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Nursing failures revealed by CQC review

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Nursing failures and poor staff supervision were discovered at a mental health unit after an investigation into the deaths of six elderly patients, the Care Quality Commission has said.

Poor care did not cause any of the deaths at the Harbourne unit, in Totnes, Devon, but “serious concerns” with its services for older people prompted a Care Quality Commission (CQC) review.

Publishing its findings, the CQC said Devon Partnership Trust could have acted quicker to tackle the now-shut ward’s problems - which included mood-altering drugs being unnecessarily handed out to patients.

Amanda Sherlock, CQC deputy director of operations, said: “It is clear that the trust should have been able to spot and address those problems earlier.

“Our report found that until these problems came to light, the trust appeared to have no oversight, leaving highly dedicated staff to cope without clear policies or guidance from the centre.

“The trust did not know whether standards of care were adequate or not.

“At an early stage of this inquiry, we shared our findings with the trust, to give them the earliest opportunity to begin to make improvements.

“To their credit, Devon Partnership have moved swiftly to improve mental health services for older people without waiting for the publication of our report before beginning a programme of redesign and improvement.”

The CQC is now working on a follow-up review to establish if the trust is meeting new standards which came into force this year.

Commenting on the report, the trust’s chief executive Iain Tulley said prompt action was taken to address problems with care at the Harbourne unit when they were identified.

He said: “We readily acknowledge the serious shortcomings in the care that was provided on the Harbourne unit in 2008.

“We have taken active steps to address these - including appropriate action with the staff concerned - and, more importantly, we have learned important lessons that have enabled us to significantly improve the quality of care we offer to this vulnerable group of people.”

The trust has started a £4.6m investment programme to improve and maintain the safety of older people’s units.

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Readers' comments (1)

  • Marjorie Lloyd

    I wish managers would listen to the nurses sooner so that these things do not happen. Even though the nurses were not to blame for the deaths poor organisation and leadership could have put everyone at risk.

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