Winifred Elliott
PFD Report
Partially Responded
Ref: 2016-0448
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
9 Apr 2017
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms That the removal of such information has made it harder for busy staff to access such information: from using and
That as such, some residents may be being inappropriately transferred thus sustaining injuries that may cause to contribute to their deaths as in this case That all homes should display as appropriate such information: That the CQC should advise all residential homes that should come up with such a system and implement it forthwith That the CQC should inspect homes and confirm that such systems are in place.
That as such, some residents may be being inappropriately transferred thus sustaining injuries that may cause to contribute to their deaths as in this case That all homes should display as appropriate such information: That the CQC should advise all residential homes that should come up with such a system and implement it forthwith That the CQC should inspect homes and confirm that such systems are in place.
Responses
Response received
View full response
Dear HM Coroner Thank you for your letter dated 15 December 2016 in which you wrote to uS under the provisions of Regulation 28 of the Coroners (Investigations) Regulations 2013 in relation to the inquest into the death of Winifred Elliott, Further to your report referenced above, we are writing to you with our response to the issues raised_ Before addressing in turn each of the concerns set out at section 5 of your report; we set out background which hope will assist, providing context to the actions that we have taken. Background CQC was notified on 5 January 2016 of the injuries sadly suffered by Mrs Elliott at Meadbank Care Home by the provider under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We were informed that Mrs Elliott had been transferred to hospital and that safeguarding alert had been submitted to the local authority as there were concerns about how the injuries had occurred_ There were no ongoing concerns about the service at the time of the incident and the lead inspector for Meadbank Care Home was in contact with the home manager, the provider and local authority safeguarding team to ensure that were kept informed of the progress and outcome of the investigation Strategy meeting minutes dated 27 January 2016 were provided to CQC detailing they
the steps the provider had taken to mitigate any further risks to people using the service. CQC carried out an unannounced comprehensive inspection of Meadbank Care Home on 4 April 2016. During this inspection no concerns were noted in relation to the moving and handling of people using the service and the service was rated Good overall but Requires Improvement in the question Safe as there were some concerns about the administration of prescribed medicines_ A further unannounced focused inspection was carried out at Meadbank Care Home on 2 September 2016 following the receipt of additional information from Detective Sergeant Wandsworth CID in relation to his investigation into Mrs Elliott's death. During this inspection we found that staff were trained in how to safely transfer people and understood the moving and handling needs of the people they were supporting: We note that you identified the 'matters of concern' in your Report as follows: That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms 2 That the removal of such information has made it harder for staff to access such information_ 3_ That as such, some residents may be inappropriately transferred and thus sustaining injuries that may cause to contribute to their deaths as in this case. That all homes should display as appropriate such information. 5_ That the CQC should advise all residential homes that should come up with such a system and implement it forthwith 6_ That the CQC should inspect homes and confirm that such systems are in place_ CQC's response to the specific concerns you have raised above are taken in turn and set below: That information in relation to transferring residents has been removed from display next to the resident We have reviewed all of the reports written following our inspections of Meadbank Care Home on 14 July 2011, 8 November 2012,21 May 2013,24 September 2013, 6 November 2014_ 4 April 2016 and 2 September 2016 and spoken with the lead inspectors involved in these inspections. We cannot find any evidence that CQC at any time asked staff at Meadbank Care Home to 2 key busy being they out
remove moving and handling guidelines for staff from display in people's bedrooms . However , it is possible that a member of an inspection team brought this to the attention of staff as a potential issue in relation to people's privacy and confidentiality_ We have drawn that conclusion as Regulation 10 of the Health and Social Care Act (Regulated Activities) Regulations 2014 states that the registered person is required to ensure the privacy of service users and Regulation 17 states that people's care records must be kept securely. Prior to this Regulation 17(1) and 20(2) or the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 may have been considered in relation to this issue_ These regulations were in force from April 2010 until 31 March 2015. Therefore it is possible that whilst assessing the provider in relation