The admission of 23 hospital patients over two weeks during the height of the Covid pandemic led to a “shocking” deterioration in levels of care, a council report has found.

The safeguarding review of Amicura Limited’s Temple Court in Kettering by North Northamptonshire Council documented how the care home struggled to cope after increasing its number of residents rose from 33 to 56 through hospital discharges between 19 March and 3 April 2020.

In its findings, the review found there was a “significant deterioration” at the service during April/May 2020 which was “truly shocking and despite intervention and support from health colleagues it failed to respond and recover”.

“There was a lack of oversight of this process from the senior managers within Amicura Limited and within the Local Resilience Forum arrangements,” the report states. “The number and speed of discharges into the care home was inappropriate and there does not appear to have been any consideration given to the previous CQC inspection rating of Requires Improvement when determining the volume and specific needs of patients being discharged to the care home.”

Nineteen residents died at the care home between January and May 2020 with four of those attributed to Covid-19.

The care home was fined £120,000 in May 2023 for “catastrophic” Covid failures following prosecution by the CQC.

The local authority and CCG took the decision to move all residents out of the home in May 2020.

Cllr Helen Harrison, North Northamptonshire Council’s Executive Member for Adults, Health and Wellbeing, said the events outlined in the report “should never have happened”.

She said “numerous measures have been put in place, with partners, to ensure that we have done as much as we can do to reduce the risk of this scenario ever being repeated”.

“Furthermore, we will continue to work within the health system of Northamptonshire to further develop the recommendations as we strive to make sure that everyone receives the quality and dignified care that they deserve.”

A spokesperson for Temple Court “apologised unreservedly to everyone affected by the failures of our systems and processes in the early stages of the Covid-19 pandemic”.

They added: “With the benefit of hindsight, we recognise now that whilst we felt at the time we were acting in the national interest and supporting the NHS by accepting patients discharged from hospitals into care homes under government policy at the start of the Covid-19 pandemic, this actually placed incredible strain on our team – leaving many of them overwhelmed, exhausted and themselves ill with the virus.

“The combination of these factors left the home disproportionately reliant on the use of available agency staff, with very little opportunity to adequately train them on our policies and procedures, and had a significant and detrimental effect on the running of the home and the care provided to our residents.

“We recognise these factors were unprecedented, but that does not excuse what happened and we know we must do better in the future. We are fully committed to our journey of continuous improvement and remain determined to deliver the best possible care for every resident.”