Merseyside care home rated ‘inadequate’ after patient found ‘in their own urine’

A patient was found by a family member ‘in their own urine’ at a nursing home on the Wirral according to a new Care Quality Commission (CQC) report.

Dundoran Nursing and Residential Home in Noctorum on the Wirral was rated inadequate, slammed for poor hygiene and management, and placed into special measures earlier this year.

The inspection took place in February 2023 with the report published on June 29. It had been rated good the previous year.

Due to concerns about the welfare of patients, Wirral Council also suspended placing any people under its care in the home and this will not be lifted until the local authority is assured there is an improvement in the quality of care.

Changes: According to the local authority, the care home has since had a change of management and an action plan now is in place.  A spokesperson for the home said the published report was historic, the views of an individual inspector and issues had been “blown out of proportion.”

They said the report was “no longer reflective of the care and services provided at Dundoran” and it had recieved positive feedback from both the NHS and the CQC since.

Initial inspection: The February inspection however found evidence that “people were at serious risk of harm” and breaches of six different regulations related to governance, providing safe care and treatment and staffing. The inspection had been prompted after concerns were raised by Wirral Council and members of the public.

• At one point, nursing staff increased someone’s dosage of oxygen without discussing or getting approval from the right medical professionals.
• A relative of someone in the care home also told the CQC that during a weekend visit the care home was understaffed with only two members of staff looking after the whole floor and their family member found in their own urine.
• The report also said faeces in a commode and smeared on the floor of a bathroom as well as a dirty medication room, no hot water in some bedrooms, and “the risk of Legionella bacteria developing in the home’s water system was not safely managed.”
• The report highlighted that records about medicines did not show that they were managed safely and staff lacked clear guidance on the risks of oxygen and blood thinning medicines. It was unclear whether some people’s medicines were in a safe format for them to have. Some people were given tablets when they had difficulty swallowing.
• Not all medicines could be accounted for, including two doses of controlled drugs and medicines were not always administered safely by nursing staff. Staff also lacked adequate information on people’s needs, risks and care.
• The report also found the environment in which people lived was not adequately maintained or safe and staff recruitment was not managed safely including having clear evidence of a full DBS check available.
• Staff rotas were not always accurately maintained to show which staff members were on duty and staff spoken with told the CQC there were not enough staff on duty to meet people’s needs.
• Two people were admitted to the home during an outbreak of flu without their risk of flu being assessed and the systems and processes to safeguard people from the risk of abuse were not always followed.
• Staff had not been shown how to use a emergency kit if someone was chokin and some staff had not had an induction. There was no evidence of staff being trained in the use of physical restraint despite some people’s care plans allowing for its use
• 52 out of the 58 staff had not completed their mandatory training. 42 had not completed dementia awareness training, 47 had not completed food hygiene training.
• The community lounge area was also described as “very chaotic” and staff members shouted over each other during meal times
• Two complaints had not been documented properly by the previous manager and there was no registered manager in post. The previous one had been dismissed just before the inspection.

Positives: However the report did say that there were ample supplies of PPE that were being used correctly and people were vaccinated against Covid-19. People living in the home also said they felt safe there and with staff, family and friends always felt welcome, and rooms were personalised with people’s things.

The care home also said they had recieved positive feedback during a re-inspection on July 11, which they said showed that “Dundoran has demonstrated that it is back to where it was in July 2022 when Dundoran was rated as good.” It was also praised on July 4 by the NHS End of Life care team for “delivering excellent end of life care.”

Cllr Janette Williamson, chair of the council’s adult social care committee, said: “The inspection’s findings were very disappointing and we would expect substantial changes to be made before the suspension can be lifted.

“The home is now under new management, an action plan is in place and monthly contract meetings have been arranged, to ensure that the plan is on track. The facility is working closely with the authority, to meet the improvements required by ourselves and the CQC.

“Through this joined up approach, all parties will monitor the situation and ensure that Dundoran can make adequate progress in addressing the issues raised.”

Information about what care homes Wirral Council has suspended services to can be found through its Infobank website. This is after a new policy was brought in by the council.