Bluebird Care
Action Planned
Bluebird Care will now contact the incoming care provider directly to discuss handover, provide customer information sheets to all new customers that can be shared with new providers, and offer/request information on existing appointments. (AI summary)
View full response
Dear Sir
Inquest touching upon the death of Anthony Friend
I write in relation to the Regulation 28 report sent to Bluebird Care Bromsgrove & Redditch regarding the death of Anthony John Friend dated 18 September 2023 and received on 29 September 2023.
Following on from the inquest and receipt of the Regulation 28 report, we have thoroughly reviewed the circumstances surrounding Mr Friend's case, both in relation to Bluebird Care and other health care providers and professionals involved. We are always committed to being an outstanding care provider and will take any feedback on board to improve our processes.
We note that the Coroner has expressed concern that there was no direct contact between ourselves, as the outgoing provider of care, and the incoming provider in this matter and he is concerned that this may have led to important information, such as concerns, not being passed on.
We are conscious that the question of handover processes between NHS Continuing Health Care ("CHC") commissioned care providers arose during the course of the inquest. It therefore may be helpful for us to provide some additional context to this process via this response which may assist in allaying HM Senior Coroner's concern in this regard.
NHS Continuing Health Care (CHC) refers to packages of care that are arranged and funded solely by the NHS Integrated Care Boards for individuals over the age of 18 years who have been deemed to have a ‘Primary Health Need’ and have ongoing complex, intense or unpredictable healthcare needs. These packages are overseen by Clinical healthcare professionals such as Clinical Nurses, and managed by the CHC teams at the relevant NHS Integrated Care Boards.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
The standard practice of handover of a CHC care package between care providers, as was followed in this case, is below:
1. Notice is served on the Hereford and Worcester CHC team by the outgoing care provider;
2. A detailed verbal update and handover is provided by the outgoing provider to CHC's clinical case handlers. This handover would include outlining any areas of concern;
3. The CHC care plan is updated to include any additional information provided by the outgoing provider and this is shared with brokerage to seek a new provider;
4. The new provider will review and assess the patient, request/obtain any information they require (including from the outgoing provider if necessary) and, if satisfied, the new provider will agree to commence care;
5. The outgoing provider will cease providing care, the new provider will commence providing care. The identity of the new care provider is not typically shared with the outgoing provider.
In our experience, the care plans prepared by the CHC clinical case handlers are generally detailed and informative.
Following the inquest, the senior management team at Bluebird Care Bromsgrove & Redditch carried out a ‘Lessons Learned’ meeting on 5 October 2023 to review Mr Friend's case in more detail. The aim of this meeting was to highlight and discuss what went well with his care, what could have gone better and also if there were any improvements to be made to any processes. This meeting provided an opportunity for us to consider the Regulation 28 report carefully.
As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
As outlined at the inquest, Bluebird Care had concerns regarding the positioning of Mr Friend’s neck whilst being hoisted in the sling, and the possibility of restricting his airways and oxygen levels, as opposed to any concerns around the possibility of Mr Friend falling from the sling. The concerns highlighted by Bluebird Care around the neck positioning are what led to the review of the sling by Occupational Therapists.
Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continue to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.
This is important not only for Bluebird Care, but also for all other health care providers supporting users of services that may be transitioning from one service or provider to another, and most importantly for those that we support. Within our letter to Herefordshire and Worcestershire CHC, we also urged them to review the processes in place for all care providers.
Within the letter, we have requested the following steps are taken when a transfer of care provider is being planned or contemplated:
1. If we take on a package of care from CHC, we request that we are informed of the identity of the outgoing care provider so, alongside the care plan provided by CHC, we are able to seek any further information from the outgoing provider that we may require.
2. If we serve notice to CHC on a care package (i.e. we become the outgoing care provider), we would like our information to be provided to the new care company, allowing us to provide a direct handover to them. This would be in addition to any handover we already provide to CHC. We also request that CHC inform us of the new provider to allow us to offer any support/information to them to make the transfer of care as seamless as possible.
