Bowden Derra Park ltd
Other
Action Taken
The facility has updated its Nocturnal CCTV Monitoring Chart to include a comments box for explaining gaps in monitoring. They have also updated their Care Plan and Training policies, with staff notified and tracked via the BrightHR application. (AI summary)
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Dear Sir Inquest: Lugh Baker (Deceased) Our Client: Bowden Derra Park Ltd Matter: Regulation 28, Report to Prevent Future Deaths We are writing further to the Report to Prevent Future Deaths, received on 14 March 2023. We write on behalf of our client to provide the documentation requested by you in that report. Section 5 of the Report to Prevent Future Deaths states as follows: The MATTERS OF CONCERN are as follows. –
i. I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh. I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form.
ii. Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident’s Care Plan to be reviewed after admission.
iii. Concern was also raised about what steps will be taken, and when, where a new resident with an unusual presentation is admitted. In this case, Lugh had a diagnosis of Angelman’s syndrome with which staff were unfamiliar. Again, I asked to see a policy document setting out what training or other steps will now be taken in such circumstances and by when. In response to the above, we enclose the following:
1. Nocturnal CCTV Monitoring Chart This is a completed Nocturnal CCTV Monitoring Chart dated 24 January 2023 until 28 January
2023. DWF Law LLP is a limited liability partnership registered in England and Wales with registered number OC423384 DWF Law LLP is authorised and regulated by the Solicitors Regulation Authority (SRA) as an Alternative Business Structure The rules of the SRA are available at www.sra.org.uk/handbook/ The term 'Partner' is used to refer to a Member of DWF Law LLP or an employee or consultant with equivalent standing and qual ifications A list of Members of DWF Law LLP and of Non-Members who are designated as Partners is open to inspection at its registered office located at 1 Scott Place, 2 Hardman Street, Manchester, M3 3AA DWF Law LLP is listed on the Financial Services Register as an Exempt Professional Firm, able to carry out certain insurance mediation activities (regulated by the Solicitors Regulation Authority)
2. Updated Nocturnal CCTV Monitoring Chart The Nocturnal CCTV Monitoring Chart has been updated since the Inquest and now includes a 'comments' box and instructions to detail any gaps in monitoring in this box. Gaps in monitoring should only happen in exceptional circumstances, such as an emergency.
3. Care Plan Policy The Care Plan Policy has been updated since the Inquest. For ease of reference, the updated sections are highlighted. The care staff have access to all policies and procedures on an application called BrightHR. All care staff receive training on this application and this specific policy during their two week induction programme. When any policy or procedure is updated, the care staff are notified automatically via the application. Once notified, all care staff must acknowledge receipt of the notification and open the document to confirm that they have read it. The BrightHR system tracks this and alerts management of any non-compliance.
4. Training Policy As above, The Training Policy has been updated since the Inquest. For ease of reference, the updated sections are highlighted. The care staff have access to all policies and procedures on an application called BrightHR. All care staff receive training on this application and this specific policy during their two week induction programme. When any policy or procedure is updated, the care staff are notified automatically via the application. Once notified, all care staff must acknowledge receipt of the notification and open the document to confirm that they have read it. The BrightHR system tracks this and alerts management of any non-compliance. This response contains reference to and copies of internal documents, which were requested in the Report to Prevent Future Deaths. It is respectfully submitted that for this reason it would be inappropriate to publish the response and/or enclosures. Please do not hesitate to contact us should you require anything further from our client.
i. I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh. I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form.
ii. Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident’s Care Plan to be reviewed after admission.
iii. Concern was also raised about what steps will be taken, and when, where a new resident with an unusual presentation is admitted. In this case, Lugh had a diagnosis of Angelman’s syndrome with which staff were unfamiliar. Again, I asked to see a policy document setting out what training or other steps will now be taken in such circumstances and by when. In response to the above, we enclose the following:
1. Nocturnal CCTV Monitoring Chart This is a completed Nocturnal CCTV Monitoring Chart dated 24 January 2023 until 28 January
2023. DWF Law LLP is a limited liability partnership registered in England and Wales with registered number OC423384 DWF Law LLP is authorised and regulated by the Solicitors Regulation Authority (SRA) as an Alternative Business Structure The rules of the SRA are available at www.sra.org.uk/handbook/ The term 'Partner' is used to refer to a Member of DWF Law LLP or an employee or consultant with equivalent standing and qual ifications A list of Members of DWF Law LLP and of Non-Members who are designated as Partners is open to inspection at its registered office located at 1 Scott Place, 2 Hardman Street, Manchester, M3 3AA DWF Law LLP is listed on the Financial Services Register as an Exempt Professional Firm, able to carry out certain insurance mediation activities (regulated by the Solicitors Regulation Authority)
2. Updated Nocturnal CCTV Monitoring Chart The Nocturnal CCTV Monitoring Chart has been updated since the Inquest and now includes a 'comments' box and instructions to detail any gaps in monitoring in this box. Gaps in monitoring should only happen in exceptional circumstances, such as an emergency.
3. Care Plan Policy The Care Plan Policy has been updated since the Inquest. For ease of reference, the updated sections are highlighted. The care staff have access to all policies and procedures on an application called BrightHR. All care staff receive training on this application and this specific policy during their two week induction programme. When any policy or procedure is updated, the care staff are notified automatically via the application. Once notified, all care staff must acknowledge receipt of the notification and open the document to confirm that they have read it. The BrightHR system tracks this and alerts management of any non-compliance.
4. Training Policy As above, The Training Policy has been updated since the Inquest. For ease of reference, the updated sections are highlighted. The care staff have access to all policies and procedures on an application called BrightHR. All care staff receive training on this application and this specific policy during their two week induction programme. When any policy or procedure is updated, the care staff are notified automatically via the application. Once notified, all care staff must acknowledge receipt of the notification and open the document to confirm that they have read it. The BrightHR system tracks this and alerts management of any non-compliance. This response contains reference to and copies of internal documents, which were requested in the Report to Prevent Future Deaths. It is respectfully submitted that for this reason it would be inappropriate to publish the response and/or enclosures. Please do not hesitate to contact us should you require anything further from our client.