Cardinal Healthcare
Other
Action Taken
Cardinal Healthcare has already implemented several actions, including a manual reminder system for documentation, monitoring via a 'Resident of the Day' system, reflective practice sessions for staff, and a mentorship program for new staff. They are also planning to introduce a multi-layered review process for investigations, train managers, and strengthen collaboration with external bodies. (AI summary)
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Cardinal Healthcare Cardinal Healthcare Image Count 328-334 Molesey Road Walton-On-Thames. Surrev; KT12 3LT Tele: 01932 253403
26.09.24 Mr David Reed HM Senior Coroner for Worcestershire Response to Regulation 28 Prevention of Future Deaths Report Regardlng the Death of Mr. Alfred Edward Sparrow Cardinal Healthcare The Meadows Nursing Home We are writing in response to the Regulatlon 28 Prevention of Future Deaths report Issued fol- lowing the Inquest into Mr Sparrow'$ death We take the coroner $ concerns verv seriously and have conducted a thorough revlew ofour practices and processes: Beiow, we address each con- cern In detall, outline the actions taken, and propose future improvements, all Informed by re- flective practice and lessons learned from thls case; 1, Concern Regarding Mealtime Assistance The coroner' $ first concern revolves around the care provlded to Mr Sparrow during mealtimes: His care plan at his previcus care home specified that he required full assistance with food and fluld Intake due to hls dlagnosis of vascular dementia. However, care notes documenting his food and fluld Intake dld nor clearly indicate whether he was assisted, raising concerns that Mr Sparrow might not always have received the assistance required, potentially putting his health at risk: Our thoughts on the Issue His care plan was assessed when Mr Sparrow was admitted t0 The Meadows Nursing Home on 11 September 2023. We concluded that; while he had a dlagnosis of vascular dementia ad his prevlous home had recorded that he requlred full asslstance with eating he stIll demonstrated some abillty to feed himself Encouraging independence was essential tO maintaining Mr Spar- being
row' s dignity and preventing deskilling; which his daughter confirmed In her statement: My fa- ther was moved into The Meadows Care Home on the Ilth of September 2023 He was alert and able t0 feed and drink unassisted However, we acknowledge that whlle our Intentions were t0 respect hls dignity ad foster Inde- pendence; our documentation needed to reflect thls nuanced approach The fallure t0 ex - pllcitly record whether staff assisted Mr Sparrow during meals created uncertainty This omission highlights where we must improve our practices to ensure transparency and clarity in care rec- ords: Actlons Taken and Future Improvements Care Plan and Documentation Review: A full review of all resident care plans is underway to en- sure they accurately reflect each resident'$ needs ad any changes In thelr condition, In Mr Spar- row"$ case; we now realise that his ability to feed himself may have flucruated, and such tions should be recorded better In care notes; Training in Person-Centered Documentation: All staff recelve additional training to Improve thelr documentatlon of the Ievel of assistance provided during meals. It Is critical that staff not only record food and fluid intake but also specify the level of support provided to theresident; whether full assistance or encouragement; Implementation of Care Vision: We are in the final stages of contracting a new care planning sys: tem, Care Visian, which we hope be fully operational by January 2025, Care Vision will prompt staff In real time to record food and fluid Inrake and flag Incomplete entries t0 the man- agement team: Thls system wlll ensure that detalled, accurate Informatlon about the level of as- sistance provlded Is recorded at the of care. Spot Checks through the "Resident of the Day" System: Until Care Vision Is fully implemented, the home manager will conduct dally spot checks of care notes as part ofthe 'Resident of the Day" system: These checks will help Identlfy any documentation gaps and ensure corrective ac tlons are taken where necessary Recruitment of new full-time clinical lead: We have recently recruited a full-time clinical lead at The Meadows; who Is now part of our management team. The Introductlon of this Clinical Lead wIll allow the Home Manager t0 focus more on overseeing the overall operations of the home and strategic planning while ensuring a more effective delegatlon of clinical responsibillties, The Cllnical Lead wIll provide enhanced support t0 nursing staff, ensuring that care plans, Including mealtime assistance, are regularly revlewed and accuratelv documented; This additlon to the management team will ensure that care Is dellvered according to each resldent' $ needs and that documentation standards are rigorously upheld, 2, Concern Regarding Inaccurate Record of Fluld Intake The coroner' $ second concern [5 a false entry In Mr Sparrows care notes. The entry Indicated that Mr Sparrow had consumed 20Oml of tea at 20.30 on Ist December 2023,which was Ewa hours after he had passed away: Thls raised serious concerns about the accurcy of care records and the possibillty that staff were documenting care actlons retrospectively; potentiallv com - promising the safety and well-being of residents. fully:` fluctua- wilI point
