Care Home Health related deaths

Concerns summary The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.

Concerns summary Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.

Concerns summary Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.

Concerns summary There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.

Concerns summary A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.

Concerns summary Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.

Concerns summary Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.

Concerns summary A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.

Concerns summary Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training on skin integrity.

Concerns summary Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.

Concerns summary Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises resident safety.

Concerns summary Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.

Concerns summary A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.

Concerns summary Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.

Concerns summary A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.

Concerns summary Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.

Concerns summary The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.

Concerns summary Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.

Concerns summary Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.

Concerns summary Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.

Concerns summary Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.

Concerns summary Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.

Concerns summary Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.

Concerns summary Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.

Concerns summary Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' for burn injuries.