Abbey Healthcare
Other
Action Taken
Abbey Healthcare has installed an app on handsets connected to Wi-Fi for direct 999 calls, is replacing Wi-Fi hotspots, and has updated the Manager Daily Walk Round Checklist to include call bell checks; also updated the Call Bell Policy to specify actions when call bells fail. (AI summary)
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Dear Coroner, RE: 26428708 Response to Regulation 28: Report to Prevent Future Deaths On 26 November 2024, following the conclusion of the Inquest touching the death of Mr Elan Adams, we received a Prevention of Future Death Report (“PFD”). We respond to those concerns herewith. Concern 1 The call to the London Ambulance Service was of very poor quality, partly due to interference in the phone line connection. The Inquest heard that the staff had problems with the phone quality ‘most of the time’ and continue to have difficulties when making emergency calls from residents bedrooms. Response 1 There are several ongoing improvements into our systems, including the phone systems and internet signal. Whilst the improvements have not all been made at the time of our response, they will be completed by February 2025. Before we could action the improvements, identified below, we needed to contact potential IT providers, to assist with the implementation and upgrade of our systems. 1
The handsets, which have our electronic care system installed (Care Vision), now have a separate app installed. This allows staff to call 999 directly from the handset. Staff are now not reliant on mobile phone signal as calls are made directly via the Home’s Wi-Fi. This became effective at Manor Farm on 17 January 2025 and the ‘Emergency Ambulance Protocol’ has been updated to reflect this (Appendix 1). All staff have been informed, both via email and at clinical meetings on 20th January 2025 to use the handsets and additional staff training will be completed by 24 January 2025. Previous sessions have been undertaken on 9, 13 and 17 January 2025 to discuss the change to the systems, amongst other areas, which we discuss further below. The Wi-Fi hotspots are in the process of being replaced and will be installed by 1st February 2025. Tests will be conducted following this, specifically to check for any signal issues post-installation. If any weak areas of signal are identified, further Wi-Fi hotspots will be installed, to boost the signal throughout the Home. Improvements are being made to the phone systems and landline separately, as follows: a) All telephones are being replaced; b) Extra cordless phones are being provided; c) Additional landline telephones (5 in total) are being installed; It is envisaged that by the end of February 2025, the Wi-Fi and phone signal across all areas of Manor Farm will be strengthened. There were unavoidable delays, owing to site surveys being completed by an external company, H20 networks, to identify any problems within the telephone network and a quote for the works to be agreed. It is regrettable the time this has taken, but we want to ensure that the improvements are completed to a good standard, so several companies were approached. Concern 2 The qualified nursing staff were concerningly unclear in the substance of communication with the emergency controller. They were unable to clearly answer the question about breathing status. They did not provide key clinical information to the controller, such as the much reduced oxygen saturation reading. 2
Response 2 In November 2024, we reviewed and updated our Emergency Ambulance Protocol (Appendix 2). This was prior to the further update to this policy, as seen at Appendix 1. This details that, where 999 are to be called, staff members need to have completed the following checks/be able to relay the following information to the call handler: a) Is the resident breathing, if no, is there a DNACPR in place? b) If there is no DNACPR in place, commence CPR and a 2nd clinician or Senior Care Assistant is to contact 999 c) If there are signs of life, a 2nd clinician or Senior Care Assistant is to dial 999, whilst the 1st clinician completes observations, including:
a. Blood pressure
b. Temperature
c. O2 saturations
d. Pulse
e. Respiration
f. Blood sugar (if diabetic) The policy sets out that once connected to the call handler, the above (and any additional information) must be relayed clearly, calmly and in an environment free of background disturbance. It states that a landline telephone is to be used. The policy also reminds staff to use ‘active positive listening skills’, to not try to interpret a question, to ask if they are unsure so that accurate information is relayed to the call handler. Following a further update in January 2025 to the handsets (referenced above), the policy now also refers to the fact the handsets can be used to contact 999, at Manor Farm as seen at Appendix 1. This has been discussed with staff at clinical meeting in addition 15th January 2025 in addition to being covered in training on 9 and 13 January 2025. We discuss the contents of this training further, below. To embed staff training in what to do in the event of a choking incident, the following further training and information has been provided to staff: a) A mannequin with a choke function has been purchased and is due to be delivered by 24 January 2025. There has been significant issues in sourcing a suitable mannequin, whereby we were forced to cancel our original order due to the excessive wait time for despatch and delivery. Simulated training with the mannequin is scheduled for week 3
commencing 27 January 2025, with a recording of the training to be circulated to our other homes by 31 January 2025. b) Choking and dysphagia training has been completed on 9 and 13 January 2025. This not only covered the awareness of the need to discuss cases of silent choking and how to deal with a 999 call, but also included a simulation of a 999 call and how it should be handled to ensure effective communication between emergency services and staff at all times. c) On 17 January 2025, Manor Farm staff attended a bespoke training session, which covered:
a. Recognising and responding to incidents within the home.
