Care Home Health related deaths

Concerns summary Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.

Concerns summary Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.

Concerns summary The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.

Concerns summary Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.

Concerns summary Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.

Concerns summary Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.

Concerns summary Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.

Concerns summary The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.

Concerns summary Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.

Concerns summary A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, family-owned companies.

Concerns summary Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.

Concerns summary Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.

Concerns summary Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.

Concerns summary Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.

Concerns summary Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.

Concerns summary Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.

Concerns summary Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.

Concerns summary The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.

Concerns summary Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.

Concerns summary The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.

Concerns summary There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding Authorisation, leaving a vulnerable patient unassessed.

Concerns summary Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.