Monarch Healthcare
Action Planned
Monarch Healthcare is implementing a new clinical oversight form for moving and handling, monitoring staff via CCTV, auditing resident bedrooms for equipment, and requiring staff signatures at handover meetings, with implementation by August 31, 2024 and review by September 30, 2024. (AI summary)
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Monarch Healthcare RECEIVED 1 SEP 2024 10929373/26/y/g.
To: _ Steve €ccleaboa
Office of HM Coroner
The Medico-Legal Centre Watery Street
. . Sheffield S3 7ES
Regulation 28 Report To Prevent Future Deaths . Date of Response: 14th August 2024 .
Background Following receiptofthe Coroner' s Inquest intothe death of Mrs Mavis Dewey; weacknowledgeand respect the medical cause of death, reportedbySteve Eccleston H.M. Assistant Coronerfor South Yorkshire (west) as follows:
1a Multi organ failure
1b Covid 19 and open fracture of right proximal tibia and fibula II Alzheimer s Disease, Heart Failure As stated in evidence, Monarch Healthcare (HB) Ltd accept the fact a carer directly employed at Heely Bank Care Home, and another carer regularly retained through the agency, neglected to follow direct instructions clearly stated in Mrs Mavis Dewev' s care plan and culminating in her untimely death: As also stated in evidence all staff, including regularly retained agency staff receive moving and handling training and undergo practical assessmenttoensure are competentto carryout movingand handling procedures This training and assessment includes where to find the information relating to a residents care needs. It was confirmed the 2 carers cited had received their training and assessment as follows: Carer 1 (employed by Heeley Bank Care Home) received Moving and Handling training with sign off of practical assessmenton 24/01/2024. She was due forher 3 month competencyassessmenton 24/04/2024. Carer 2 (retained by agency agreement) received Moving and Handling training with sign off for practical assessment on 25/10/2023and further competency assessment signed for on 06/02/2024 The above detail was taken fromthe home's training matrix at the time of the investigation following Mrs Dewey' s fall; Monarch Healthcare (HB) Ltd believes appropriate instruction and assessment was in place andthe accidentoccurredbecause the carers failed to adhereto the care plan and failed to carry outcorrec Page 1of 4 Heeley Bank Care Home | Heeley Bank Road Sheffield S2 3GL wwwmonarchhealthcare.co.uk Email; heeleybank@monarchhealthcare co.uk Tel: 0114 2245100 Fax: 0114 2555803 registered in england no: 13239535
they:
movingand handling techniques_ Mrs Dewey's care plan clearly stateda stand aid should be used to assist her to stand and further stated that a walking frame must not be used. The appropriate stand aid was available in Mrs Dewey's ensuite bathroom at the time it was required for use_ Following the accident; immediate action was taken to suspendboth carers,removing them fromthe home; Appropriate HR procedures followedandneithercarerreturnedtoworkat Heeley Bank Care Home_ or for any other Monarch Healthcare Service. Areferralto the Disclosure and Barring Service (DBS) was submitted forcarer 1 anda requesttothe agency for carer 2 to undergo similar proceedings and to also be referred to the DBS_ Evidence during the inquestraised concern to the Coronerin respectofagency workers notalways reading residents' care plans. An explanation for this is that care plans are often lengthyand detailed documents. Anagency carer be allocated to supporta numberof residents duringthe working shift; It wouldnot be possiblefor them toread and rememberthe entire care plan forallresidents theyare expected to interactwith and to provide supportfor: We recognise this is a risk to residents if staffare not fully aware ofa person'sspecific needs:
2. Risk Mitigation To mitigate this accepted risk the following processes were already in place for agency workers, (and regularly employed staff) prior to 23r March 2024: Working with a preferred and limited number of agencies.
Obtaining profiles for all agency workers and checking NMC PIN, references, DBS and training
status, prior to accepting and commencing the shift.
