Penley Grange, a residential care home on Marlow Road in Stokenchurch owned by Centurion Health Care Limited, was given the lowest rating after a surprise visit from the health and social care watchdog Care Quality Commission in April and May last year.

The inspection report, which was published by the CQC on January 6, comes after assessment of the care home in five key categories.

Penley Grange, which looked after five residents at the time of the inspection, received inadequate score for safety, effectiveness, responsiveness, and level of leadership, while level of care scored ‘requires improvement.’

The report noted that “people did not always live safely” at the care home, and they were at risk od “avoidable harm.”

CQC said: “Chemicals or substances hazardous to health (COSHH), were not safely stored.”

“There was no legionella risk assessment on file. Water temperature monitoring, and flushing of infrequently used water outlets, was not correctly implemented to monitor and prevent the risk of legionella,” the report continued.

A person had “slapped and hit other people using the service,” but this was not included in the safeguarding log, CQC said.

Safety concerns included lack of system to log, monitor and investigate safeguarding concerns, including failure by the registered manager at the time to report concerns to authorities.

Another person had scratches on their back according to a body chart, while another person had “unexplained bruising” around the eye.

However, there was no explanation about “how the scratches occurred and the nominated individual confirmed no investigation was completed”, and no “accessible record of internal investigation” about the bruising, the report said.

The report said: “People were not protected from risks of abuse associated with people's behaviours. We observed one person push another person on their shoulder.”

This was not acknowledged by agency staff member, the inspectors said, who were themselves pushed, grabbed and pulled “forcefully” by the same person.

The inspector said: “We also witnessed a person being hit, a contractor was pushed and a staff member was forcefully pushed against a door.”

Staff practice reportedly “placed people at increased risk of harm.” For example, two staff members were seen assisting a resident to stand from a trampoline, placing their hands under the person’s upper arms not forcefully, while another staff held their hands to pull them up. The inspectors said the approaches “could have placed the person or staff at risk of injury.”

Another person’s epilepsy risk was not “well managed.” A staff member could not locate written guidance, and told the inspectors “they would shout at the person to wake up, and if they didn't respond would call an ambulance,” which was not in line with protocol.

Another resident’s epilepsy records were incomplete and not personalised, including no mention of the person’s history of epilepsy.

At the time of the inspection, there was no registered manager. The previous registered manager had resigned, and they had been suspended by the provider over concerns about their performance. The provider told CQC the registered manager “had been difficult to work with”, the report noted.

Penley Grange was supported by an on-site care consultant. Some staff gave positive feedback about the consultant, saying they “have been brilliant, has been really approachable.”

The report said: “Prior to the recent arrival of a care consultancy, there was limited evidence the provider had taken steps to address longstanding risks the service presented of a closed culture.”

Closed culture is described was poor culture that can lead to harm, the CQC said.

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Staff meeting minutes from July 27 2021  described poor culture, including residents copying what the staff had said on the floor and “all staff problems, fights, arguments must be left outside the building.”

Not all staff were treated fairly at the time of the inspection. The inspectors were told that “cultural” attitudes among some staff meant “there was an expectation females would complete domestic tasks,” the report said.

Some relatives said communications had started to improve since the arrival of the care consultancy.

The provider Centurion Health Care Limited declined to comment.