Care Home Health related deaths

Action Taken (AI summary) HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system.

Action Taken (AI summary) Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in the kitchen, and clearer documentation of meals served.

Action Taken (AI summary) The care home has implemented a Resident of the Day procedure for care file updates, reviews of care plans, and a diary record for tracking residents' dental care; staff have also attended CCG training on dental hygiene for vulnerable residents.

Action Taken (AI summary) HC-One implemented an action plan at Bakers Court to address the concerns highlighted. Multi-factorial Falls Risk Assessments will inform the development and implementation of a daily plan of care.

Action Taken (AI summary) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide strong leadership and governance is to commence employment at the Home before the end of April 2019.

Action Taken (AI summary) Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended.

Action Taken (AI summary) The care home revised its policy on observations and record keeping, trained all registered nurses in January 2019, issued them with the new procedure, and implemented monthly audit checks on care records. Nurse Bogdan completed an observations training module on National Early Warning Score (NEWS2) on 17 January 2019.

Action Taken (AI summary) Care plans now incorporate specific risk issues like falls, with monthly reviews and audits. Staff have been retrained and reminded to record incidents, and a new qualified nurse has been employed as Manager since February 2018.

Action Taken (AI summary) Beechwood Lodge has put in place more robust risk assessments for residents who have had falls, documenting all conversations with relatives and professionals. They have added new risk assessments in all care plans about safety equipment, and have a falls matrix to monitor falls and make referrals.

Action Taken (AI summary) • The practice determined that sensitivities to opioid drugs could be recorded in the notes on a case-by-case basis, requiring clinical judgement. • A meeting was held to discuss how the sensitivity to opioids could have been coded appropriately in the GP notes. • A meeting was held with a Royal Free Geriatrician and Compton Lodge Dept Care Home Manager to share Adelaide’s learning and see how this may support recording at the Royal Free and Compton Lodge. • The Trust wrote to the family to seek further information regarding the issues raised during the Inquest. • The patient was cared for throughout her stay in 8 West in what is known as a “high bay”, meaning that staff were present in the bay at all times to supervise the patients. • Water is normally kept on the patients’ bedside tables.

Action Taken (AI summary) Twinglobe Care Homes has implemented changes across its group of homes, including a Choking Risk Assessment, Choking and Aspiration Care Plan, Aspiration Guidance, Nutrition and Fluid Chart, Nutritional Profile, leaflet for relatives/visitors, poster, Deprivation of Liberty Screening Checklist, Mental Capacity Assessment Record, Best Interests Decision Form, Visiting and Visitors Policy, Meal and Mealtimes in Care Homes Policy, and Food bought in by Visitors Policy.

Action Taken (AI summary) HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; CQC inspection evidenced significant improvements in the quality and safety of care.

Action Taken (AI summary) Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, and ensuring nurse-led interventions for diabetic residents.

Action Taken (AI summary) FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither would add a further method of entry for emergency services.

Action Taken (AI summary) Rosewood Lodge has overhauled care plans, improved the management team structure, provided further staff training, and implemented a new computerised care plan software system and CCTV in communal areas. They also use sensor mats for residents at high risk of falls.