A Norfolk care home, run by the former owners of Cawston Park hospital, where three patients died, has been rated as inadequate after inspectors raised "serious concerns".
Treehaven Rants, which provides residential care for people with learning disabilities and/or autism, was "dirty and poorly maintained" and not safe for patients, inspectors from the Care Quality Commission (CQC) found.
The home, in West Runton, is run by Jeesal Residential Care Services.
The Dereham-based Jeesal group also ran the now closed Cawston Park hospital, near Aylsham, which was recently subject to a scathing report over the quality of its care.
During their two-day unannounced inspection in July at Treehaven Rants, triggered by concerns raised by Norfolk County Council, inspectors found there were not enough suitably qualified, competent, skilled and experienced staff on shift.
They found a number of breaches of the Health and Social Care Act, including that residents at the Sandy Lane home were not protected from the risk of abuse or from avoidable incidents and accidents.
The home, which has capacity for 12 people, but had eight people living there at the time of inspection, was downgraded from its 2019 good rating to inadequate and placed in special measures.
Inspectors said: "We identified a continued decline in the environment people were living in, a poor response to the Covid-19 outbreak and infection control processes.
"High levels of incidents and accidents put staff and people using the service at risk and adequate safeguards were not in place.
"Systems and processes were not in place to monitor, assess and evaluate people's risk assessments and care plans.
"This meant people were at risk of receiving unsafe care and care was not adequately planned around people's assessed needs.
"The environment was no longer fit for purpose, neither was it hygienically clean.
"We found multiple issues with the environment which posed some immediate risks and had resulted in one person being temporarily removed from their flat without consultation with family or other health care agencies to ensure it was in their best interest.
"We found no evidence that staff were routinely cleaning the service or that enhanced cleaning schedules had been put in place since Covid-19. The building was visibly dirty throughout."
Inspectors said the registered manager was not well supported and the provider had not invested in staff training, with high turnover.
Inspectors said: "People did not receive safe, well planned care by staff who were familiar with their needs.
"Frequent changes of staff and poor forward planning and communication put people at risk.
"A poor staff culture meant staff were not working together in a cohesive way to make lives for people living at the service better."
And the home was not reporting incidents of abuse or allegations of abuse.
Inspectors said: "During our inspection we identified that the service was not routinely reporting: any abuse or allegation of abuse in relation to a service user.
"It was also not reporting anything which could affect the service provider's ability to continue to carry on the regulated activity safely, such as staff shortages, and physical damage to the property."
Inspectors have asked the owners to produce an action plan on how they intend to improve.
That means the CQC will keep it under review and could propose to cancel its registration. If the watchdog does not go down that route, then it will re-inspect in six months.
If improvements have not been made it could take action and stop the home from operating.
Jeesal Residential Care Services has apologised and said it is taking action.
But the inadequate report further shines the spotlight over the quality of care provided by the group, particularly following the deaths of Cawston Park patients.
Ben King, 32, Nicholas Briant, 33, and Joanna Bailey, 36, died within just over two years of each other while they patients there
Dr Margaret Flynn, the author of the scathing report, commissioned by Norfolk Safeguarding Adults Board, called on the government to reduce the use of such hospitals.
The Jeesal Akman Care Corporation had apologised and said the care the three received was "far below the standards we would have expected".
Last week, Bill Borrett, Norfolk County Council's cabinet member for adult social care, urged families with loved ones in the company's nine Norfolk care homes to consider moving them out.
We have contacted Jeesal about the Treehouse Rants report.
The EDP is keen to speak to family members who are concerned about the care their loved ones have received. Email newsdesk@archant.co.uk
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