Care Home Health related deaths

Action Taken (AI summary) Blackpool Teaching Hospitals addressed concerns about bed lever fitting at Thornton House by clarifying that Occupational Therapists, now correctly trained, will prescribe and fit them after a full assessment. The intermediate care team and LCC were informed of updated processes at a meeting on December 2, 2020, and the Trust shared findings with senior Allied Health Professionals across the Lancashire and South Cumbria Integrated Care System. Lancashire County Council updated their 'Bed Rail and Bed Lever Policy and Procedure' to clarify the escalation process for concerns, effective January 8, 2021, with a further review planned for April 2021. They also rectified a miscommunication regarding bed lever usage at Thornton House, agreeing with Blackpool Teaching Hospitals that bed levers can be used when appropriate and fitted only by trained Occupational Therapy staff. Mobility 2000 Ltd has carried out further training with staff on fitting bed levers and straps, and will now supply a hard copy of the manufacturer's instructions with every bed lever.

Action Taken (AI summary) Borough Care implemented extra measures to review falls on a weekly/monthly basis after a previous PFD report, including weekly falls analysis, GP/falls clinic referrals for residents with more than 2 falls in 2 weeks, and monthly reviews. These measures have been discussed with CQC and their policy updated.

Action Taken (AI summary) Rossendale Nursing Home has implemented Person Centred Software, walk around handovers, pre-admission falls risk assessments, motion sensors, staff presence in communal areas, a post-fall protocol, referrals to the Falls team, CCTV, and monthly environmental audits to reduce falls risk.

Action Taken (AI summary) Birmingham and Solihull Mental Health Trust has provided pharmacists with additional training on Clozapine, will build further education into the Post Graduate Medical Education programme and is drafting a safety alert to all clinicians; also reviewing and updating Trust Clozapine guidelines to reflect updated MHRA guidance in August 2020, to be approved in November 2020. The Department of Health and Social Care notes that Birmingham and Solihull Mental Health NHS Foundation Trust has responded to the report by undertaking a review and update of its guidance on the use of clozapine, and have taken additional measures such as additional training and education and an audit of patients.

Action Taken (AI summary) The Department of Health and Social Care acknowledges the poor care received by Mr. Garner and highlights regulatory action taken by the CQC at Stepping Hill Hospital. The response also mentions national initiatives to improve patient flow, including funding for winter pressures and enhanced discharge arrangements. The GMHSCP highlights actions taken to address ED pressures including implementation of a GM Discharge Pathway, use of a single GM Discharge to Assess Referral Form with triage within 30 minutes, adherence to COVID-19 testing guidance and PPE requirements, supply of two weeks of medication on discharge, and next-day follow-up processes.

Action Taken (AI summary) Pelham House has implemented several changes including family members signing pre-assessment forms, recording calls, implementing a new CQC-recognized care plan system, employing an external auditor for monthly audits, and ensuring all staff have access to updated policies and procedures.

Action Taken (AI summary) Following the inquest, the nursing home implemented the News Scoring System, NEWS 2 Charts, Algorithm for managing suspected sepsis, and Sepsis guidance implementation advice. One-to-one discussions were held with nursing staff to confirm their understanding, and agency staff are also advised on the use of these tools.

Action Taken (AI summary) Holdingham Grange Nursing Home investigated the circumstances around a resident's fall, finding sufficient staffing levels were in place, staff receive training, and no summons to the inquest were received. They have reviewed all falls risk assessments and are working with OTs, and falls training is available for all staff.

Action Taken (AI summary) Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation and patient safety.

Action Taken (AI summary) The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development.

Action Taken (AI summary) The organisation has conducted team meetings and supervision sessions and is introducing a specific audit relating to the handover process from 29 January 2020. They have reviewed and updated robust systems and ensured they are in place.

Action Taken (AI summary) Windmill Manor has created a new Agency Folder with key policies. Barchester is rolling out a modified induction checklist, pocket guide and poster across all homes by the end of February 2020, and compliance will be checked via the Quality Governance Framework.

Action Taken (AI summary) Stockport CCG reports that Fernlea Nursing Home now uses photographs to track the progress of pressure sores, and referrals to the Tissue Viability Team are escalated if not actioned within 2 working days. A "React to Red" training programme has been developed and rolled out across the Stockport Care Home community. Fernlea Care Home has arranged for all Registered Nurses to undertake third party wound management refresher training and has extended "React to Red" training to 87% of the care team. They have adopted the NHS wound management document, changed referral processes to TVNs, and will notify the GP of all TVN referrals. The CQC inspected Fernlea Care Home and found the service had failed to send a statutory notification regarding Mr. Ward's pressure ulcer. They will consider further enforcement action regarding this and will provide a copy of the inspection report to HM Coroner.

Action Taken (AI summary) Rosewood Healthcare has implemented an Accidents and Incidents file, follows a Triage system, and has online and face-to-face training for falls and manual handling. They also have a new training provider who will be providing SALT and MUST training and audit systems are in place. The CQC conducted a comprehensive inspection of Barley Brook, and found that appropriate referrals were being made to dieticians and the falls team. They are highlighting possible breaches of the Health and Social Care Act 2008 and CQC Registration Regulations 2009 to the provider and will carry out a further inspection within 12 months. Wigan Council has taken action following a safeguarding enquiry, including developing a protection plan defining expectations for service delivery at Barley Brook. Staff will receive training in record keeping, dementia, and nutrition, and the council will monitor the uptake and impact of this training.

Action Taken (AI summary) The care home implemented a new care plan template that includes a system for recording outcomes of meetings with professionals. Staff receive regular training and supervision, and a manual handling assessment is included in the new care plan.