Care Home Health related deaths

Concerns summary The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.

Concerns summary The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.

Concerns summary A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.

Concerns summary Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.

Concerns summary Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.

Concerns summary Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.

Concerns summary Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.

Concerns summary An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.

Concerns summary The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.

Concerns summary Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.

Concerns summary Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.

Concerns summary Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.

Concerns summary Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.

Concerns summary The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected or poorly recorded. Additionally, medication was administered inappropriately and care plans lacked regular review or audit.

Concerns summary The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.

Concerns summary Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.

Concerns summary Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, contradicting best practice.

Concerns summary Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.

Concerns summary Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.

Concerns summary Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments should be conducted face-to-face, ideally involving family members, for accurate needs identification.

Concerns summary Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.

Concerns summary Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.

Concerns summary The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to a crucial falls risk assessment not being updated after multiple falls, increasing future risk.

Concerns summary Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.

Concerns summary The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.