Victoria Residential Home
Other
Action Taken
Victoria Residential Home has already closed off the front lounge area where the escape door was located, secured the outside front door with electronic fob access, and made the conservatory door permanently inaccessible. They have also improved shift handover procedures with a senior WhatsApp group, completed new paperwork to evidence refreshments for residents, and staff have been re-enrolled on Safeguarding, Nutrition, DOLS and Communication training. (AI summary)
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Provider Victoria House (Wallasey) Ltd Service/Establishment Victoria House CQC Overall rating Requires Improvement Date of inspection
20.01.25 Date action plan created
13.01.25 Nominated Individual
Registered Manager to 22.01.25 until
22.01.25 Contact from
23.01.25 Background Information Coroner’s Report dated 13.01.25 in to the death of resident Diane Poole Deceased. Diane left the Home with another resident on
31.08.24 through a conservatory push bar exit which was alarmed, however the alarm failed to activate on opening. Staff were unaware that the residents were missing for three hours. Diane Pool was found following an unwitnessed fall on Steel Avenue, Wallasey. She was taken to the trauma centre at Aintree University Hospital where she was treated for head and facial fractures. She was discharged from Aintree University Hospital on the 17.09.24 to Acorn Residential Home. She died on 23.09.24. Coroner concluded that Diane Pool died from an accidental death and that the fall and injuries sustained more than minimally contributed to her death. It was unclear as to whether the fall would have occurred had she been noticed as missing earlier. This action plan is to identify improvements required, monitor progress of the improvements, and ensure the regulatory compliance is achieved at the service. The action plan focusses on the initial assessments identified in the Homes Investigation Outcome of 15.10.24. The action plan will be developed as progress is made and any further areas for improvement identified will be added to this overarching action plan.
2 KEY Green – Completed Amber – Started/Ongoing Red – Not yet started. Area for improvement identified Action to be taken. Detail that includes measurable action Who is responsible for the Action Aim completio n Date Date completed Updates Rigorous Alarm Checks Regular inspections of all emergency exit alarms to ensure they are functioning correctly. Team Leader at the start of each shift PLUS management daily Already completed Introduced following the incident and ongoing daily. Now signed for by seniors and handyman daily. Signatures are for checks at 08:00hrs and 20:00 hrs, specifically when shifts are changing. Increased Resident “Headcounts” Staff will conduct hourly “headcounts” of all residents, with half hour checks for those deemed high risk Team Leaders Already Completed Introduced immediately following the incident and ongoing daily. Engaging Activities for High-Risk Residents Structured, stimulating activities to engage high-risk residents and reduce behaviours that may lead to attempts to leave the Home Activities co- ordinator with input from Management Completed 07/02/2025 The activities co-ordinator is now in place for 5 afternoons per week to engage with residents in daily activities. Improved Shift Handover Procedures Shift handovers will be more resident focussed, ensuring clean communication and continuity of care. Team Leaders and Management Already completed Introduction of senior what’s app group that is shared with all seniors and management at the end of every shift Ongoing Staff Training Regular training to reinforce the importance of supervision, resident safety and emergency procedures Management March 25 Staff re-enrolled on Safeguarding training along with Nutrition and Hydration (as it was found that staff did not notice that residents were missing during morning drinks round). Staff also enrolled on DOLS course and a further general role centred course covering the importance of Communication, Reporting and Recording, Daily Tasks and Team Working.
