A care home at which a 90-year-old with dementia and Parkinson's fell and broke his neck has been put into special measures by the Care Quality Commission (CQC).
Peter Dawson died in hospital after suffering three unsupervised falls in one day at Brundall Care Home last September.
Following an inspection of the service in February, on May 4 the CQC rated the care home inadequate, saying they had 'identified widespread failings in the service which put people at risk of harm'.
Eastern Healthcare Ltd, which runs the service for up to 39 people, said it has 'introduced a robust improvement programme' to address the issues.
They included a 'lack of oversight' of the risk of potentially fatal Legionella's disease, a 'lack of staff presence' for residents at risk of falls, 'chaotic' meal times, and that the home 'did not have sufficient end of life care plans in place'.
The CQC had previously taken enforcement action against the service after it was rated inadequate in two earlier inspections.
Despite a temporary improvement in 2016, inspectors this year found it 'had not been sustained'.
MORE: 90-year-old's last days turned into nightmare after care failings
Inspectors found the home in breach of six regulations in the Health and Social Care Act 2008 and that a GP had recently raised concerns about the service.
Their report added there was 'ineffective oversight over falls and other incidents in the service'.
'The manager told us there had been no falls in January or February 2018 and there were none noted on their record of falls,' inspectors said. 'However, care records we reviewed and discussions with staff indicated that people had fallen in this time.
'In addition, the operations manager told us that one person was found on the floor earlier on the day of our inspection. 'Care records indicated one person had fallen three times in 2018, but the manager was unaware of this and had not taken action to put in place strategies to reduce the risk of them falling again.'
'There were not enough staff to provide people with support when they needed it,' they added. 'The manager told us there were three members of care staff and one team leader on each day shift. 'The manager said there were six people using the service who may require the assistance of two care staff to mobilise or for personal care. 'This meant that if two people required support at any one time there would be no care staff available to provide support to anyone else using the service.'
To read the CQC report click here.
Welfare of residents 'top priority'
Inspectors from the Care Quality Commission said they were so concerned following the inspection they requested urgent information from Eastern Healthcare Ltd to reassure them they would take immediate action.
They said the response was 'adequate in reassuring us that action was being taken to make the service safe'.
Marc Scott, operations manager at Brundall Care Home, added the team is busy addressing the issues identified by the CQC in February.
He said: 'Eastern Healthcare Ltd have introduced a robust improvement programme working with and in partnership with outside professionals to comprehensively address the issues highlighted in the recent CQC report.
'We are currently restructuring our management team to bring a wealth of care management experience to support the home, its staff, residents and family members.
'Eastern Healthcare Ltd is resolute in the belief that the welfare of the residents is and always will remain our top priority.'
90-year-old fell three times in a day unsupervised
A former warehouseman from Bowthorpe, 90-year-old Peter Dawson died in hospital three days after falling at Brundall Care Home on September 3 last year.
It was the third time that day the man suffering Parkinson's and dementia had fallen while unsupervised at the home, which his son, Ivan, believes should not have happened.
After the inquest into his father's death on Thursday, Ivan Dawson said: 'There was a lack of staffing and he should not have been left in that lounge on his own - especially having had two falls that day. If there had been an intervention they would not have left him to have the third.
'He was treated as just a number - not as a person. He was 90 years old so he was treated like he had no more life left.
'I am pleased he died because he is in a better place now and he is with my mum. It seems cruel but it comes from the way he was treated in his last days. It was a nightmare.'
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