Lean on Me Care Agency
Other
Action Planned
The agency has contracted training providers and a consulting agency to support ongoing training, including RQF courses for care workers. They are also recruiting more field care supervisors to improve shadowing and appraisal of new care workers. (AI summary)
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16 ARROW SCOUT WALK, RUISLIP ROAD, NORTHOLT, MIDDLESEX, UBS 6EE
8th May 2023 TO THE CORONER'S INQUEST-
REFRLECTION ON THE ACCIDENT THAT HAPPENED TO THE LATE MRS GR. I have read the Coroner's record of inquest and the concern raised in the report and I make this submission in response to the Coroner's request. Anywhere I fail to make or answer to specific issues raised, this should not be deemed as an admission of any fact. I am conscious of the fact that the Coroner in the cause of this inquest, would have received lots of evidential submissions, therefore I apologise in advance if I attach any evidence that the Coroner may have previously seen, which therefore is a duplication. However, I have the following observation to make. An additional statement A5b, submitted by a family member of the Late Mrs GR, expressed the view that 4 days of the carer shadowing the experienced carer was not sufficient. In the past, when the family expressed concerns, we have always immediately actioned any concerns raised to meet the desired outcome. Occupational therapist assessment stated the Late Mrs GR was frail and unsteady but despite this report, Social Services over-looked the risk element and continued to press that one care assistant is needed to Care for Late Mrs GR. Social Services for some reason under-estimated Mrs GR's care needs, possibly because of their quest for financial saving. They ignored the risk posed to the client. I draw these facts from the records that the Late Mrs GR's care needs, when under the CCG, was provided by two Carers. However, for some reason, when the Late Mrs GR care was taken over by Social Services, the provision of care was reduced to one carer to avoid charges that would have been imposed on the Late Mrs GR to make partial contribution for her care. I understand that Mrs GR expressed her inability to pay, because she only has her late husband's pension as her income, and any such payment would impoverish her and diminish her quality of life. Mrs GR's care was assigned to my agency on 5TH August 2020, to provide a total of, 2hrs15min. care hours a day (broken down in: 45mins in the Morning X1Care Worker, 30mins Lunch Visit X1Care Worker, Tea time Visit X1 Care Worker 30mins, and Bed Time Visit X 1 Care Worker 30mins. All these daily visits are X 7 Days a week. It was known by Social Services that the Late Mrs GR was 86 years of age, with a desire to mobilise with her Zimmer frame. She was frail, and has health condition
which affects her mobility, and had a previous fall in the past, prior to LCM taking over her care, which family did not disclosed this to us. All these factors in her safe handling, which should have involved 2 carers, as stated in the original NHS care plan was ignored by her family and by social services, who again, in their quest to cut costs, reduced the number of carers from 2 to 1. Turning now to our training programs and policies, our agency has training procedures beyond those submitted to the Coroner at this inquest. Please see attached correspondence with our new Training provider and our new Policies & Procedures Consultants. With their support, these are the actions we have put in place. The Coroner will note that most of the training given to staff were regularly assigned to an external body, which includes training entrusted to Social Services training portals. We had a shadowing procedure in place at the time of the accident. I accept that it may not have been entirely adequate, but the accident of the Late Mrs GR has exposed the need for improvement. The seriousness of this accident prompted me to suspend trading and place LCM in dormancy to enable me to re-evaluate our entire operation, develop decision making and organisational structure with a service development blueprint for future practice. ACTION REQUIRED AND TAKEN TO DATE There will be new management in place. I will step down in my role as Registered Manager.
• New training and assessment systems will be considered and implemented.
• Moving and handling component to specifically include in testing knowledge of safe Zimmer frame transfers, and how to respond to emergencies.
• New policies and procedures to be developed, including records for shadowing and competency observations.
• An ongoing quality monitoring of training is to be implemented.
• New care plan and risk assessment format to be developed and implemented.
• Senior staff training in all areas to be redeveloped, including importance of "new carer test" in Manual Handling.
