Care Home Health related deaths

Concerns summary The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.

Concerns summary The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.

Concerns summary A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.

Concerns summary Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot provide, risk inadequate and delayed emergency response.

Concerns summary Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.

Concerns summary The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.

Concerns summary Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.

Concerns summary Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

Concerns summary CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.

Concerns summary The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.

Concerns summary Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.

Concerns summary Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.

Concerns summary Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.

Concerns summary A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.

Concerns summary Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.

Concerns summary Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.

Concerns summary Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite prior assurances of resolution.

Concerns summary Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.

Concerns summary Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.

Concerns summary Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.

Concerns summary A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.

Concerns summary Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.

Concerns summary The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.