Two care home residents were 'seriously hurt' after getting into a fight, according to an official report.
The incident was among a series of concerns highlighted by the Care Quality Commission (CQC) following an inspection at The Old Vicarage in Ludham.
They placed the facility, which is run by the Ashley Care Group, in special measures, rating it inadequate in every area.
The watchdog said the home was in breach of numerous regulations regarding safe care and treatment, person-centred care, need for consent, staffing and good governance.
Inspectors found there was no registered manager at the time and that there had been a high turnover of management since a previous inspection in June 2023.
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They also identified problems with the recording of accidents and incidents on the site.
According to the report, two people using the service had a physical altercation with no staff present resulting in significant injuries to both.
A similar incident had occurred a few days before, with the same people, but staff intervened.
There were 25 residents at the time of the inspection, which took place in January this year.
Bosses at the home have criticised the CQC, saying the "delay" in publishing the report undermined the hard work that has taken place over the subsequent six months.
Among the CQC's findings were that:
- care plans and risk assessments were generic and lacked person-centred information
- overflowing, unlocked bins were filled with clinical waste
- staff were not consistently supporting residents in a respectful way
- the service was not well-led and there was a high turnover of managers
READ MORE: Care home suffered more than 100 health and safety incidents in just six months
Stuart Dunn, CQC deputy director of operations in the east of England, said: “Our experience tells us that when a service isn’t well-led, this has a knock-on effect to the level of care being given, which is what we found when we inspected The Old Vicarage."
At the inspection in June 2023, the CQC rated leadership as inadequate, and at the January inspection they found the level of care being provided to people had "deteriorated further".
“It was clear to us that the service wasn’t well-led. Staff told us there’d been a high turnover of managers and that lack of consistency was impacting on their ability to provide good care.
"They also told us management hadn’t provided them with effective systems to enable them to provide the best possible care for the people who call The Old Vicarage home," Mr Dunn said.
During the inspection, CQC made referrals to the fire service due to concerns about the home’s physical environment, and also to the local authority due to safeguarding concerns.
The CQC said the service will be kept under close review to ensure rapid and widespread improvements are being made, and to keep people safe while this happens.
But the Ashley Care Group, which runs The Old Vicarage, has hit back at the CQC, and urged the watchdog to "establish clear timelines for publishing reports on care homes".
They said the report's delay - six months after the inspection - can undermine the hard work and improvements made by care homes.
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Ashley George, CEO of The Ashley Care Group, said: “We’re devastated that CQC has released the report so late.
"Our team has worked tirelessly over the past six months to improve our services and rebuild trust.
"We have been communicating with CQC every month sending all action plans and updating them on the new governance systems that are now in place.
"They know the report doesn’t reflect where we are now. The late release of this report negatively impacts our team and the families we support," he added.
A statement on behalf of the care home said: “Since January, we’ve introduced new technology for improved reporting, updated personalised care plans with residents and families, and introduced key workers.
"We also have the support of an in-house trainer. The Old Vicarage has been transformed into a positive community with excellent feedback."
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