• Induction training to include the importance of reporting when care plans are notusefuloroutofdate.
• Spot checks to include accuracy of the care plan and assessments, suitable recording format to be implemented. (Electronic recordings).
• Office and senior staff training to include written communication skills.
• Management and senior training to include "blame free" culture and duty of candour.
• Care planning and consent - Staff training in this area to be improved.
• Quality assurance and governance - Calendar and systems to be developed and implemented.
Moving forward, Lean on Me Community Care Services Ltd has taken decisive action and requested that the CQC place Lean on Me on Dormancy Status. This was to allow me the time and space needed to reflect upon the entirety of the Day-to-Day operations of Lean on Me as a result of the accidental death of Mrs GR. In future, all our staff training needs will be sourced out to a Training Agency that has been suitably vetted by my Local Authority as their preferred training providers, so that the training needs of Lean on Me are fully in line with Skills for Care and CQC Standards of good practice. In this response, you will notice further action plans in the email correspondence I have had with the Local Authority's preferred training providers dated: February 2nd 3rd 2023, March 2023, March 9th 2023, March 1oth 2023, March 13th 2023, March 31 st 2023, April 21 st 2013 and April 26th 2023. Please see attached evidence of such communication. You will notice that I have identified a wide range of training needs, which I believe Lean On Me staff will benefit from, so that future care related accidents and incidents will not occur under Lean On Me's watch. You will also notice a breakdown of the Health and Social Care training courses which I have identified to be beneficial to all Lean On Me care workers, including the Management Team; regardless of their previous experience, qualifications acquired in care or in other professions. All applicants who have been successfully vetted and who have accepted our offer of employment, must attend all grassroots training courses Level 1 and Level 2 Induction Training. All staff must work within Lean On Me's Policies and Procedures guidelines , which are in line with CQC standards of good practice, at office level and in the field. You will notice that in my correspondence with the training providers, a breakdown of the training durations - that is, the start and finish times - have been stated for each of the courses that they will provide to Lean On Me staff. It is in the best interests of Lean On Me to adhere to these training guidelines, working in close collaboration with the training providers, because they are experts in care training. In addition, as they are the Local Authority's preferred training providers, I believe that their training would be up to date to reflect any changes that may have occurred in Skills for Care and/or the CQC as a regulatory body. I have also requested specific areas of support from the training providers which I believe would benefit me and my team. I am grateful for the support that the training providers have given to me so far, signposting where I can access and learn more about further training needs, so that all prospective staff of Lean On Me can benefit from these trainings. I am committed to see that all the logistics required for this agency are firmly on the ground while I am still in post. It is my responsibility to ensure that Managers, Field Supervisors, Care
Coordinators, Quality assurance officers and Field care workers, must all, again, undergo the training courses starting at level 1 Induction training, and level 2 Care Award. This will be followed by further training in "STRENGTH BASED" COURSES, including "TRAIN THE TRAINER", so that our field supervisors, care coordinators, managers, quality assurance officers all have the knowledge required to support field care workers when they require additional support from the office staff. All office Management staff, field supervisors, field Care workers who wish to take extra training in Specialist courses as CPD for their own learning, will equally be encouraged and supported to take the advantage of these courses. There will also be ongoing Refresher courses that are Mandatory for all Staff to attend as the need arises including Continuous Professional Development (CPD) courses. Ongoing performance monitoring will be implemented. Lean on Me will also source out further training in Leadership and Management qualifications for those Management staff, who have not yet acquired such qualifications. This will be linked with the volume of clients we have acquired, that can enable us to sustain training support for of our staff, who are happy to acquire further skills in Health & Social Care. Lean on Me will ensure that incentive opportunities are made available and are given to our most committed care workers, who have demonstrated their commitment. working very well with the clients we have. Loyalty incentives will be awarded as an additional