A care home in Liverpool for people with learning disabilities, autism and mental health needs has been rated inadequate and placed in special measures following an inspection by the Care Quality Commission (CQC).

The CQC initially set out to investigate the home to look at how the service was preventing and managing Covid-19 outbreaks, but due to issues found during the inspection, it was widened to include whether it was safe, effective, caring, responsive and well-led.

Gracefield Health Care Limited (GHC) on St Domingo Grove was rated inadequate on all five areas, leading the inspectors to place the home in special measures.

Issues identified during the inspection were in relation to safe care and treatment, safeguarding people from abuse, consent, recruitment practices, person centred care, governance and treating people with dignity.

Physical and verbal abuse by staff

Hayley Moore, CQC’s head of adult social care inspection, said: “During the inspection, we found people were at risk of serious harm as the service wasn’t well-led. The registered manager wasn’t aware of incidents involving physical restraint, which meant there wasn’t any oversight to ensure these practices were the most appropriate intervention or that they were carried out safely.”

One of the residents told the inspectors they had been physically and verbally abused by a member of staff and had reported this to the manager, yet no action was taken. The inspectors also found that some people had unexplained bruising, but there was no follow up action taken and no evidence staff shared these concerns with relevant partner organisations.

Covid-19 safety protocols were not followed, and staff were seen to walk through the home at the start of their shift touching surfaces before doing a test, increasing the risk of infection spreading to people living in the home.

General hygiene and cleanliness were also poor, and the inspectors found dirty carpets, doors and handrails. One person’s mattress was heavily stained and another person’s duvet was soiled.

Privacy, dignity and independence not respected

Additionally, people’s privacy, dignity and independence were not respected, and the inspectors note that one person was on the toilet with the door open and three staff members present, allowing inspectors to walk past with no consideration of the person’s privacy or dignity.  

Another person’s bedroom had no bed linen, ripped curtains, a smashed window, no toilet seat, damaged walls and clothes were lying on a chair as they had no access to a wardrobe. There were no plans to refurbish the room to improve the conditions, despite the fact the person was visibly upset with their environment.

Ms Moore said this was “totally unacceptable” and it was clear that St Domingo Grove was failing to guarantee its residents “respect, equality, dignity, choices and independence and good access to local communities.”

The CQC will now continue to monitor service to ensure the people who live there are safe. If the inspectors are not assured people are receiving safe care during the next visit, Ms Moore says the CQC “will not hesitate to take further action.”