Marion Glover
PFD Report
All Responded
Ref: 2021-0004
All 1 response received
· Deadline: 11 Mar 2021
Coroner's Concerns (AI summary)
Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
View full coroner's concerns
During the course of (he Inquest the evidence revealed maltters giving rise t0 concem Residents at Melboure Court lived Independenlly within their own flals and that are free to come and g0 a5 wished; from thelr flats and from Ihe building: That included Ihose residents who were suffering from cognltive Illnesses such as Alzheimer's or dementia, of which Mrs Glover was one. The entrancelexit door was not locked, other than overnighl Durlng Ihe course of evidence Mrs Glover's daughler lold me that on a number of occaslons when she called to visit her mother she had come across olher residents wandering in lhe comdors in a state of confusionand who requlred asslstance getting Mrs day: Ihey they her them back lo the Ilats. Such scenarios as described were confirmed by the Senlor Manager of Melbourne Court at the tlme of Mrs Glover's death, during the course of her evidence: As slaled above Mrs Glover fell in the area. Thls was not on roule to her fat. The evidence suggested that Mrs Glover was starting to lose cognitive function and beglnning to suffer confusion: will never know but might she been intending to go out. Had she done her absence would likely have gone unnoliced for some lime. On exploralion of this issue, It became apparent that in Ihe absence of any restriction on residents leaving the bullding or observation of the foyer area there Is a serious risk that such residents suffering cognitive Illnesseslconfusion can unknowingly leave the building: In the clrcumstances Melbourne Court does not appear to be suitable accommodalion for residents who are suffering cognitive Illnesses and confusion In my opinion there Is risk that fulure deaths wlll occur unless action Is laken: In the circumstances It Is my statulory duty lo report to you: ACTION SHOuLD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you have the power to lake such action: YouR RESPONSE You are under a duty (0 respond to Ihls report within 56 of date of this report;, namely by 4t Feb 2020. 1, the coroner , may extend the pertod. Your response must contaln delails of action taken or proposed (o be laken, selting out the timelable for action . Olherwise you must explain why no aclion Is praposed.
Responses
Action Taken
Able Care and Support Services Ltd, under new ownership, has implemented enhanced pre-admission risk assessments, weekly meetings with authorities, multi-disciplinary meetings, and a falls management reporting form. Scheduled annual reviews of resident needs, with updated support plans, are also in place. (AI summary)
Able Care and Support Services Ltd, under new ownership, has implemented enhanced pre-admission risk assessments, weekly meetings with authorities, multi-disciplinary meetings, and a falls management reporting form. Scheduled annual reviews of resident needs, with updated support plans, are also in place. (AI summary)
View full response
Able Care & Support Services Ltd
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
This response is provided by Y1 Capital Ltd who acquired Able Care and Support Services Ltd on 1st July 2021. Though the incident happened prior to the acquisition of Able Care and Support Services, we recognise our responsibility for the need to implement measures in ensuring that present and future residents who are suffering cognitive illnesses and confusion are fully assessed for their suitability to reside at Melbourne Court. Partnership Working A range of joint working is already in evidence with Tameside Metropolitan Borough Council and other professional agencies relating to the admission process and continued residency at Melbourne Court including:
• Continued development of shared processes in ensuring that all risks are fully assessed pre-admission to Melbourne Court to include cognitive illnesses and confusion.
• Weekly meetings/telephone calls with Local Authority and Healthcare/Social Care professionals in supporting residents and their needs.
• When need identified through care staff observations, alerts and monthly audits, Multi-Disciplinary meetings are held to support people to live as independently as possible at Melbourne Court taking into consideration their wellbeing, support needs, medical issues to include cognitive illnesses and confusion and if their environment is conducive for their tenancy to remain in place.
• Extra care panel held every two weeks with Tameside Metropolitan Borough Council and all Extra Care providers within the Tameside area. The panel enables all providers of extra care to discuss voids and referrals to the scheme, concerns raised, activities and the sharing of best practice.
Able Care & Support Services Ltd
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
Continued Development of Service Provision Able Care and Support Services have introduced new systems to include:
• On-Care digital care management software enabling care staff to record care delivery and all interaction with residents. The system enables care staff to raise an alert with the office if they should have any concerns or issues associated with a resident they care for. The
• office ensures that all alerts are promptly dealt with, linked information recorded on On-Care in how the raised alert has been actioned, measures put in place, and progress in resolving issues raised.
• EMAR (Electronic Medication Administration Record) software has been introduced allowing care staff to update MAR sheets automatically and enabling the care office to have an accurate view of resident's medications in real time thus reducing medication errors.
• Introduction of Falls Managing report form. The form is to report all falls, whether witnessed or not, with follow up actions we have made in reducing/mitigating any further falls to the individual or other residents.
• Scheduled annual reviews, or sooner should changes in the resident's needs be identified, of residents care and support plans with associated risk assessments to mitigate and further reduce risks to include those linked with cognitive illnesses, confusion and falls. Resulting actions required post review are recorded on Care Planner software and if identified, allied health professionals are contacted for advice and direction. Care and support plans are updated and shared with relevant care staff.
Able Care & Support Services Ltd
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
Action By Whom By When Evidence of completion Progress Status (RAG) 1 Collaborative working:- Enhanced Pre- admission risk assessment of new tenants Able Care Management and TMBC Commissioning Team/Social Work Team December 2020 Minutes of meetings.