bonus to those care workers who have demonstrated loyalty to Lean on Me through "thick and thin". Again, I will no longer be actively involved in the day-to-day activities of Lean on Me Agency. As soon as I am satisfied that all the Logistics of Lean On Me are firmly in place. I have recently recruited 7 management personnel. The 7 applicants already have acquired more than 5 years' experience working in Health and Social Care. One has Leadership and Management qualifications in care, and has been earmarked as a future Manager, because she has worked as a Registered Manager for a large Care provider in the past. Another possible manager has Adult Nursing qualifications from Massachusetts USA, and is currently doing UK NMC adaptation. He has also acquired other qualifications in the USA: A bachelor's degree in public health and an NBA master's degree in business administration. I have two field care supervisors with over 10-years previous care experience, including specialist training courses acquired when they worked in other Care provider organisations. This being said, we are still recruiting all who are interested to work with Lean On Me - Care workers and field Care Supervisors. Our goal is to have a good number of field care supervisors who are competent to work alongside care workers during their field shadowing training, so that they can appraise their performance in the field and decide if the new care worker is fit to
continue as a care worker or not. For those care workers who have not acquired RQF, they too will be supported to enrol in RQF courses. Although we have recruited 7 management staff, we still have a long way to go to reach our desire number. The current number of 7 staff, will not make business sense to pay for their training, because the training provider has informed us that the maximum number of staff cannot exceed 12 attendees in any given course. BELOW ARE CONTACT DETAILS OF THE TRAINING PROVIDERS AND THE CONSULTING AGENCY THAT WE HAVE CONTRACTED TO SUPPORT US ON AN ONGOING BASIS. (1). FIRST RESPONSE TRAINING COMPANY,
Ealing Council also uses First Response Trainers as one of their vetted providers. (2). CQC EXPERTS has provided all new Policies and Procedures that are required to run an effective and efficient Health & Social Care Service.
. They have supplied over 600 new care documents to Lean On Me, including over 100 Policies and Procedures, available on request. Lean On Me now has complete A -Z Policies and Procedures in place. As we do not have any service users whose care needs involve regulation 9 Regulated Activities. we are attaching to you a blank copy of our new FIELD SHADOWING FORM. I hope the attached information is helpful to enable you to consider how I have seriously reflected on this accident, to prevent accidents or incidents from happening in the future. Sincerely
(Registered Manager)
8th May 2023 TO THE CORONER'S INQUEST-
REFRLECTION ON THE ACCIDENT THAT HAPPENED TO THE LATE MRS GR. I have read the Coroner's record of inquest and the concern raised in the report and I make this submission in response to the Coroner's request. Anywhere I fail to make or answer to specific issues raised, this should not be deemed as an admission of any fact. I am conscious of the fact that the Coroner in the cause of this inquest, would have received lots of evidential submissions, therefore I apologise in advance if I attach any evidence that the Coroner may have previously seen, which therefore is a duplication. However, I have the following observation to make. An additional statement A5b, submitted by a family member of the Late Mrs GR, expressed the view that 4 days of the carer shadowing the experienced carer was not sufficient. In the past, when the family expressed concerns, we have always immediately actioned any concerns raised to meet the desired outcome. Occupational therapist assessment stated the Late Mrs GR was frail and unsteady but despite this report, Social Services over-looked the risk element and continued to press that one care assistant is needed to Care for Late Mrs GR. Social Services for some reason under-estimated Mrs GR's care needs, possibly because of their quest for financial saving. They ignored the risk posed to the client. I draw these facts from the records that the Late Mrs GR's care needs, when under the CCG, was provided by two Carers. However, for some reason, when the Late Mrs GR care was taken over by Social Services, the provision of care was reduced to one carer to avoid charges that would have been imposed on the Late Mrs GR to make partial contribution for her care. I understand that Mrs GR expressed her inability to pay, because she only has her late husband's pension as her income, and any such payment would impoverish her and diminish her quality of life. Mrs GR's care was assigned to my agency on 5TH August 2020, to provide a total of, 2hrs15min. care hours a day (broken down in: 45mins in the Morning X1Care Worker, 30mins Lunch Visit X1Care Worker, Tea time Visit X1 Care Worker 30mins, and Bed Time Visit X 1 Care Worker 30mins. All these daily visits are X 7 Days a week. It was known by Social Services that the Late Mrs GR was 86 years of age, with a desire to mobilise with her Zimmer frame. She was frail, and has health condition
