'Significant abuse' uncovered at Leagrave care home placed in special measures by CQC

CQC inspectors visited Capwell Grange Care Home on Addington Way on July 16 and observed poor Covid-19 infection controls, as well as direct episodes of abuse.

One resident was witnessed screaming in the shower and then pushed by staff - wet and dripping - to their bedroom, with only towels draped over them.

Another resident was found lying unattended after a bed-wetting incident, which posed a risk to their skin care as well as personal hygiene.

The report, published last week, stated: "There had been two significant allegations of abuse, prior to our inspection.

"Some staff and nurses had known about the abuse but had not told anyone about this. Some staff were aware of the alleged abuser's concerning behaviour outside of Capwell Grange, but this had not raised their suspicions. Nor did they tell a manager about this.

"When we spoke with a sample of staff, most had a poor understanding about what abuse could look like..."

Beds Police and Luton Borough Council were eventually contacted by the care home's manager about the abuse allegations, but the inspection team found that leaders still did not have a "robust" approach to safeguarding.

The inspection team also found serious concerns with Covid-19 management at Capwell Grange, with a coronavirus outbreak taking place shortly after the inspection.

The report added: "The manager, unit lead and staff told us a person had Covid-19, and their bedroom door was open when we visited.

"Next to the person's room, a PPE (personal protective equipment) station was set up for staff to wear the right equipment when entering this person's room, however visors were not made readily available as per Public Health England's (PHE) guidance...

"A person in the same unit had a fan on in their bedroom and their bedroom door left open. This can increase the risk of this virus spreading. Also, the person opposite this bedroom had health needs which put them at very high risk of becoming ill or dying if they contracted the virus."

Capwell Grange is run by HC One care home group, after being sold by BUPA in 2017.

A HC One spokesman said: “The health, safety and wellbeing of our residents is our number one priority, and we take all feedback from the Care Quality Commission (CQC) very seriously.

“We were therefore deeply disappointed by the CQC’s findings from the inspection in July and we acknowledge we fell short of the high standards our residents rightfully expect and deserve. We have a comprehensive action plan in place, the implementation of which is being overseen by our senior regional team and significant improvements have already been made.

“We have appointed an experienced home manager who will start at the home soon. The home also gained an experienced deputy manager earlier this year, who now has full oversight of all clinical matters. We have also appointed a new weekend Manager to provide further support and full clinical oversight on the weekends.

"Additionally, our learning and development team is supporting colleagues make sure they have completed our bespoke and comprehensive training programme, including our additional infection control training, which has been expanded and updated to reflect the latest government advice on coronavirus. All nurses at the home are also being supported to refresh their training in all areas.

“The home has implemented HC-One’s coronavirus contingency plan and we are confident in the infection control processes the home has in place to allow the team to continue to deliver the highest quality care during this challenging time.

"We are working closely with all relevant authorities and have received positive reports on our progress since the CQC visited. We are determined to continue making improvements and to ensure that these are sustained. We are confident that, by the time of our next inspection, the CQC will be able to see further improvements.”

Although the care home is run by HC One, Luton Borough Council and Luton Clinical Commissioning Group (CCG) have stepped in to safeguard residents and a temporary block has been imposed upon new admissions.

A council spokesman said: “The safety and welfare of vulnerable adults is of paramount importance to the council and Luton Clinical Commissioning Group (LCCG). Therefore a joint exercise was undertaken in implementing our 'Escalating Concerns Procedure' to ensure that individuals currently residing at the home are safeguarded. This has resulted in a voluntary embargo being agreed with Capwell Grange in regard to new admissions.

“Capwell Grange are working to an improvement plan to address the identified shortfalls in quality, which we are monitoring to ensure timely and sustainable improvements are achieved.

"As part of our ongoing work with Capwell Grange, we will be conducting unannounced visits to the home to ensure individuals are safe and their needs are being met. We will continue to work with the home to ensure they have robust quality assurance processes in place to deliver the services to individuals safely and effectively.”