A care home has been placed into special measures by the health watchdog because of “very serious” safeguarding concerns, with instances of patients being left lying in urine-soaked sheets.
There were also claims that staff were told to be “firm” with incontinent patients and to show them their soiled clothing and hands if they had an accident.
Scholars Mews Care Home in Stratford-upon-Avon, Warwickshire, provides residential and dementia care services.
The facility is operated by Avery Homes (Nelson) Ltd, part of Avery Healthcare, which has homes across England.
The unannounced visit by the Care Quality Commission (CQC) took place in October, when 43 residents were living at the site.
It came “in part due to concerns received about safeguarding, staffing numbers and risk management specifically related to falls,” the watchdog’s report said.
Amanda Lyndon, the CQC’s deputy director of operations in the Midlands, said the visit highlighted “a home where poor leadership had resulted in a significant deterioration in the standard of care being provided since our last inspection.”
She added: “We found very serious concerns regarding safeguarding procedures, safe staffing and the management of risks to people’s health and well-being.
“Staff didn’t have the right skills to support people safely and we heard people being spoken to disrespectfully. People’s needs were not being met which the provider must address urgently.”
The CQC’s report claims patients “were not always well supported or treated with respect and compassion”.
It added: “There was a culture where staff encouraged people to stay in their bedrooms. Some people expressed distress through their behaviour. Records did not show this was always responded to consistently.”
Inspectors found injuries were not always reported or recorded, while safeguarding measures were “ineffective” and not always followed by staff.
They added that workers at the home did “not always take action to mitigate any identified risks” and some staff did not feel able to challenge unsafe practices “because their concerns were not always listened to”.
Ms Lyndon said staff had shared examples with inspectors regarding poor care practices.
“One staff member had instructed someone not to ring their assistance bell at night in a derogatory manner,” she added.
“Another staff member carried out personal care with someone while they were lying in urine-soaked sheets without changing them which is totally unacceptable and undignified.
“We also saw one person’s care plan that instructed staff to be firm with them and show them their soiled clothing and hands if they had been incontinent which is abusive behaviour and totally inappropriate.”
Following the inspection, Scholars Mews Care Home has been rated inadequate. It had previously been rated as “good” overall.
It has also been placed into special measures, which means it will be kept under close review by the CQC.
Ms. Lyndon said the provider “did not ensure staff had the right skills which put people at risk of not having their needs met”.
“A healthcare professional and staff at the home told us they were really concerned that people weren’t being supported properly and were at risk of falling due to insufficient staffing numbers,” she added.
“Some staff tried their best to provide compassionate care to people, had raised concerns, and were dedicated to making the required improvements at the home, but were let down by poor leadership.
“We will continue to monitor the service closely to ensure the necessary improvements are made and keep people safe during this time. If improvements are not made by the time we next inspect, we will not hesitate to take further enforcement action.”
The CQC said Scholars Mews took “some immediate actions” in response to its findings, including making a safeguarding referral to the police and local authority and giving staff “safeguarding-themed supervision” to ensure they understood expectations.
An Avery Healthcare spokesperson said: “We are dedicated to delivering high-quality care and service to our residents and families. We take the findings in the report extremely seriously and have taken immediate actions to address the concerns raised.
“We have a new leadership team in place at Scholars Mews, supporting our staff team and are working with CQC to ensure we consistently meet the regulatory requirements.”
