‘Inadequate’ care home where resident ESCAPED and people with Covid could ‘move about freely’


A care home where a resident escaped, staff were ‘constantly firefighting’ and people were ‘free to move around’ after a coronavirus outbreak has been plunged into special measures. There was no manager in place when inspectors from the Care Quality Commission (CQC) first turned up for the latest unannounced visit to Bourne House, in Ashton-under-Lyne. They found the care home to be ‘inadequate’ – with a host of worrying concerns about its safety, effectiveness and leadership.

In a report released this month, the CQC said those inside Bourne House were ‘not being protected from the risk of infection’ – including from Covid. Staff reportedly told inspectors that they had not been asked to complete lateral flow tests to check for Covid on a regular basis, while records kept at the care home ‘did not reflect’ who was infected with coronavirus at the time.

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The report said: “On the first day of inspection we were told two staff had a positive Covid-19 LFT result that morning. We raised this with the provider and ensured these staff members were sent home and arrangements were made for staff cover.

“We could not ascertain whether the provider had been aware of this and were not assured the provider understood the requirements of testing, current isolation guidance and associated risks.” The CQC visited the Taunton Road care home on January 24 and 25, before returning on February 2.

‘People were free to move’

Following the initial visit, Tameside Council’s infection control team came to support Bourne House staff, but the CQC says advice given by the team – such as improving ventilation – did not appear to have been followed by the third visit a week later. Inspectors added: “People who had tested positive for Covid-19 were not effectively cohorted from those who had not tested positive and people were free to move throughout the building through the day.

“Records did not reflect who had a current Covid-19 status, and the regular checks of symptoms for both people who had tested positive for Covid-19 and those who had not been not being completed. Robust systems for the donning and doffing of PPE (personal protective equipment) and additional hand hygiene were not evident.”



People with Covid at the home were allowed to move freely

Inspectors raised concerns about record-keeping at Bourne House in a number of areas. This included whether staff had been vaccinated, whether DBS checks had been carried out and whether appropriate risk assessments were being made – while inspectors found some confidential documents were not being filed securely.

On one occasion during the inspection, a resident who was considered to be at risk of leaving Bourne House managed to ‘briefly’ leave the care home. The report added: “Care plans and risk assessments did not demonstrate that this risk had been mitigated as much as possible.”

Red flags were raised about the control of medicines – with staff having ‘not had the appropriate level’ of training, while some were medicine was not stored securely and checks to see if the room they were kept in was clean and at the correct temperature were not being completed. Inspectors say they found some residents had not received new supplies before their medicine ran out.

Concerns were also flagged up about residents’ care needs not being met appropriately, while kitchen staff had not had formal training on how to prepare dishes such as pureed meals for those who needed them. Inspectors said: “We found examples where people appeared to have lost weight, their health appeared to be declining or they had been consistently refusing their medicines, but records did not demonstrate what action had been taken.”

The CQC says a manager was recruited at Bourne House during the course of the inspection, but staff had been suffering with a lack of support. One worker told inspectors: “I feel like I’m constantly firefighting. I was meant to be shown how to do [certain tasks] but the staff member meant to show me you have left.”

Inspectors added: “A number of sources suggested the provider would not always be forthright about the challenges being faced. We found the provider was not always proactive in seeking advice and support when this was needed.

“Staff told us they were not confident action would be taken when shortfalls were identified, or concerns raised. Staff told us they would often bring in resources to make up for any shortfalls, for example with cleaning equipment or toiletries.”

Bourne House has capacity for the 33 people, and 21 residents were living at the care home while the inspection took place. Two residents died from coronavirus at Bourne House during the first year of the pandemic, from March 2020 to March 2021, according to the CQC.

Bourne House was approached for comment.

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George Holan

George Holan is chief editor at Plainsmen Post and has articles published in many notable publications in the last decade.

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