St Petroc's Care Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

We carried out an unannounced on site assessment between 18 and 27 September 2024. We carried out our unannounced first on site assessment on the 18 September 2024 which began in the early morning to enable overnight staffing arrangements to be assessed. A second on site assessment occurred on the 27 September 2024. This assessment was completed following concerns raised to CQC in relation to deaths at the service, overnight staffing arrangements and the use of restraint. We looked at the key quality statements, safe and well-led. The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of unplanned restraint. This inspection examined those risks. We identified 7 breaches of the regulations. These were in relation to person-centred care, dignity and respect, consent, safe care and treatment, safeguarding and the use of restraint, staffing and management of the service. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

People's experience of this service

People were exposed to risk of abuse and harm as staff did not have the skills and training necessary to meet their needs. People told inspectors they had witnessed staff ‘bullying’ other people in communal areas. Staff reported that incidents where people had sustained injury had been minimised and or misrecorded in the service' records. These failures in combination with the lack of effective oversight by the provider had enabled a closed culture to develop which exposed people to additional risk. People’s dignity was not consistently respected by the staff team and inspectors witnessed people receiving personal care in toilets with the door open. People’s choices and decisions in relation to how and when personal care should be provided had not been respected. Records showed staff had used unplanned restraint to enable them to provide personal care against people’s wishes.