A failing Wirral nursing home did not test residents for Covid-19 often enough and placed one person at increased risk of choking or contracting a form of pneumonia.
Sandrock Nursing Home, at 1-3 Sandrock Road in New Brighton, was given the worst possible rating, inadequate, following a report by the Care Quality Commission (CQC).
At the time of the inspection, carried out over four dates in December and January, 22 people lived in the home, some of whom lived with dementia.
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One major issue at the home was the way medicines were managed.
One section of the report read: “Medication management was unsafe and placed people at risk of significant harm. Basic good practice guidance was not being followed. People did not always receive the medicines they needed.
“Medicines could not always be accounted for, and were not always given safely. Safeguards in respect of controlled drugs were not adhered to.”
Another worrying section of the document added: “Some people did not always receive the medicines they needed either, because there was no stock of the medicine in the home or nursing staff were unaware people had been prescribed certain medicines.”
The CQC gave examples of this including one person's end of life medicines not being given at the right time as there was no stock available and another person who was only given half the prescribed dose of antibiotic on three occasions which meant their infection was not treated properly.
Further issues at the nursing home placed one resident at increased risk of choking.
The report added: “People's special dietary requirements were not always adhered to. One person with swallowing difficulties required their drinks to be thickened with a special medicine to prevent them from choking.
“Guidance for staff to follow in relation to this was unclear, and records showed that staff did not always thicken the person's drinks to the right consistency. This increased their risk of choking or aspiration pneumonia.”
Sandrock Nursing Home was also “not adhering in full” to the best practice guidance issued by the government in respect of Covid-19.
On the ground, this meant failing to follow guidance on residents having a PCR test every 28 days, having their temperature checked twice per day and having their individual risks of Covid-19 assessed and mitigated.
Another issue at the home was its failure to assess the risks the virus posed to individual staff members to protect them from preventable harm or to prevent disruption to the care home’s services.
One part of the report read: “Improvements to the management of staff testing had been made, but records showed gaps in the testing of some staff members, which meant that not all staff were adhering to government guidelines.”
Cleaning issues were also identified, one part of the CQC document read: “No evidence of the cleaning of frequently touched surfaces or shared equipment were provided to show that risks in relation to cross contamination were effectively managed.
“Deep cleaning records pertaining to people's bedrooms were available but did not show that all bedrooms were deep cleaned.”
However, the report did state that improvements to the safety of visiting had been made which complied with government guidelines and that some of the provider's infection control policies and procedures had also been updated with more information about coronavirus and its management.
Sandrock Nursing Home reported the majority of “safeguarding events” according to the report, but inspectors noted one example of an incident which was not investigated.
The report read: “The majority of safeguarding events had been reported accordingly. One person however, had alleged another person had pushed them over, causing them injury.
“The manager had not investigated this allegation or referred them to the local authority safeguarding team or CQC. We spoke with the manager about this and asked them to investigate this incident.”
Another part of the report read: “One person was being deprived of a personal possession, despite them having capacity to make their own decisions.
“When asked, the manager could offer no satisfactory explanation as to why this practice was in the person's best interests. We had discussed this practice with the manager at the last inspection, yet this poor practice was still being allowed.
“We observed the person was distressed by this practice at both inspections.”
But residents and their relatives who spoke to the CQC made complimentary comments about Sandrock Nursing Home.
One part of the report said: “The people and relatives we spoke with felt they were safe living in the home.
“Their comments included ‘it is a lovely place to be, and the staff are perfect’ and ‘staff treat [name of person] really well’.”
Another section added: “All of the people and relatives we spoke with were positive about the home.”
Sandrock Nursing Home was approached for comment.
