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A Covid-hit care home has been plunged into special measures after staff members claimed "they had never been told they had to" wear masks.
A catalogue of concerning findings was gathered by Care Quality Commission (CQC) inspectors during a visit to St Peter’s in Herne Bay.
The seaside home, which cares for up to 43 dementia sufferers, has been given a rating of “inadequate”, the worst possible, as the watchdog stated residents “were not protected from the risk of avoidable harm”.
And worryingly, it found staff did not use personal protective equipment (PPE) appropriately – even though the site had already been rocked by a coronavirus outbreak.
In their report, inspectors noted: “We were not assured the provider was protecting people from the risk of infection.
“There had been a Covid-19 outbreak at the service previously. A contingency plan to respond to another outbreak had not been implemented.
“The deputy manager said, ‘No contingency [plan is in place] for further outbreaks. It's in my head, but we don't have it written down. I like to feel the staff would know what to do.’
“Some staff did not use PPE appropriately. We observed both cooks not wearing masks.
“When asked why, the staff said they had never been told they had to. They then put face masks on.”
The inspectors said neither of them – nor a visiting professional - had their temperatures checked or were asked to give evidence of a negative Covid test before entering the home last month.
They also discovered that the service had failed to report an incident in which a person sustained a serious injury to either the CQC or Kent County Council, as required.
And it was even found not to have notified the CQC when people had died.
“The provider had not been open and honest in line with their legal responsibilities,” the report continued.
“When people had been harmed or allegations of abuse were made the provider had not shared this information openly with stakeholders.
“When people had died the provider had not sent the CQC notifications which they are required to do.”
The report raised concerns that residents could be given outdated medicine that was no longer prescribed.
Meanwhile, risks concerning people’s specific health needs were also considered to have been “poorly managed”, putting some users at risk of not drinking enough.
“One person was at risk of developing urine infections and to reduce the risk of these occurring they needed to drink plenty of fluids,” the report added.
“Their fluid intake was not monitored. After the inspection we were informed the person had been admitted to hospital with a urine infection.
“Risks to people were not well managed. There had been approximately 70 incidents of people either slipping or falling which had not been analysed.
“Some people who were at risk of falling did not have risk assessments in place. Other people had been identified as being at high risk of falls, but no action had been taken to mitigate the risks.”
Carers at the home also complained to inspectors that they were receiving “no direction” from their bosses.
"With our leadership team recently depleted due to long Covid, the CQC inspection took place and this new rating was deservedly issued..."
The CQC report concluded that staff did not understand their responsibilities and, consequently, “people were harmed”.
When the visit was conducted – in May – the deputy manager was in day-to-day charge of the service, even though they “felt out of their depth” and unsupported in the role.
“Staff did not feel listened to or empowered,” the inspectors observed.
“Staff told us they had not received fire training, they had reported this to the management, but no action had been taken.
“A staff member said, ‘During the Covid-19 outbreak, we were just left to it. We were fighting fire. No-one came to support us. It has had a big impact on the staff as we lost so many people. It was awful.’"
As part of being in special measures, the home is set to be inspected again at some point over the next six months.
If it is not adjudged to have made sufficient improvements, the CQC says it “will begin the process of preventing the provider from operating this service”.
A spokesman for St Peter's says bosses are working with the watchdog to address the concerns raised.
He said: "During the first wave of Covid-19, we put all the necessary steps in place to keep our residents and staff safe, well and as happy as possible.
"Our experienced staff followed those same processes during the second wave.
"Even though we had no visitors in the care home, regular screenings and appropriate PPE, the more transmissible strain got into the care home and, sadly, affected several of our residents and staff.
"At the height of this situation, with our leadership team recently depleted due to long Covid, the CQC inspection took place and this new rating was deservedly issued.
"At that time we were already taking steps to bring ourselves back up to the right level, and have now successfully recruited an experienced leadership team to manage that process.
"We look forward to welcoming the next inspection at the earliest possible opportunity."
