Residents in a Scottish care home at the centre of Covid outbreak experienced “unnecessary harm and suffering”, according to inspectors.
They found people who were dying were among those whose “health needs were neglected” at Thornlea nursing home in Loanhead, Midlothian.
Concerns were also raised about the competency of nursing staff and the cleanliness of the home following the inspection in December 2020.
Fifteen residents died with Covid.
Within days of the Care Inspectorate’s visit to the home on 14 December, it had its registration suspended.
Operator Thornlea Nursing Homes Ltd has since gone into liquidation and the care home has been permanently closed.
It is one of at least 474 care homes in Scotland being investigated by a special Crown Office unit set up to probe Covid-linked deaths in care homes.
The report, published on the Care Inspectorate’s website, judged Thornlea Nursing Home “unsatisfactory” following an unannounced inspection.
Inspectors found that some of the 27 people who were using the service at the time were not receiving good care.
“We were very concerned that people who were unwell and nearing the end of their life were not being given appropriate palliative care,” they said.
“The nurses had not ensured that end of life medication to help people stay comfortable was available.
“People were not being checked for signs of changing needs that would then help other professionals such as a GP to be called quickly.”
There was a lack of checks on residents’ temperature, pulse rate and oxygen saturation levels, and their medication was not reviewed regularly.
It meant the need for end-of-life care was not being recognised and “people’s experiences of care at the end of their life may have been compromised as a result”, inspectors added.
Cleanliness was also a concern of inspectors who concluded the home was “not a safe environment to live and work in”.
They had enough PPE but it was not stored properly. In one instance it was found on a trolley next to an open bag of clinical waste – something which risked further spread of infection.
Staff did not clean their hands at every opportunity, following each episode of care or removing PPE.
And clinical waste was not managed properly, with bags left in overfull and unsecured waste bins, and in a bath in a room which was not secure.
Inspectors said enhanced Covid guidance had not been implemented, presenting “a serious risk to people” in the home.
They said there was a lack of management support, with no clear direction being provided.
“This had resulted in people experiencing unnecessary harm and suffering due to their health needs being neglected, including at the end of life,” they said.
The Care Inspectorate made an application to the courts to have Thornlea Nursing Home’s registration suspended following the inspection.
During a hearing at Edinburgh Sheriff Court on 22 December, its registration was suspended from 18 January 2021.
The operator went into liquidation in March.