b. Recognising deterioration and injury, including providing a comprehensive handover to the ambulance service.
c. Understanding the incident reporting process.
d. Understanding the process to follow after an incident has occurred, including updates to care plans, risk assessments as required and communication with key stakeholders.
e. Understanding their duty of candour and CQC notifiable incidents.
f. Understand their professional accountability as a registered nurse (where applicable).
g. Discussion around learning strategies, and support, including reflective practice, debriefs and supervision. d) Manor Farm care and nursing staff have all been asked to complete the e-learning course ‘Duty of Care’. The course contents can be seen at Appendix 3 and will have been completed by all staff by the end of February 2025. 39 staff members have completed this already. To ensure that as a company, we have implemented change across all our sites, on 5 December 2024 we contacted each service to make them aware of the Coroner’s concerns following the Inquest in this matter. A copy of the Coroner’s Regulation 28 was provided to all managers. The Emergency Protocol, which was updated in November 2024, was circulated simultaneously. We asked all Home Managers to check the following in their service: a) That their phonelines within the service were stable and retained a good signal. b) That CPR dummies were available, which included a choke element. c) That suction machines are in situ, and maintained. d) All call bells are working, and checked regularly. 4
e) DE choke devices are in date and staff are fully trained. As a result of the request for feedback, some issues have been identified and we are in the process of updating the entire call bell system at Manor Farm (discussed below). No issues were reported by our other services. We have also updated our Duty of Candour Policy, as seen at Appendix 4. Concern 3 The resident call bell had been faulty for an extended period of time. Whilst a handbell was provided, there was little assurance that staff could hear this during busy periods, such as during mealtimes. The family had been present on a prior occasion when the temporary bell had been rung and no staff attended. Response 3 Following the Inquest and a request for feedback from all services within Abbey Healthcare, intermittent faults were identified with the call bell systems at Manor Farm. This was in keeping with our immediate checks following the Inquest. There were no call bell issues identified elsewhere. We have therefore taken steps to update the entire nurse call system in the Home. This has been at a significant expense to the business and will take several weeks to be installed. Time has been taken to identify a suitable provider to improve these systems, to provide a quote to undertake the work and for the work to be commissioned. It is expected that the upgrades will be completed by 31st March 2025 at Manor Farm. Whilst these works are ongoing, we have taken additional steps to ensure our residents are safeguarded at all material times. Our Manager Daily Walk Round Checklist has been updated (Appendix 5). Where spot checks of residents rooms are completed, it is now part of the check to ascertain if ‘all call bells are within reach and operational’. This includes a: a) Test of the call bell itself and recording of the emergency response time and b) Check of if any additional/all assistive technology is in place and operational. c) If a resident is unable to use a call bell, the Manager checks to ensure that a risk assessment (referred to earlier) is in place. 5
Half hourly checks are also conducted on residents, and ad-hoc tests of their call bells are undertaken. Where call bell failures are identified, staff are expected to follow the procedure as set out in our updated Call Bell Policy (Appendix 6). The policy, updated in November 2024, makes clear that in the event of a call bell failure, the following steps should be taken: (a) The identifying member of the team must inform the Nurse and Home Manager immediately; (b) Any faulty equipment should be reported immediately to the maintenance team and replaced or repaired urgently. (c) In the event that a call bell isn’t functioning and cannot be repaired instantly, the Home Manager must implement a risk assessment, outlining measures to take to mitigate the risk. (d) The above risk assessment requires approval by the Regional Director. All staff, as part of their induction, will receive training on this policy. Compliance with this policy will be monitored and any non-compliance may result in disciplinary action. We hope the above demonstrates how seriously we are taking the concerns raised by the Coroner, and we are focused on ensuring lessons have been learned not only at Manor Farm, but across all services within Abbey Healthcare.
