Dormy House rated inadequate as death investigated in care home

Dormy House, which is managed by Aria Healthcare Group, received the Care Quality Commission’s (CQC) lowest possible rating, judging that residents 'were not always protected from the risk of abuse or neglect'.

The report said the inspection was prompted - in part - due to concerns around the safe care and treatment of people, and staffing levels. However, it also mentions concerns raised around the death of a resident which continues to be investigated.

During the visit to the home CQC inspectors spoke with three people and 11 relatives of care home residents about their experiences including around meal times.

Inspectors described mealtimes witnessed during the visit as ‘chaotic’ and that in some cases there was a risk of choking.

The report said: “One person was in a lying down position in bed with their lunch plate balancing on their lap. Staff had entered the person’s room and had not offered to move them to a better position to eat their meal.

“Another person was supposed to be having a soft meal due to the risk of choking however, the mashed potato looked dry with a crispy film on top. This placed the person at further risk of choking.”

A relative who was interviewed explained: “My [family member] is supposed to be on a diet that it moist and not too chewy.”

The resident involved was being given meat that was hard to chew.
The report reveals healthcare inspectors also found that residents were at high risk of falling due to the behaviour of staff and that risks were not managed safely or reported.

A member of staff told inspectors: “We have to make a decision whether to accompany a person who is walking and who is at risk, or going to help the person who is slipping out a chair.”

Whilst examining resident’s records, it was found that major incidents and accidents were not always recorded in detail or investigated to reduce further risks.

Care and Quality Commissions inspectors said in the report: “Another incident recorded one person had an unwitnessed fall and ‘had a major injury sustained'. There was no additional information on what the injury was, how it was treated or any investigation into how it occurred.

“This was also the same for another person that according to the incident report had been hit by another person whilst walking past them in the corridor.”
After observing these issues, it was concluded that the service was no longer safe and that the resident’s safety was being put at risk.

Although it was found that at times people were not treated in a kind and dignified manner, many of the members of staff have been praised by both relatives and residents of the service.

Inspectors said: “We observed some examples of staff being considerate and kind to people. One member of the staff went to find a person to say goodbye. The member of staff told us they always had a good chat with the person and liked to say goodbye when they went off duty.

“There were staff that greeted people warmly when they went into their rooms, and we saw this was appreciated by people.”

A spokesperson from Dormy House said: “The health, safety and wellbeing of our residents is our absolute priority and we take feedback from the Care Quality Commission very seriously. We are sorry that the home has fallen short of the standards that residents, relatives and friends rightly expect and we will continue to listen to their feedback."

The care home said several actions have been taken to address areas identified as requiring improvement which includes the recruitment of a new experienced manager and two new deputy managers.

They said: “Since the report was first published in December, we have communicated with our residents and their families the actions we are taking to improve the standards and will continue to do so.

“We take our duty to treat our residents with respect and dignity extremely seriously and we believe the Care Quality Commission will recognise the positive progress that has already been made at our next inspection.”