3 Improved shift paperwork New paperwork to evidence that all residents receive morning and afternoon refreshments Healthcare Assistants Completed Staff complete nutrition forms. Closure of the front lounge area where the escape door is situated Area closed off following the incident Management
31.08.24 The lounge area was immediately closed off and is now closed to residents (now being used a meeting room – family room). Environment Restructuring Areas to the front of the Home are being restructured to prevent possible future incidents Providers 14/02/20 25 Work has been completed on securing the outside front door to the premises. By electronic fob and self- closer. This now gives a further layer of protection against the possibility of residents on Dol’s leaving the premises. The area leading to the foyer also has restricted access via a fob system. Conservatory door Door to be made permanently inaccessible Management/ Providers
22.01.25 Conservatory door made permanently inaccessible by way of change to hinges and removal of opening mechanism and hand le. Note: this is not a fire door, the fire door is situated a few feet away
20.01.25 Date action plan created
13.01.25 Nominated Individual
Registered Manager to 22.01.25 until
22.01.25 Contact from
23.01.25 Background Information Coroner’s Report dated 13.01.25 in to the death of resident Diane Poole Deceased. Diane left the Home with another resident on
31.08.24 through a conservatory push bar exit which was alarmed, however the alarm failed to activate on opening. Staff were unaware that the residents were missing for three hours. Diane Pool was found following an unwitnessed fall on Steel Avenue, Wallasey. She was taken to the trauma centre at Aintree University Hospital where she was treated for head and facial fractures. She was discharged from Aintree University Hospital on the 17.09.24 to Acorn Residential Home. She died on 23.09.24. Coroner concluded that Diane Pool died from an accidental death and that the fall and injuries sustained more than minimally contributed to her death. It was unclear as to whether the fall would have occurred had she been noticed as missing earlier. This action plan is to identify improvements required, monitor progress of the improvements, and ensure the regulatory compliance is achieved at the service. The action plan focusses on the initial assessments identified in the Homes Investigation Outcome of 15.10.24. The action plan will be developed as progress is made and any further areas for improvement identified will be added to this overarching action plan.
2 KEY Green – Completed Amber – Started/Ongoing Red – Not yet started. Area for improvement identified Action to be taken. Detail that includes measurable action Who is responsible for the Action Aim completio n Date Date completed Updates Rigorous Alarm Checks Regular inspections of all emergency exit alarms to ensure they are functioning correctly. Team Leader at the start of each shift PLUS management daily Already completed Introduced following the incident and ongoing daily. Now signed for by seniors and handyman daily. Signatures are for checks at 08:00hrs and 20:00 hrs, specifically when shifts are changing. Increased Resident “Headcounts” Staff will conduct hourly “headcounts” of all residents, with half hour checks for those deemed high risk Team Leaders Already Completed Introduced immediately following the incident and ongoing daily. Engaging Activities for High-Risk Residents Structured, stimulating activities to engage high-risk residents and reduce behaviours that may lead to attempts to leave the Home Activities co- ordinator with input from Management Completed 07/02/2025 The activities co-ordinator is now in place for 5 afternoons per week to engage with residents in daily activities. Improved Shift Handover Procedures Shift handovers will be more resident focussed, ensuring clean communication and continuity of care. Team Leaders and Management Already completed Introduction of senior what’s app group that is shared with all seniors and management at the end of every shift Ongoing Staff Training Regular training to reinforce the importance of supervision, resident safety and emergency procedures Management March 25 Staff re-enrolled on Safeguarding training along with Nutrition and Hydration (as it was found that staff did not notice that residents were missing during morning drinks round). Staff also enrolled on DOLS course and a further general role centred course covering the importance of Communication, Reporting and Recording, Daily Tasks and Team Working.
3 Improved shift paperwork New paperwork to evidence that all residents receive morning and afternoon refreshments Healthcare Assistants Completed Staff complete nutrition forms. Closure of the front lounge area where the escape door is situated Area closed off following the incident Management
31.08.24 The lounge area was immediately closed off and is now closed to residents (now being used a meeting room – family room). Environment Restructuring Areas to the front of the Home are being restructured to prevent possible future incidents Providers 14/02/20 25 Work has been completed on securing the outside front door to the premises. By electronic fob and self- closer. This now gives a further layer of protection against the possibility of residents on Dol’s leaving the premises. The area leading to the foyer also has restricted access via a fob system. Conservatory door Door to be made permanently inaccessible Management/ Providers
22.01.25 Conservatory door made permanently inaccessible by way of change to hinges and removal of opening mechanism and hand le. Note: this is not a fire door, the fire door is situated a few feet away