Multiple breaches affected patient safety

Alexandra Nursing Home

A NURSING home in Oldham has been put into special measures after multiple breaches were found to affect the safety and wellbeing of patients.

The inspection at Alexandra Nursing Home was brought forward when a coroner issued a report on a death at the home.

A family has filed a lawsuit against the home in Queens Road following an inquest into the death of a "loved and missed" mother who died there.

The Care Quality Commission (CQC) found the home had "not completed an investigation" relating to the coroner's verdict.

Inspectors have rated the home as "inadequate" and the service has been prevented from taking in new residents.

Inspectors found breaches of the Health and Social Care Act affecting safety, wellbeing and the quality of service provided.

Their report said: "Medicines were not safely managed.

"We could not be sure that people received their medicines as prescribed by their GP.

"Safeguarding incidents had not been investigated to ensure the ongoing safety of the people involved nor had they been reported to the CQC.

"Governance systems for the running of the home were not effective. We found that where issues had been identified, the registered manager had not ensured these were addressed in a timely manner.

"The CQC is considering the appropriate regulatory response to resolve the problems we found."

Inspectors brought their visit to the site forward after a Regulation 28 - "Preventing Future Deaths" - report was issued by a coroner.

Assistant Coroner for Greater Manchester North Catherine McKenna launched an investigation into the death of Joyce Harewood in November, 2015, after she died "from complications arising from a bleeding duodenal ulcer" in October.

She said in her report findings: "On Wednesday, October 28, the care home staff administered medication to Mrs Harewood which included Apaxiban. The Apaxiban will have caused the bleed that Mrs Harewood was suffering to become catastrophic.

"There was a failure on the part of the care home staff to respond appropriately to the deterioration in Mrs Harewood's physical condition.

"In my opinion there is a risk that future deaths will occur unless action is taken."

The coroner's report was handed over to the home in May, 2016, in relation to staff's response to people's needs, administering medicines and seeking medical attention.

A registered manager had attended a safeguarding meeting with Oldham Council to discuss the report but no appraisals were organised to ensure the safe delivery of care.

The CQC said: "The nominated individual and registered manager confirmed they had not completed an investigation in relation to the coroner's verdict.

"We found the provider and registered manager had failed to implement all the necessary actions they had identified within the timeframes they had set out in their response to the regulation 28 report."

Joyce's daughter Linda Clarke (56), from Royton, said: "I'm sincerely hoping that the investigations have saved others from suffering or even death. My mum should still be with us today.

"We all love and miss her so much but she is at peace now and will no longer suffer the pain and endurance she was facing."

Following an unannounced inspection in July and August last year the CQC rated safety, effectiveness and leadership as "inadequate" while care and responsiveness were said to "require improvement."

The home was found to be clean and tidy and people who used the service said they felt safe and staff were trained to provide appropriate support.

The CQC observed some caring and patient interactions between staff and those using the service. Complaints raised by residents and their relatives were also recorded, investigated and action was taken in response.

A total of 29 people were living at the home, which is registered to provide nursing or personal care and treatment for disease, disorder or injury.

The service will be inspected again within six months by which time improvements are expected to have been made.