Our Thoughts on the Issue While we acknowledge the Inaccuracy ofthe 20.30 entry, we believe it was the result of late documentatlon rather than intentional falsification. Staff members sometimes input care notes after their shifts when our current care planning system, Fusion; which does not prompt staff to document care In real-time Care and resident safety tend to be prioritised over adminis- trative tasks, occasionally leading to in notetaking However, we agree that thls practice Is unacceptable, and the incident has exposed a important: weakness In our system that must be addressed Immedlately The late entry of care notes is & known issue that can lead t0 mistakes; as demonstrated In Mr Sparrow' $ case, where 2 staff member from the day shift inputted the 20;30 after thelr shift Actions Taken and Future Improvements Implementation of Care Vision: The new care planning system, Care Vision, wllI prompt staff to document care activities, including food and fluid Intake at the point of care: Thls system will flag If records are not completed In a tImely manner, and managers wlll be alerted to any Incon- plete or delayed entries Care Vision will be fullv operational by January 2025, Reflective Practice and Staff Accountabllity; All staff have already participated in reflective prac- tice sessions; whlch on the Importance of timely and accurate documentation. During these sessions, staff discussed the Impact of inaccurate entries on resident safety znd the legal and ethical responsibilities they carry in their role. In the future, staff who fall to complete doc: umentatlon in real tIme wIll be sublect t0 dlscipllnary action; Spot Checks and Monltoring: In the Interim; the home manager wlll continue to Use the "Resi- dent of the Day" svstem t0 revlew daily care notes and ensure that staff complete documenta- tlon accurately and in 2 timely manner; This system provides an Immedlate Iayer of overslght while we await the full Implementation 0f Care VIsion. Supervislon and Mentorshlp: Senlor staff mentor new staff members to ensure know the importance of recording notes promptly We will also ensure that staff have the time and sup- port needed to document care without feeling pressured by other dutles:
3. Concern Regarding Oversight in Investigation The third concern relates to the Internal investigation conducted Dy the manager af The Mead: ows Nursing Home following Mr Sparrow' $ death: Whlle revlewing hls care plan and care notes and speaking t0 staff, Mrs Hawkins did not identify the false entry made on Ist Dzcember 2023, The coroner expressed concern that tls oversight could have delayed Iden- tifving the Issues raised In concerns 1 and 2 Our Thoughts on the Issue The investigation into Mr Sparrow' $ death was initiated by the Care Quallty Commisslon (CQC) In December 2023. Ms Hawkins conducted a thorough review based an the information avallable: Her investigation report was submitted to CQC, the local authorlty (Kerion), and the safeguarding team, all of whom reviewed the findings ad rised no concerns. The safeguarding team Ultmate: using delavs entry focus they
Iy closed the case with a single recommendation: to ensure that a duty of candor was exercised with Mr Sparrow 5 famlly Although the error regarding the 20.30 entry was not Identified during this Investigation, we be- Ileve It was an unfortunate oversight rather than a fallure of the investigation process. Multiple commissioning and compliance teams reviewed the evidence, and none flagged the error: How- ever, we recognise that this oversight highlights the need for more rigorous revlew processes and enhanced investigative procedures Actions Taken and Future Improvements Improved Investigative Procedures: Moving forward, all Internal Investigatlons Involve a mul: ti-lavered review process, ensuring that senior management reviews the findings betore reports are finalised. Thls additional oversight could help prevent essential detalls from being over- looked_ Tralning for Managers: All home managers, Including Twlll recelve further train- @n conducting Investigations With a specific focus on reviewing care documentation and identifying discrepancies: This training will ensure that managers are equlpped to identily and address potential issues more effectively In the future. Collaborative Reviews with External Bodles;: wlll continue t0 work closely with external agen- cies such as COC, the lacal authority and the sateguarding team t0 ensure thorough, collabora- tive reviews cf all future investlgations. Thls will allow for multiple perspectives and