Shock findings at council-run nursing home in Keynsham

A council-run nursing home in Keynsham has been rated as Inadequate after a team of inspectors revealed shocking findings.

The report, published today, follows a three-day inspection of Charlton House Resource Centre in Hawthorns Lane that was prompted by safeguarding concerns. The council has tonight apologised.

Charlton House provides support to people living with dementia, older and younger people and those living with a physical disability. At the time of the inspection there were 29 people there.

The catalogue of concerns includes:

One person’s records stated they were found with their window “wide open” and just a sheet for warmth. Their temperature was recorded as 35°C, placing them at increased and avoidable risk of hypothermia.

The provider failed to ensure people were supported to access emergency medical support without delay. One person fell and trapped their arm, which was said to be “purple” in colour. Staff failed to contact the GP until two hours later. Another person told staff they had experienced a stroke; staff recorded the person had arm weakness. Staff failed to seek emergency medical assistance until approximately seven hours after the stroke was first reported. On arrival to hospital, it was confirmed the person had experienced a stroke.

People’s sensor alarms were inexplicably turned off and their doors closed. One day a person suffered two unwitnessed falls, on both occasions the bedroom door was closed and the falls sensor inexplicably turned off. The person had been assessed as being at “high risk of falls”.

Soiled items were not always stored in ways that helped to minimise the spread of infection. Inspectors found one bin in the communal bathroom was “overflowing with soiled items”.

The provider failed to ensure people were consistently and robustly protected from abuse, and the risk of abuse. There was no oversight of safeguarding. Photographs showed one person with an imprint of a watch on their wrist, bruising and marks to their torso. The registered manager did not know who the victim was, or that the photographs existed. This meant that no action was taken to investigate, or refer, the cause of the injuries. The provider failed to implement processes that ensured potential safeguarding concerns were investigated effectively and immediately. One safeguarding investigation was delayed because the lead investigator felt “shocked from the distress of the situation” despite the investigator identifying in the same report a staff member was “mocking and taunting” a person and that other recordings were evident.

The provider failed to implement robust, preventative measures in response to the same concerns. For example, staff used mobile phones to record people covertly, without their consent, and mock a person with dementia. However, the provider allowed staff to continue bringing their mobile phones into work, while on duty for approximately two months after they were aware of the recording.

During a late-night visit as part of the inspection, two inspectors accessed the service without being asked for identification by staff until they reached the first floor.

The provider failed to ensure medicines were managed safely.

There was a failure to ensure agency staff had moving and handling training required for their roles. On one occasion, a person fell and sustained a fracture. The staff member lifted the person into bed from the floor, without using equipment or additional staff support. An investigation found the staff member did not have practical moving and handling training. The provider failed to ensure that subsequent agency staff working in the service had received practical moving and handling training.

The CQC report also says: “We observed there were not always sufficient numbers of staff to attend people. For example, when one person fell and required support from three staff, there were no additional staff to meet the needs of other people using their call bells. On another occasion in the dining area we observed a person calling, “Nurse” for approximately 10 minutes before they were attended.”

There was also a failure to ensure records were stored securely. The inspectors observed people’s care plans unattended in the lounge, meaning confidential information was accessible to anyone.

Yet another shocking finding was that the provider failed to identify the service’s mobile phone contained photographs of people, including of their intimate areas. While the photographs were taken to document wounds or injuries, some were over a year old and should have been deleted to protect people’s dignity and privacy.

The report also notes: “The registered manager and provider were aware of their responsibility to act openly and transparently when things went wrong. However, when notifiable safety incidents occurred, they did not always act in line with the regulation and issue a written apology.”

The Week In understands that the Abbey Park unit at Charlton House is closing from Wednesday 30th November and has told relatives of residents that this is to “focus on getting things right in the home”.

In July we reported that the Care Quality Commission had told Charlton House to make improvements in terms of being safe, effective and well-led. The home had previously been inspected in 2018, when it was run by Sirona care and health. It required improvements in the same categories back then.

Read the latest report in full at

Report ‘distressing to read’ says council as apologies for failings

Bath and North East Somerset Council has tonight apologised for the failings set out in the Care Quality Commission inspection report.

Cllr Alison Born, Cabinet member for Adult Services and Council House Building, said: “Our purpose is to improve people’s lives which makes reading this report very distressing. No amount of explanation can get away from the fact that we have let people down and I want to apologise to the residents and their families who will find this report very difficult to read.

“I want to reassure residents and their families that an action plan to improve the care provided at Charlton House is in place, which the Care Quality Commission has approved. We took immediate action following the inspection and this will continue. We have written to families and met with them and we will continue to keep everyone updated as we work to make the improvements that are needed

“We are all aware of the crisis facing the care sector. It is a fact that staffing in adult social care is at breaking point. However, the safety of our residents has to be our priority and we agree with the CQC that some aspects of the care residents received was unacceptable.”

Following the inspection the council says it has:

  • Made immediate staffing changes to improve the quality of care provided at Charlton House.
  • Supported staff at Charlton House to help them continue to provide care to residents in such challenging circumstances.
  • Reported a number of concerns about the actions of agency staff to the relevant regulatory body.
  • Closed the home to new admissions and reduced bedspaces so we can focus our staff on delivering the best possible care to permanent residents.
  • Been open about the issues raised in the CQC report and discussed them with residents and their families.
  • Agreed an action plan, approved by the CQC