STAFF numbers at a Haydon Wick care home were too low to ensure the safety of residents, the health regulator has said.

Despite staff and resident representatives’ concerns about low staff levels at 83-bed Orchid Care Home, “nothing had been done”.

In a damning report, the Care Quality Commission criticised the management at Orchid Care Home as inadequate, with “widespread and significant shortfalls in service leadership”. There was no registered manager in post.

The care home had breached four areas of the health regulations.

The CQC demanded managers send them an action plan detailing the improvements after being told by health professionals that staff levels at the home were insufficient.

It was last inspected in 2018, when the CQC found numerous regulation breaches and the service was rated as requiring improvement.

Seven months later, the regulator said issues previously flagged by inspectors had still not been addressed.

The CQC wrote: “We found improvements had not been made and the provider continued to be in breach of the regulations.”

Inspectors would be meeting with the care home and Swindon Borough Council to discuss improvements.

The CQC said: “People told us they felt safe living at the service. However, we found people were not protected from all risks because assessments regarding the risks of mobility and falls were not always reviewed and updated following an incident.

“Accidents and incidents were not always analysed for trends and patterns which resulted in some people not being referred to health care professionals. People told us there were not enough staff to keep them safe.”

And inspectors heard that managers had been repeatedly warned about inadequate staffing levels. At one meeting between group Friends of Orchid Care Home and the management team, the issue had been raised.

But the CQC said: “The management team had not effectively investigated staffing levels or reviewed people’s dependency assessments and the tool used to calculate staffing levels.

“Staff told us they had asked the deputy manager to increase the staffing levels, however, nothing had been done to address this issue. A member of staff told us, ‘we’ve been going on about having more staff but nothing has been done’.”

Staff were unable to provide safe care with existing workforce levels: “One of the registered nurses told us, ‘We have two healthcare assistants and one nurse at night. At the moment we have 29 people in this unit.

“As one person is allocated one-to-one hours, one of the healthcare assistants goes to that person which leaves only one healthcare assistant and one nurse for the whole unit. Two staff members cannot manage at night.”

The situation was improving under an interim manager, staff told inspectors. The previous manager had stepped down to become deputy at the home.

However, inspectors raised concerns about care plans being reviewed by more senior staff who “did not know people’s needs well and therefore were not accurate”. “One member of staff said, ‘People’s dependency needs proper reassessing. [The deputy manager] has done that not knowing person’s needs’,” the CQC wrote. Care plans are used to direct the support offered to residents at the home.

Staff morale was low, with high levels of stress and work overload. Reporting of incidents, risks, issues and concerns was said to be “unreliable and inconsistent”. The CQC was not always notified about accidents, incidents and even, in one case, an allegation of neglect.

A spokeswoman for Orchid Care Home said: “Our first priority is the safety and wellbeing of residents. We take feedback from the CQC extremely seriously and are working closely and transparently with all relevant authorities to implement necessary improvements.

“Following the inspection we immediately implemented a comprehensive improvement plan which included raising staffing levels and appointing a new and experienced home manager. The senior management team is also working closely with staff at the care home to provide continued and robust oversight.”

The home offers nursing care and has a specialist dementia unit.