addltional oversight, reducing the likelihood of errors being missed ReflectIve Practice on Investigation Processes: Reflective practice sessions have been held with management t0 evaluate the investigatlon Into Mr Sparrow' $ care: These sessions have identified several areas for Improvement; including more careful scrutiny of care notes and more transpar- ent communicatlon between staff and management; Patterns and Areas for Improvement Upon reviewlng all three concerns we have Identified several common patterns; Documentation; A recurring theme in concerns ! and 2 Is the importance of accurate and tImely documentatlon; Staff must record what care is provided and how it is delivered, including specific detalls such as the level of asslstance during meals. Systemic Oversighr: Concern 3 highlights the need tor stronger internal and external oversight during investigations: The failure t0 detect the entry in Mr Sparrow s care notes occurred within The Meadows and during multiple external revlews: This could suggest a need for better com- munication and collaboration with external agencles, Technology: Concerns 1 and ? reveal the Imitations of our current care planning system, Fusion; The absence of real-time prompts for Staff to record care activitles Increases the Ilkellhood of late entries; which In turn can lead to Inaccuracles. Implementing Care Vision will address this directly by ensuring care Is recorded at the point of delivery: Retlective Practice; We have conducted reflectlve practlce sessions with our staff and manage- ment tean, focusing on the lessons learned from Mr. Sparrow' $ case, These sessions have been will ing We Issue
Instrumental in identifying areas for Improvement and reinforcing the Importance of accurate documentatlon, timely reporting and thorough Investigations We are committed to fostering a culture of continuous learning and accountability within our team. Conclusion The Meadows Nursing Home Is deeply committed to addressing the concerns ralsed In the Regu- lation 28 report and ensuring that we provide our residents with the highest standard of care_ The steps we are taking_Implementing Care Vision, enhancing our documentation practices, Improving investigative procedures, and conducting reflective practice sessions-demonstrate our dedication to learning irom this incident and preventing future occurrences: We recognise that the key to our improvement lies not only in the systems we implement but also in the invaluable feedback from our Staff. Thelr insights and experiences are crucial In shap- our practices and ensuring that we continually evolve to meet the needs of our residents: We are fostering 3 culture of open communication and collaboration where every team member feels empowered t0 contribute t0 our shared of excellence in care. While we acknowledge the mistakes made In this case flrmly belleve that the changes we are implementing will significantlv enhance our processes and ensure that our residents receive the care they need and deserve We extend our slncere condolences to Mr Sparrow' $ famlly and re- main committed t0 acting on the coroner' 5 recommendations a5 we strive tO continuously Im- prove Our care practices We extend our sincere condolences to Mr Sparrow'$ family and are commltted t0 acting on the coroner $ recommendations Action Plan: Response to Regulation 28 Prevention of Future Deaths Report (Mr. Sparrow) Objective: To acdress the coroner'$ concerns regarding Mr Sparrow'$ death and Implement necessary Improvements t0 ensure the highest standard of care at The Meadows Nursing Home 1, Care Plan and Documentatlon Revlew Action: Complete a full review of all resident care plans t0 ensure accurately reflect the needs and care provided: Implement consistent documentation practices for fluctuating levels af assistance, espe- cially during mealtimes. Responsible Person: Home Manager Clinical Lead Timellne: Care plan revlew completed bv ISth October 2024 Ongoing documentation checks: From I6th October 2024
2. Tralning on Person-Centered Documentation Actlon: Ing goal we thev
Provide training to all staff on accurate and detailed documentation, especiallv regarding levels o1 mealtime assistance Ensure training covers the ethical and legal responsibllities of real-time documentatlon: Responsible Person: Clinical Lead / Training Coordinator Timellne: Training sessions to be completed by: 30th October 2024 Follow-up competency assessments; By 15th November 2024 3 . Implementation of Care Vision System Action; Finalise the contract and implement Care Vision, a new care planning system that prompts real-[lme documentation, Ensure all staff are trained on using the new system effectively Responsible Person: IT Department / Home Manager Timellne: Full implementatlon by 31st January 2025 Staff tralning on Care VIsion completed bY ISth February 2025
