementia friendly signage in place around the service, despite some people living with dementia.
Inspectors also found people’s experience of living at this service was poor:
- People were not always treated with dignity and respect. Inspectors observed people with no clothes on with just a sheet or blanket covering their private parts, doors were wide open, and they were in full view of other people
- People told inspectors they felt isolated as they were often unable to speak with loved ones and maintain important relationships because of poor internet access in the service
- People told inspectors that the meals were of poor quality and lacked vegetables and were not balanced
- People didn’t feel like they always had dignity when speaking to staff: “I feel when asking for things I have to beg. This used to be a jolly place and nice to live, I wanted to die here because it is my home now I want to move."
Full details of the inspection are given in the report published on our website.
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