Reginald Weston
PFD Report
All Responded
Ref: 2022-0008
All 1 response received
· Deadline: 8 Mar 2022
Coroner's Concerns (AI summary)
The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
View full coroner's concerns
Evidence was given in relation to the Majesticare Falls Management Policy and Procedure requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: a) Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall b) Timely process for completing it
Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
Responses
Action Taken
The care home now requires that falls are recorded, and risk assessments are completed within 24 hours of any fall. Falls equipment audits have been taking place and more detailed accident and incident analysis has been included into the monthly accident audit. Pre-admission assessments are taking place in person when possible and The Berkley Care Group Training Manager is supporting Blenheim House with additional Falls Prevention Champion Training in Q2. (AI summary)
The care home now requires that falls are recorded, and risk assessments are completed within 24 hours of any fall. Falls equipment audits have been taking place and more detailed accident and incident analysis has been included into the monthly accident audit. Pre-admission assessments are taking place in person when possible and The Berkley Care Group Training Manager is supporting Blenheim House with additional Falls Prevention Champion Training in Q2. (AI summary)
View full response
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FROM: Management Team, Blenheim House Care Home The MATTERS OF CONCERN expressed by the Coroner were as follows. – Evidence was given in relation to the Majesticare Falls Management Policy requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall Timely process for completing it Response
1. Further to the inquest onto the death of Mr Weston and the Report issued by the Coroner, the management team at Blenheim House have carefully considered the concerns expressed in relation to Mr Weston and have reviewed the Majesticare Falls Management Policy and Procedure.
2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response.
3. Monthly clinical and governance meetings continue to be held with the senior team, trends and patterns are identified in accidents and incidents audit from each month with monthly action plans in place. A weekly care review meeting is now also being explored to support this governance process.
4. Alongside care plans and risk assessments reviews during resident of the day, falls equipment audits have taken place in July, October and January by the Deputy Manager and the Home Manager. Daily walk round checks of equipment continue to take place.
5. In addition, more detailed accident and incident analysis has been included into the monthly accident audit.
6. Pre-admission assessments are now taking place in person when possible so that a proper assessment from a residential or nursing care perspective can be carried out. All residents at high risk of falls are identified at ‘high risk’ of falls prior to admission and the General Manager will seek the additional support of 1:1 care during required isolation period.
7. The Berkley Care Group Training Manager is also supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
1. Further to the inquest onto the death of Mr Weston and the Report issued by the Coroner, the management team at Blenheim House have carefully considered the concerns expressed in relation to Mr Weston and have reviewed the Majesticare Falls Management Policy and Procedure.
2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response.
3. Monthly clinical and governance meetings continue to be held with the senior team, trends and patterns are identified in accidents and incidents audit from each month with monthly action plans in place. A weekly care review meeting is now also being explored to support this governance process.
4. Alongside care plans and risk assessments reviews during resident of the day, falls equipment audits have taken place in July, October and January by the Deputy Manager and the Home Manager. Daily walk round checks of equipment continue to take place.
5. In addition, more detailed accident and incident analysis has been included into the monthly accident audit.
6. Pre-admission assessments are now taking place in person when possible so that a proper assessment from a residential or nursing care perspective can be carried out. All residents at high risk of falls are identified at ‘high risk’ of falls prior to admission and the General Manager will seek the additional support of 1:1 care during required isolation period.
7. The Berkley Care Group Training Manager is also supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
Sent To
- Blenheim House Care Home
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Mar 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 04/08/2021 I commenced an investigation into the death of Reginald Howard Weston. The investigation concluded at the end of the inquest. The conclusion of the inquest was Accident
Circumstances of the Death
Mr Weston died due to injuries sustained in a fall on 7 July 2021. It was identified in evidence that he had moved and bypassed the sensor mat that had been placed at his feet and that care staff were aware he had done so on previous occasions. Although the presence of an in-place sensor mat unlikely made a difference in Mr Weston’s fall, it may do so in different circumstances where a resident is known to bypass the sensor mat. He had fallen twice on 4 July 2021 but there was no evidence to indicate his falls risk assessment was reviewed following those falls and recorded as required by the Majisticare Falls Management Policy and Procedure.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Draw up maternity risk assessment protocol
Morecambe Bay Investigation
Care plan failures
Care risk assessment failures
Audit maternity and paediatric services
Morecambe Bay Investigation
Care plan failures
Care risk assessment failures
Require comprehensive child needs assessment before admission to care
Waterhouse Inquiry
Care plan failures
Care risk assessment failures
Follow emergency child admissions with comprehensive assessment within prescribed period
Waterhouse Inquiry
Care plan failures
Care risk assessment failures
Base care plans on comprehensive assessment, prepared with child consultation
Waterhouse Inquiry
Care plan failures
Care risk assessment failures
Require social worker assessment and inter-departmental consultation before residential school placement
Waterhouse Inquiry
Care plan failures
Care risk assessment failures
Amend GLOS to allow claimants oral submissions at panel hearings
Post Office Horizon Inquiry
Care risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.