3. If we serve notice on a package and a new care provider is sourced, we would like them to be informed by CHC (if we have not already had an opportunity to do so ourselves) that the
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
Bluebird Care folder will be in the Customer’s property, containing the customer’s care plan as well as an up-to-date list of tasks for each visit.
4. Where we are the outgoing provider, we would like to offer any new provider the opportunity to observe our care staff carrying out a care call so any necessary observations can be made and any questions asked. We would like to be given notice of when this would occur to ensure a senior member of staff can be present and ensure the most thorough handover possible.
5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.
6. We would request that CHC share the reasons that an outgoing care provider has served notice on a package. This would allow us to make a more informed decision as to whether we are in a position to take on the package of care, or if we would be likely to experience the same issues and concerns. It also allows us to pay particular attention to these key areas of concern, and conduct the relevant risk assessments to ensure the best and safest care is provided at all times.
7. We would also appreciate if, as a new care provider, we could be advised of any existing appointments the customer may have that would be helpful to know of e.g., occupational therapist visits. Likewise, we would share any appointments we were aware of with CHC, so the new provider could be made aware at the earliest time. From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.
We feel confident that if the above steps are adhered to by all parties, this will lead to better outcomes and a more robust handover process. In particular, the process will no longer be solely reliant upon information being passed between care providers by CHC clinical case managers, as there will be opportunities for direct handover between care providers and a conduit for sharing additional information as required.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
As a care provider, the safety and wellbeing of those we provide service to is paramount. Despite the unfortunate circumstances in which these issues have arisen, we welcome the opportunity HM Coroner has provided for us to revisit Mr Friend's case in order to learn from this experience and implement steps to ensure that we continue to provide the best quality care.
We are aware that this response will be shared with the family. We wish to reiterate our sincere condolences to them on the loss of Mr Friend. We also wish to thank them for their kind comments at the inquest about the quality of care we provided.
Inquest touching upon the death of Anthony Friend
I write in relation to the Regulation 28 report sent to Bluebird Care Bromsgrove & Redditch regarding the death of Anthony John Friend dated 18 September 2023 and received on 29 September 2023.
Following on from the inquest and receipt of the Regulation 28 report, we have thoroughly reviewed the circumstances surrounding Mr Friend's case, both in relation to Bluebird Care and other health care providers and professionals involved. We are always committed to being an outstanding care provider and will take any feedback on board to improve our processes.
We note that the Coroner has expressed concern that there was no direct contact between ourselves, as the outgoing provider of care, and the incoming provider in this matter and he is concerned that this may have led to important information, such as concerns, not being passed on.
We are conscious that the question of handover processes between NHS Continuing Health Care ("CHC") commissioned care providers arose during the course of the inquest. It therefore may be helpful for us to provide some additional context to this process via this response which may assist in allaying HM Senior Coroner's concern in this regard.
NHS Continuing Health Care (CHC) refers to packages of care that are arranged and funded solely by the NHS Integrated Care Boards for individuals over the age of 18 years who have been deemed to have a ‘Primary Health Need’ and have ongoing complex, intense or unpredictable healthcare needs. These packages are overseen by Clinical healthcare professionals such as Clinical Nurses, and managed by the CHC teams at the relevant NHS Integrated Care Boards.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
The standard practice of handover of a CHC care package between care providers, as was followed in this case, is below:
1. Notice is served on the Hereford and Worcester CHC team by the outgoing care provider;
2. A detailed verbal update and handover is provided by the outgoing provider to CHC's clinical case handlers. This handover would include outlining any areas of concern;
3. The CHC care plan is updated to include any additional information provided by the outgoing provider and this is shared with brokerage to seek a new provider;
4. The new provider will review and assess the patient, request/obtain any information they require (including from the outgoing provider if necessary) and, if satisfied, the new provider will agree to commence care;
5. The outgoing provider will cease providing care, the new provider will commence providing care. The identity of the new care provider is not typically shared with the outgoing provider.