to these regulations that an inspector advised staff to consider the implications of displaying information in people's bedrooms. CQC would not systematically object to the display of and handling information in people's bedrooms but would expect that staff had considered people's consent to this and what was in their best interests_ 2 Removal of information has made it more difficult for staff to access this information: The registered persons within care homes are required to ensure that staff have access to the information they require to meet the individual needs of the people support which includes their moving and handling needs_ This includes care plans and risk assessments and any guidance for staff to support them to meet people's needs appropriately and safely. Whilst it is accepted that information should be easily accessible to enable staff to complete their roles effectively, consideration must be given to the views of the person or their representatives in relation to displaying information in people's bedrooms to ensure their consent is given for this_ If people are unable to make this decision, a decision must be made in their best interests in line with the Mental Capacity Act 2005. The two inspections that took place of Meadbank Care Home following the death of Mrs Elliott found that staff were aware of the correct moving and handling practices to follow for the individuals they supported and the content of people's care plans and risk assessments
3. Some residents may be being inappropriately transferred and thus sustaining injuries that cause to contribute to their deaths as in this case. Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 require registered persons to provide care in a safe way for service users which includes assessing risks to health and safety and all that is reasonably practicable to mitigate such risks It is not acceptable for staff to transfer people without reviewing the information available in people's care moving they may doing
plans and risk assessments to ensure that this is completed safely. It is expected that staff who are working with people have access to these records in order to them in the appropriate moving and handling techniques to transfer people safely and this is assessed as part of our inspection methodology: 4 . That all homes should display as appropriate such information. CQC has the statutory objective of performing its functions for the general purpose of encouraging the improvement of health and social care services This is achieved by monitoring and inspecting services to ensure that are meeting the regulations. Providers develop ways of meeting the regulations that are individual to the service and meet people's individual needs. CQC as the regulator does not have the power to insist that provider's meet the regulations in particular way. However; CQC does provide guidance for providers about how to meet the regulations on our website which can be found here: http:ILwWW cYc org Uklcontentlquidance-providers: Also we can ensure as part of our inspections that staff have access to all of the information that they require to meet people's individual needs appropriately and safely and take action where this is not the case. Care services find different ways of ensuring that care staff have access to the information they need to provide people with safe and appropriate care. For example, some services ensure that staff receive protected time to read and understand care plans and risk assessments and others keep care plan folders in people's bedrooms so that staff can access these easily for each individual_
5. CQC should advise all residential homes that they should come up with such a system and implement it forthwith During the inspection process the inspection team will assess the performance of the provider against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014_ As part of this process inspectors will assess whether or not providers are providing safe care and treatment under Regulation 12. This will include the assessment and management of risks associated with moving and handling: As stated above CQC does not have powers to insist on how providers meet the regulations and therefore could not compel providers to develop and implement systems for displaying moving and handling information However, CQC will assess the effectiveness of the systems providers have to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using services and will take action against providers who fail to keep people safe from avoidable harm: 6_ That the CQC should inspect homes and confirm that such systems are in place. guide they the
At all comprehensive inspections the inspection team will assess whether the provider is meeting legal requirements under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure that people are receiving safe care and treatment This will include assessing staff understanding of people's individual needs and access to information about people's needs as detailed in their care plans and any associated risk assessments. CQC will take action in accordance with its enforcement policy where providers are failing to provide safe care and treatment which includes the failure to operate safe moving and handling procedures. If you have any further questions or concerns, please do not hesitate to contact uS on the above number.
