Sidney Barnett
PFD Report
Partially Responded
Ref: 2015-0222
Coroner's Concerns (AI summary)
The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
View full coroner's concerns
Whilst at Berrycroft; the level and quality of observation of the client appears to have been inadequate. There was an insufficiency of care shown to the deceased in terms of his general welfare (whether he was warm enough; whether he was washed and shaved; whether he was able to take his meals safely, whether his clothing_was adequate and clean etc The
The 'cleaner' at the care Home "opens the windows, whatever: There seemed to be no clear rule in place as regards the appropriateness of the windows being open: [Items Ito 3 should be addressed by Berrycroft] As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council: Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the 'complaint' was unsubstantiated: The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation: Too much reliance is placed on what the "Care home employees say, without testing that and further querying what actually happened: [Items 4 and 5 to be answered by S.MB.C:]
The 'cleaner' at the care Home "opens the windows, whatever: There seemed to be no clear rule in place as regards the appropriateness of the windows being open: [Items Ito 3 should be addressed by Berrycroft] As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council: Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the 'complaint' was unsubstantiated: The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation: Too much reliance is placed on what the "Care home employees say, without testing that and further querying what actually happened: [Items 4 and 5 to be answered by S.MB.C:]
Responses
Action Taken
The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks. (AI summary)
The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks. (AI summary)
View full response
BERRYCROFT MANOR Response to regulation 28 issued by Mr J Pollard Senior Coroner_resulting from concerns raised at the inquest of Mr Sydney Barnett (deceased )Completed by Manager on 19th June
2015. CONCERN ACTION TAKEN COMPLETED BY Observation of resident was inadequate All resident' s with in the This action is home to have a room visit enforce with chart in place ,this is to be immediate effect completed by care staff and checked by Senior care staff: This form must be completed when a resident wishes to remain in their room and or takes meals in their rooms. A resident is to be checked hourly and every fifteen mins if meals are taken in rooms General welfare of resident'$ was All personal care forms to Action is on going insufficient ,=,ie clothes soiled with food be completed in care plans and should be concern around warmth ,personal care documentation must be delivered to all and supervision of meals while being made if a residents refuses staff by October taken in room: care 2015 rolling programme of dignity training (DELIVERED BY THE MANAGER ) is in place for all staff focusing on personal care standards and dignity_ Concerns raised around domestic The room visit checks In place with opening windows and leaving them open incorporate a section for immediate affect in residents room particularly in the the opening and closing of winter months windows The home is a new build with insulated walls and has heating on 24hours a ,seven days a year a resident may wish to have the window open if they become to warm this choice must be documented in the care plan Ifa residents has capacity to ask for the window to be open this choice is to be documented day
BERRYCROFT MANOR in the care plan.
2015. CONCERN ACTION TAKEN COMPLETED BY Observation of resident was inadequate All resident' s with in the This action is home to have a room visit enforce with chart in place ,this is to be immediate effect completed by care staff and checked by Senior care staff: This form must be completed when a resident wishes to remain in their room and or takes meals in their rooms. A resident is to be checked hourly and every fifteen mins if meals are taken in rooms General welfare of resident'$ was All personal care forms to Action is on going insufficient ,=,ie clothes soiled with food be completed in care plans and should be concern around warmth ,personal care documentation must be delivered to all and supervision of meals while being made if a residents refuses staff by October taken in room: care 2015 rolling programme of dignity training (DELIVERED BY THE MANAGER ) is in place for all staff focusing on personal care standards and dignity_ Concerns raised around domestic The room visit checks In place with opening windows and leaving them open incorporate a section for immediate affect in residents room particularly in the the opening and closing of winter months windows The home is a new build with insulated walls and has heating on 24hours a ,seven days a year a resident may wish to have the window open if they become to warm this choice must be documented in the care plan Ifa residents has capacity to ask for the window to be open this choice is to be documented day
BERRYCROFT MANOR in the care plan.
Sent To
- Stockport Metropolitan Borough Council
Response Status
Linked responses
1 of 2
56-Day Deadline
7 Aug 2015
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 14th January 2015 commenced an investigation into the death of Sidney Barnett dob 7th February 1924. The investigation concluded on the 12" June 2015 and the conclusion was one of Natural Causes. medical cause of death was Ia Bronchopneumonia 1b Dementia 11. Coronary Artery Atheroma and Type 2 Diabetes Mellitus
Circumstances of the Death
The deceased was resident at a Care Home for the elderly. He was gradually declining in health: On the 21st December 2014 he was in his room and was seen by his relatives to be without socks, he had the remnants of his dinner all over the front of his clothes, he was unshaven and he was struggling to eat a bowl of custard, alone and unattended:. The following day his relatives again visited him at the home and he was seen to be wearing only a T shirt and was sitting in his chair close to a window which was open, even though it was late December and the weather was cold. Later that evening he was seen by a District Nurse who was there to administer his insulin, and she, through the out-of-hours doctor; immediately admitted him to hospital where he died from pneumonia on the 3rd January 2015.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.