Meadow House
Action Taken
Meadow House has implemented face-to-face 1st aid training for staff, reviewed systems and processes to minimize risk of human error, reoriented staff to the escalation guidance for care homes, and provided ongoing supervision. The Provider has recirculated the International Dysphagia Diet Standardized Descriptors to staff team, and notified relevant statutory bodies of the incident, findings, and improvement actions. (AI summary)
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I MEADOW HOUSE 27-29 Links Road
Radford
Coventry
CV63DQ
10/05/2024 FAO: Delray Henry, Area Coroner, Coventry Coroner's Office, The Register Office, Manor House Drive, Coventry, CV1 2ND REF: Response from J&K Partnership regarding report issued by the coroner regarding the death of Mr. Ronald James Jepson under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. Investigation and Inquest: J&K Partnership acknowledges the findings from the investigation and inquest and the conclusion into the death as a 'misadventure' J&K Partnership appreciates the Coroners' Concerns and their opinion that without further actions future deaths might occur at the service, as a result we have taken and continue to take measures to remedial the stated concerns. Actions that have been taken and currently in implementation are outlined below:
1. To reduce the risk of such incidences occurring in the service the Provider has taken steps where pos- sible to Prevent and Mitigate such incidence from occurring; to reduce the risk: i) The 1st step is ensuring there is a Policy in place to provide guidance to staff on the recognition, management and support of Service Users who may present with swallowing difficulties. Also, to provide guidance on the risk of choking. At the time of Mr. Ronald James Jepson's incident, J&K Partnership had a robust policy in place, Policy reference CC78-Dysphagia (Swallowing Difficulty) and Risk of Choking Policy and Proce- dure provided by Quality Compliance Systems Ltd, and the Provider held a valid License Certifi- cate from QCS at the time of the incident and currently continues to do so. The Registered Man- ager is now continuous working on ensuring effective application of policy in day-to-day delivery of care and support. ii) To support in the identification and standardized assessment of choke risk for all Service Users at Meadow House the policy provides a Choke Risk Assessment. At the time of Mr. Ronald James Jepson's incident all Service Users receiving support and care at Meadow House including the deceased had this risk assessment completed and where required, risk mitigation action plans in place alongside Speech and Language Therapists input sought. iii) Ingraining the Policy in Practice: Since the incident t he Registered Manager of the Service has taken numerous measures to ingrain policy in practice including recirculating the Dysphagia and Risk of Choking Policy and Procedure as well as holding group supervisions with staff at M eadow House to discuss the practicalities of implementing policy in practice. PAGE 1
I MEADOW HOUSE 27-29 Links Road
Radford
Coventry
CV6 JDQ
2. The Service Preparedness to deal with such incidences should they occur: i) Since the incident, J&K Partnership have ensured Service Users identified through risk assess- ment as at risk of choke have necessary measures taken including implementing mitigating plans and onward referral to community specialty services for assessment, guidance, advice, and treatment. The staff team providing care and support in the service are aware of service users at risk, level of risk and management plans. ii) At the time of Mr. Ronald James Jepson, staff at Meadow House had all completed e-learning 1st aid training. To ensure staff team are further prepared to deal with medical emergencies that might arise during support and care delivery, Provider sourced Face-to-Face Basic Life Support Training for staff, for which 82% of the staff attended. Since the incident, the Provid- er has sourced and supplied Level 11st Aid The training encompassed a practical session for various emergencies that might arise in the service including recognizing when a resident is chocking, immediate actions to take and escalation. iii) Remedial measures have been implemented for when the 2members of staff are on duty that haven't had their face-to-face training; they have received step by step guide for dealing with a choking service user from the registered manager as well as having completed their e- learning. iv) Advanced Life Support Training for all Senior Care and Support Workers in the Services. To ensure a high level of skill set in dealing with medical emergencies in the service, the Provider has taken further steps by sourcing face to face 3-day course, Level 3 Award in First Aid at Work (RQF). The training is aimed at all Shift Leaders in the Service and is due to be delivered from the 15th of May 2024 to the 18th May 2024
3. Appropriate Escalation: i) In response to staff contacting 111 rather than 999 further discussions with staff team on duty on the day indicates staff acted out of panic. J&K Partnership can confirm at the time of the incident staff at the Service had an appropriate escalation guidance aimed at care homes provided by Coventry and Warwickshire ICB in place within the Service (Appedix1). The Regis- tered Manager has recirculated the escalation guidance to all staff in the service, posters of these also displayed in key areas of the service. ii) The face-to-face 1st aid trainings also encompasses appropriate assessment of medical emer- gencies and escalation pathway. The Provider is confident that should such an incident reoc- cur staff at Meadow House will escalate appropriately. iii) From the face-to-face training provided and the desk top exercises now in place, the provid- er is assured that should a similar incident occur staff will act accordingly without panic and in a timely manner. PAGE2
