Mansfield care home rated ‘inadequate’ after failing to tell inspectors it had a legionella problem

Beechdene Care Home in Woodhouse Road, was looking after 14 people with learning disabilities at the time of inspection.

Inspectors said the home was already due to close within a few months.

The legionella was treated and no-one fell ill.

But the home was rated ‘inadequate’ after the checks from the Care Quality Commission (CQC) in November 2023 and placed in special measures.

Inspectors held the unannounced visit after concerns were received about safety and staffing from members of the public and other organisations.

The home was rated ‘inadequate’ overall and also in two specific areas – safe and well-led, and ‘requires improvement’ in three other areas.

The last rating was ‘good’ in 2019, when it was run by a previous provider.

A risk assessment found the home was at high risk of developing legionella bacteria in the water system.

Legionella bacteria can be inhaled in droplets of water and result in serious ill health from Legionnaires disease.

The risk assessment required refurbishments to be put in place within one month, but these had not been completed.

The home said it would inform the CQC within two hours if legionella developed.

But the report said: “When we returned to the service a few days later, we found legionella had developed in the water system.

“This bacterial outbreak had been effectively treated.

"However, the provider had not followed the action plan as we had not been informed of the positive legionella test.”

Inspectors also found alleged abuse was not referred to the local council to investigate.

"Staff had recorded a person harming another person living at the service three times in a month.

These incidents had not been referred to the local authority safeguarding team to investigate.

Inspectors also said the environment was ‘not safe’ with residents at risk of scalding in the showers, burning from uncovered radiators and illness from food being stored in fridges that were too warm.

Inspectors added: “People were also at risk of falling from open windows.

"Multiple windows in the property could open wide enough for people to climb out or fall from.

"This could result in serious injury.”

Inspectors said the home was unclean with bathroom light pullcords ‘visibly dirty’ and some bathroom taps were broken or did not have soap.

Some medicines were also not stored correctly.

The report added that people were not always given privacy.

The kitchen could be accessed via a person’s bedroom and staff were ‘seen repeatedly’ walking through the bedroom to enter the kitchen.

Another resident said their bedroom blinds had broken a year ago and they had to get changed in another room for privacy.

Since 2005, people with learning disabilities should have a health action plan including guidance on conditions and treatment.

Additionally, there were no health action plans stored at the home.

The report added that ‘staff were recruited safely’ and ‘references had been gathered from previous employers to ensure the staffwere of good character’.

The report said that there were no recorded complaints and relatives felt any concerns would be acted on.

The home did not respond to a request for comment.