A care home has been plunged into special measures after inspectors found a resident had missed 19 doses of vital medication - leaving them at risk of a stroke.

A string of failings was discovered by Care Quality Commission (CQC) officials at St Brelades in Beacon Hill, Herne Bay, during an unannounced visit last month.

Those living in the building, which houses up to 37 dementia sufferers, were adjudged to not be safe, as they were at risk “of not receiving their medicines safely”, and seen wearing each other’s clothes.

Inspectors also say the home was not “always providing dignified and respectful care”, as staff failed to help a resident out of trousers that “kept falling down”, even though he had other pairs.

The business has since been given a rating of “inadequate”, the worst score possible, which bosses say has left them in “disbelief”.

Reacting to the findings, CQC head of inspection Hazel Roberts said: “When we inspected, people told us they were happy living there, and relatives felt their loved ones were safe.

“But we found there was a lack of strong leadership and the provider and the registered manager had failed to identify a number of shortfalls at the service.

“One staff member put a person at risk of choking when they tried to put a spoon full of food in their mouth while the person was chewing. The person looked distressed and pulled their head away.”

St Brelades was last assessed four years ago, receiving a rating of “good”.

The CQC visit in May was prompted by the receipt of “information of concern regarding the management of medicines”.

And on this occasion, inspectors found a resident ate food containing another person’s prescribed medication in October – but “robust action had not been taken to ensure this did not occur again”.

No checks were completed to ensure staff were administering covert doses safely, leaving officials to conclude bosses did not always do enough “to learn lessons when things went wrong”.

"We found a number of shortfalls at the service..."

“We also found medicines weren’t being managed safely,” Ms Roberts added.

“One person had been given a lower dose of blood-thinning medicine than they should have had three times in the week before our inspection, and they had previously missed 19 doses.

“If people don’t receive their medicine as prescribed, they could be at risk of blood clotting, leading to serious health conditions, such as a stroke.

“Most of the issues boil down to the fact that the management team wasn’t working effectively to lead the service.”

The watchdog says there were “widespread and significant shortfalls in service leadership”, with an “allegation of abuse at the service” not reported by its registered manager.

Inspectors described the registered manager as being “unclear” about what they were required to notify the CQC of, telling the assessors they were “learning” on the job.

Despite saying staff “cared for people and did their best”, officials concluded they “had not been supported to always offer people dignified and respectful care”.

“Most employees hadn’t completed in-depth dementia care training – which is essential – and they weren’t always providing dignified and respectful care,” Ms Roberts continued.

“For example, one person was upset as they were wearing trousers which kept falling down.

“They had other trousers they could have worn, but staff hadn’t helped them to change into these. Some people were wearing other people’s clothes, despite relatives complaining to staff about this.”

Morale among staff was described as low, with some of feeling unappreciated by the manager or provider.

They had been given a bonus for work done during the pandemic, but those “who had gone over and above did not feel this had been recognised”.

Speaking to KentOnline, St Brelades’ nominated individual Larry Berkowitz insisted the home “is definitely safe”.

“We were hugely disappointed when we saw the rating," he stressed.

"There were a lot of things the inspectors pointed out that we fixed almost on the day.

“The chemist gave us a digital care plan for medication, but there were bugs in it and we missed a few things. It wasn’t good, so we scrapped it.

“It’s really damaging, this. The home’s still recovering from Covid, and it sends a horrible message to potential residents.

“We have a four-page action plan and we’re going through everything line by line, and we’ve introduced new training and medication systems.

“We’ve also hired consultants - some of them are ex-CQC inspectors - and they’ll support us by telling us how we can improve in certain areas.”

In the wake of the concerning inspection, the CQC has placed the service in special measures.

This means it will be kept under review, both by the watchdog and Kent County Council, before being re-inspected.

Mr Berkowitz says the business is aiming for a rating of “good” or “outstanding” when the next visit takes place.