The Care Quality Commission (CQC) has imposed urgent conditions on the registration of Holmesley Care Home in Sidmouth, Devon following an inspection in February.
At the time of the inspection there were 47 residents living at the home, and the inspection was carried out to follow up on specific concerns CQC had received. These related to staff not treating people with dignity and respect, people not receiving care in a timely way, or at times that suited them, low staffing levels, a lack of staff training, and unsafe moving and handling practices used on people.
During the inspection, CQC had concerns about infection prevention and control procedures, as well as records relating to the delivery of care and people’s needs and choices not being assessed in line with current legislation. Because of this, the scope of the focused inspection was widened to look at whether the service was safe, effective and well-led.
Shortly after the second day of inspection, the home reported an outbreak of COVID-19. Many of the residents and staff were affected and some of the residents later died from the infection. At this time, CQC received concerns about poor leadership decisions in relation to the management of the COVID-19 outbreak. A police investigation regarding the circumstances of the outbreak is currently underway.
Once it became clear that there was an outbreak, the provider worked closely with the local authority and CQC to ensure people’s safety.
Following the inspection, CQC imposed conditions because inspectors were concerned about the safety of care provided to residents, as well as governance of the service.
The conditions prevent Holmesley Care Home from admitting new residents, or re-admitting former residents without prior written agreement from CQC. The provider must also ensure that systems are in place to prevent and control the spread of COVID-19 to protect patients and staff.
Holmesley Care Home’s rating for safe and well-led deteriorated from good to inadequate. The service was inspected for its effectiveness for the first time and was rated requires improvement.
Amanda Stride, CQC’s head of adult social care, said:
“When we inspected Holmesley Care Home, we found that people were not protected from the spread of infection. During the first day of our inspection we observed seven members of staff wearing face masks under their chin, or not at all. Soon afterwards, the care home experienced a widespread outbreak of COVID-19. As the circumstances which led to this are now subject to a police investigation, we are unable to comment further on this.
"There were also widespread and significant shortfalls in the way in which the service was led. Residents were at risk of neglect and abuse because systems to monitor the quality of care were either not in place, or not operating efficiently.
“We will continue to monitor the service closely, in conjunction with the local authority, to ensure that improvements are made and fully embedded. We will also meet with the provider to discuss how they plan to make the required changes to improve their rating and we will re-inspect to check the improvements have been made.”
Inspectors found the following areas of concern:
- Staff did not always have the training, assessment and supervision needed to ensure they know how to perform their roles
- Staff did not have a clear understanding of their roles and responsibility under the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and were making decisions for people which they should not have made
- Systems and processes were not robust enough to identify where things had gone wrong, so that lessons could be learnt
- People’s needs were not always assessed, and poor record-keeping meant the home was unable to demonstrate that they were delivering good care
- Some care plans lacked essential details and instructions. Daily records and charts were not sufficiently detailed to demonstrate what care had been provided and some people’s records indicated that they had not been checked for long periods of time
- Systems that had previously been in place to review risks to residents, such as falls, accidents and incidents, had not been maintained.
Full details of the inspection are given in the report published on our website.
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