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A care home which looks after people with autism and learning difficulties has been put into special measures.
Shore Lodge in Dartford was rated Inadequate by the Care Quality Commission (CQC) after a report found several problems, including some patients experiencing neglect by staff.
The facility in Bow Arrow Lane was visited in March and told it requires improvement, but failed to show progress after a reinspection over a two-week period in June and July.
A report from the CQC detailed how the care home looks after eight people and was rated Inadequate in being safe and well-led.
It stated: “We found three continued breaches of regulation in relation to safe care and treatment, consent and governance.
“People continued to be placed at risk of and experienced physical harm. We found no improvement in staff understanding of capacity and consent and national guidelines had not been followed.”
Criticising the leadership at the care home, the report said “leadership of the service was inadequate”.
‘People's human rights were not upheld...’
It added: “There was a closed culture which was not person-centred. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse.
“Processes to keep people safe were not in place. People experienced institutionalised neglect, their distressed behaviours were ignored and not acted upon to ensure people were safe and felt safe. People’s human rights were not upheld.
“Quality monitoring systems were inadequate. There were widespread failures by the provider and the registered manager to assess and act on risk. The provider and the registered manager had not been open and honest in line with their legal responsibilities.
“They had not shared information with CQC or with stakeholders.”
The CQC report revealed how a number of whistle-blowers at the care home detailed how they had tried to raise concerns with leaders but were told to “zip their mouths”.
“People and staff were not encouraged to speak up, and when they did, they were either ignored or bullied and threatened by the provider,” the report added.
Elsewhere in the report, it claimed staff agency had not seen any risk assessments for the person they were providing 1:1 support to. These documents included “crucial records in relation to the risks the person posed to themselves and others”.
When inspectors showed agency staff the person’s care file with all care plans and risk assessments, they confirmed they had not seen this.
The care home was criticised for not protecting people from harm. On one occasion, a patient was allowed to take a glass photo frame into their room which later broke and left fragments in their bed and on the floor.
Night staff reported the incident to day staff during handover and said they had cleared the glass and made sure the person was safe.
The report added: “However, day staff found the person had received cuts from glass and glass was still in the bed. The incident had not been referred to the local authority safeguarding team until a CQC inspector contacted the registered manager when they had been informed of the incident by local authority staff.”
Inspectors also claimed to hear “poor bullying interactions” between staff and people.
This included one member of staff threatening to prevent a resident from speaking to their loved ones on the phone.
Another resident explained how one staff member told them “the next move is Broadmoor” – referring to the psychiatric hospital in Crowthorne, Berkshire.
The concerned resident told inspectors: “I don’t know if they are joking or not.”
Despite being plunged into special measures and rated Inadequate, a spokesman for Leonard Cheshire, which runs the care home, says things are different now.
They said: “We believe this report does not in any way reflect the situation at the service now and we have requested a return visit by the CQC.
“On a fortnightly basis we have been updating the regulator about how the service has moved forward. Management is different with additional oversight and support being provided by senior staff, as well our specialist mental capacity, safeguarding and service improvement teams. Other measures have included the development of new care plans and risk assessments, bringing in external clinical expertise and additional training for staff.
“The safety and wellbeing of people living at Shore Lodge remains our ongoing priority, with families being regularly updated on the considerable progress we have made to date.”
Jim Dickson, MP for Dartford, said: “It’s extremely disappointing that very clear advice from the CQC to improve services for all relying on Shore Lodge have not resulted in change.
“I’m going to be seeking firm assurances from Leonard Cheshire that they will be acting fast and effectively on the recommendations that have been made by the regulator.
“Residents deserve better than this”