Northern Ireland's health watchdog uncovered scenes of chaos inside a scandal-hit care home at the centre of a deadly Covid-19 outbreak, it can be revealed.
Among the litany of failings, the Regulation and Quality Improvement Authority (RQIA) found that residents in the dementia unit of Clifton Nursing Home were able to access cleaning chemicals.
The RQIA carried out inspections at the facility in north Belfast on May 15 and 21. Inspectors found the manager was wearing her personal protective equipment inappropriately and information provided by the Belfast Trust on the use of PPE was incorrect.
Information for staff on the use of PPE did not reflect the guidance from the Public Health Agency (PHA), there were insufficient PPE stations and the equipment was not being stored properly, the inspectors said. They were also worried about the location of handwashing facilities and there was no bin to dispose of contaminated protection equipment inside one unit.
Staff also told inspectors they "did not have a clear understanding" of safely putting on and taking off PPE. One worker was wearing a cloth face mask and another was wearing two masks.
"It was concerning that neither the home staff nor trust staff had been able to effectively address these practices," the inspection report said.
Equipment such as stethoscopes and thermometers were either not available or the equipment was faulty, some communal areas required a deep clean, and dementia patients could access cleaning materials.
It has also emerged that concerns over PPE identified during the visit on May 15 had not been addressed by the time inspectors returned on May 21.
During the first visit, one registered nurse "was observed to be very upset and overwhelmed", while the RQIA inspectors also raised a series of concerns over the management of the home. In particular, the inspectors noted a "lack of oversight and physical presence" by senior management, including the responsible individual, Gavin O'Hare-Connolly, the chief operating officer of Runwood Homes, which owns the facility.
"From discussions with staff and observations made it was identified that there was a lack of oversight and physical presence by the senior management team in all three units of the home," said the RQIA report. "It was noted that the responsible individual and regional manager were office-based during the inspections."
The findings of the May 15 inspection, carried out after the Belfast Trust raised concerns, were so serious that a meeting was called with the chief operating officer and Runwood Homes' regional operations' director on May 19. Reassurances were provided by Mr O'Hare-Connolly to the RQIA that failings would be addressed.
However, it has now emerged that, in a damning indictment of conditions inside the home, concerns were subsequently raised by the Belfast Trust, PHA and Department of Health. The RQIA returned to the home on May 21 and "found that the home's management team had not implemented the actions they had assured us of".
By this stage, Clifton Nursing Home was considered so dangerous that health bosses took the unprecedented decision to move residents for their own safety. However, this was avoided when a new care home provider stepped in to manage the home temporarily.
Alliance health spokeswoman Paula Bradshaw MLA (left) said the findings reinforce the need for an investigation into how care homes are run.
Last week, a nurse received an apology from Belfast Trust after she was sent to work in Clifton Nursing Home but was left fighting for her life with Covid-19. Nine residents are known to have died with the virus.
A Runwood Homes spokesperson said the company "continues to work in partnership with our colleagues at Healthcare Ireland regarding Clifton Nursing Home".
"We can confirm that, on 24 June 2020, RQIA re-inspected this service and the failure to comply notice was lifted," they said. "We extend our thanks to all staff at Clifton Nursing Home for their continued professionalism and hard work."