Residents at 'inadequate' care home learnt about COVID-19 on TV and staff failed to wear masks

A care home in Norfolk has been rated ‘inadequate’ by the Care Quality Commission after inspectors found residents learnt about COVID-19 by watching the TV and staff failed to wear PPE and carry out additional cleaning.

Heathers care home in Bacton, Norwich, was inspected the first day by visiting the home but subsequent day inspections were carried out remotely due to the pandemic, with inspectors calling staff and relatives and asking for documents to be sent to them. The inspection was carried out in June.

Heathers is a residential care home providing personal care to eight people with learning disabilities, autism and mental health conditions.

At its last inspection in March, the CQC found 'serious incidents of abuse by members of staff' and despite this, at this inspection, the regulator found there had been no additional safeguarding training or competency checks for staff.

In addition inspectors found 'incidents recorded of unexplained marks on people's bodies'. These had not been investigated or reported to safeguarding. They were explained as being the result of distressed behaviour. However, this was not witnessed at the time and there was nothing noted in the records to indicate that such marks were a risk.

Inspectors concluded that residents 'continued to be at risk of abuse'.

Staff received no guidance on COVID-19

Staff told inspectors they had not received guidance from the provider about COVID-19 and they said people using the service learned about the virus through 'watching TV'.

The CQC found staff were not using any additional personal protective equipment such as masks, with the manager saying some people became distressed if staff were wearing masks and it also hindered communication for some people. 'However, there was no risk assessment in relation to this and no consideration of alternative measures that could be taken to keep people safe from the virus,' said the report.

In one of the resident meetings it was recorded that a person had become distressed as they were worried about COVID-19. They had been reassured in the meeting, however there was no evidence of any other work with people to reassure them about the virus and how they could stay safe. There was no signage or use of easy read materials to help people understand.

Inspectors found there was no assessment of what would happen if somebody did develop symptoms of COVID-19 or test positive.

In addition there were no additional cleaning routines in place as a result of the pandemic, for example cleaning of high touch surfaces, such as door handles.

The report also highlighted that ‘there was no clear leadership’ and ‘repeated changes of management’.

In addition, ‘communication with people and their relatives was poor’ and the care home ‘failed to properly assess and manage risks, particularly risks in relation to people's distressed behaviours’.

‘Staffing levels had improved since the last inspection, however there were still significant gaps in the evenings where there were insufficient staff to support people safely. There were occasions at night when there were not enough staff on duty and on one of these occasions a serious incident had occurred which could have resulted in harm to people living at the service and staff.’

The service is rated as Inadequate overall and remains in special measures.

Matthew Jenkins, CQC head of inspection for adult social care, said: “Our inspection of Heathers identified that several improvements are needed.

“At our last inspection we found evidence of a closed culture where staff failed to report concerns and escalate them to managers. At this inspection, while we found that some staff had left the service which improved the atmosphere in the short term, the provider had failed to address the concerns about the poor culture.”

He added: “We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

“We have requested an action plan from the provider to understand what they will do to improve the standards of quality and safety. We are continuing to monitor progress and will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.”

CQC stopped routine inspections from Monday 16 March, to focus on supporting providers to deliver safe care during COVID-19 pandemic.

Heathers care home has been in Special Measures since 15 April 2020. The CQC carried out the inspection partly due to concerns relating to notification of an incident which could have resulted in serious harm to staff and people using the service.

'These concerns related to the management of risk in relation to people's behaviours. When we followed up our concerns it became apparent the provider had not made the improvements they said they would make following our last inspection. As a result, we undertook a focused inspection to review the key questions of safe and well-led only,' said inspectors.

The findings of June’s inspection can be found here

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