Care Home Health related deaths

Action Planned (AI summary) Milton Keynes City Council has agreed to a reciprocal arrangement with CNWL to access healthcare (System One) and social care (Liquid Logic) systems, with technical issues to be addressed in early 2023. Central and North West London NHS Foundation Trust is updating assessment templates to include mandatory questions about family involvement and other service providers, and sharing lessons learned with staff.

Action Planned (AI summary) Derbyshire County Council is developing an action plan to improve information transfer from care homes to hospitals, including implementing an interim transfer document by September 2022 and reviewing digital transfer standards by August 2022, aiming for 80% digital social care records by March 2024. NHS Derby and Derbyshire has distributed updated 'Red Bag' documentation and communications to care homes, ambulance, and hospital trusts, and held meetings with Deputy Directors of Nursing to ensure effective handover communications. They will also implement an interim transfer document by September 2022 and monitor its use.

Action Planned (AI summary) Tower Bridge Care Home describes arrangements for diabetic foot clinic attendance, communication with GPs and multidisciplinary meetings, and identifies residents with high needs to the consultant geriatrician for face-to-face reviews, since September 2022. They also describe processes for DNAR (Do Not Attempt Resuscitation) orders and managing capacity issues. The RCGP is working to improve communication between secondary and primary care with colleagues across specialities, and with NHS England and NHS Improvement to improve communication links. King's College Hospital has established a working group to improve consent and MCA assessments, reviewing consent and MCA training programmes, and updated the Trust's consent policy. The Trust also initiated a Trust-wide consent audit in September 2022.

Action Planned (AI summary) Radcliffe Manor House plans to introduce a digital care planning system and an online total quality system by the end of the year. They have implemented changes to the falls protocol to ensure relatives are informed and are inviting family members to participate in monthly reviews of the resident’s care plan. Swift Management Services conducted a clinical governance review of Radcliffe Manor House and recommended improvements including investment in an electronic care planning system and training for staff and trustees on clinical governance, risk management, and escalation pathways. The trustees have already made significant improvements in falls management and overall clinical governance.

Action Planned (AI summary) LCC will review the format of its overview document in line with the adoption of a strength based approach framework, which is planned to be rolled out across all Adult Social Care teams within the next 18 months. LCC have agreed to meet with and will continue to work with the Trusts in the future. BTHFT will collaborate with LSCFT and LCC to examine LSCFT's Admission, Discharge and Transfer of Care Policy and Procedure, to ensure that all relevant information, including suicide risk, is known, managed and communicated. A Joint Mental Health Governance Committee will meet quarterly to support the delivery and development of high quality care to patients with psychological and psychiatric needs. Nightingale's has implemented a new pre-admissions checklist covering relevant assessments, and will no longer admit residents with a similar history to Ms Stringer without 1:1 care. All staff receive training to facilitate communication with residents.

Action Planned (AI summary) NYCC has requested ICES to provide instruction leaflets for equipment and will include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans in future training for new or existing OTs (February/March 2022); a specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans. Abbeyfield The Dales Ltd has introduced a new care plan format with images of mobility equipment and updated systems of work, launched a service delivery audit to check care delivery against the care plan, and plans to implement a new equipment process in January 2022 to ensure staff competency with new equipment.

Action Planned (AI summary) Intastop identified a 'blind spot' on the door mechanism, confirmed timing delay was between 5-6 seconds, recommends checking thoroughly all alarms and re-setting the sensors and to inspect their testing protocol prior to dispatch.