In our experience, the care plans prepared by the CHC clinical case handlers are generally detailed and informative.
Following the inquest, the senior management team at Bluebird Care Bromsgrove & Redditch carried out a ‘Lessons Learned’ meeting on 5 October 2023 to review Mr Friend's case in more detail. The aim of this meeting was to highlight and discuss what went well with his care, what could have gone better and also if there were any improvements to be made to any processes. This meeting provided an opportunity for us to consider the Regulation 28 report carefully.
As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
As outlined at the inquest, Bluebird Care had concerns regarding the positioning of Mr Friend’s neck whilst being hoisted in the sling, and the possibility of restricting his airways and oxygen levels, as opposed to any concerns around the possibility of Mr Friend falling from the sling. The concerns highlighted by Bluebird Care around the neck positioning are what led to the review of the sling by Occupational Therapists.
Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continue to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.
This is important not only for Bluebird Care, but also for all other health care providers supporting users of services that may be transitioning from one service or provider to another, and most importantly for those that we support. Within our letter to Herefordshire and Worcestershire CHC, we also urged them to review the processes in place for all care providers.
Within the letter, we have requested the following steps are taken when a transfer of care provider is being planned or contemplated:
1. If we take on a package of care from CHC, we request that we are informed of the identity of the outgoing care provider so, alongside the care plan provided by CHC, we are able to seek any further information from the outgoing provider that we may require.
2. If we serve notice to CHC on a care package (i.e. we become the outgoing care provider), we would like our information to be provided to the new care company, allowing us to provide a direct handover to them. This would be in addition to any handover we already provide to CHC. We also request that CHC inform us of the new provider to allow us to offer any support/information to them to make the transfer of care as seamless as possible.
3. If we serve notice on a package and a new care provider is sourced, we would like them to be informed by CHC (if we have not already had an opportunity to do so ourselves) that the
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
Bluebird Care folder will be in the Customer’s property, containing the customer’s care plan as well as an up-to-date list of tasks for each visit.
4. Where we are the outgoing provider, we would like to offer any new provider the opportunity to observe our care staff carrying out a care call so any necessary observations can be made and any questions asked. We would like to be given notice of when this would occur to ensure a senior member of staff can be present and ensure the most thorough handover possible.
5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.
6. We would request that CHC share the reasons that an outgoing care provider has served notice on a package. This would allow us to make a more informed decision as to whether we are in a position to take on the package of care, or if we would be likely to experience the same issues and concerns. It also allows us to pay particular attention to these key areas of concern, and conduct the relevant risk assessments to ensure the best and safest care is provided at all times.
7. We would also appreciate if, as a new care provider, we could be advised of any existing appointments the customer may have that would be helpful to know of e.g., occupational therapist visits. Likewise, we would share any appointments we were aware of with CHC, so the new provider could be made aware at the earliest time. From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.
We feel confident that if the above steps are adhered to by all parties, this will lead to better outcomes and a more robust handover process. In particular, the process will no longer be solely reliant upon information being passed between care providers by CHC clinical case managers, as there will be opportunities for direct handover between care providers and a conduit for sharing additional information as required.
Bluebird Care (Bromsgrove & Redditch) 3 Millennium Court, Buntsford Park Road Bromsgrove, B60 3DX
Bluebird Care Bromsgrove & Redditch Registered in England and Wales as R D (Bromsgrove) Ltd. Company No. 7099683
As a care provider, the safety and wellbeing of those we provide service to is paramount. Despite the unfortunate circumstances in which these issues have arisen, we welcome the opportunity HM Coroner has provided for us to revisit Mr Friend's case in order to learn from this experience and implement steps to ensure that we continue to provide the best quality care.
We are aware that this response will be shared with the family. We wish to reiterate our sincere condolences to them on the loss of Mr Friend. We also wish to thank them for their kind comments at the inquest about the quality of care we provided.