Irene Baker
PFD Report
All Responded
Ref: 2017-0363
All 1 response received
· Deadline: 6 Feb 2018
Coroner's Concerns (AI summary)
The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.
View full coroner's concerns
In circumstances it is my statutory duty to report to you No revision of the mobility care plan in response to monthly reviews documenting a deterioration in mobility in November and December 2016; No monthly mobility reviews were undertaken in January and February 2017;
3. A failure to contact the GP or call an ambulance in response to a documented inability to weight-bear 12th 23rd April 201 the my
3. A failure to contact the GP or call an ambulance in response to a documented inability to weight-bear 12th 23rd April 201 the my
Responses
Action Taken
Rosewood Lodge has overhauled care plans, improved the management team structure, provided further staff training, and implemented a new computerised care plan software system and CCTV in communal areas. They also use sensor mats for residents at high risk of falls. (AI summary)
Rosewood Lodge has overhauled care plans, improved the management team structure, provided further staff training, and implemented a new computerised care plan software system and CCTV in communal areas. They also use sensor mats for residents at high risk of falls. (AI summary)
View full response
Dear Sir, In response to your concerns raised at an inquest held on 11th December 2017, [ respond as follows: wwas employed from &"h May 2017 as Registered Manager and have made improvements to Rosewood Lodge highlighted following the incident which led to the inquest_ The management team structure now consists of myself, Registered Manager, Deputy Manager and Head of Care Care plans were completely overhauled and re-written by Ithis was evidenced at our North Somerset Council inspection on 14 September
2017) In March 2017 we were inspected by North Somerset Council and rated as Amber; however following improvements implemented throughout the home, on 14th September 2017 we were rated as Green. Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times Staff received further training, andjob descriptions outlining their responsibilities during a shift and expectation of their duties to the residents_ Head of Care, Deputy Manager and appointed Shift Leader will cover every shift to ensure continuity of care and high standards are maintained Families are informed immediately when a GP; Occupational Therapist or any other medical professional has been contacted and are updated with an outcome. From 318 January 2018, we have implemented a new computerised care plan software system, :Person Centred Software' which allows care staff to Sc )SA LMITTH) "IA ROSEWOOD [ODCH RETIREMINT HOME RE(ilSTERED AIHRESS: HAZEL StAW: , 34 DOWNS WAY, TADWORTH SURREY. KT2U SHYZ 'EL JFAX 01737 279667 RECESTRATI )N NO. 4319250 canin have the they update
mnore efficiently, flagging any incidents, accidents, mobility changes etc, ensuring that the care plans are up-to-date at all times as it is a live system The system also allows reports to be printed immediatey ie: falls, mobility, nutrition etc t give a better overall indication of any decline in the residents needs_ Consent has been received from residents and families for Rosewood Lodge to have CCTV installed in the communal areas to monitor their safety_ Each resident who is high risk of falls 0" unsteady on their feet has a sensor mat in their rooms connected to their call bells to highlight the staff should they have a fall ensuring staff are able to contact the relevant medical support ie: GP Ambulance ctc, Ongoing support is received from the Compliance Manager who visits on a monthly basis as well as the owner_ Rosewood Lodge is continuing to make changes to ensure the safety and wellbeing of residents is maintained at all times. Should you any further information then please do not hesitate to contact me
2017) In March 2017 we were inspected by North Somerset Council and rated as Amber; however following improvements implemented throughout the home, on 14th September 2017 we were rated as Green. Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times Staff received further training, andjob descriptions outlining their responsibilities during a shift and expectation of their duties to the residents_ Head of Care, Deputy Manager and appointed Shift Leader will cover every shift to ensure continuity of care and high standards are maintained Families are informed immediately when a GP; Occupational Therapist or any other medical professional has been contacted and are updated with an outcome. From 318 January 2018, we have implemented a new computerised care plan software system, :Person Centred Software' which allows care staff to Sc )SA LMITTH) "IA ROSEWOOD [ODCH RETIREMINT HOME RE(ilSTERED AIHRESS: HAZEL StAW: , 34 DOWNS WAY, TADWORTH SURREY. KT2U SHYZ 'EL JFAX 01737 279667 RECESTRATI )N NO. 4319250 canin have the they update
mnore efficiently, flagging any incidents, accidents, mobility changes etc, ensuring that the care plans are up-to-date at all times as it is a live system The system also allows reports to be printed immediatey ie: falls, mobility, nutrition etc t give a better overall indication of any decline in the residents needs_ Consent has been received from residents and families for Rosewood Lodge to have CCTV installed in the communal areas to monitor their safety_ Each resident who is high risk of falls 0" unsteady on their feet has a sensor mat in their rooms connected to their call bells to highlight the staff should they have a fall ensuring staff are able to contact the relevant medical support ie: GP Ambulance ctc, Ongoing support is received from the Compliance Manager who visits on a monthly basis as well as the owner_ Rosewood Lodge is continuing to make changes to ensure the safety and wellbeing of residents is maintained at all times. Should you any further information then please do not hesitate to contact me
Sent To
- Rosewood Lodge Nursing Home
Response Status
Linked responses
1 of 1
56-Day Deadline
6 Feb 2018
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 17/h May 2017 an investigation was commenced into the death of Irene Winifred BAKER, Aged 84, The investigation concluded at the end of the inquest on 11th December 201 The medical cause of death was: la Acute on chronic post-operative cardiac failure Ib Coronary arterial atherosclerosis II Recent fractured neck of femur, repaired surgically Healed myocardial infraction Cirrhosis of liver; diabetes mellitus The conclusion of the inquest was Natural causes
Circumstances of the Death
Mrs_ Baker died following an operation on a fractured hip which the evidence suggested occurred at Rosewood Lodge Nursing Home. However the Nursing Home had no record of it. The fracture was recorded under section 2 of the cause of death_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and belleve you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.