the steps the provider had taken to mitigate any further risks to people using the service. CQC carried out an unannounced comprehensive inspection of Meadbank Care Home on 4 April 2016. During this inspection no concerns were noted in relation to the moving and handling of people using the service and the service was rated Good overall but Requires Improvement in the question Safe as there were some concerns about the administration of prescribed medicines_ A further unannounced focused inspection was carried out at Meadbank Care Home on 2 September 2016 following the receipt of additional information from Detective Sergeant Wandsworth CID in relation to his investigation into Mrs Elliott's death. During this inspection we found that staff were trained in how to safely transfer people and understood the moving and handling needs of the people they were supporting: We note that you identified the 'matters of concern' in your Report as follows: That information in relation to transferring residents has been removed from display next to the resident e.g. from above their beds or inside their rooms 2 That the removal of such information has made it harder for staff to access such information_ 3_ That as such, some residents may be inappropriately transferred and thus sustaining injuries that may cause to contribute to their deaths as in this case. That all homes should display as appropriate such information. 5_ That the CQC should advise all residential homes that should come up with such a system and implement it forthwith 6_ That the CQC should inspect homes and confirm that such systems are in place_ CQC's response to the specific concerns you have raised above are taken in turn and set below: That information in relation to transferring residents has been removed from display next to the resident We have reviewed all of the reports written following our inspections of Meadbank Care Home on 14 July 2011, 8 November 2012,21 May 2013,24 September 2013, 6 November 2014_ 4 April 2016 and 2 September 2016 and spoken with the lead inspectors involved in these inspections. We cannot find any evidence that CQC at any time asked staff at Meadbank Care Home to 2 key busy being they out
remove moving and handling guidelines for staff from display in people's bedrooms . However , it is possible that a member of an inspection team brought this to the attention of staff as a potential issue in relation to people's privacy and confidentiality_ We have drawn that conclusion as Regulation 10 of the Health and Social Care Act (Regulated Activities) Regulations 2014 states that the registered person is required to ensure the privacy of service users and Regulation 17 states that people's care records must be kept securely. Prior to this Regulation 17(1) and 20(2) or the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 may have been considered in relation to this issue_ These regulations were in force from April 2010 until 31 March 2015. Therefore it is possible that whilst assessing the provider in relation to these regulations that an inspector advised staff to consider the implications of displaying information in people's bedrooms. CQC would not systematically object to the display of and handling information in people's bedrooms but would expect that staff had considered people's consent to this and what was in their best interests_ 2 Removal of information has made it more difficult for staff to access this information: The registered persons within care homes are required to ensure that staff have access to the information they require to meet the individual needs of the people support which includes their moving and handling needs_ This includes care plans and risk assessments and any guidance for staff to support them to meet people's needs appropriately and safely. Whilst it is accepted that information should be easily accessible to enable staff to complete their roles effectively, consideration must be given to the views of the person or their representatives in relation to displaying information in people's bedrooms to ensure their consent is given for this_ If people are unable to make this decision, a decision must be made in their best interests in line with the Mental Capacity Act 2005. The two inspections that took place of Meadbank Care Home following the death of Mrs Elliott found that staff were aware of the correct moving and handling practices to follow for the individuals they supported and the content of people's care plans and risk assessments
3. Some residents may be being inappropriately transferred and thus sustaining injuries that cause to contribute to their deaths as in this case. Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 require registered persons to provide care in a safe way for service users which includes assessing risks to health and safety and all that is reasonably practicable to mitigate such risks It is not acceptable for staff to transfer people without reviewing the information available in people's care moving they may doing
plans and risk assessments to ensure that this is completed safely. It is expected that staff who are working with people have access to these records in order to them in the appropriate moving and handling techniques to transfer people safely and this is assessed as part of our inspection methodology: 4 . That all homes should display as appropriate such information. CQC has the statutory objective of performing its functions for the general purpose of encouraging the improvement of health and social care services This is achieved by monitoring and inspecting services to ensure that are meeting the regulations. Providers develop ways of meeting the regulations that are individual to the service and meet people's individual needs. CQC as the regulator does not have the power to insist that provider's meet the regulations in particular way. However; CQC does provide guidance for providers about how to meet the regulations on our website which can be found here: http:ILwWW cYc org Uklcontentlquidance-providers: Also we can ensure as part of our inspections that staff have access to all of the information that they require to meet people's individual needs appropriately and safely and take action where this is not the case. Care services find different ways of ensuring that care staff have access to the information they need to provide people with safe and appropriate care. For example, some services ensure that staff receive protected time to read and understand care plans and risk assessments and others keep care plan folders in people's bedrooms so that staff can access these easily for each individual_
