'Lessons not learned' at care home where man, 37, died

Sapphire House, in Bradwell, was rated as "requires improvement" in April 2019, but has now been placed in the worst possible category following the unannounced inspection by the Care Quality Commission.

Sapphire House in Bradwell has been put into special measures after CQC inspectors said it had got worse. (Image: Archant)

A spokesman for the home said they were "disappointed" but confident improvements were "well under way".

Regimes at the home came under scrutiny in June 2019 when an inquest heard how staff had neglected type one diabetic James Delaney, 37, who died in his room having not taken his insulin for three days.

At the time senior coroner Jacqueline Lake said she was confident the care home had made the "much needed changes of culture" following Mr Delaney's death and accepted many members of staff had a good relationship with him.

The changes included staff being given "ring-fenced" time to read and understand patients' care plans and documents.

However, a report published on March 11 revealed some things had got worse since the last visit in January 2019 when it was found to be in breach of four regulations.

Watchdogs who visited on January 26, 2021, found a range of concerns at the setting in Long Lane, home to five people with a learning disability or autism spectrum disorder.

An inquest into Mr Delaney's death concluded he died of natural caused aggravated by neglect. Picture: Submitted (Image: Archant)

The inspection team said the setting was unsafe because of issues to do with risk assessments, staffing, and Covid-infection control - although the home had been virus free.

And while there was positive feedback for the new management team, and staff were seen supporting residents positively, there were problems with the "culture, ethos, attitude and practice."

Acting on the whistle blowers' concerns the inspection team looked at the issues of safety and leadership finding them both inadequate.

One staff member said they did not feel safe around a resident whose care plan did not reflect an increasing level of violence.

Meanwhile, a resident was said to have suffered an injury at the hands of another, and inspectors noted a glass ashtray and planks of wood in the garden which could be used as weapons.

There were also concerns about staffing, with rotas showing some staff had worked a 12-hour night shift, followed by a day shift, which was unsafe.

In terms of infection control the inspector was not screened for Covid-19 symptoms on arrival.

Generally the home was "not clean" with "heavy dust" and PPE thrown away in open bins increasing the risk of transmission.

In response there had been a deep clean and new bins ordered, the report said.

There was also "confusion" about whether emergency medicines should be used, or the emergency services called in the event of an episode like a seizure.

The report added that allegations about abusive practices made by the whistle blowers were being investigated by the local authority.

On the issue of being "well led" the report said leaders and the culture they created "did not ensure the delivery of high-quality care."

Elsewhere it said "lessons had not been fully learnt" from previous breaches.

Relatives spoken to by inspectors, however, spoke highly of management saying they went "the extra mile".

The home has been asked to draw up an action plan, and external agencies are said to have confidence in the new manager being able to make improvements.

A statement from its operations manager said: "Whilst we are very disappointed with the outcomes of the inspection and the findings of the CQC inspector, many which have already been identified by the new management team, we take these observations on board and we are confident that improvements are well under way.

"Our priority remains with the wellbeing and safety of our service users, and we are dedicated in working alongside our local quality assurance team to ensure that standards are raised and maintained.

"Our team continues to work tirelessly to keep our service users safe, as they have done throughout the pandemic, and we have managed to remain covid free."

Being in special measures means the care home will be inspected within six months to check for significant improvements.

If none are made the CQC will take take enforcement action.