A Tameside care home which failed to address patient safety issues including falls and unexplained bruising has been placed into special measures by the Care Quality Commission (CQC).
Darnton House Nursing Home in Ashton-under-Lyne has accommodation for 96 patients – 32 with dementia, 32 with physical care needs and 32 who are in the process of transitioning back into the community – but just 18 were housed there at the time of the inspection.
The home received the lowest possible ‘inadequate’ rating in all five areas of assessment by the CQC, after their inspection in November whilst new admissions have been prevented by stakeholders due to the findings.
Safeguarding concerns led to four patients suffering inexplicable bruising, whilst another fell seven times within a two month period without any action being taken to update their risk assessment.
“Overall, there have been a significant number of concerns raised regarding care in the service that have been upheld as neglect,” the inspector said.
“A review of care records showed that the service did not always have nutritional risk assessments that monitored individual weight loss or gain – where they were in place, they were not kept up to date.
“Risk assessments for the development of pressure ulcers were undertaken but not reflected in care records.
“When wounds were identified, the treatments in place to prevent further risks were not clear. The monitoring of positional changes to assist in preventing further pressure ulcers were not always in place.
“People’s records showed that moving and handling risk assessments were not updated and did not contain clear information that would inform staff how to appropriately move and handle people safely.”
Specific concerns were raised over medication, with staff ill-trained to handle medicines and records completed inaccurately.
It was found that medicines that were supposed to be administered at specific times were not given correctly, whilst one patient was left with an empty inhaler, out of breath and not within reach of a panic button.
“People were not getting their medications as they should in a safe way,” the report said.
“We saw from the records that five people had not received their medicines for two or more days. There was no explanation available as to why the people had not received their medicines in accordance with the prescription.
“Where medicines were given, these were not always given accurately… and medicines were not given at the correct times.
“Staff on the top floor reported that they had not received training in the medication administration process and that they were unfamiliar with how this worked.
“The service did not have any arrangements in place to make sure that its staff gave medicines correctly on the top floor. We were informed that the pharmacy team from the adjacent hospital checked daily that medicines were given correctly.
“We looked at these records and found no evidence that medicines were checked as given correctly by the staff.”
Despite these failings, both residents and their families expressed satisfaction with conditions at the home, with one patient describing it as ‘a beautiful place’ and another stating that they were ‘very comfortable’ and staff were ‘kind and helpful’.
Furthermore, meal times were described as ‘relaxed and unhurried’, whilst patients enjoy the range food.
However, patients reported that they had no input as to what they ate, nor what time they went to bed or what activities they took part in.
And the report was damning in its indictment of the home’s leadership. The home did not have a manager registered with the CQC at the time of the inspection, and the manager who was in place did not have a formal system to assess and monitor the quality of care provided.
“The culture of the service was not based on the needs of the people who lived in the home but was task orientated,” the report stated.
“This could be seen by the routines in place in the service that were not flexible to meet people’s needs, the lack of choices available to people, care that did not meet people’s needs and care that was not appropriately planned.
“Risks to people’s health, safety and welfare were not appropriately reported, managed and analysed.
“We found that the service was not aware of how many incidents of suspected abuse were being investigated, how many complaints they had received or how many applications for Deprivation of Liberty Safeguards (DoLS) had been authorised.
“The systems in place were not sufficient to ensure the delivery of high quality care.”
Darnton were unavailable for comment at the time of publishing.
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