4. "Resident of the Day" Spot Checks Action: Continue dally spot checks of care notes until the Care Vision system Is fully operational: Focus on identifying gaps in documentation and taking Immediate corrective action; Responsible Person; Home Manager Timeline: Dally checks are to be conducted Immedlately, starting 25th September 2024 Continue untll Care Vision Is operational; Until 31st January 2025
5. Recruitment of Full-Time Clinical Lead Actlon: Ensure the Clinical Lead monitors the accuracy of care plans, documentation, and mealtime assistance: Assign clear cllnical responslbllities t0 the new lead for oversight of resident care, Responsible Person: Home Manager Timeline:
Clinical Lead In full operatlonal role: Already recruited, ongoing monitoring
6. Addressing Late Documentation Action: Implement an Interim system of manual reminders t0 staff t0 ensure tImely documenta- tion until Care Vlsion is operatlonal; Immediate disciplinary action should be taken against staff members falling to document care In real-time. Responsible Person: Cllnical Lead / Home Manager Timellne: Manual reminder sstem active: Immediate Monitoring via "Resident of the Day" system: Ongolng
7. Staff Reflective Practice on Documentation and Accountabillty Action: Continue rellective practice sessions for all t0 emphasise the importance cf accurate and tImely documentation. Introduce further reflective practice specifically for those involved in Mr, Sparrow'$ care; Responsible Person; Home Manager / Clinical Lead Timellne: Reflective practice sessions: Monthly; starting 1Oth October 2024
8. Improved Investigation Procedures Action; Introduce a multi-lavered review process for internal Investigatlons tO prevent oversights. Traln all managers on thorough documentation review and the investigation process:. Responsible Person: Operations Manager Home Manager Timeline: New review procedure established by: 3Oth November 2024 Manager tralning completed by ISth December 2024
9. Collaborative Reviews with External Bodies Action: Strengthen collaboration with external bodies Ilke COC and the safeguarding team during future Investigations; staff
Responsible Person: Home Manager / Compliance Manager Timellne: Initiate collaboration framework bY Ist October 2024 Ongoing for future Investigations
10. Supervlsion and Mentorship for New Staff Actlon: Assign senior staff to mentor and supervise new staff, ensuring they understand the Im- portance Of prompt and accurate documentation; Implement ongping mentorship to foster accountabllity. Responsible Person: Cllnical Lead Timellne; Mentorship program to begin: Immediately; from 25th September 2024 Conclusion: This action plan ensures timely and effective improvements t0 address the coroner'$ concerns; focusing on enhancing documentation accuracy, staff accountabllity, ad care quallty; wlll manitor progress regularly and adjust timellnes as necessary tO ensure 3ll actions are completed on schedule. Dlrector We
26.09.24 Mr David Reed HM Senior Coroner for Worcestershire Response to Regulation 28 Prevention of Future Deaths Report Regardlng the Death of Mr. Alfred Edward Sparrow Cardinal Healthcare The Meadows Nursing Home We are writing in response to the Regulatlon 28 Prevention of Future Deaths report Issued fol- lowing the Inquest into Mr Sparrow'$ death We take the coroner $ concerns verv seriously and have conducted a thorough revlew ofour practices and processes: Beiow, we address each con- cern In detall, outline the actions taken, and propose future improvements, all Informed by re- flective practice and lessons learned from thls case; 1, Concern Regarding Mealtime Assistance The coroner' $ first concern revolves around the care provlded to Mr Sparrow during mealtimes: His care plan at his previcus care home specified that he required full assistance with food and fluld Intake due to hls dlagnosis of vascular dementia. However, care notes documenting his food and fluld Intake dld nor clearly indicate whether he was assisted, raising concerns that Mr Sparrow might not always have received the assistance required, potentially putting his health at risk: Our thoughts on the Issue His care plan was assessed when Mr Sparrow was admitted t0 The Meadows Nursing Home on 11 September 2023. We concluded that; while he had a dlagnosis of vascular dementia ad his prevlous home had recorded that he requlred full asslstance with eating he stIll demonstrated some abillty to feed himself Encouraging independence was essential tO maintaining Mr Spar- being
