Care home ignored distressed patients and ran out of medicine

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A Leicestershire care home has been put into special measures after a damning report found that distressed residents calling out for help were ignored and a lack of medicines on-site led to epileptic seizures.

Charnwood Oaks Nursing Home in Shepshed has been downgraded from “requires improvement” to “inadequate” by the Care Quality Commission (CQC) after concerns were raised by visitors.

At the time of inspection in March 2026, the service, ran by Prime Life Limited, looked after 80 older people, many with dementia.

According to the report, inspectors witnessed “multiple instances” of distressed patients being ignored.

One one occasion, a resident was “shouting for help” while a nearby staff member sat nearby with their “head in their hands”, and on another, staff walked past the bedroom of a resident “screaming”, leaving them distressed in bed with no assistance.

The government watchdog also reports that carers left patients in “undignified positions”, with one person’s “torn-up” incontinence pad on show.

Other occupants were not supported to be mobile, according to the CQC. While one person was stuck in an armchair after staff moved their walking frame back to their bedroom, another was left to watch TV in bed for up to eight hours a day.

The way the care home stocked and stored medicines was also found to be lacking.

After leaders failed to ensure sufficient stock of one patient’s epilepsy medicine, they reportedly missed two doses and experienced a seizure.

Another patient, who had low blood sugar readings, was left unmedicated as the service had run out of stock.

Inspectors noted unclean beds, bathrooms and floors, and were told a recent diarrhoea and vomiting outbreak was handled poorly, with staff only being informed after arriving at work.

Staff were also put at risk through the service’s shortfalls in behaviour plans for individuals known to be aggressive. The impact was evidenced when two members of staff were punched, and the lack of guidance was said to increase the likelihood of the situation escalating further.

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The watchdog said that carers generally knew people’s likes and dislikes and tried to treat them as individuals, helping them plan for important life changes.

However, according to the family members of residents, the site manager could be “difficult to deal with” and is rarely around during visiting hours.

Relatives also said their loved ones were thirsty when they arrived to visit them, and fluid records showed a “significant” lack of drinks offered to patients.

Finally, although the manager understood their duty to report safeguarding concerns, there was a “lack of evidence” to demonstrate that incidents had always been “robustly investigated”, especially around “unexplained bruising”.

The CQC will now closely monitor the facility in order to protect its patients and staff.

Leaders have been handed a strict timeframe for improvements, and were also told that they had breached three legal regulations in operating the care home.

Ultimately, the CQC rated the service as “inadequate” for how safe and well-led it is, down from “requires improvement”. Caring dropped from “good” to “inadequate”, while effectiveness and responsiveness have been re-rated as “requires improvement”.

Greg Rielly, CQC’s deputy director of adult social care for the East Midlands, said: “When we inspected Charnwood Oaks Nursing Home, we identified serious concerns around people’s safety and day-to-day experiences, and witnessed several examples of people being put at avoidable risk of harm.

“We were sad to see multiple instances where staff didn’t respond promptly to people when they were distressed or calling out. We saw one staff member walk past a person when they asked for help without acknowledging them. People were also left in undignified positions, such as with their incontinence pads on show to others, making it clear that people’s privacy wasn’t respected.

“When people were admitted to the home, staff hadn’t made sure there were enough medicines on hand, which led to them running out. For example, one person who had epilepsy ended up missing two doses of medicine and experienced seizures, which had previously been controlled.

“During our inspection, we found evidence that leaders had failed to follow advice from the local authority and infection prevention and control professionals, meaning the home had been in outbreak of diarrhoea and vomiting for several weeks. It was clear that lessons hadn’t been learnt from previous concerns to prevent repeat failures, putting people at continued risk of harm.

“Worryingly, we also found significant shortfalls in risk management for people known to be physically aggressive. Staff didn’t have sufficient guidance to prevent incidents from escalating, putting staff at risk and resulting in two staff members being punched. There also wasn’t enough information to enable meaningful reviews of incidents to prevent them happening again.

“We have been clear with leaders about what we expect to see moving forward to ensure they are no longer in breach of regulations. We will return to check on their progress and have proposed using our regulatory powers further to ensure people are receiving the care they have a right to expect.”

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