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A nursing home has been put in special measures after inspectors found residents at risk of drowning in the pond and falling out of windows.
Shottendane Nursing Home in Margate has been told it must make improvements, with its rating downgraded from 'good' overall to 'inadequate'.
Inspectors from the Care Quality Commission visited the home - which supports up to 38 people, including those with dementia and needing end of life care - in February and have now published their report.
The visit was made after concerns were raised relating to safeguarding and people’s nursing care needs.
During the inspection, the CQC found Covid was being managed poorly and that relatives of people in the home were being prevented from visiting, despite being allowed to do so under government guidance.
Thickening powder - used to thicken up fluids, but deemed a choking hazard if used without liquid - was left in residents' rooms, which presented a particular risk for those with dementia.
Two first-floor rooms, which were left unlocked, didn't have window restrictors in place, with inspectors warning this put residents at risk of falling out.
They also pointed out the lack of a fence or barrier around the pond in the large garden, meaning there was nothing in place to prevent people from falling in and drowning.
Hazel Roberts, CQC’s head of adult social care inspection, says they will continue to monitor the service closely.
"When we inspected Shottendane Nursing Home we were very concerned about how poorly Covid-19 was being managed as the home wasn’t following government guidance to keep people safe," she said.
"They admitted new people into the home without considering the risk to them, and some people who were Covid-19 positive had signs on their doors to indicate they were infected, but others didn’t.
"Personal protective equipment (PPE), such as masks, gloves and aprons, had been discarded in general bins which anyone could access, rather than being labelled as offensive waste. Some staff weren’t wearing masks or wearing them incorrectly, and nothing was done when we raised this.
"Relatives told us they had been prevented from visiting the home, or had time restrictions placed on their visits, which again was not in line with government guidance."
Ms Roberts says the CQC team was told by relatives that staff were kind and caring, but the service was understaffed, and people were left to sit in their rooms all day with little engagement from employees.
Inspectors also found oversight and governance systems were ineffective, medicines were not managed safely and some staff lacked understanding of safeguarding principles.
Relatives said while they felt well informed about the care their loved ones received, they had not been kept up to date in other matters.
For example, they were not informed the registered manager had left the home until a month later.
Ms Roberts said: "When we raised issues with the management team, they took some action, for example completing an infection control audit and an audit on all window restrictors. However, further improvements are needed.
"Our priority is for the safety of people living in the home and the quality of care they receive, and we will continue to monitor the service closely."
The overall rating was dropped from 'good' to 'inadequate'. The safe and well-led categories went from 'good' to 'inadequate'. Effective, caring and responsive categories were not rated on this occasion.
The service will be re-inspected within six months to check improvements have been made.
A spokesman for Shottendane Nursing Home said: "Following the departure of the former registered home manager, it was deemed by the CQC, in an inspection carried out two weeks later, that Shottendane Nursing Home fell short of the required standard of its registration.
"However, eight weeks since, we have made significant inroads towards improving the home throughout.
"The new management regime has changed the overall culture, which is now more communicative, inclusive and engaging and this has brought about a drastic positive effect for all concerned.
"We have also recently engaged with a professional consultancy who are assisting us in our aim to be reinstated with a ‘good’ rating, which we have achieved for several years."