A diabetic resident at a Swindon care home was hospitalised with hyperglycemia when the service stopped providing diabetic diets, a damning report by the care watchdog has revealed.

The manager of Downs View Care Centre in Badbury has stepped down after inspectors found people at the home were not safe and “at risk of avoidable harm”. 

The service for elderly people with varying stages of dementia has been rated ‘inadequate’ in the March report and is now in special measures; less than two years ago it was ‘outstanding’.

A series of failings at the care centre, outlined by the Care Quality Commission’s report, include confidential records not being stored securely, “inaccurate” records being kept and a medicine trolley being left in an unlocked room accessible to residents. 

Inspectors detailed how some elderly people were left sleeping on bare plastic mattresses with no bed linen and were not provided with toothbrushes and toothpaste in their bathrooms.

“By the second day of our inspection the provider had purchased toothpaste and toothbrushes for people and oral health care plans had been created," the report says.

“There was a risk that people living with dementia could access medicines which were not prescribed to them. The staff member continued to leave the medicines unlocked after the inspector pointed out the risk.” 

And staffing issues meant there were not always enough staff members to help meet elderly people’s needs, including support to eat and drink.

One person's relative said: "Sometimes she doesn't have water when we visit. Staffing seems quite low. Sometimes it would seem there are only a couple of them on." 

Staff did not all receive training for handling diabetes, mental health conditions, behaviours associated with dementia or pressure ulcers prevention. The report reveals that medical conditions were “not managed safely”.

The blood sugar of another resident with diabetes reached an “unsafe level” on two occasions in December but health professionals were not consulted.

There were no records of correct processes being followed when the centre stopped providing the specialist diabetic diet.

Staff were not always aware which residents had pressure sores.

The report says: “A district nurse visiting on the first day of inspection was not aware of one person's pressure wound until the CQC inspectors told her. When the district nurse attended to the person, they found a dressing was required."

And “incidents” within the home were not always recorded and investigated.

Some records were found to be “inaccessible, inaccurate” and “could potentially put people at risk of harm”. 

Care plans lacked personal information and one resident's care plan even referred to another person’s name.

During their visit, inspectors witnessed staff handle an outbreak of diarrhoea and vomiting and noted the same sling hoist was used for two different people consecutively. 

They found this presented a risk of cross infection and assessed that infection protection control measures “required improvement”.

One relative explained that the care home’s communication was poor. They said: "Only three emails since [person] has been there. All general, not personal. [Person] has had to go to hospital. Then she had COVID-19 and they did not tell me."

Staff had undertaken training in safeguarding procedures but the inspectors revealed that they were not always able to describe how to safeguard vulnerable people.

CQC inspectors said: “One staff member told us, ‘If I saw a staff member behaving in a bad way, I would challenge it with them. If it carried on, I would report it.’ The member of staff told us they never had to report any safeguarding concerns but had seen bad practice at the service. “

Downs View has now had an experienced manager appointed and the home is now taking new admissions until improvements have been introduced.

Coate Water Care was approached for comment.