row' s dignity and preventing deskilling; which his daughter confirmed In her statement: My fa- ther was moved into The Meadows Care Home on the Ilth of September 2023 He was alert and able t0 feed and drink unassisted However, we acknowledge that whlle our Intentions were t0 respect hls dignity ad foster Inde- pendence; our documentation needed to reflect thls nuanced approach The fallure t0 ex - pllcitly record whether staff assisted Mr Sparrow during meals created uncertainty This omission highlights where we must improve our practices to ensure transparency and clarity in care rec- ords: Actlons Taken and Future Improvements Care Plan and Documentation Review: A full review of all resident care plans is underway to en- sure they accurately reflect each resident'$ needs ad any changes In thelr condition, In Mr Spar- row"$ case; we now realise that his ability to feed himself may have flucruated, and such tions should be recorded better In care notes; Training in Person-Centered Documentation: All staff recelve additional training to Improve thelr documentatlon of the Ievel of assistance provided during meals. It Is critical that staff not only record food and fluid intake but also specify the level of support provided to theresident; whether full assistance or encouragement; Implementation of Care Vision: We are in the final stages of contracting a new care planning sys: tem, Care Visian, which we hope be fully operational by January 2025, Care Vision will prompt staff In real time to record food and fluid Inrake and flag Incomplete entries t0 the man- agement team: Thls system wlll ensure that detalled, accurate Informatlon about the level of as- sistance provlded Is recorded at the of care. Spot Checks through the "Resident of the Day" System: Until Care Vision Is fully implemented, the home manager will conduct dally spot checks of care notes as part ofthe 'Resident of the Day" system: These checks will help Identlfy any documentation gaps and ensure corrective ac tlons are taken where necessary Recruitment of new full-time clinical lead: We have recently recruited a full-time clinical lead at The Meadows; who Is now part of our management team. The Introductlon of this Clinical Lead wIll allow the Home Manager t0 focus more on overseeing the overall operations of the home and strategic planning while ensuring a more effective delegatlon of clinical responsibillties, The Cllnical Lead wIll provide enhanced support t0 nursing staff, ensuring that care plans, Including mealtime assistance, are regularly revlewed and accuratelv documented; This additlon to the management team will ensure that care Is dellvered according to each resldent' $ needs and that documentation standards are rigorously upheld, 2, Concern Regarding Inaccurate Record of Fluld Intake The coroner' $ second concern [5 a false entry In Mr Sparrows care notes. The entry Indicated that Mr Sparrow had consumed 20Oml of tea at 20.30 on Ist December 2023,which was Ewa hours after he had passed away: Thls raised serious concerns about the accurcy of care records and the possibillty that staff were documenting care actlons retrospectively; potentiallv com - promising the safety and well-being of residents. fully:` fluctua- wilI point
Our Thoughts on the Issue While we acknowledge the Inaccuracy ofthe 20.30 entry, we believe it was the result of late documentatlon rather than intentional falsification. Staff members sometimes input care notes after their shifts when our current care planning system, Fusion; which does not prompt staff to document care In real-time Care and resident safety tend to be prioritised over adminis- trative tasks, occasionally leading to in notetaking However, we agree that thls practice Is unacceptable, and the incident has exposed a important: weakness In our system that must be addressed Immedlately The late entry of care notes is & known issue that can lead t0 mistakes; as demonstrated In Mr Sparrow' $ case, where 2 staff member from the day shift inputted the 20;30 after thelr shift Actions Taken and Future Improvements Implementation of Care Vision: The new care planning system, Care Vision, wllI prompt staff to document care activities, including food and fluid Intake at the point of care: Thls system will flag If records are not completed In a tImely manner, and managers wlll be alerted to any Incon- plete or delayed entries Care Vision will be fullv operational by January 2025, Reflective Practice and Staff Accountabllity; All staff have already participated in reflective prac- tice sessions; whlch on the Importance of timely and accurate documentation. During these sessions, staff discussed the Impact of inaccurate entries on resident safety znd the legal and ethical responsibilities they carry in their role. In the future, staff who fall to complete doc: umentatlon in real tIme wIll be sublect t0 dlscipllnary action; Spot Checks and Monltoring: In the Interim; the home manager wlll continue to Use the "Resi- dent of the Day" svstem t0 revlew daily care notes and ensure that staff complete documenta- tlon accurately and in 2 timely manner; This system provides an Immedlate Iayer of overslght while we await the full Implementation 0f Care VIsion. Supervislon and Mentorshlp: Senlor staff mentor new staff members to ensure know the importance of recording notes promptly We will also ensure that staff have the time and sup- port needed to document care without feeling pressured by other dutles:
3. Concern Regarding Oversight in Investigation The third concern relates to the Internal investigation conducted Dy the manager af The Mead: ows Nursing Home following Mr Sparrow' $ death: Whlle revlewing hls care plan and care notes and speaking t0 staff, Mrs Hawkins did not identify the false entry made on Ist Dzcember 2023, The coroner expressed concern that tls oversight could have delayed Iden- tifving the Issues raised In concerns 1 and 2 Our Thoughts on the Issue The investigation into Mr Sparrow' $ death was initiated by the Care Quallty Commisslon (CQC) In December 2023. Ms Hawkins conducted a thorough review based an the information avallable: Her investigation report was submitted to CQC, the local authorlty (Kerion), and the safeguarding team, all of whom reviewed the findings ad rised no concerns. The safeguarding team Ultmate: using delavs entry focus they
Iy closed the case with a single recommendation: to ensure that a duty of candor was exercised with Mr Sparrow 5 famlly Although the error regarding the 20.30 entry was not Identified during this Investigation, we be- Ileve It was an unfortunate oversight rather than a fallure of the investigation process. Multiple commissioning and compliance teams reviewed the evidence, and none flagged the error: How- ever, we recognise that this oversight highlights the need for more rigorous revlew processes and enhanced investigative procedures Actions Taken and Future Improvements Improved Investigative Procedures: Moving forward, all Internal Investigatlons Involve a mul: ti-lavered review process, ensuring that senior management reviews the findings betore reports are finalised. Thls additional oversight could help prevent essential detalls from being over- looked_ Tralning for Managers: All home managers, Including Twlll recelve further train- @n conducting Investigations With a specific focus on reviewing care documentation and identifying discrepancies: This training will ensure that managers are equlpped to identily and address potential issues more effectively In the future. Collaborative Reviews with External Bodles;: wlll continue t0 work closely with external agen- cies such as COC, the lacal authority and the sateguarding team t0 ensure thorough, collabora- tive reviews cf all future investlgations. Thls will allow for multiple perspectives and addltional oversight, reducing the likelihood of errors being missed ReflectIve Practice on Investigation Processes: Reflective practice sessions have been held with management t0 evaluate the investigatlon Into Mr Sparrow' $ care: These sessions have identified several areas for Improvement; including more careful scrutiny of care notes and more transpar- ent communicatlon between staff and management; Patterns and Areas for Improvement Upon reviewlng all three concerns we have Identified several common patterns; Documentation; A recurring theme in concerns ! and 2 Is the importance of accurate and tImely documentatlon; Staff must record what care is provided and how it is delivered, including specific detalls such as the level of asslstance during meals. Systemic Oversighr: Concern 3 highlights the need tor stronger internal and external oversight during investigations: The failure t0 detect the entry in Mr Sparrow s care notes occurred within The Meadows and during multiple external revlews: This could suggest a need for better com- munication and collaboration with external agencles, Technology: Concerns 1 and ? reveal the Imitations of our current care planning system, Fusion; The absence of real-time prompts for Staff to record care activitles Increases the Ilkellhood of late entries; which In turn can lead to Inaccuracles. Implementing Care Vision will address this directly by ensuring care Is recorded at the point of delivery: Retlective Practice; We have conducted reflectlve practlce sessions with our staff and manage- ment tean, focusing on the lessons learned from Mr. Sparrow' $ case, These sessions have been will ing We Issue
Instrumental in identifying areas for Improvement and reinforcing the Importance of accurate documentatlon, timely reporting and thorough Investigations We are committed to fostering a culture of continuous learning and accountability within our team. Conclusion The Meadows Nursing Home Is deeply committed to addressing the concerns ralsed In the Regu- lation 28 report and ensuring that we provide our residents with the highest standard of care_ The steps we are taking_Implementing Care Vision, enhancing our documentation practices, Improving investigative procedures, and conducting reflective practice sessions-demonstrate our dedication to learning irom this incident and preventing future occurrences: We recognise that the key to our improvement lies not only in the systems we implement but also in the invaluable feedback from our Staff. Thelr insights and experiences are crucial In shap- our practices and ensuring that we continually evolve to meet the needs of our residents: We are fostering 3 culture of open communication and collaboration where every team member feels empowered t0 contribute t0 our shared of excellence in care. While we