Forest Hill Care Home, in Forest Hill Park, was given the rating by the Care Quality Commission after inspectors visited for two days in February.
The care home, run by Barchester Healthcare, provides personal and nursing care for up to 55 people, including those aged over-65, people with dementia, and adults aged under-65 with mental health needs and associated challenges.
The CQC inspection was prompted by concerns received about cleanliness and how people were safeguarded from the risk of abuse.
In February, Paula Yarnall visited her mother, who has been a resident at the home since January 2021 after being diagnosed with dementia, and found her with dirty feet and with unsanitary toilet conditions.
Paula said the treatment of her mother showed ‘serious failings with care and overall safeguarding’ at the home, and she demanded ‘immediate intervention’.
The inspection report, published last week, has confirmed ‘breaches of regulations’ at the home, including an increased risk of residents being harmed; areas of poor cleanliness; staff shortages which affected people’s needs being met; and inconsistent leadership.
The CQC provides ratings based on five categories: safety, effectiveness, leadership, care and responsiveness.
Forest Hill was judged to have fallen short in all categories but effectiveness, which was rated as ‘good’. This means the overall rating of the facility was downgraded from ‘outstanding’, which is was given in November 2017, to 'requires improvement'.
The report noted that staff felt there were not enough of them to be able to provide care to the standard expected by the provider.
Analysis of the staff rota for January and February showed there were 10 days on the dementia unit where there were less staff than the provider had assessed as necessary to provide care safely.
Residents were also found to not always be protected from the risk of abuse, and relatives had mixed views about whether their family members were cared for safely.
Recent local authority safeguarding investigations identified a number of occasions where the provider had failed to keep people safe from avoidable harm and had not always put clear plans in place to reduce the risk of repeat incidents.
In one case, this had led to further incidents where people were put at risk from people's behaviour.
It was also found that were not enough domestic staff to keep the building clean, resulting in pressure cushions being stained with urine and debris, poor cleanliness in kitchenette areas and visibly unclean mattresses and wheelchairs.
The home was however found to promote a good quality of life. Residents were supported and encouraged to have a varied diet and records showed varied menus; they were encouraged to personalise their bedrooms, and bathing and shower facilities were designed to be fully accessible for everyone to promote independence.
The report also stated that the staff they spoke to demonstrated good knowledge of people's needs, and that they were caring and showed that they enjoyed the work they do.
The CQC has said it will continue to monitor the service and has asked the provider to send a report outlining what action is going to be taken.
A spokesperson at Barchester said: “We take the findings of the CQC very seriously and recognise that changes needed to be made.
"As such we took immediate action to put robust plans in place to make positive permanent changes for the improvement of the service.
"This included an internal restructure and hiring of new staff to join the general manager who has returned from maternity leave, focused training for staff including support from one of our team of specialist dementia trainers and a refurbishment programme which is underway.
"The team is working closely with the CQC and the local authority who have acknowledged the positive changes that have been made.
"We would like to reassure every one of our commitment to provide the highest quality of care to those living at Forest Hill and to emphasise that their health and wellbeing is at the forefront of everything we do.”
For the full report click here.