A Nantwich care home where tragic pensioner Roy Tomlinson disappeared and was found dead days later, has been ruled as ‘inadequate’ by Care Quality Commission.
Brookfield House Care Home, on Shrewbridge Road, is now being placed in ‘special measures’ by CQC after it was found to be failing in many areas.
Mr Tomlinson, 83, was found dead in an outbuilding off Wellington Road, just a few hundred yards from the home in February.
A massive police search involving more than 100 officers, search and rescue volunteers and many residents was conducted for six days.
CQC inspectors called at the home unannounced twice in February after Mr Tomlinson’s death, and again in April after a second dementia patient was allowed to walk out unchallenged.
Now, in its report published this week, the full scale of failures at the home owned by Astley Care Homes Ltd in Birmingham have been unveiled.
The CQC report states inspectors “found that the premises were insecure on the first two visits of our inspection”.
“The registered persons had not responded effectively to assess, monitor and mitigate risks
and had failed to improve the quality and safety of services provided,” it continues.
“We identified breaches of the relevant regulations in respect of the need for consent, safe care and treatment, premises and equipment, staffing and good governance.”
Special measures means the home’s owners will need to show care can “significantly improve” an provide a clear time frame to improve the quality of care or face further action.
“It will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take
action in line with our enforcement procedures to begin the process of preventing the provider from operating the service,” the report continues.
“This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
“The service will be kept under review and if needed could be escalated to urgent enforcement action.
“Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.”
It states the service was “not safe”.
“The health and well-being of the people who lived at the home was at risk because the registered persons were failing to provide care in accordance with each person’s assessed needs.
“Managers and staff were not doing all that was reasonably practicable to identify, control and mitigate risks and ensure that people were protected from unsafe and ineffective care.”
It also states the leadership of the home was “inadequate”.
“The registered persons had failed to ensure the premises were sufficiently secure to protect vulnerable people from harm.
“They did not learn from mistakes and failed to make required improvements in a timely manner resulting in vulnerable people being placed at risk of severe harm.
“Systems and processes established to ensure compliance with the regulations were not always operated effectively so the health and well-being of the people who lived at the home was not assured.
“Records which should have been written contemporaneously were written up in advance or retrospectively rendering them of little or no use in the protection of vulnerable people.”
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