which affects her mobility, and had a previous fall in the past, prior to LCM taking over her care, which family did not disclosed this to us. All these factors in her safe handling, which should have involved 2 carers, as stated in the original NHS care plan was ignored by her family and by social services, who again, in their quest to cut costs, reduced the number of carers from 2 to 1. Turning now to our training programs and policies, our agency has training procedures beyond those submitted to the Coroner at this inquest. Please see attached correspondence with our new Training provider and our new Policies & Procedures Consultants. With their support, these are the actions we have put in place. The Coroner will note that most of the training given to staff were regularly assigned to an external body, which includes training entrusted to Social Services training portals. We had a shadowing procedure in place at the time of the accident. I accept that it may not have been entirely adequate, but the accident of the Late Mrs GR has exposed the need for improvement. The seriousness of this accident prompted me to suspend trading and place LCM in dormancy to enable me to re-evaluate our entire operation, develop decision making and organisational structure with a service development blueprint for future practice. ACTION REQUIRED AND TAKEN TO DATE There will be new management in place. I will step down in my role as Registered Manager.
• New training and assessment systems will be considered and implemented.
• Moving and handling component to specifically include in testing knowledge of safe Zimmer frame transfers, and how to respond to emergencies.
• New policies and procedures to be developed, including records for shadowing and competency observations.
• An ongoing quality monitoring of training is to be implemented.
• New care plan and risk assessment format to be developed and implemented.
• Senior staff training in all areas to be redeveloped, including importance of "new carer test" in Manual Handling.
• Induction training to include the importance of reporting when care plans are notusefuloroutofdate.
• Spot checks to include accuracy of the care plan and assessments, suitable recording format to be implemented. (Electronic recordings).
• Office and senior staff training to include written communication skills.
• Management and senior training to include "blame free" culture and duty of candour.
• Care planning and consent - Staff training in this area to be improved.
• Quality assurance and governance - Calendar and systems to be developed and implemented.
Moving forward, Lean on Me Community Care Services Ltd has taken decisive action and requested that the CQC place Lean on Me on Dormancy Status. This was to allow me the time and space needed to reflect upon the entirety of the Day-to-Day operations of Lean on Me as a result of the accidental death of Mrs GR. In future, all our staff training needs will be sourced out to a Training Agency that has been suitably vetted by my Local Authority as their preferred training providers, so that the training needs of Lean on Me are fully in line with Skills for Care and CQC Standards of good practice. In this response, you will notice further action plans in the email correspondence I have had with the Local Authority's preferred training providers dated: February 2nd 3rd 2023, March 2023, March 9th 2023, March 1oth 2023, March 13th 2023, March 31 st 2023, April 21 st 2013 and April 26th 2023. Please see attached evidence of such communication. You will notice that I have identified a wide range of training needs, which I believe Lean On Me staff will benefit from, so that future care related accidents and incidents will not occur under Lean On Me's watch. You will also notice a breakdown of the Health and Social Care training courses which I have identified to be beneficial to all Lean On Me care workers, including the Management Team; regardless of their previous experience, qualifications acquired in care or in other professions. All applicants who have been successfully vetted and who have accepted our offer of employment, must attend all grassroots training courses Level 1 and Level 2 Induction Training. All staff must work within Lean On Me's Policies and Procedures guidelines , which are in line with CQC standards of good practice, at office level and in the field. You will notice that in my correspondence with the training providers, a breakdown of the training durations - that is, the start and finish times - have been stated for each of the courses that they will provide to Lean On Me staff. It is in the best interests of Lean On Me to adhere to these training guidelines, working in close collaboration with the training providers, because they are experts in care training. In addition, as they are the Local Authority's preferred training providers, I believe that their training would be up to date to reflect any changes that may have occurred in Skills for Care and/or the CQC as a regulatory body. I have also requested specific areas of support from the training providers which I believe would benefit me and my team. I am grateful for the support that the training providers have given to me so far, signposting where I can access and learn more about further training needs, so that all prospective staff of Lean On Me can benefit from these trainings. I am committed to see that all the logistics required for this agency are firmly on the ground while I am still in post. It is my responsibility to ensure that Managers, Field Supervisors, Care