acknowledge the mistakes made In this case flrmly belleve that the changes we are implementing will significantlv enhance our processes and ensure that our residents receive the care they need and deserve We extend our slncere condolences to Mr Sparrow' $ famlly and re- main committed t0 acting on the coroner' 5 recommendations a5 we strive tO continuously Im- prove Our care practices We extend our sincere condolences to Mr Sparrow'$ family and are commltted t0 acting on the coroner $ recommendations Action Plan: Response to Regulation 28 Prevention of Future Deaths Report (Mr. Sparrow) Objective: To acdress the coroner'$ concerns regarding Mr Sparrow'$ death and Implement necessary Improvements t0 ensure the highest standard of care at The Meadows Nursing Home 1, Care Plan and Documentatlon Revlew Action: Complete a full review of all resident care plans t0 ensure accurately reflect the needs and care provided: Implement consistent documentation practices for fluctuating levels af assistance, espe- cially during mealtimes. Responsible Person: Home Manager Clinical Lead Timellne: Care plan revlew completed bv ISth October 2024 Ongoing documentation checks: From I6th October 2024
2. Tralning on Person-Centered Documentation Actlon: Ing goal we thev
Provide training to all staff on accurate and detailed documentation, especiallv regarding levels o1 mealtime assistance Ensure training covers the ethical and legal responsibllities of real-time documentatlon: Responsible Person: Clinical Lead / Training Coordinator Timellne: Training sessions to be completed by: 30th October 2024 Follow-up competency assessments; By 15th November 2024 3 . Implementation of Care Vision System Action; Finalise the contract and implement Care Vision, a new care planning system that prompts real-[lme documentation, Ensure all staff are trained on using the new system effectively Responsible Person: IT Department / Home Manager Timellne: Full implementatlon by 31st January 2025 Staff tralning on Care VIsion completed bY ISth February 2025
4. "Resident of the Day" Spot Checks Action: Continue dally spot checks of care notes until the Care Vision system Is fully operational: Focus on identifying gaps in documentation and taking Immediate corrective action; Responsible Person; Home Manager Timeline: Dally checks are to be conducted Immedlately, starting 25th September 2024 Continue untll Care Vision Is operational; Until 31st January 2025
5. Recruitment of Full-Time Clinical Lead Actlon: Ensure the Clinical Lead monitors the accuracy of care plans, documentation, and mealtime assistance: Assign clear cllnical responslbllities t0 the new lead for oversight of resident care, Responsible Person: Home Manager Timeline:
Clinical Lead In full operatlonal role: Already recruited, ongoing monitoring
6. Addressing Late Documentation Action: Implement an Interim system of manual reminders t0 staff t0 ensure tImely documenta- tion until Care Vlsion is operatlonal; Immediate disciplinary action should be taken against staff members falling to document care In real-time. Responsible Person: Cllnical Lead / Home Manager Timellne: Manual reminder sstem active: Immediate Monitoring via "Resident of the Day" system: Ongolng
7. Staff Reflective Practice on Documentation and Accountabillty Action: Continue rellective practice sessions for all t0 emphasise the importance cf accurate and tImely documentation. Introduce further reflective practice specifically for those involved in Mr, Sparrow'$ care; Responsible Person; Home Manager / Clinical Lead Timellne: Reflective practice sessions: Monthly; starting 1Oth October 2024
8. Improved Investigation Procedures Action; Introduce a multi-lavered review process for internal Investigatlons tO prevent oversights. Traln all managers on thorough documentation review and the investigation process:. Responsible Person: Operations Manager Home Manager Timeline: New review procedure established by: 3Oth November 2024 Manager tralning completed by ISth December 2024
9. Collaborative Reviews with External Bodies Action: Strengthen collaboration with external bodies Ilke COC and the safeguarding team during future Investigations; staff
Responsible Person: Home Manager / Compliance Manager Timellne: Initiate collaboration framework bY Ist October 2024 Ongoing for future Investigations
10. Supervlsion and Mentorship for New Staff Actlon: Assign senior staff to mentor and supervise new staff, ensuring they understand the Im- portance Of prompt and accurate documentation; Implement ongping mentorship to foster accountabllity. Responsible Person: Cllnical Lead Timellne; Mentorship program to begin: Immediately; from 25th September 2024 Conclusion: This action plan ensures timely and effective improvements t0 address the coroner'$ concerns; focusing on enhancing documentation accuracy, staff accountabllity, ad care quallty; wlll manitor progress regularly and adjust timellnes as necessary tO ensure 3ll actions are completed on schedule. Dlrector We