Margaret Greenacre
PFD Report
All Responded
Ref: 2022-0119
All 1 response received
· Deadline: 22 Jun 2022
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
22 Jun 2022
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1. On 4th September 2020 the Care Quality Commission received information from a whistle-blower regarding information of a safeguarding nature in that a service user had fallen and was taken to hospital having sustained a leg and head injury. This was confirmed to be Betty who died on 18th September 2020. Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 provides that registered persons must notify the Care Quality Commission, without delay. The 81h Care Quality Commission contacted Baedling Manor Care Home on September · 2020. Statutory notification was received at the Care Quality Commission on 12 September 2020. It is of concern to me that the Care Quality Commission were notified of concerns by a whistle-blower and, that statutory notification was -not made until 12 days after the incident. It came to light during the inquest that an incident also arose in July 2020 but no reports have been submitted to date. It is of concern to me that matters are not being reported or are being notified late which may prevent incidents being investigated.
2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident's care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty's care needs for lifting.
2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident's care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty's care needs for lifting.
Responses
Response received
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Dear Mr Hetherington Re: Baedling Manor Letter of response to the Coroner; Regulation 28 Report to prevent future deaths
With reference to the cases and , please find outlined in this response the measures taken to prevent future deaths. Please note, the response is in summary form due to the circumstances around the current provision, as follows: As of 12th February, Baedling Manor is currently under notification to close due to significant and multiple failures in regulatory activities. As a result, the current provider has taken the view that attempts to make the home safe under the previous management team has proven unsuccessful and therefore has made the decision to sell the business to an established provider. The home is currently going though transition to a new and established provider operator and a new management team has been employed as part of this process with significant support of the incoming provider. It is anticipated that the changeover will complete before the end of August 202. The new team are unable to comment on historical cases, however all efforts are being made to significantly develop the safe operation of the home during the transition, this includes but is not limited to:
Email: admin@alcyone-hcalthcarc.co.uk Company Registration: 71 50325
• Routine access and support from Director of Care of the management support team
• Enhanced leadership and communication amongst the staff team
• Full time, onsite support from experience nominated Individual.
• Responsive and collaborative communication with CQC leads, Northumberland Safeguarding team, Northumberland Contracts team, Northumberland Infection control team, other visiting professionals, families and residents.
• Full review and implementation of new compliance systems and reporting processes
• Full review and implementation of new care planning processes
• Increased face to face training
• Full health and safety audit and associated actions
• Staffing structure review and revised recruitment and induction processes
• Monitored and audited management action plans A realistic timeframe to move the home into a safe and well led establishment is anticipated to be a 3-6 month period. A CQC inspection review is due in December
2021. If you require any further information, please do not hesitate to contact me.
With reference to the cases and , please find outlined in this response the measures taken to prevent future deaths. Please note, the response is in summary form due to the circumstances around the current provision, as follows: As of 12th February, Baedling Manor is currently under notification to close due to significant and multiple failures in regulatory activities. As a result, the current provider has taken the view that attempts to make the home safe under the previous management team has proven unsuccessful and therefore has made the decision to sell the business to an established provider. The home is currently going though transition to a new and established provider operator and a new management team has been employed as part of this process with significant support of the incoming provider. It is anticipated that the changeover will complete before the end of August 202. The new team are unable to comment on historical cases, however all efforts are being made to significantly develop the safe operation of the home during the transition, this includes but is not limited to:
Email: admin@alcyone-hcalthcarc.co.uk Company Registration: 71 50325
• Routine access and support from Director of Care of the management support team
• Enhanced leadership and communication amongst the staff team
• Full time, onsite support from experience nominated Individual.
• Responsive and collaborative communication with CQC leads, Northumberland Safeguarding team, Northumberland Contracts team, Northumberland Infection control team, other visiting professionals, families and residents.
• Full review and implementation of new compliance systems and reporting processes
• Full review and implementation of new care planning processes
• Increased face to face training
• Full health and safety audit and associated actions
• Staffing structure review and revised recruitment and induction processes
• Monitored and audited management action plans A realistic timeframe to move the home into a safe and well led establishment is anticipated to be a 3-6 month period. A CQC inspection review is due in December
2021. If you require any further information, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 1st October 2020 I opened the inquest into the death of Margaret Elizabeth GREENACRE, held a pre-inquest review hearing on 3rd November 2020 and heard the inquest on 10 February 2021 . Dr found the cause of death to be: 1 a Aspiration Pneumonia 1 b Immobility 1 c Traumatic Haematoma of Right Leg 2 Frailty of Old Age The conclusion of the inquest was: Box 3: On 30 August 2020 the deceased suffered an unwitnessed fall at Baedling Manor Residential Care Home. She was taken to Northumbria Specialist Emergency Care Hospital and was found to have a traumatic haematoma to her right leg. She was transferred to Wansbeck General Hospital for continued monitoring. A fracture and intracranial injury had been excluded. She was initially prescribed antibiotics, but cultures did not identify an infection and were discontinued. The haematoma developed into a wound that required regular dressing. She continued to deteriorate and was receiving palliative care until her death on 18 September 2020 within Wansbeck General Hospital. Box 4: Accident 5
Copies Sent To
Care Quality Commission
Northumbria Healthcare Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.