Care Home Health related deaths

Concerns summary Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.

Concerns summary The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.

Concerns summary Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.

Concerns summary The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.

Concerns summary The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.

Concerns summary The provided concerns text for this report does not detail specific safety issues or systemic failures related to the deceased's care at Carlton House Rest Home.

Concerns summary The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.

Concerns 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.

Concerns summary The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a systemic failure in falls safety.

Concerns summary A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.

Concerns summary The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.

Concerns summary Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.

Concerns summary The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Concerns summary Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.

Concerns summary Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.

Concerns summary The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local authority. Delays in urgent assessments and unclear interim safety plans for high-risk residents pose a significant risk.

Concerns summary Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.

Concerns summary The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.

Concerns summary Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.

Concerns summary A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.

Concerns summary Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.

Concerns summary Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.

Concerns summary Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.

Concerns summary Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered effective emergency response and learning.

Concerns summary A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.