5. CQC should advise all residential homes that they should come up with such a system and implement it forthwith During the inspection process the inspection team will assess the performance of the provider against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014_ As part of this process inspectors will assess whether or not providers are providing safe care and treatment under Regulation 12. This will include the assessment and management of risks associated with moving and handling: As stated above CQC does not have powers to insist on how providers meet the regulations and therefore could not compel providers to develop and implement systems for displaying moving and handling information However, CQC will assess the effectiveness of the systems providers have to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using services and will take action against providers who fail to keep people safe from avoidable harm: 6_ That the CQC should inspect homes and confirm that such systems are in place. guide they the
At all comprehensive inspections the inspection team will assess whether the provider is meeting legal requirements under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure that people are receiving safe care and treatment This will include assessing staff understanding of people's individual needs and access to information about people's needs as detailed in their care plans and any associated risk assessments. CQC will take action in accordance with its enforcement policy where providers are failing to provide safe care and treatment which includes the failure to operate safe moving and handling procedures. If you have any further questions or concerns, please do not hesitate to contact uS on the above number.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them:
Report Sections
Investigation and Inquest
On the 4"h and 5lh December 2016 heard evidence in relation to the Inquest touching the death of Mrs Winifred Elliott. Medical Cause of Death 1 (a) Bronchopneumonia (b) Immobility and lower limb fractures associated with severe osteoporosis II. Chronic renal failure, dementia How, when and where and in what circumstances the deceased came by her death: Winifred Elliott resided in Meadbank Care Home. She was assessed as non-weight bearing and requiring a hoist for all transfers with the assistance of two persons. A hoist was rarely if ever used. She was transferred either by being lifted by one person or transferred partially weight bearing with the assistance of a handling belt: On 31/12/2015 she was transferred into bed using a handling belt This necessitated rotation of her left leg: As a result of this the left leg fractured in four places The injuries sustained caused or contributed to her death: Despite severe underlying osteoporosis if she had been transferred in accordance with her moving and handling plans ie_ non-weight bearing this would not have occurred on the balance of probabilities There was evidence of systemic failings in staffing levels , supervision, and communication that when taken together with the failure to apply the moving and handling plan, constitute a gross failure. The death was therefore contributed to by neglect: She was admitted to Chelsea and Westminster Hospital on 2/1/2016 where despite care the injuries led to and caused her death on 10/1/2016. Conclusion as to the death Mrs Winifred Elliott died as a result of injuries sustained during a transfer her chair to bed techniques not recommended for her;
Circumstances of the Death
The evidence was that the staff generally had no time to read care plans and relied on staff handovers for information in relation to moving or handling Hoists were at times slow to locate and there were often insufficient staff to effect two person transfer; They had been training in relation to the techniques to be employed but staff often ignored that training There appeared to a culture of collusion with this by some of the more senior staff, for example the nurses_ Things do seem to have improved under new management: Evidence was taken as to how it could be made completely clear to staff transferring residents how transfers should be effected for the individual resident; and there was consensus that a written display somewhere effective,
e.g. above a residents bed or inside their door could act as an effective prompt to staff, especially for example agency or bank staff. Since transfers are happening in the public areas of the home as well as in residents' rooms, such information would not be confidential, It would be in the best interest of disabled residents to ensure that such matters could not be confused by staff: Various methods for doing this such as a traffic light scheme were discussed in evidence but it would be for each home to come up with the most appropriate method for them. was also informed in court that such information was displayed previously but was removed on the instruction of the CQC due to misplaced concerns about confidentiality_
e.g. above a residents bed or inside their door could act as an effective prompt to staff, especially for example agency or bank staff. Since transfers are happening in the public areas of the home as well as in residents' rooms, such information would not be confidential, It would be in the best interest of disabled residents to ensure that such matters could not be confused by staff: Various methods for doing this such as a traffic light scheme were discussed in evidence but it would be for each home to come up with the most appropriate method for them. was also informed in court that such information was displayed previously but was removed on the instruction of the CQC due to misplaced concerns about confidentiality_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.