Public bodies which oversaw a troubled Yorkshire nursing home that went on to close had a “high tolerance for continued provider failure”, a review found.

Lake and Orchard Residential and Nursing Home at Kelfield, between Selby and York, closed after a damning inspection in 2020 found it put people at risk.

Residents were described as dirty, thirsty and hungry as staff were not dedicating time to support them with nutrition. Many had skin damage and one resident weighed just over 4 stone 7lb.

A nurse described the home as “the worst we have yet seen”, with “seasoned social workers…upset by what we have found”, according to a report.

The home, which was run by Sanctuary Care, had been on the radar of the authorities for several years. It had received seven poor inspection reports from the Care Quality Commission (CQC) and had been in ‘collective care’, a process aimed at improving struggling care services, since 2018.

A North Yorkshire Safeguarding Adults Board report was carried out to look at the circumstances of the home’s closure and the involvement of: NHS Vale of York CCG; North Yorkshire County Council; community services provided by York and Scarborough Teaching Hospitals NHS Foundation Trust; the CQC and primary care.

The report, carried out by an unnamed assistant coroner, said there was an “over-reliance placed on the provider describing minor improvements in care quality”, which resulted in the home not being monitored as closely.

There was also “no sense of urgency” following collective care meetings and safeguarding investigation outcomes were, on occasion, “based on inappropriate evidence or inappropriate thresholds".

“Safeguarding investigations were not robust and timely and therefore potentially missed opportunities to safeguard others from harm,” the report added.

The assistant coroner said they could not understand why the home provider, given the known concerns, was not classified as high risk as the country went into lockdown.

The report said: “It is clear that everyone I have spoken to had concerns about Lake and Orchard; however, these do not seem to have come together in a timely manner to enable earlier intervention.

“As this provider had been on the radar of organisations for such a long period of time, there is evidence that desensitisation had set in with public bodies which potentially meant that poor quality was tolerated for longer than it ought to be.”

The coroner did, however, praise what happened in the home’s final weeks, when residents began to be moved out.

“The multi-agency working at the end of July and into early August to close the home and safely move all residents was exemplary and ought to be celebrated as outstanding practice,” the report said.

The report made a number of recommendations to the individual agencies involved and the safeguarding adults board as a whole, which have been accepted in full.