Requesting agency workers who have worked in the home previously and who are reported a5 knowledgeable and competent: Completingan Induction to ensure the agency workeris familiar with the building, fire safetyand infection controlprocedures;also the correctuse ofthe systemsfor safe medication administration and care plans Allocation of agency staff to work with an experienced member of the team for guidance Access to Monarch Healthcare's suite of training and competencyassessments for regular agency workers retained and working to Heeley Banks staff rota_ Summary Care Plans are available to all staff via hand-held mobile point of care devices. Summary Care Plans are available to all staff via electronic tablet devices located aroundthe home (larger viewing platform) _ Full Care Files are available to all staff via the nurses' laptops_ Handover Form The document includes a photo of the resident; their room number ad identifiable information, including their diagnoses and care needs. The Handover Form also includes information about a resident's recent presentation to impart between shifts, Manager walkarounds to monitor and complete spot checks. Regional Manager visits and clinical oversight (Visits were increased to minimum 3 days/week from January 2024 in conjunction with support from Sheffield Council and ICB, Adhocviewingof CCTV followinga fall in a communalarea, toestablish cause and assess likelihood of injury: Please note, this is in addition and does not replace the nurse examination or protocol for actions to be taken following a fall; The above actions have been reviewed and are confirmed as embedded into practice as of the date of this report:
may key
Despite the above procedures in place and both carers having received training and confirming they were familiar with Mrs Dewey' s movingand handling care plan, they chose notto follow it, for reasons we were unable to fully establish during the pursuing investigation. For this reason the carer employed dire ctl by Monarch Healthcare was referredtothe DBSas unsafe to continue practicing: A request was also made to the agency for similar proceedings to take place.
3. Actions Implemented Following Mrs Dewey's accident ad subsequent investigation, we implemented additional processes between 23r March and 1st June 2024,for all staff: Key Care Plan details transferredto individual posters for display in residents' bedrooms(on inside of wardrobe door to maintain GDPR regulations for sensitive information) Care Plan details transferredto chains' , issuedto all staff on shift for easy reference and planning of residents' care. Readingout and reiterating each resident' s diagnoses and referencingkey care and clinical needs, including their moving and handling requirements, the equipment to be used (and not used), number of staff and reminder of risks. Implementation of the Daily Clinical Oversight Form and increased management spot checks, to report to Sheffield Counciland ICB. Appointment of 2 Clinical Leads to provide guidance tothe care and nursing teamsand to complte clinical governance and the Daily Clinical Oversight form The above actions have been reviewed and are embedded into practice as of the date of this report:
4. Further Actions to Prevent Future Deaths Following the Coroner s Inquest on 7th August 2024, we further reviewed risks and are in the process of implementing the following: A review and implementation of a new Clinical Oversight form to further breakdown observations of movingand handling practice; to ensure robustrecordingofthe observation Regular observation of the CCTV to monitor staff carrying out moving and handling procedures in communal areas, when they are not aware they are being watched: Trainers also have access to CCTV footage to support completion of training needs analysis Implementation of routine audit for checking residents' bedrooms to ensure all required equipment is in place and no surplus equipment is in the room_ All staff to sign attendance to the handover meeting; as indicated on the handover form. The timeframe for implementation of the above actions is 31" August 2024. The timeframe for review of the above actions is z0t September 2024 We deeply regretthe accidentand tragic consequences for Mavis and herfamily. Mavis was a much-loved residentof Heeley Bank Care Home_ She was a larger-than-life characterknownto all the team,as wellas to Senior Management and other visiting Monarch employees and external professionals. We miss her banter;her expressionsand mostofallheraffectionforeveryonewhocared forher: We againexpress our sincere apologies to Mavis' family for failing Mavis and for the loss of their trust:
Key" 'key"
We wish to reassure all reading this reportthatwe have reviewed our policies and procedures in depth and also sought and acted upon advice and guidance from various professionals , and continue to do so. The above responsetothe Regulation 28 Preventionof Future Death Reportisan accurate andtrue account to the best of my knowledge_ Signed: Date: 29 Augnl Managing Director Monarch Care Group, on behalf Heeley Bank Care Home
.
