A care facility where one resident went three days without food and another “turned blue” while lying flat in a shower has been plunged into special measures.
It is the second time in three years Strode Park House in Herne Bay has found itself under fire for the quality of its care – with its most vulnerable residents left at the most risk.
Strode Park House in Herne Bay has been given the worst possible rating by Care Quality Commission
The Lower Herne Road facility – which cares for adults with physical disabilities and complex needs – has been slapped with the worst available rating of “inadequate” by the Care Quality Commission (CQC).
CQC carried out the inspection after receiving notifications of numerous medicines errors – but the inspection in July laid bare other issues within the home, with the report published today (Thursday) for the first time.
One person admitted for respite care received “limited hydration and no nutrition for three days” because staff failed to document their feed regime.
Inspectors said the error placed them at risk of dehydration and significant weight loss.
Inspectors visited Strode Park House in Herne Bay earlier this year. Picture: Google
People who needed feeding tubes were found to be at risk of choking as staff did not always position residents correctly.
In another case, a resident “turned blue” when left lying flat on a shower tray. Staff raised the headrest to relieve the situation, but there was no written guidance anywhere in the service about how to position people safely during personal care.
The report says there had been “numerous medicine errors” and that similar concerns had been flagged previously.
Staff were using an electronic system that required them to manually re-enter prescriptions, but many were incorrectly transcribed.
One resident went a whole week without essential blood-thinning medicine because it had been missed from the records.
CQC inspectors described Strode Park House in Herne Bay as unsafe. Picture: Stock photo
Despite some positive comments about long-term residents who enjoyed independence, inspectors said people who could not express their needs did not always receive person-centred care.
Activities were described as limited, and some residents said staff shortages meant they were not supported to get up in time to join them.
A CQC manager explained “people weren’t always treated with dignity or in a way that upheld their rights”.
The service was also criticised for breaching mental capacity rules.
People who lacked capacity had been moved rooms without individual assessments or best-interest decisions.
Photographs of residents were posted on social media without any documented consent or evidence that relatives had the legal authority to agree.
The CQC branded the service “inadequate” in three of its five categories – safe, effective and well-led – and warned it had deteriorated sharply since its last visit.
“There was no one in overall charge of a shift who had a complete picture of people’s care, to make decisions and referrals to healthcare professionals,” said the report.
“The management of risk and medicines was poor, there was limited guidance for staff to reduce risk.
“There was no effective system in place to learn lessons from incidents. The provider had not always followed the Mental Capacity Act 2005 (MCA) when decisions were made about people’s care and support.
“People were not safe, and were at risk of avoidable harm.
“The effectiveness of people’s care, treatment and support did not achieve good outcomes or was inconsistent.
“People did not always feel well-supported, cared for or treated with dignity and respect.”
CQC has placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements.
Amy Jupp, CQC deputy director of operations in Kent, said: “Leaders hadn’t identified or acted on serious safety concerns.
“We saw some people required bed rails for safety, but risks of injury or entrapment hadn’t been assessed, and bumpers were only fitted after unexplained bruising occurred.
“People receiving nutrition via feeding tubes were at risk of aspiration or choking because staff weren’t given clear guidance on how to prevent it.
“In one incident, a person turned blue while lying flat on a shower tray this was only resolved when staff raised the headrest.
“We expect health and social care services to ensure all people receive safe, dignified and respectful care that promotes independence, choice and equality.
“It was unacceptable that leaders had allowed a culture to exist where people’s basic safety, rights and freedoms were not protected.
“We’ve told leaders at Strode Park House where they must make urgent and significant improvements, and we’re monitoring them closely to keep people safe while this happens.”
A spokesperson for Strode Park Foundation, which runs Strode Park House, told KentOnline: “Strode Park Foundation manages six registered services, and five are currently rated Good by CQC.
“We are confident that the quality of care at Strode Park House is also good, and we will continue to work with our NHS partners and KCC to ensure an improved rating will be achieved at the next inspection.”