Weekly meetings. Scheduled Multi- Disciplinary Meetings. December 2020 2 Introduction of Falls Management Reporting Form Completion by Able Care staff. Reviewed/actioned by Able Care office management December 2020 Completion of forms to include action taken. Recorded on Care-planner In place December 2020 3 Alerts raised - Concerns/issues re residents Raised/logged by Able Care staff. Reviewed/actioned by Able Care office management. December 2020 Alert with resulting action recorded on On- Care. In place December 2020 4 Scheduled annual review of resident’s needs (or sooner should changes in the resident’s need’s be identified). Able Care Office Management December 2020 Reviewed/revised support plan in place and recorded on Careplanner. In place December 2020
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
This response is provided by Y1 Capital Ltd who acquired Able Care and Support Services Ltd on 1st July 2021. Though the incident happened prior to the acquisition of Able Care and Support Services, we recognise our responsibility for the need to implement measures in ensuring that present and future residents who are suffering cognitive illnesses and confusion are fully assessed for their suitability to reside at Melbourne Court. Partnership Working A range of joint working is already in evidence with Tameside Metropolitan Borough Council and other professional agencies relating to the admission process and continued residency at Melbourne Court including:
• Continued development of shared processes in ensuring that all risks are fully assessed pre-admission to Melbourne Court to include cognitive illnesses and confusion.
• Weekly meetings/telephone calls with Local Authority and Healthcare/Social Care professionals in supporting residents and their needs.
• When need identified through care staff observations, alerts and monthly audits, Multi-Disciplinary meetings are held to support people to live as independently as possible at Melbourne Court taking into consideration their wellbeing, support needs, medical issues to include cognitive illnesses and confusion and if their environment is conducive for their tenancy to remain in place.
• Extra care panel held every two weeks with Tameside Metropolitan Borough Council and all Extra Care providers within the Tameside area. The panel enables all providers of extra care to discuss voids and referrals to the scheme, concerns raised, activities and the sharing of best practice.
Able Care & Support Services Ltd
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
Continued Development of Service Provision Able Care and Support Services have introduced new systems to include:
• On-Care digital care management software enabling care staff to record care delivery and all interaction with residents. The system enables care staff to raise an alert with the office if they should have any concerns or issues associated with a resident they care for. The
• office ensures that all alerts are promptly dealt with, linked information recorded on On-Care in how the raised alert has been actioned, measures put in place, and progress in resolving issues raised.
• EMAR (Electronic Medication Administration Record) software has been introduced allowing care staff to update MAR sheets automatically and enabling the care office to have an accurate view of resident's medications in real time thus reducing medication errors.
• Introduction of Falls Managing report form. The form is to report all falls, whether witnessed or not, with follow up actions we have made in reducing/mitigating any further falls to the individual or other residents.
• Scheduled annual reviews, or sooner should changes in the resident's needs be identified, of residents care and support plans with associated risk assessments to mitigate and further reduce risks to include those linked with cognitive illnesses, confusion and falls. Resulting actions required post review are recorded on Care Planner software and if identified, allied health professionals are contacted for advice and direction. Care and support plans are updated and shared with relevant care staff.
Able Care & Support Services Ltd
‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
Action By Whom By When Evidence of completion Progress Status (RAG) 1 Collaborative working:- Enhanced Pre- admission risk assessment of new tenants Able Care Management and TMBC Commissioning Team/Social Work Team December 2020 Minutes of meetings.
Weekly meetings. Scheduled Multi- Disciplinary Meetings. December 2020 2 Introduction of Falls Management Reporting Form Completion by Able Care staff. Reviewed/actioned by Able Care office management December 2020 Completion of forms to include action taken. Recorded on Care-planner In place December 2020 3 Alerts raised - Concerns/issues re residents Raised/logged by Able Care staff. Reviewed/actioned by Able Care office management. December 2020 Alert with resulting action recorded on On- Care. In place December 2020 4 Scheduled annual review of resident’s needs (or sooner should changes in the resident’s need’s be identified). Able Care Office Management December 2020 Reviewed/revised support plan in place and recorded on Careplanner. In place December 2020
Sent To
- Able Care and Support Services Ltd
Response Status
Linked responses
1 of 1
56-Day Deadline
11 Mar 2021
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
Circumstances of the Death
On tha afternoon of 24.02.20 Mrs Glover suffered an unwitnessed fall In the entrancelfoyer of Melbourne Court, where she had resided slnce May 2018. That afternoon she had been in the communal lounge area socialising following the 'luncheon club'. Although Mrs Glover was able lo mobillse Independenly and did not need support per se, she was ta be escorted back lo her fat When a care worker arrived lo take Mrs Glover back to her flal she was no longer In the lounge area. Where Glover fell was not on ay route back lo her flat from the communal lounge. In the fall Mrs Glover sustained facial and rib fractures and was admitted lo Tameside General Hospllal; where It was delermined that her Injurles would be managed conservatively: Mrs Glover Was discharged from Tameslde
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Quarterly assessment of staffing levels against population needs
Brook House Inquiry
Care home staffing levels
Ensure senior manager presence and accessibility to staff
Brook House Inquiry
Care home staffing levels
Risk-based visitor restrictions for radicalising prisoners
Manchester Arena Inquiry
Unsupervised High-Risk Residents
Responsibility for regulating and monitoring compliance
Mid Staffs Inquiry
Care home staffing levels
NHS Litigation Authority Improvement of risk management
Mid Staffs Inquiry
Care home staffing levels
Ensure adequate staffing by suitably trained personnel in station operations rooms
Fennell Inquiry
Care home staffing levels
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.