.
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To: _ Steve €ccleaboa
Office of HM Coroner
The Medico-Legal Centre Watery Street
. . Sheffield S3 7ES
Regulation 28 Report To Prevent Future Deaths . Date of Response: 14th August 2024 .
Background Following receiptofthe Coroner' s Inquest intothe death of Mrs Mavis Dewey; weacknowledgeand respect the medical cause of death, reportedbySteve Eccleston H.M. Assistant Coronerfor South Yorkshire (west) as follows:
1a Multi organ failure
1b Covid 19 and open fracture of right proximal tibia and fibula II Alzheimer s Disease, Heart Failure As stated in evidence, Monarch Healthcare (HB) Ltd accept the fact a carer directly employed at Heely Bank Care Home, and another carer regularly retained through the agency, neglected to follow direct instructions clearly stated in Mrs Mavis Dewev' s care plan and culminating in her untimely death: As also stated in evidence all staff, including regularly retained agency staff receive moving and handling training and undergo practical assessmenttoensure are competentto carryout movingand handling procedures This training and assessment includes where to find the information relating to a residents care needs. It was confirmed the 2 carers cited had received their training and assessment as follows: Carer 1 (employed by Heeley Bank Care Home) received Moving and Handling training with sign off of practical assessmenton 24/01/2024. She was due forher 3 month competencyassessmenton 24/04/2024. Carer 2 (retained by agency agreement) received Moving and Handling training with sign off for practical assessment on 25/10/2023and further competency assessment signed for on 06/02/2024 The above detail was taken fromthe home's training matrix at the time of the investigation following Mrs Dewey' s fall; Monarch Healthcare (HB) Ltd believes appropriate instruction and assessment was in place andthe accidentoccurredbecause the carers failed to adhereto the care plan and failed to carry outcorrec Page 1of 4 Heeley Bank Care Home | Heeley Bank Road Sheffield S2 3GL wwwmonarchhealthcare.co.uk Email; heeleybank@monarchhealthcare co.uk Tel: 0114 2245100 Fax: 0114 2555803 registered in england no: 13239535
they:
movingand handling techniques_ Mrs Dewey's care plan clearly stateda stand aid should be used to assist her to stand and further stated that a walking frame must not be used. The appropriate stand aid was available in Mrs Dewey's ensuite bathroom at the time it was required for use_ Following the accident; immediate action was taken to suspendboth carers,removing them fromthe home; Appropriate HR procedures followedandneithercarerreturnedtoworkat Heeley Bank Care Home_ or for any other Monarch Healthcare Service. Areferralto the Disclosure and Barring Service (DBS) was submitted forcarer 1 anda requesttothe agency for carer 2 to undergo similar proceedings and to also be referred to the DBS_ Evidence during the inquestraised concern to the Coronerin respectofagency workers notalways reading residents' care plans. An explanation for this is that care plans are often lengthyand detailed documents. Anagency carer be allocated to supporta numberof residents duringthe working shift; It wouldnot be possiblefor them toread and rememberthe entire care plan forallresidents theyare expected to interactwith and to provide supportfor: We recognise this is a risk to residents if staffare not fully aware ofa person'sspecific needs:
2. Risk Mitigation To mitigate this accepted risk the following processes were already in place for agency workers, (and regularly employed staff) prior to 23r March 2024: Working with a preferred and limited number of agencies.
Obtaining profiles for all agency workers and checking NMC PIN, references, DBS and training
status, prior to accepting and commencing the shift.