MEADOW HOUSE \--1 I 27-29 Links Road Radford
Coventry
CV63DQ
Post Incident Organizational Learning and Improvement from Investigation. J&K Partnership is committed to on going learning and quality improvement which is a critical factor in delivery safe high standard care. In line with our policy, CC200-Patient Safety Incident Response Framework (PSIRF) Policy and Procedure, which aim to: i) Ensure Meadow House responds to patient safety incidents when they happen, t o prevent recur- rence, learn and improve Service User safety. ii) Ensure staff have the relevant knowledge and training as outlined in Patient Safety Incident Re- sponse Framework In response to the PSIRF J&K Partnership have undertaken an internal investigation into the incident as well as working with staff in the care home on lessons learned from the incident. As per policy, information from incident investigation and lessons learned and actions taken has been shared with staff and key stakeholders to minimize similar events from re-occurring. The Provider has also implemented quality improvement measures to improve the quality of care as part of a continuous improvement cycle. As part of our commitment to continuous improvement we have taken the following actions. i) Face to Face 1st Aid Training for Staff, desk top exercise has been introduced and e-learning re- mains in place to commensurate training to be ingrained in staff. ii) The Provider has reviewed system and processes in the home to ensure they are designed to min- imize the risk of human error at every stage, this includes the mandatory use of choke risk assess- ment for all residents, the identification of those at risk, referrals to specialist services (GP & SALT) as well as clear ease to follow risk mitigation plans for everyone at risk. iii) Staff have been reorientated to the escalation guidance for care homes as provided by Coventry and Warwickshire ICB iv) Staff have received and continue to receive on going supervision with a focus of raising aware- ness of patient safety. v) Duty of candour, Provider have completed notifications to relevant statutory bodies of the inci- dent, findings, and improvement actions, as well as to the Family of Mr. Ronald James Jepson. vi) The Provider has recirculated the International Dysphagia Diet Standardized Descriptors to staff team, which also are adopted and used by the British Dietetic Association and Royal College of Speech & Language Therapists and these posters are also displayed in the service. vii) The evaluation ofthe above actions is an integral part of ensuring that lessons are learnt from incidents so that improvements in care and support delivery are achieved and will be undertaken periodically. The actions above and the provider continuing to work collaboratively with key stakeholders and regulators we should avert an adverse outcome for a resident in need of emergency care/ assistance at Meadow House going forward. Jujely For J&K Partnership PAGE3
Radford
Coventry
CV63DQ
10/05/2024 FAO: Delray Henry, Area Coroner, Coventry Coroner's Office, The Register Office, Manor House Drive, Coventry, CV1 2ND REF: Response from J&K Partnership regarding report issued by the coroner regarding the death of Mr. Ronald James Jepson under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. Investigation and Inquest: J&K Partnership acknowledges the findings from the investigation and inquest and the conclusion into the death as a 'misadventure' J&K Partnership appreciates the Coroners' Concerns and their opinion that without further actions future deaths might occur at the service, as a result we have taken and continue to take measures to remedial the stated concerns. Actions that have been taken and currently in implementation are outlined below:
1. To reduce the risk of such incidences occurring in the service the Provider has taken steps where pos- sible to Prevent and Mitigate such incidence from occurring; to reduce the risk: i) The 1st step is ensuring there is a Policy in place to provide guidance to staff on the recognition, management and support of Service Users who may present with swallowing difficulties. Also, to provide guidance on the risk of choking. At the time of Mr. Ronald James Jepson's incident, J&K Partnership had a robust policy in place, Policy reference CC78-Dysphagia (Swallowing Difficulty) and Risk of Choking Policy and Proce- dure provided by Quality Compliance Systems Ltd, and the Provider held a valid License Certifi- cate from QCS at the time of the incident and currently continues to do so. The Registered Man- ager is now continuous working on ensuring effective application of policy in day-to-day delivery of care and support. ii) To support in the identification and standardized assessment of choke risk for all Service Users at Meadow House the policy provides a Choke Risk Assessment. At the time of Mr. Ronald James Jepson's incident all Service Users receiving support and care at Meadow House including the deceased had this risk assessment completed and where required, risk mitigation action plans in place alongside Speech and Language Therapists input sought. iii) Ingraining the Policy in Practice: Since the incident t he Registered Manager of the Service has taken numerous measures to ingrain policy in practice including recirculating the Dysphagia and Risk of Choking Policy and Procedure as well as holding group supervisions with staff at M eadow House to discuss the practicalities of implementing policy in practice. PAGE 1
I MEADOW HOUSE 27-29 Links Road
Radford
Coventry
CV6 JDQ
