An unannounced visit from inspectors took place in November, and the Nottinghamshire care home had failed to report that legionella bacteria was found in its water system, resulting in an "inadequate" rating by the healthcare watchdog.
Beechdene Care Home in Mansfield, was looking after 14 people with learning disabilities at the time of the inspection in November.
Fortunately, the legionella was treated quickly when found and no-one fell ill. However the home was given an overall rating of "inadequate" by the Care Quality Commission (CQC) and placed in special measures.
Inspectors held the unannounced visit after concerns were received about safety and staffing from members of the public and other organisations.
A risk assessment found the home was at high risk of developing legionella bacteria in the water system. Legionella bacteria can be inhaled in droplets of water and result in serious ill health from Legionnaires' disease.
Unsafe radiators
The risk assessment required refurbishments to be put in place within one month, but these had not been completed.
The home said it would inform the CQC within two hours if legionella developed.
But the report said: "When we returned to the service a few days later, we found legionella had developed in the water system. This bacterial outbreak had been effectively treated. However, the provider had not followed the action plan as we had not been informed of the positive legionella test."
Inspectors also said the environment was "not safe" with residents at risk of scalding in the showers, burning from uncovered radiators and illness from food being stored in fridges that were too warm.
When last inspected in 2019, the care home received a "good" rating. The home did not respond to a request for comment from the Local Democracy Reporting Service.
It's important to note that while IoT technology offers promising solutions for legionella prevention, it should be implemented alongside best practices in water management, maintenance, and hygiene. Regular system checks, maintenance, and adherence to established protocols remain crucial for effective legionella risk management.
Learn more about how we help promote safe and healthy water systems and actively prevent Legionella bacteria with our IoT Remote monitoring Legionella Management. Or get in touch now!