Coordinators, Quality assurance officers and Field care workers, must all, again, undergo the training courses starting at level 1 Induction training, and level 2 Care Award. This will be followed by further training in "STRENGTH BASED" COURSES, including "TRAIN THE TRAINER", so that our field supervisors, care coordinators, managers, quality assurance officers all have the knowledge required to support field care workers when they require additional support from the office staff. All office Management staff, field supervisors, field Care workers who wish to take extra training in Specialist courses as CPD for their own learning, will equally be encouraged and supported to take the advantage of these courses. There will also be ongoing Refresher courses that are Mandatory for all Staff to attend as the need arises including Continuous Professional Development (CPD) courses. Ongoing performance monitoring will be implemented. Lean on Me will also source out further training in Leadership and Management qualifications for those Management staff, who have not yet acquired such qualifications. This will be linked with the volume of clients we have acquired, that can enable us to sustain training support for of our staff, who are happy to acquire further skills in Health & Social Care. Lean on Me will ensure that incentive opportunities are made available and are given to our most committed care workers, who have demonstrated their commitment. working very well with the clients we have. Loyalty incentives will be awarded as an additional bonus to those care workers who have demonstrated loyalty to Lean on Me through "thick and thin". Again, I will no longer be actively involved in the day-to-day activities of Lean on Me Agency. As soon as I am satisfied that all the Logistics of Lean On Me are firmly in place. I have recently recruited 7 management personnel. The 7 applicants already have acquired more than 5 years' experience working in Health and Social Care. One has Leadership and Management qualifications in care, and has been earmarked as a future Manager, because she has worked as a Registered Manager for a large Care provider in the past. Another possible manager has Adult Nursing qualifications from Massachusetts USA, and is currently doing UK NMC adaptation. He has also acquired other qualifications in the USA: A bachelor's degree in public health and an NBA master's degree in business administration. I have two field care supervisors with over 10-years previous care experience, including specialist training courses acquired when they worked in other Care provider organisations. This being said, we are still recruiting all who are interested to work with Lean On Me - Care workers and field Care Supervisors. Our goal is to have a good number of field care supervisors who are competent to work alongside care workers during their field shadowing training, so that they can appraise their performance in the field and decide if the new care worker is fit to
continue as a care worker or not. For those care workers who have not acquired RQF, they too will be supported to enrol in RQF courses. Although we have recruited 7 management staff, we still have a long way to go to reach our desire number. The current number of 7 staff, will not make business sense to pay for their training, because the training provider has informed us that the maximum number of staff cannot exceed 12 attendees in any given course. BELOW ARE CONTACT DETAILS OF THE TRAINING PROVIDERS AND THE CONSULTING AGENCY THAT WE HAVE CONTRACTED TO SUPPORT US ON AN ONGOING BASIS. (1). FIRST RESPONSE TRAINING COMPANY,
Ealing Council also uses First Response Trainers as one of their vetted providers. (2). CQC EXPERTS has provided all new Policies and Procedures that are required to run an effective and efficient Health & Social Care Service.
. They have supplied over 600 new care documents to Lean On Me, including over 100 Policies and Procedures, available on request. Lean On Me now has complete A -Z Policies and Procedures in place. As we do not have any service users whose care needs involve regulation 9 Regulated Activities. we are attaching to you a blank copy of our new FIELD SHADOWING FORM. I hope the attached information is helpful to enable you to consider how I have seriously reflected on this accident, to prevent accidents or incidents from happening in the future. Sincerely
(Registered Manager)