2. The Service Preparedness to deal with such incidences should they occur: i) Since the incident, J&K Partnership have ensured Service Users identified through risk assess- ment as at risk of choke have necessary measures taken including implementing mitigating plans and onward referral to community specialty services for assessment, guidance, advice, and treatment. The staff team providing care and support in the service are aware of service users at risk, level of risk and management plans. ii) At the time of Mr. Ronald James Jepson, staff at Meadow House had all completed e-learning 1st aid training. To ensure staff team are further prepared to deal with medical emergencies that might arise during support and care delivery, Provider sourced Face-to-Face Basic Life Support Training for staff, for which 82% of the staff attended. Since the incident, the Provid- er has sourced and supplied Level 11st Aid The training encompassed a practical session for various emergencies that might arise in the service including recognizing when a resident is chocking, immediate actions to take and escalation. iii) Remedial measures have been implemented for when the 2members of staff are on duty that haven't had their face-to-face training; they have received step by step guide for dealing with a choking service user from the registered manager as well as having completed their e- learning. iv) Advanced Life Support Training for all Senior Care and Support Workers in the Services. To ensure a high level of skill set in dealing with medical emergencies in the service, the Provider has taken further steps by sourcing face to face 3-day course, Level 3 Award in First Aid at Work (RQF). The training is aimed at all Shift Leaders in the Service and is due to be delivered from the 15th of May 2024 to the 18th May 2024
3. Appropriate Escalation: i) In response to staff contacting 111 rather than 999 further discussions with staff team on duty on the day indicates staff acted out of panic. J&K Partnership can confirm at the time of the incident staff at the Service had an appropriate escalation guidance aimed at care homes provided by Coventry and Warwickshire ICB in place within the Service (Appedix1). The Regis- tered Manager has recirculated the escalation guidance to all staff in the service, posters of these also displayed in key areas of the service. ii) The face-to-face 1st aid trainings also encompasses appropriate assessment of medical emer- gencies and escalation pathway. The Provider is confident that should such an incident reoc- cur staff at Meadow House will escalate appropriately. iii) From the face-to-face training provided and the desk top exercises now in place, the provid- er is assured that should a similar incident occur staff will act accordingly without panic and in a timely manner. PAGE2
MEADOW HOUSE \--1 I 27-29 Links Road Radford
Coventry
CV63DQ
Post Incident Organizational Learning and Improvement from Investigation. J&K Partnership is committed to on going learning and quality improvement which is a critical factor in delivery safe high standard care. In line with our policy, CC200-Patient Safety Incident Response Framework (PSIRF) Policy and Procedure, which aim to: i) Ensure Meadow House responds to patient safety incidents when they happen, t o prevent recur- rence, learn and improve Service User safety. ii) Ensure staff have the relevant knowledge and training as outlined in Patient Safety Incident Re- sponse Framework In response to the PSIRF J&K Partnership have undertaken an internal investigation into the incident as well as working with staff in the care home on lessons learned from the incident. As per policy, information from incident investigation and lessons learned and actions taken has been shared with staff and key stakeholders to minimize similar events from re-occurring. The Provider has also implemented quality improvement measures to improve the quality of care as part of a continuous improvement cycle. As part of our commitment to continuous improvement we have taken the following actions. i) Face to Face 1st Aid Training for Staff, desk top exercise has been introduced and e-learning re- mains in place to commensurate training to be ingrained in staff. ii) The Provider has reviewed system and processes in the home to ensure they are designed to min- imize the risk of human error at every stage, this includes the mandatory use of choke risk assess- ment for all residents, the identification of those at risk, referrals to specialist services (GP & SALT) as well as clear ease to follow risk mitigation plans for everyone at risk. iii) Staff have been reorientated to the escalation guidance for care homes as provided by Coventry and Warwickshire ICB iv) Staff have received and continue to receive on going supervision with a focus of raising aware- ness of patient safety. v) Duty of candour, Provider have completed notifications to relevant statutory bodies of the inci- dent, findings, and improvement actions, as well as to the Family of Mr. Ronald James Jepson. vi) The Provider has recirculated the International Dysphagia Diet Standardized Descriptors to staff team, which also are adopted and used by the British Dietetic Association and Royal College of Speech & Language Therapists and these posters are also displayed in the service. vii) The evaluation ofthe above actions is an integral part of ensuring that lessons are learnt from incidents so that improvements in care and support delivery are achieved and will be undertaken periodically. The actions above and the provider continuing to work collaboratively with key stakeholders and regulators we should avert an adverse outcome for a resident in need of emergency care/ assistance at Meadow House going forward. Jujely For J&K Partnership PAGE3