Response: Coroners Report: Regulation 28: To Prevent Future Deaths: From The Heathers Nursing Home Bradwell Yarmouth: Health and Social Care Act 2008. (Regulated Activities) Regulations 2009 and the Care Quality Commission Regulations (2009). Compliance. Prior during and since this event concerning Mrs M Connor, the Heathers Nursing Home has, and continues to meet the regulated standards as laid down in the act as stated and has remained compliant with the Essential Standards of Quality and Safety' (Section 20) Regulations of the Health and Social care Act 2008). This has included the supply and maintenance of equipment and aids and adaptations used for the benefit of residents and patients in the home: See previous unannounced inspection reports for the home (December 2012, Oct 2013 and March 2014,) Wheelchair management: It has been the responsibility of nurses and care staff and included in the policies and procedures of the home to ensure that any item of equipment in use should be checked prior to immediate use to ensure that the equipment in question is in full working order and 'fit for purpose'. Where resident or patient with limited mobility has been assessed the use of a wheelchair, on regular basis or as part of their overall plan of care, the key worker has the responsibility of ensuring all aids and adaptations are in good working order and meeting the individual needs of the client: problems or notable defects in the wheelchairs would be referred to the maintenance /handyman: Where he was able to carry out a repair he would do so recording the event: Otherwise the chair would be taken out of commission and the external wheelchair specialists be asked to attend the repair. Reporting and recording There are clear guidelines and instructions regarding the reporting and recording of information about residents and patients. Care staff are required to report to the senior carers or in the case Of suspected illness or injury directly to the trained nurse on duty. The information is recorded in as much detail as possible and, depending on the severity of the incident or illness, the trained nurse will make a judgement regarding the immediate course f action and monitored throughout the next 24-72 2 Heathers MC_Coroners response.060614,JS to, Any

hours. Relatives or the designated next of kin are always notified of any event affecting residents' /patients' well being: Information or contributions from relatives regarding the health and welfare of residents or patients is always noted and recorded by nursing staff. Outcomes and Action Although all the appropriate procedures and processes for the management and safe handling of equipment is in place in the home and monitored on regular basis; it is acknowledged that this event has highlighted the lack of attention to detail by the individual staff concerned directly with this matter, and did not carry out the checking processes for wheelchairs as directed by the management; They have also failed to maintain good levels of communication as would be expected between management and staff and as set out in their conditions 0f service and code of contract: As a direct outcome of this event and in response to your matters of concern' , the following action has been undertaken: All staff currently employed in the home have received updated health and safety guidance and instruction regarding the use of wheelchairs and their management; All staff have been directed to read review each resident's/patient's plan of care regarding their mobllity and use of aids and adaptations, including wheelchairs, to ensure they are familiar with the written assessment and the equipment in use. All staff have been issued with a written directive from the Nurse Manager giving clear instructions on the use and management of wheelchairs (see attached 1). The home currently has eleven wheelchairs in use, Of which seven are in use and four are held in stock. Six are new. Four chairs, although still serviceable have been decommissioned as were showing signs of general wear. The wheelchairs in use have been issued with numbers and allocated to rooms or /and residents and patients. It is intended that this will improve the process of tracking the use of the chair and in the event of any query or incident it should be possible to pinpoint the location and identify the user The footplates each of the chairs have been checked and correctly fitted. The majority of them are now fixed, although they can be swung 3 Heathers MC.Coroners response.060614JJS they for

out of the to allow the patient/resident to place their feet on the floor. Staff directives issued recently now state that the plates must not be removed; The management will also be reviewing the current practice of allowing relatives to use wheelchairs both in and outside the premises The review will look at ensuring that persons other than staff can safely manage and manoeuvre the chair during use: As well as the instructions to staff regarding the monitoring of wheelchairs, they are also required to carry out safety checks before use_ All the wheelchairs in use will be checked each week by the maintenance handyman. (see attached formats now in use (2 and 3) All wheelchairs will be serviced every six months by the external wheelchair specialists. Receipts and as before a written record will be maintained, Recording and reporting A review of the process has been carried out and some minor changes have been into place with special emphasis on staff to record and report all events at the time occur, Carers must not delay passing on the information to trained and senior staff. Training AIl staff will undertake updated Health and Safety training sessions to ensure they have a clear understanding about their role and responsibility in maintaining the safety and well being of the patients and residents especially when using equipment to support their care One of the visiting physiotherapists will be offering two training sessions to the staff group covering the management of aids and equipment and moving people with limited mobility. At the same time The manager will be providing group sessions to carers on understanding what is 'referred pain' and how it differs from 'local pain' , which is what is usually experienced and reported in the event of a fall or injury. The manager will also be looking at ways that staff can be advised on how to respond to complaints of pain where there may not be corroborative evidence of a trauma having occurred. This is work in progress and the instruction may take the Heathers MCCoroners response.060614JJS way put they

form of 'what to do in the event of' printed guide to ensure consistency of action and care Through the processes of supervision the staff will also be reminded of their responsibilities to maintain good observation skills, interpret and respond appropriately to non verbal cues, especially physical expressions that may denote distress or and anxiety in those residents and patients with limited cognitive awareness The Manager and Quality Assurance Manager for the service will also review the management care staff and nurses' interpersonal skills to ensure the relationships with relatives and other health care staff is open and professional: Staff at all levels will be reminded that must maintain at all times good standards of care combined with honesty and professional integrity. The management team will also review how staff can be supported and protected when dealing with challenging and inappropriate behaviour, whether it is from patients, residents, relatives or external health professionals: The training will be completed within the next twelve months: Signed= Date: G.Q6_0/4 Registered Manager. Heathers MC Coroners response.060614JJS they

Staff Directive: Appropriate use of wheelchairs Guidance and instruction. Wheelchairs are currently allocated to designated rooms and meet the assessed needs of the resident patient; Wheelchairs are numbered for ease of identification and whereabouts. Before using any wheelchair please carry out all safety checks see format 3) After use RETURN chair to designated room Iresident: DO NOT Teave wheelchairs in any communal areas such as bathrooms corridors or lounges. ALWAYS return them to the designated room_ DO NOT attempt to remove footplates from wheelchairs; Please ensure that your knowledge regarding the accurate use of wheelchairs and other aids and adaptations is up to date: Please ensure that you have completed all the refresher) Health and Safety training sessions and that you can confidently and competently assist people to move, transfer, appropriately and safely. Please report any faults immediately to maintenance/handyman and If necessary remove the wheelchair from service_ Please note that all wheelchairs will be checked once a week in house and a record kept, and every six months by external wheelchair services. To assist with this process please ensure the wheelchairs can be located in their designated room: Please ensure that you adhere to these guidelines and instructions as directed in the interests of resident's and patient's safety and well being: Failure to do so may lead to disciplinary action. Please sign both copies to say that you have read and understood the directive and will comply with the instructions. Return one copy to the manager. Signed. Date Print name_ Heathers MC Coroners response.060614JJS

Heathers Nursing Home Wheelchair Safety Maintenance Check Allocated chair to: Personal /Own Wheelchair YES NO Date Brakes fully functional ON OFF Tyres accurate pressure Footplate in situ & in use Cushion /seat in place Seatbelt in place & fully operational comments: Any

Heathers Care Home Carers Wheelchair Safety Checklist Wheelchair checklist to be used each time & resident uses a wheelchair. Tick in the box when the function has been checked and safe to use. If there is any area 0f concern, d0 not use the wheelchair. Allocated chair to: Date Time Brakes Tyres Footplates Cushion Seatbelt full accurate in situ & in place in place functional pressure use Sign