The handsets, which have our electronic care system installed (Care Vision), now have a separate app installed. This allows staff to call 999 directly from the handset. Staff are now not reliant on mobile phone signal as calls are made directly via the Home’s Wi-Fi. This became effective at Manor Farm on 17 January 2025 and the ‘Emergency Ambulance Protocol’ has been updated to reflect this (Appendix 1). All staff have been informed, both via email and at clinical meetings on 20th January 2025 to use the handsets and additional staff training will be completed by 24 January 2025. Previous sessions have been undertaken on 9, 13 and 17 January 2025 to discuss the change to the systems, amongst other areas, which we discuss further below. The Wi-Fi hotspots are in the process of being replaced and will be installed by 1st February 2025. Tests will be conducted following this, specifically to check for any signal issues post-installation. If any weak areas of signal are identified, further Wi-Fi hotspots will be installed, to boost the signal throughout the Home. Improvements are being made to the phone systems and landline separately, as follows: a) All telephones are being replaced; b) Extra cordless phones are being provided; c) Additional landline telephones (5 in total) are being installed; It is envisaged that by the end of February 2025, the Wi-Fi and phone signal across all areas of Manor Farm will be strengthened. There were unavoidable delays, owing to site surveys being completed by an external company, H20 networks, to identify any problems within the telephone network and a quote for the works to be agreed. It is regrettable the time this has taken, but we want to ensure that the improvements are completed to a good standard, so several companies were approached. Concern 2 The qualified nursing staff were concerningly unclear in the substance of communication with the emergency controller. They were unable to clearly answer the question about breathing status. They did not provide key clinical information to the controller, such as the much reduced oxygen saturation reading. 2
Response 2 In November 2024, we reviewed and updated our Emergency Ambulance Protocol (Appendix 2). This was prior to the further update to this policy, as seen at Appendix 1. This details that, where 999 are to be called, staff members need to have completed the following checks/be able to relay the following information to the call handler: a) Is the resident breathing, if no, is there a DNACPR in place? b) If there is no DNACPR in place, commence CPR and a 2nd clinician or Senior Care Assistant is to contact 999 c) If there are signs of life, a 2nd clinician or Senior Care Assistant is to dial 999, whilst the 1st clinician completes observations, including:
a. Blood pressure
b. Temperature
c. O2 saturations
d. Pulse
e. Respiration
f. Blood sugar (if diabetic) The policy sets out that once connected to the call handler, the above (and any additional information) must be relayed clearly, calmly and in an environment free of background disturbance. It states that a landline telephone is to be used. The policy also reminds staff to use ‘active positive listening skills’, to not try to interpret a question, to ask if they are unsure so that accurate information is relayed to the call handler. Following a further update in January 2025 to the handsets (referenced above), the policy now also refers to the fact the handsets can be used to contact 999, at Manor Farm as seen at Appendix 1. This has been discussed with staff at clinical meeting in addition 15th January 2025 in addition to being covered in training on 9 and 13 January 2025. We discuss the contents of this training further, below. To embed staff training in what to do in the event of a choking incident, the following further training and information has been provided to staff: a) A mannequin with a choke function has been purchased and is due to be delivered by 24 January 2025. There has been significant issues in sourcing a suitable mannequin, whereby we were forced to cancel our original order due to the excessive wait time for despatch and delivery. Simulated training with the mannequin is scheduled for week 3
commencing 27 January 2025, with a recording of the training to be circulated to our other homes by 31 January 2025. b) Choking and dysphagia training has been completed on 9 and 13 January 2025. This not only covered the awareness of the need to discuss cases of silent choking and how to deal with a 999 call, but also included a simulation of a 999 call and how it should be handled to ensure effective communication between emergency services and staff at all times. c) On 17 January 2025, Manor Farm staff attended a bespoke training session, which covered:
a. Recognising and responding to incidents within the home.
