The Flowers Care Home Limited

The service was inadequate across all areas, placing people at significant risk of harm and, in some cases, life-threatening danger. Fire safety failings and uncontrolled access to steep, unsupervised stairs created an immediate risk to life. People were not safeguarded from known risks of potential harm or abuse, and systems to identify, monitor and respond to safeguarding concerns were ineffective. Staffing levels were unsafe, with agency staff lacking knowledge of people’s needs. Infection control was poor, bedding and equipment were unclean, and essential maintenance and safety checks were incomplete or undocumented. Medicines were not consistently managed, and care plans contained contradictions and omissions.

People’s basic needs were not consistently met. People were left hungry, offered limited food choices, and did not always receive fortified or nutritious meals. Care was not person-centred, with little choice over routines, meals, or activities. Communication and cultural needs were often unmet, and residents cared for in bed had minimal meaningful interaction. People with mental health needs were admitted without assurance staff were trained or competent to support them safely.

Leadership and governance were ineffective. Audits were inaccurate, incidents were not consistently recorded or acted upon, and staff feared speaking up. The previous registered manager’s absence and lack of provider oversight left the service without competent leadership.

We raised all identified concerns with the provider, who failed to take any effective action to protect people’s safety. As a result, the Local Authority had to intervene directly, arranging meal provisions to ensure people were fed, deploying additional senior staff to support safe care, and we escalated our fire safety concerns to West Yorkshire Fire and Rescue Service. This lack of provider action placed people at ongoing and avoidable risk and demonstrates a complete failure of leadership and accountability.

The provider was in breach of 9 legal regulations in relation to person-centred care, dignity and privacy, safe care and treatment, safeguarding, nutrition and hydration, safe environments, good governance, staffing and fit and proper persons.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.