Overdene House, which is registered to provide support for up to 70 people over 65, was caring for 50 people at the time of the inspection.
The CQC report said: “We previously carried out an unannounced comprehensive inspection of this service on 15 February 2017. Breaches of legal requirements were found.
“The registered provider had not notified the CQC of two events that had occurred within the service as required by law. After this was raised with the manager these were submitted to the CQC.
“This inspection was unannounced and took place on April 21 and June 9. It initially started as a focussed inspection to look at concerns that had been raised in relation to the ‘safe’ and ‘well led’ domains.”
The service did not have a registered manager in post. The previous registered manager had left shortly before the inspection in April 2017. At the time of the inspection visit the deputy manager was running the service with support from the area director.
The report didn’t provide comment on the concerns being investigated by the police, as the investigation is still underway.
“People were not always protected from the risk of harm. For example staff did not have a good knowledge around people’s dietary needs which had resulted in two people being given an inappropriate diet, and one person choking. Effective measures had not been put in place following initial incidents which had enabled the incidents to reoccur. This showed poor risk management and placed people at ongoing risk of harm.”
Staff had not always received the training they needed to carry out their role effectively, and staff had not received supervision or appraisals.
A spokesperson from the company said: “We were very disappointed by the CQC findings from the inspection in June. We take all feedback from the regulator very seriously and, since the last inspection, we have implemented a robust action plan to directly address the CQC’s concerns. A new home manager is in place who is being supported by the wider regional team, and we are pleased with the progress that is being made.
“We are continuing to work closely with the CQC, local authorities and relatives groups as we strive to provide the high quality care that Residents expect and deserve.
“We look forward to welcoming the CQC back to the home in the near future to show them the progress that we are making.”