By Anne North

A Bodmin care home where an elderly woman died last year in “unexplained” circumstances has been rated “inadequate” and placed in special measures.

St Petroc’s care home, in Nicholas Street, opened in 1987.  Last July a resident died following an incident involving “unplanned restraint.”

Police investigated the woman’s death, describing it at the time as “unexplained.”  Residents complained to the Care Quality Commission about bullying.

The CQC has praised residents who spoke out for their courage, describing a “closed culture” at St Petroc’s where reported abuse was not investigated.

Now the CQC has said : “The incident which occurred is subject to further investigation by CQC as to whether any further regulatory action should be taken.”

The CQC has meanwhile served four warning notices to St Petroc to focus their attention on making rapid and widespread improvements around safe care and treatment, consent to care, safeguarding, and the management of the service.

St Petroc provides care for up to 30 elderly residents, some of whom have dementia.  The home is owned and managed by the Devon-based Stonehaven Care group.

The service’s overall rating has dropped from good to inadequate as have the ratings for safe and well-led. The ratings for effective, caring and responsive were not reviewed in this inspection and remain rated as good.

The service has also been placed in special measures, which means it will be kept under close review by CQC to keep people safe and it will continue to monitor to check sufficient improvements are being made.

If CQC does not see rapid and widespread improvements, it may use its regulatory powers further.

Catherine Campbell, CQC deputy director of operations in the south, said: “When we inspected St Petroc's Care Home, we found it did not have strong leadership. This was exposing people to a risk of abuse and harm because they didn’t ensure staff had the skills and training necessary to meet the needs of people living there.

"Residents told inspectors they saw staff bullying others in communal areas. Vulnerable people were relying on all staff members to act as their advocates, to help them live their best lives, and it is unacceptable the people they relied on were treating them this way.

“I want to thank the staff who came forward to tell us they felt colleagues were minimising and mis-recording injuries in service records.

“In one case, a staff member incorrectly logged a significant incident where their colleague injured someone twice as unexplained. This is particularly important as leaders had allowed a closed culture to develop and staff who did raise concerns were treated poorly by their colleagues and manager.

“It is hard to make a stand, and we want to acknowledge their bravery.

"Staff who witnessed abuse had reported their concerns to leaders, but these concerns had not been investigated and prior to our inspection action had not been taken to protect vulnerable individuals. In addition, staff described incidents where their colleagues discriminated against a visually impaired person by silently walking away when they asked for help.

“We also found staff had subjected people to restrictive practices by delivering personal care without consent. Staff involved in these incidents told us it had been in the person’s best interest but there was no documentation or guidance that supported this approach.

The Care Quality Commission report on St Petroc's home, Bodmin, describes a "closed culture" which failed to investigate allegations of bullying.  In July an elderly woman died following an incident of "unplanned restraint."  Police investigated what they called an "unexplained death."  The CQC has called for urgent improvements.  It is potentially the worst crisis in any care home in Cornwall since 2016, when the BBC's Panorama programme exposed conditions at the former Clinton House care home,  St Austell, as "grim,, shoddy and unsafe."

“Following these and further allegations made to us through the inspection, we made safeguarding alerts to the local authority about the quality of care provided to seven people living there and shared details of these allegations with the owner, Stonehaven (Healthcare) Ltd. Shortly after the inspection the registered manager left the service.

"We have told leaders at St Petroc's Care Home where we expect to see rapid and widespread improvements and will continue to monitor them closely to keep people safe while this happens. We will return to check on their progress and won’t hesitate to take use our regulatory powers further if people are not receiving the care they have a right to expect.”

Inspectors found:

Care wasn’t private or dignified, with inspectors observing staff members providing personal care in bathrooms with the door open. Inspectors immediately highlighted this to the registered manager and subsequently informed the service’s directors.

Staff had no confidence that concerns would be investigated. Staff described how they had been punished and discriminated against by other staff and the registered manager.

The home consisted of three distinct areas and at night only two staff were on duty to support the 23 people living in the service. This impacted on staff availability and response times while meeting these individual’s needs.

Staff and people living in the service described incidents of conflict that had repeatedly occurred between the registered manager and the previous deputy manager in communal areas of the home.

The service used cut up old towels, with frayed edges as flannels during personal care. The manager didn’t like this, but no action had been taken to improve the quality of flannels, prior to the inspection.

Risk assessments and people’s care plans were not accurate or detailed enough to ensure safe and effective care.

Staff training was not completed at a satisfactory level across the service.

People didn’t feel involved in their care planning.

People’s dignity was not always maintained.

The report will be published on CQC’s website in the next few days.

annenorth@cornwallreports.co.uk