Rest home where 89-year-old woman was 'over sedated' told to improve by CQC

As reported in The Oldham Times on September 19, the inspection at Edge Hill Rest Home in Oldham Road, Royton, was prompted by the death of Miriam Tighe and the resulting investigation by assistant coroner Rachel Galloway.

Mrs Galloway concluded that Mrs Tighe’s death was “exacerbated” by high levels of sedation and immobility in the months before she passed away.

The flaws in the care “worsened her underlying frailty”, said Mrs Galloway.

The investigation revealed that from November, 2106 Mrs Tighe was regularly over-sedated despite a psychiatrist treating her recommending that the medication be stopped. Mrs Tighe died on February 28, 2017 at Tameside Hospital.

Following Mrs Galloway’s report, the CQC inspected the home on July 17 and concluded that in categories of both safety and leadership it “requires improvement”.

Its report said Edge Hill’s quality assurance and monitoring system for the management of medicines was “not effective”.

“This meant the storage and administration of medicines was not always safe and people were put at risk of harm,” it said.

“The registered manager carried out monthly medicines audits. However, they were not robust enough, as they had not 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.”

It said medicines were not always stored within the recommended temperature range. If medicines are not stored properly they may not work in the way they are intended.

The controlled drugs register had not always been completed correctly and in line with controlled drugs regulations.

Medicines administration records (MARs) had not always been completed accurately.

It went on: “We could not be sure people had received their medicines as prescribed. Some people had not received their medicines at the correct time.

“Although this 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 for two people who managed their own medicines. This meant staff could not be sure the people were capable of looking after their medicines themselves.”

The report also criticised leadership at the home, saying it also “requires improvement”.

It said the service management and leadership was “inconsistent”.

“The registered manager and the provider did not have sufficient oversight of the management of medicines,” it said.

“The quality assurance and monitoring system for medicines was not effective. The storage and administration of medicines was not always safe and people were put at risk of harm.”

Following the inspection the CQC took action to ensure the provider improved the management of medicines.

It asked the Oldham Clinical Commissioning Group (CCG) medicines optimisation team to carry out an audit of the management of controlled drugs at the home.

The CQC will request an action plan for Edge Hill to “understand what they will do to improve the standards of quality and safety”.

It said: “We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.”

A statement released on behalf of Edge Hill said: "“We were concerned at the findings of the (assistant coronor's) investigation and have taken the report extremely seriously.

"Following the inspection visit we put in place an improvement plan, agreed by the CQC, and this was implemented over the summer.

"We are confident that the changes in our processes and management of drugs is now even more effective and we are sure that this will be reflected in a positive rating at our next inspection.

"We take the control and management of medication for our residents extremely seriously at all times.”