The Care Quality Commission has published a report which sets out a raft of concerns about the quality of care at the former Southern Cross Tower Bridge Care Centre at Bricklayers Arms.
Last year we reported on the CQC's decision to issue a formal warning notice after an inspection in September when the care centre was run by the troubled Southern Cross group.
In November the centre was taken over by HC-One along with 240 other former Southern Cross care homes.
The commission's inspectors visited the centre on 6 December and their report was published this week.
"Although the generally positive views [expressed by residents] were borne out by some of the care and interventions we observed, our report identifies concerns in respecting and involving people; care and welfare; safeguarding; medicines management, safety and suitability of premises, staffing support and quality assurance," says the introduction to the CQC's 33-page document [PDF].
• Residents "are not given enough opportunities to contribute to decisions about their care, treatment and support. Their privacy, dignity and choices about their own care are not always respected or valued"
• Residents "do not always receive the care and treatment they need, sufficiently centred on them as individuals and their individual circumstances"
• Residents "cannot be confident at present that [safeguarding] arrangements ensure in all cases that the service responds appropriately when it is suspected that abuse has occurred or is at risk of occurring"
• "The service does not fully protect people against the risks associated with the unsafe use and management of medication by means of making of the appropriate arrangements for the receipt, using, safe administration, and recording of medicines"
• Residents "are not sufficiently protected against the risks of unsafe or unsuitable premises"
The commission's strongest criticism – a "major concern" in the report's terminology – was reserved for the centre's handling of medicines.
The inspectors found that morning medicines were given to patients all at the same time, including medicines which needed to be given before food and those which needed to be given after food.
They also found that some residents had missed doses of vital medicines, or the administration of medicines had not been properly recorded.
The inspectors were told that due to a lack of senior care staff on the night shift, some night-time medicines were not administered at the prescribed time, being issued before the day shift ended at 8pm.
Inspectors were also concerned that a medicine trolley and a cleaning trolley containing potentially hazardous substances had been left unattended by staff in places where they were accessible to people with dementia.
They also found pest control boxes in places where they could be handled by dementia sufferers.
We invited HC-One to comment on the CQC's findings but no response had been received by the time of publication.
Southwark Council's cross-party health and adult social care scrutiny sub-committee is carrying out a review of the former Southern Cross homes in the borough.
Councillors will discuss plans for the review at their meeting on Wednesday. They are expected to agree to send a questionnaire to residents and their relatives asking them to comment on the impact of the collapse of Southern Cross.