Mandeville Grange Nursing Home
Other
Action Taken
Mandeville Grange Nursing Home has engaged Care4Quality to rewrite its policies, implemented Bright HR for policy distribution, transitioned training to Access Learning for Care, engaged four additional trainers, and ordered a CPR training manikin; emergency CPR drills will start within 1 month pending staff competency assessment. (AI summary)
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Dear Sir Inquest touching the death of Ms Sheila Ann Nicholls Response to Regulation 28 Report to Prevent Future Deaths On 8 January 2025 following the conclusion of the Inquest touching the death of Ms Sheila Ann Nicholls a Prevention of Future Deaths (“PFD”) report was issued. We respond to that report by way of this letter. To confirm, the report was shared with on 9 January 2025 via email. ’s email and postal address was provided to Ms Mullin on 9 and 10 January 2025. (1) Management and circulation of internal written policies At the time of the Inquest in October 2024, we had instructed Care4Quality (“C4Q”) to assist around our admissions process. We were considering whether or not it was practical for them to manage our suite of policies in totality. Having considered this further, we took the decision to engage C4Q to re-write all of our policies to ensure they are (i) relevant (ii) specific and (iii) that we remain up to date with current legislation. (our new Nominated Individual) is managing this process. Beginning in October 2024, C4Q now work closely with our Home Managers to review and thereafter tailor the policies to the specific requirements of our services. The process is:
1. Drafting: C4Q prepare a near-final draft of the policy and send it to the Home Manager for review.
2. Review: The Home Manager reviews the draft and provides any feedback or queries to C4Q.
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5. Finalisation: Once all discussions have taken place, and revisions agreed upon, the policy is deemed finalised. Upload: The policy is then uploaded to C4Q’s policy platform, Astute, which our team has access to. Distribution: Our HR team then uploads the final policy to Bright HR, our HR platform. This enables direct circulation to staff. The date the policy is uploaded to Bright HR is the date the policy is deemed in force. In terms of onward monitoring and review:
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10. Review: policies are reviewed yearly, or in the event of new legislation or guidelines / guidance. Acknowledgment: Bright HR generates both a “read receipt” to confirm that all staff members have read the policy and an “acceptance receipt” to confirm that all staff members have both read and accepted the contents. Communication: Any new or updated policies are discussed during the daily flash meetings, which are recorded in meeting minutes. Monitoring: Each week, the HR team meets with the Home Manager to review staff compliance data on Bright HR and follow up on any outstanding acknowledgments. Training: If additional training is required as a result of a new or updated policy, the need is identified in the weekly Manager/HR meeting, and the necessary training is then scheduled. In terms of the project’s current status:
- We have 85 policies in circulation;
- nalised; 17 are with the Manager for final review; and
- 14 are still in a drafting phase. It is envisaged all 85 policies will be in force by 30/04/2025. For the avoidance of doubt in place already are:
- Initial Assessment and Admissions Policy;
- Person-Centred Care Policy;
- Nutrition and Hydration (including dysphagia); and
- Resuscitation Policy (including choking). (2) Training in emergency response Effective from 14 October 2024, we transitioned the majority of our training to an eLearning format provided by The Access Group (Access Learning for Care). This platform automatically generates a training matrix for Mandeville Grange and also records any face-to-face sessions, ensuring the matrix remains accurate and up to date. Our HR team and the Home Manager meet weekly to review the matrix, and any face-to-face training that is due to expire within two months is immediately scheduled with one of our external trainers.
- 54 are fi
To maintain consistency in our face-to-face training, we have recently engaged four additional trainers. For eLearning modules, the Access system sends automatic reminders to staff members three weeks, two weeks, and one week before their training expires. Our current training matrix indicates 100% compliance. There is some training which is scheduled to expire within one month. That training will be organised in good time. We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month. We have ordered a PractiMan Advanced CPR Adult/Child Manikin, 2-in1 Life-like CPR Training Manikin for Adult/Child CPR Training for the home. By way of additional information: left her role with Mandeville on 25 October 2024. Steps had begun to be taken to provide her with additional training and supervision, but unfortunately could not be completed before she left. (3) Investigating and learning from adverse inferences We remain committed to instructing an external person or organisation to investigate any future deaths. There has been one incident and Fulcrum Care completed a Root Cause Analysis for this. We hope the above demonstrates how seriously the concerns raised have been taken.
1. Drafting: C4Q prepare a near-final draft of the policy and send it to the Home Manager for review.
2. Review: The Home Manager reviews the draft and provides any feedback or queries to C4Q.
3.
4.
5. Finalisation: Once all discussions have taken place, and revisions agreed upon, the policy is deemed finalised. Upload: The policy is then uploaded to C4Q’s policy platform, Astute, which our team has access to. Distribution: Our HR team then uploads the final policy to Bright HR, our HR platform. This enables direct circulation to staff. The date the policy is uploaded to Bright HR is the date the policy is deemed in force. In terms of onward monitoring and review:
6.
7.
8.
9.
10. Review: policies are reviewed yearly, or in the event of new legislation or guidelines / guidance. Acknowledgment: Bright HR generates both a “read receipt” to confirm that all staff members have read the policy and an “acceptance receipt” to confirm that all staff members have both read and accepted the contents. Communication: Any new or updated policies are discussed during the daily flash meetings, which are recorded in meeting minutes. Monitoring: Each week, the HR team meets with the Home Manager to review staff compliance data on Bright HR and follow up on any outstanding acknowledgments. Training: If additional training is required as a result of a new or updated policy, the need is identified in the weekly Manager/HR meeting, and the necessary training is then scheduled. In terms of the project’s current status:
- We have 85 policies in circulation;
- nalised; 17 are with the Manager for final review; and
- 14 are still in a drafting phase. It is envisaged all 85 policies will be in force by 30/04/2025. For the avoidance of doubt in place already are:
- Initial Assessment and Admissions Policy;
- Person-Centred Care Policy;
- Nutrition and Hydration (including dysphagia); and
- Resuscitation Policy (including choking). (2) Training in emergency response Effective from 14 October 2024, we transitioned the majority of our training to an eLearning format provided by The Access Group (Access Learning for Care). This platform automatically generates a training matrix for Mandeville Grange and also records any face-to-face sessions, ensuring the matrix remains accurate and up to date. Our HR team and the Home Manager meet weekly to review the matrix, and any face-to-face training that is due to expire within two months is immediately scheduled with one of our external trainers.
- 54 are fi
To maintain consistency in our face-to-face training, we have recently engaged four additional trainers. For eLearning modules, the Access system sends automatic reminders to staff members three weeks, two weeks, and one week before their training expires. Our current training matrix indicates 100% compliance. There is some training which is scheduled to expire within one month. That training will be organised in good time. We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month. We have ordered a PractiMan Advanced CPR Adult/Child Manikin, 2-in1 Life-like CPR Training Manikin for Adult/Child CPR Training for the home. By way of additional information: left her role with Mandeville on 25 October 2024. Steps had begun to be taken to provide her with additional training and supervision, but unfortunately could not be completed before she left. (3) Investigating and learning from adverse inferences We remain committed to instructing an external person or organisation to investigate any future deaths. There has been one incident and Fulcrum Care completed a Root Cause Analysis for this. We hope the above demonstrates how seriously the concerns raised have been taken.