Liverpool care home placed into special measures following death of patient

An inspection at a Walton care home where a service user died indicated concerns around how staff handled vital medicines for residents.

Officials from the Care Quality Commission (CQC) have placed Grace Lodge Care Home into special measures after the management of medicines put residents at risk of overdose. A total of 31 people were in situ at the home when inspectors visited the two-storey site last year.

The previous manager resigned a week prior to the inspection, leaving a nurse to be promoted into the role.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of people’s prescribed medicines. A report made public by the CQC said residents did not always receive their prescribed medicines due to lack of stock. 

Additionally, where people were prescribed time specific medicines, such as paracetamol, staff were not always recording the times they had been administered. This meant health inspectors could not always be certain the required time gap was being observed, placing them at risk of overdose.

Despite the provider indicating they had changed medicines supplier to ensure stock levels were maintained, the CQC said it was “not assured at this time that medicines will be consistently and effectively managed as the provider had not identified all of these concerns themselves.”

Staff were observed following unhygienic practices while providing people with their breakfast. This was raised with the acting manager during the inspection, but the home was described as visibly clean and hygienic.

Additional concerns were raised about the arrangements around patients’ mental capacity. The report said: “One person who had been assessed as not having capacity, had a family member with legal authorisation to make decisions about their care. 

“However, their consent form had been signed by a representative of the home and not the family member.” Additionally, family members said they did not feel their complaints had been listened to, investigated or acted upon.

The CQC said: “This meant there were missed opportunities to improve the care people received.”

Issues were mentioned around how kitchen staff had not been provided with accurate and up-to-date information about people’s dietary requirements. The report added: “For example, four people with diabetes had been assessed as requiring a low sugar diet.

“However, kitchen staff were only aware of one person who required this.”

Despite the concerns raised, the report said people told inspectors they felt safe. It added: “One person said, ‘I’ve never had any problems. The staff are nice. They look after me. Yes, I feel safe.’”

The overall rating for the service is inadequate and the service is therefore in special measures. This means the CQC will keep the service under review and, if it does not propose to cancel the provider’s registration, it will re-inspect within six months to check for significant improvements.

The LDRS contacted Grace Lodge for comment.