It's emerged that the Sidbury care home at the centre of a police inquiry over a deadly Covid outbreak was told not to admit any more residents shortly after a Care Quality Commission inspection in February.

The Covid outbreak was first reported soon after the second inspection. Eleven residents of the Holmesley Care Home died after contracting Covid, and two members of staff were arrested.

The 57-year-old woman from Sidmouth and 30-year old man from Exeter were held on suspicion of wilful neglect, and the police investigation is still ongoing.

The Care Quality Commission (CQC) report, published today, reveals that the inspectors had concerns about infection prevention and control procedures at the home during their visit.

Shortly after the second day of the inspection, February 26, the CQC imposed strict conditions on admissions because inspectors were concerned about the safety of care provided to residents, as well as governance of the service.

The conditions prevented Holmesley Care Home from admitting new residents, or re-admitting former residents without prior written agreement from CQC. Management were told to ensure that systems were in place to prevent and control the spread of Covid-19 to protect patients and staff.

Inspection was prompted by other concerns

The CQC inspection had been carried out to follow up on specific concerns the health watchdog had received about other care issues. They related to staff not treating people with dignity and respect, people not receiving care in a timely way or at times that suited them, low staffing levels, a lack of staff training, and unsafe moving and handling practices used on people.

Once it became clear that there was an outbreak, the provider worked closely with the local authority and CQC to ensure people's safety. A senior infection prevention control nurse visited the home in March to provide support and advice regarding management of the outbreak, and found no major grounds for concern.

Holmesley Care Home's rating for safe and well-led deteriorated from good to inadequate. The service was inspected for its effectiveness for the first time and was rated 'requires improvement'.

Staff 'not wearing face masks properly' shortly before Covid outbreak

Amanda Stride, CQC's head of adult social care, said:

"When we inspected Holmesley Care Home, we found that people were not protected from the spread of infection.

"During the first day of our inspection we observed seven members of staff wearing face masks under their chin, or not at all. Soon afterwards, the care home experienced a widespread outbreak of Covid-19. As the circumstances which led to this are now subject to a police investigation, we are unable to comment further on this.

"There were also widespread and significant shortfalls in the way in which the service was led. Residents were at risk of neglect and abuse because systems to monitor the quality of care were either not in place, or not operating efficiently.

"We will continue to monitor the service closely, in conjunction with the local authority, to ensure that improvements are made and fully embedded. We will also meet with the provider to discuss how they plan to make the required changes to improve their rating and we will re-inspect to check the improvements have been made."

Inspectors found the following areas of concern.

• Staff did not always have the training, assessment and supervision needed to ensure they know how to perform their roles.
• Staff did not have a clear understanding of their roles and responsibility under the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and were making decisions for people which they should not have made.
• Systems and processes were not robust enough to identify where things had gone wrong, so that lessons could be learnt.
• People's needs were not always assessed, and poor record-keeping meant the home was unable to demonstrate that they were delivering good care.
• Some care plans lacked essential details and instructions. Daily records and charts were not sufficiently detailed to demonstrate what care had been provided and some people's records indicated that they had not been checked for long periods of time.
• Systems that had previously been in place to review risks to residents, such as falls, accidents and incidents, had not been maintained.

The full report can be viewed here.