1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient been admitted to the home.

I can confirm that all admissions to the Home are subject to a pre-admission assessment. Said assessment is a comprehensive document outlining and identifying an individual resident’s needs regarding their activities of daily Living. The assessment identifies clinical need and risk and formulates the beginnings of the care planning process. In the instance of Catherine Jux, the preadmission assessment and the care needs assessments had both been completed but had not been formulated into individual plans of care. This was an oversight by the management team at that time.

Following admission to the home an Avery healthcare ‘admission to care home’ checklist is completed. This is a guiding document which informs staff of what assessments are required for each category of care, for example nursing or residential care. The checklist is utilised in conjunction with the Avery ‘new admission care plan audit. This document clearly outlines the timescales for assessment completion which should be completed by the nurse in charge and reviewed five days post admission by the management team to satisfy that all relevant documentation is in place and has been completed effectively, within the allocated timescales. Within 24 hours of admission, any areas identified as high need , both a care plan, and risk assessment must be completed. Once all clinical assessments and care plans have been added to the electronic system, a facility is in situ whereby the user is alerted to any pending or overdue reviews. The system uses a RAG rated process, which visually informs the user of when a review must be completed and clearly identifies the date of next review.

2) None of the care home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s needs and requirements noticed the oversight in respect of this.

Upon completion of the pre-admission assessment, the information is shared with all staff, inclusive of the care team and ancillary staff member. The findings of the assessment, including priority of clinical risk, is discussed at the start of each shift on the days leading up to the planned day of admission. This is to ensure that staff have a knowledge of the resident and their needs before admission to the Home. The findings of the assessment inform the initial clinical assessments within the care plan and can be populated prior to the date of admission. Through the use of the five-day audit, post admission, the home can monitor and ensure all relevant clinical assessments and care plans are completed in line with company expectations and timescales.

The home operates a process of daily meetings, which are referred to as “10 at 10“. These meetings are devised to facilitate the sharing of pertinent information, to the team, regarding any changes within the home. The meetings also include the details of any prospective resident that will be new to the service or have been recently admitted. This process of information sharing is further strengthened by a weekly clinical risk meeting, whereby the management team and clinical staff review all relevant aspects of clinical need across the home ensuring appropriate measures are in situ to manage and mitigate any clinical risk. This process is inclusive of reviewing documentation pertaining to care delivery.

3) There is not an adequate process in place for auditing the assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission.

There is an auditing process to ensure clinical risk is identified and responded to through appropriate assessment and care planning of resident’s needs. This process is led by the home management team and reviewed during operational visits by the Regional Manager. At the pre-admission stage, a degree of clinical judgement is applied by the assessor to ensure that any prospective resident’s needs can be effectively met by the Home. This process also includes consideration of the current level of dependency and acuity of resident’s within the service and the number of admissions planned. All admissions to the home are conducted in a structured manner allowing staff the time to complete all relevant assessments and documentation before any further admissions are facilitated.