Requesting agency workers who have worked in the home previously and who are reported a5 knowledgeable and competent: Completingan Induction to ensure the agency workeris familiar with the building, fire safetyand infection controlprocedures;also the correctuse ofthe systemsfor safe medication administration and care plans Allocation of agency staff to work with an experienced member of the team for guidance Access to Monarch Healthcare's suite of training and competencyassessments for regular agency workers retained and working to Heeley Banks staff rota_ Summary Care Plans are available to all staff via hand-held mobile point of care devices. Summary Care Plans are available to all staff via electronic tablet devices located aroundthe home (larger viewing platform) _ Full Care Files are available to all staff via the nurses' laptops_ Handover Form The document includes a photo of the resident; their room number ad identifiable information, including their diagnoses and care needs. The Handover Form also includes information about a resident's recent presentation to impart between shifts, Manager walkarounds to monitor and complete spot checks. Regional Manager visits and clinical oversight (Visits were increased to minimum 3 days/week from January 2024 in conjunction with support from Sheffield Council and ICB, Adhocviewingof CCTV followinga fall in a communalarea, toestablish cause and assess likelihood of injury: Please note, this is in addition and does not replace the nurse examination or protocol for actions to be taken following a fall; The above actions have been reviewed and are confirmed as embedded into practice as of the date of this report:
may key
Despite the above procedures in place and both carers having received training and confirming they were familiar with Mrs Dewey' s movingand handling care plan, they chose notto follow it, for reasons we were unable to fully establish during the pursuing investigation. For this reason the carer employed dire ctl by Monarch Healthcare was referredtothe DBSas unsafe to continue practicing: A request was also made to the agency for similar proceedings to take place.
3. Actions Implemented Following Mrs Dewey's accident ad subsequent investigation, we implemented additional processes between 23r March and 1st June 2024,for all staff: Key Care Plan details transferredto individual posters for display in residents' bedrooms(on inside of wardrobe door to maintain GDPR regulations for sensitive information) Care Plan details transferredto chains' , issuedto all staff on shift for easy reference and planning of residents' care. Readingout and reiterating each resident' s diagnoses and referencingkey care and clinical needs, including their moving and handling requirements, the equipment to be used (and not used), number of staff and reminder of risks. Implementation of the Daily Clinical Oversight Form and increased management spot checks, to report to Sheffield Counciland ICB. Appointment of 2 Clinical Leads to provide guidance tothe care and nursing teamsand to complte clinical governance and the Daily Clinical Oversight form The above actions have been reviewed and are embedded into practice as of the date of this report:
4. Further Actions to Prevent Future Deaths Following the Coroner s Inquest on 7th August 2024, we further reviewed risks and are in the process of implementing the following: A review and implementation of a new Clinical Oversight form to further breakdown observations of movingand handling practice; to ensure robustrecordingofthe observation Regular observation of the CCTV to monitor staff carrying out moving and handling procedures in communal areas, when they are not aware they are being watched: Trainers also have access to CCTV footage to support completion of training needs analysis Implementation of routine audit for checking residents' bedrooms to ensure all required equipment is in place and no surplus equipment is in the room_ All staff to sign attendance to the handover meeting; as indicated on the handover form. The timeframe for implementation of the above actions is 31" August 2024. The timeframe for review of the above actions is z0t September 2024 We deeply regretthe accidentand tragic consequences for Mavis and herfamily. Mavis was a much-loved residentof Heeley Bank Care Home_ She was a larger-than-life characterknownto all the team,as wellas to Senior Management and other visiting Monarch employees and external professionals. We miss her banter;her expressionsand mostofallheraffectionforeveryonewhocared forher: We againexpress our sincere apologies to Mavis' family for failing Mavis and for the loss of their trust:
Key" 'key"
We wish to reassure all reading this reportthatwe have reviewed our policies and procedures in depth and also sought and acted upon advice and guidance from various professionals , and continue to do so. The above responsetothe Regulation 28 Preventionof Future Death Reportisan accurate andtrue account to the best of my knowledge_ Signed: Date: 29 Augnl Managing Director Monarch Care Group, on behalf Heeley Bank Care Home
.
.
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