Independent Review: Dunmurry Manor Care Home (2018)

What happened?

Dunmurry Manor Care Home opened in 2014, providing specialist dementia care to residents in Belfast. Families of residents and the care inspectorate raised concerns about the home, detailing poor standards of care. Patient buzzers were left unanswered, one resident was sexually abused by another resident, and incidences and records were not appropriately kept or reported to the correct agencies. 

The home had failed to properly prepare for admissions, placing residents at increased risk of neglect and psychological distress. One resident developed pressure sores, though this was not recorded properly, and morphine was not administered before dressings were changed causing the resident significant distress and pain.

What went wrong?

• Lack of clear and cohesive sexual abuse policy: A lack of policy, which would protect older female residents from possible sexual assaults by ambulatory male residents, left an unmanaged risk.
• Lack of consistency of terms across trusts: There was a lack of consistency across Health and Social Care Trusts as to what ‘quality monitoring’ incident and ‘adult safeguarding issue’ means. This led to insufficient responses to enable early intervention.
• Inconsistent record keeping: There were multiple safeguarding forms and documentation in use, which were left incomplete. This reflected poor and inconsistent record keeping.
• Poor management of the home: The home failed to conduct 15-minute monitoring visits where needed as per policy, indicating poor oversight and management at the home.
• Medication errors: There was a high-level of medication errors, which increased the number of safeguarding incidences.
• Poor management of service: Poor treatment of residents by staff evidenced a lack of management and oversight of the service.

Recommendations for improvement

•  An Adult Safeguarding Bill for Northern Ireland should be introduced promptly to support consistent and unambiguous responses.
• Everyone involved in adult social care should receive training on the implications of human rights, dignity and respect.
• Practitioners should be trained to report concerns about care and support.
• Clear guidelines, centring on the use of CCTV in care home settings, should be developed to ensure that people’s privacy and dignity is upheld.
• Highlighted the need for better partnership working and joined up responses, to enable an increased robust response to concerns of abuse and neglect.

Access full report here.