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Incontinent residents were “wet through” and in need of a change of clothes at a “chaotic” care home where checks for a deadly disease were also not always completed, inspectors have found.

The Care Quality Commission (CQC) has put Rowan Garth Care Home in the Anfield area of Liverpool back into special measures following an inspection in June.

The care regulator, which previously put the home under special measures in November 2022, found “serious failings” this summer, despite a plan having been made last year to improve conditions. The CQC said “no effective action had been taken”.

Wellington Healthcare Ltd, which runs the site, said it had taken “immediate action”.

The care home on Lower Breck Road provides accommodation for older people requiring nursing or personal care.

At the time of inspection, only three of its five units were in operation.

There were 82 people living there.

The CQC downgraded the home’s overall rating from “requires improvement” to “inadequate”.

Assessments for being “safe, effective and well-led” were rated as “inadequate” while the “responsive and caring” assessment criteria were rated as “requires improvement”.

The findings in the CQC report include:

• the management of medicines was unsafe, with residents not receiving them at the right time, exposing people to “often painful or uncomfortable symptoms”
• staff did not have sufficient clinical guidance on people’s clinical risks and medicines for complex health conditions such as diabetes and epilepsy
• Medicines were not always stored at the right temperatures, increasing the risk of them being ineffective
• Some people’s continence records showed they were wet through and in need of a change of clothes on multiple occasions, indicating people’s continence care was insufficient
• Some residents did not have access to a working bath or an accessible call bell to ring for staff support when needed
• Infection control standards were “poor”
• Furnishing, fittings and equipment was not always clean or in a good state or repair
• Checks to monitor for the risk of Legionella bacteria in the home’s water system were not always completed.

An agency nurse told inspectors how, from their point of view, there were not enough staff and it was “too much”.

The home was described as “very chaotic” with staff described as “knackered”.

Andrew Peck, of the CQC, said inspectors found “serious failings in leadership that placed people at unnecessary risk of harm”.

He said some residents received time-critical medications hours late which was “especially serious for people with conditions like Parkinson’s disease, where timing is vital”.

He added: “Leaders didn’t ensure the environment was safe and we saw broken equipment and inadequate facilities.

“The call bell system wasn’t fit for purpose and although the provider had been aware of this for over six months, no effective action had been taken to ensure people were able to call for staff help when needed.”

He said: “While we found staff were kind and caring, they weren’t supported by leaders to deliver safe care.

“Leaders also didn’t ensure staffing levels were sufficient, meaning people often experienced delays in receiving support.”

Mr Peck said the regulator expected to see “rapid and continued improvements” and would continue to monitor the home closely to keep people safe.

“We have begun the process of taking regulatory action in order to protect people further.”

A spokesperson for the care home said it was “disappointed” with the “inadequate” CQC rating and said “our priority is to learn from this and take immediate corrective action”.

They said it had “implemented a comprehensive improvement plan to address all concerns raised”.

“We acknowledge there were areas where we did not meet the high standards our residents and their families rightfully expect and deserve.

“The safety and wellbeing of our residents is paramount. We have appointed a highly experienced turnaround manager to lead the improvements at Rowan Garth and ensure sustainable change.

“We remain committed to delivering the quality of care our residents deserve and look forward to demonstrating significant progress at the CQC’s next inspection.”