March 11, 2019 2.06 pm This story is over 62 months old

Care home at centre of abuse claims “Requires Improvement”

It was rated as ‘Requires Improvement” by CQC

A Lincoln care home was rated as “Requires Improvement” by CQC after an inspection prompted by an incident of alleged abuse.

As previously reported, a man understood to have dementia was filmed being allegedly tormented by a female employee at Cathedral Nursing Home on Nettleham Road in May 2018.

New operator St Philips Care took over the running of the home in October 2018. It suspended registered manager Tina Bardsley in January 2019 as soon as it became aware of the situation.

An inspection report published by CQC this month confirms that on the day of the inspection the registered manager was absent.

CQC said it was concerned the registered manager was not an effective role model to other staff. The registered manager submitted their resignation to the provider which was accepted.

The alleged abuse took place before the current provider took over the service. The service provides accommodation and personal care for 38 older adults, people living with dementia and younger adults.


On the day of the inspection – January 9 – there were 29 people living at Cathedral Nursing Home.

CQC spoke to eight people and three relatives regarding their experience of the care provided. Seven staff members were also spoken to along with the area manager and two visiting professionals.

CQC also reviewed a range of records including seven people’s care records. Four staff files were looked at around recruitment as well as various records in relation to training, supervision and management of the service.

Staff told CQC they felt supported by the deputy manager and senior care staff in their roles. Staff were also aware of the whistleblowing police and reporting procedure and would not hesitate to share any concerns.

No whistleblowing concerns were raised since the service was registered to its new provider in October 2018.

Police investigation

CQC said the incident is subject to a criminal investigation so the inspection did not examine its circumstances.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of abuse. The inspection examined those risks.

CQC said it will continue to monitor the service to ensure people receive safe, high quality care. Further inspections will be planned for future dates yet to be announced.

Although the registered manager was suspended, the CQC said it had no information to support that the abuse had stopped or that other members of staff who may have been involved no longer worked at the service.

However, on inspection, CQC officials said people were cared for by kind, caring and compassionate staff from all disciplines. The report said there was “friendly banter between people and staff and we could see that they were at ease with each other”.

The Lincolnite approached Lincolnshire Police for an update on the investigation and were told it is still ongoing.

CQC Report

The service was given an overall rating of ‘Requires Improvement’ by CQC.

It requires improvement regarding whether it is safe, effective and well-led. However, it scored a ‘Good’ rating for being caring and responsive.

A breach of the Health and Social Care Act Regulations 2014 was identified relating to people subject to certain safeguards not being appropriately transferred from the previous provider.

Positive points were noted in the report though, including about how people received care from kind and compassionate staff.

According to CQC systems were in place to identify and reduce the risks to people living in the service.

Most people’s care plans included detailed and informative risk assessments with guidance, which CQC said was not always followed.

This included one person admitted to the service four weeks before the inspection who was a diet controlled diabetic.

Blood sugar levels were not recorded as the service did not have a monitor nor had it taken steps to access one. Once this was brought to the deputy manager’s attention a monitor was ordered.

Another concern was raised when the local authority mental capacity team informed CQC that seven people were being lawfully deprived of their liberty or waiting assessment.

At inspection CQC were informed that this number was in fact 15. The reason was because the provider was unaware that a DoLS authorisation was not transferrable from one care setting or provider to another.

The provider had failed to notify the local authority mental capacity team it had taken ownership of the home. After the inspection the team supported the provider to rectify the issue.

CQC also looked at audits from December 2018 and found actions had been identified for areas that required improvement. However, the care plan audit did not identify the discrepancies found by CQC in the between risk assessments and care plans.