A ROYTON rest home, the subject of an assistant coroner’s criticism after an elderly woman’s death, “requires improvement” according to the health watchdog.
South Manchester assistant coroner, Rachel Galloway ruled in May 2019 the pensioner died as a “consequence of naturally occurring diseases exacerbated by high levels of sedation and immobility in the months prior to her death.”
Now Edge Hill, rated ‘good’ across all areas in July 2018, has been ruled to “require improvement” by the Care Quality Commission (CQC) under two of five headings: ‘Is the service safe’ and ‘Is the service well led?’
Edge Hill provides residential care for up to 36 people but at the time of the CQC’s inspection on July 17, 2019 there were 22 people living in the home.
“The inspector was prompted by concerns raised at an inquest about some aspects of the management of medicines at the home,” the report stated.
“As a result we undertook a focused inspection to review the Key Questions of safe and well led.
“We looked specifically at the management of medicines and the oversight of the registered manager and provider of these aspects of care.
“We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore we did not inspect them.”
However, the report goes on: “We identified breaches in relation to the management of medicines and governance.
“The provider’s quality assurance and monitoring system for the management of medicines was not effective.
“This meant storage and administration of medicines was not always safe and people were put at risk of harm.
“The registered manager carried out monthly medicines audits. However, they were not robust enough as they had no identified the concerns we found during our inspection.
“Staff who gave out medicines had been trained and assessed as competent to do this.
“However, we found concerns around the administration of medicines. This showed the training and competency checks were not robust.
“Medicines were no always stored within the recommended temperature range. If medicines are not stored properly they may not work in the way they are intended.
“Some people had not received their medicines at the correct time. Although his was a dispensing error by a pharmacist, the service had not taken any steps to seek clarification about the problem.
“Risk assessments had not been completed by two people who managed their own medicines.
“This meant staff could not be sure the people were capable of looking after their medicines themselves.”
In the case of Miriam Tighe, the assistant coroner said there were flaws in the care received at Edge Hill from a psychiatrist working in the Memory Clinic – part of Pennine Care NHS Foundation – and Royton and Crompton Family Practice “worsened her underlying frailty”.
In October 2016 she was experiencing episodes of aggression and agitation and various medications were prescribed by GPs and the psychiatrist to address her symptoms.
However, she continued to receive promazine medication after the psychiatrist had advised that it be stopped, on November 16, 2016 and again on December 16, 2016.
“From November, 2016, Mrs Tighe was regularly over sedated, leading to increased immobility and deconditioning,” said Mrs Galloway.
“Immobility was further contributed to by limited simulation and the promotion of a sedentary lifestyle by staff under the instruction of the home manager.
“In turn, this contributed to and worsened Miriam Tighe’s underlying frailty.”
On December 30, 2016, Mrs Tighe was sedated with promazine and after consultation with the GP an ambulance was called and she was taken to the Royal Oldham Hospital.
Mrs Galloway went on: “The home manager refused to accept Miriam Tighe back at the home on the basis that an EMI (elderly mentally ill) nursing bed was required. Mrs Tighe was admitted to hospital while a bed was found.”
Mrs Galloway launched an investigation into the lady’s death in April 2019 and during the course of the inquest into Mrs Tighe’s death, the evidence revealed matters giving rise to concern.
“In my opinion there is a risk that future deaths will occur unless action is taken,” she said.
“I found Miriam Tighe had been over-sedated during her time as a resident at Edge Hill.”
“It was clear the GPs and the psychiatrist were not aware of decisions being made by each other in October to December, 2016, which led to unsafe prescribing of sedatives and anti-psychotic medication.”
Her report was sent to Edge Hill, Royton and Crompton Family Practice, Pennine Care NHS Foundation Trust and Oldham Clinical Commissioning Group.
Mrs Galloway added: “In my opinion action should be taken to prevent future deaths and I believe you (the organisations mentioned) have the power to take such action.”
A spokesperson for NHS Oldham Clinical Commissioning Group (OCCG) said: “The findings from the coroner’s report for this case have been received by the CCG and will be reviewed to ensure that any improvements are made within local services as needed.”
Since the CQC inspection, OCCG’s medicine optimisation team carried out a controlled drugs audit at Edge Hill and issued the registered manager with an action plan to complete.
The registered manager had also “recently strengthened their (Edge Hill’s) admission procedure to ensure the service could meet people’s needs fully before they were accepted by the home.”
The Correspondent contacted Edge Hill but was unable to get a comment prior to going to press.