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A care home resident was given a double dose of sleeping pills while others were left calling for staff for more than 50 minutes, inspectors have found.
Strode Park House in Herne Bay has been plunged into special measures after Care Quality Commission officials made a string of alarming discoveries at the site.
A damning report published by the watchdog last week tells of a resident found with a continence pad in their mouth and of medication being sloppily managed.
The document also reveals carers only realised they had run out of epilepsy rescue medicine when a client had a seizure.
The Lower Herne Road facility has since been slapped with a rating of "inadequate" - the worst available.
"Staff did not always administer medicines safely," the report says.
"One person was given a double dose of their sleeping medicine as staff had not communicated between them the person had already had that medicine.
"Another person was administered an antibiotic they were allergic to.
"The provider took immediate action when the error was identified. While there was no harm to the person the risk of harm had not been managed."
Of the 52 people using the service, the CQC found that 18 residents' medicines were not being stored securely.
This was despite a prior incident that saw a client gaining access to their drugs and taking more than prescribed.
"People were not safe and were at risk of avoidable harm," the report continues.
"The electronic medicines administration system was not providing staff with accurate information about stock levels due to technical issues.
"This had resulted in some people not receiving their medicines due to stock shortages.
"One incident occurred when an epilepsy rescue medicine was not in stock for a person who it was prescribed for. This was only noted by staff as being out of stock when the person had a seizure."
Residents and staff interviewed during the unannounced inspection, agreed under-staffing was an issue.
One client said they often waited long periods for help with managing their continence, while others felt they were not always able to get out of bed when they wanted due to the shortage.
One of the facility's employees conceded: "I'd be lying if I said we have enough staff."
"An incident had occurred where another person had put their continence pad in their mouth," the report adds.
"Appropriate action had not been taken to assess the risk of this happening again and to consider the risk of this causing choking.
"Following the inspection the provider told us they had implemented a risk assessment and sought advice from the speech and language therapist team. We will review this at our next inspection."
Records viewed by CQC assessors revealed three occasions in which call bells were ringing for almost an hour.
The watchdog also heard residents say they felt “institutionalised” during the inspections in September and October.
"People's dignity was not always respected and promoted," the report states.
"One person told us staff did not always believe them when they said they needed support with personal care and had to evidence they needed support before it was provided."
However, some of the residents at the facility - which supports people with physical and learning diabilities - did say staff were caring and approachable.
A former employee, who asked to remain anonymous, also told KentOnline people working at the site were “dedicated and responsible individuals working under enormous pressures due to staff shortages”.
The publication of the report comes just a few weeks after the Coach House - which is next door to Strode Park House and also managed by the Strode Park Foundation - was rated “inadequate”.
Despite this bosses have questioned the latest set of findings.
“We believe several key areas of the report are unfair, inaccurate or disproportionate,” a spokesman said.
“We have some concerns about the way the inspection was carried out and these have been raised with and are currently being considered by CQC.
“In the meantime, everyone at the home is working hard to implement an action plan to make improvements where this is practical.
“We aim to ensure the quality of the service is as good as possible, and regain the 'good’ rating the home has achieved continuously since ratings were introduced."