b. Recognising deterioration and injury, including providing a comprehensive handover to the ambulance service.
c. Understanding the incident reporting process.
d. Understanding the process to follow after an incident has occurred, including updates to care plans, risk assessments as required and communication with key stakeholders.
e. Understanding their duty of candour and CQC notifiable incidents.
f. Understand their professional accountability as a registered nurse (where applicable).
g. Discussion around learning strategies, and support, including reflective practice, debriefs and supervision. d) Manor Farm care and nursing staff have all been asked to complete the e-learning course ‘Duty of Care’. The course contents can be seen at Appendix 3 and will have been completed by all staff by the end of February 2025. 39 staff members have completed this already. To ensure that as a company, we have implemented change across all our sites, on 5 December 2024 we contacted each service to make them aware of the Coroner’s concerns following the Inquest in this matter. A copy of the Coroner’s Regulation 28 was provided to all managers. The Emergency Protocol, which was updated in November 2024, was circulated simultaneously. We asked all Home Managers to check the following in their service: a) That their phonelines within the service were stable and retained a good signal. b) That CPR dummies were available, which included a choke element. c) That suction machines are in situ, and maintained. d) All call bells are working, and checked regularly. 4
e) DE choke devices are in date and staff are fully trained. As a result of the request for feedback, some issues have been identified and we are in the process of updating the entire call bell system at Manor Farm (discussed below). No issues were reported by our other services. We have also updated our Duty of Candour Policy, as seen at Appendix 4. Concern 3 The resident call bell had been faulty for an extended period of time. Whilst a handbell was provided, there was little assurance that staff could hear this during busy periods, such as during mealtimes. The family had been present on a prior occasion when the temporary bell had been rung and no staff attended. Response 3 Following the Inquest and a request for feedback from all services within Abbey Healthcare, intermittent faults were identified with the call bell systems at Manor Farm. This was in keeping with our immediate checks following the Inquest. There were no call bell issues identified elsewhere. We have therefore taken steps to update the entire nurse call system in the Home. This has been at a significant expense to the business and will take several weeks to be installed. Time has been taken to identify a suitable provider to improve these systems, to provide a quote to undertake the work and for the work to be commissioned. It is expected that the upgrades will be completed by 31st March 2025 at Manor Farm. Whilst these works are ongoing, we have taken additional steps to ensure our residents are safeguarded at all material times. Our Manager Daily Walk Round Checklist has been updated (Appendix 5). Where spot checks of residents rooms are completed, it is now part of the check to ascertain if ‘all call bells are within reach and operational’. This includes a: a) Test of the call bell itself and recording of the emergency response time and b) Check of if any additional/all assistive technology is in place and operational. c) If a resident is unable to use a call bell, the Manager checks to ensure that a risk assessment (referred to earlier) is in place. 5
Half hourly checks are also conducted on residents, and ad-hoc tests of their call bells are undertaken. Where call bell failures are identified, staff are expected to follow the procedure as set out in our updated Call Bell Policy (Appendix 6). The policy, updated in November 2024, makes clear that in the event of a call bell failure, the following steps should be taken: (a) The identifying member of the team must inform the Nurse and Home Manager immediately; (b) Any faulty equipment should be reported immediately to the maintenance team and replaced or repaired urgently. (c) In the event that a call bell isn’t functioning and cannot be repaired instantly, the Home Manager must implement a risk assessment, outlining measures to take to mitigate the risk. (d) The above risk assessment requires approval by the Regional Director. All staff, as part of their induction, will receive training on this policy. Compliance with this policy will be monitored and any non-compliance may result in disciplinary action. We hope the above demonstrates how seriously we are taking the concerns raised by the Coroner, and we are focused on ensuring lessons have been learned not only at Manor Farm, but across all services within Abbey Healthcare.