Priory Group
Private Sector
Action Planned
The Priory's operational management team will review the findings of the inquest and other information related to the incident, to identify any remaining salient themes and trends. They are also recruiting an additional Investigations Officer and adopting the Patient Safety Incident Response Framework. (AI summary)
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Dear Ms Lake,
Peter Gary Seaby - Response to Regulation 28 Report
I write to you in response to the Regulation 28 Report dated Monday 27 February 2023. The report was issued following the Inquest touching the death of Mr Peter Seaby. You have raised two matters of concern that directly relate to The Oaks and Woodcroft Care Home and a further matter of concern relating to an aspect of governance within Priory Adult Care.
The responses to the matters of concern are as follows below. Please note that each concern has been raised and discussed directly with the management team at the home in order for them to reflect on the issues and take appropriate remedial actions.
1. The provision of care
You have raised a concern that staff operate an informal approach in respect of the delivery of care to residents at the home.
You will note that Priory Adult Care’s Director of Quality outlined in Inquest statement the enhancements that have been put in place at The Oaks and Woodcroft Care Home. The enhancements include: Having in place person centred support plans, handovers and one-page resident profiles. Arrangements to promptly report and review each incident and ‘near-miss’ incident. Systems to identify areas of improvement and lessons learned in response to incidents and ‘near- miss’ incidents. An overarching policy: OP47 Supporting Service Users with Swallowing Difficulties (Dysphagia) which is supplemented by a summary of the policy and ‘flash’ cards made available to staff at the home. Detailed individual resident swallowing / choking risk assessments. Systems to ensure robust handovers between outgoing and incoming shifts. Arrangements to ensure that residents are escorted to appointments with experienced staff who know the particular resident. A process for inducting and training colleagues with reference to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Competency assessments to be completed by staff to ensure that they can articulate the resident’s support needs and observation levels. An internal training team of experts to deliver emergency first aid at work training to colleagues across Priory Adult Care. This has helped to ensure that staff consider the risk of choking and the practical measures that can be put in place to reduce the risk. The introduction of ‘Nourish’, a bespoke electronic care records system enabling colleagues at the home to have quick and easy access to resident profiles and support plans. Nourish also assists the management team to check that effective support plans are in place.
2
There is an experienced and knowledgeable management team in place at The Oaks and Woodcroft Care Home. The team are supported by an effective central divisional management and compliance team who maintain a detailed oversight of the home and resident safety and welfare. Our view is that the home continues to operate safely and the residents are well cared for and supported.
We were however disappointed to learn that a witness, a current member of staff, gave evidence of care being delivered to residents in an ‘informal’ manner, despite the significant measures that we have in place at the home, some of which are listed above.
Since the Inquest we have offered support to the staff member and explored with her what meant by the term ‘informal’. We have asked her to identify the areas of day-to-day practice that feels would benefit from being made more precise. More widely, the staff team as a whole have been given feedback, as part of the debrief process, on the outcome and learning from the Inquest and have been asked for their views on resident care and what, if any, improvements need to be made. This exercise has resulted in some additional improvements having been made in terms of the process for allocation of roles, staff understanding their roles and responsibilities particularly at mealtimes and the process for staff handovers has been strengthened. We will continue to consult with, listen to and respond to staff at the home using, for example, the supervision process, staff meetings and colleague engagement surveys and continue to develop the service where improvement opportunities are identified.
2. Staffing levels
Our operational management team, together with the home management team, regularly review staffing levels at each of our homes, for example prior to the admission of a new resident and in response to the deterioration of a resident’s health. The operational management team have taken this opportunity to review staffing numbers again in response to your report, by consulting with the home management team, seeking feedback from colleagues at the home and reviewing resident support plans and considering resident needs. We are satisfied that staffing levels at The Oaks and Woodcroft Care Home are satisfactory, that staff are being effectively allocated to care for residents and that staffing numbers are sufficient to ensure that residents are safe and well looked after.
On a practical level, meal times are now undertaken in two sittings to enable closer supervision of each resident whilst eating and drinking.
We are aware however that it is impossible to take into account all eventualities for example, where a resident falls ill and needs to be escorted to hospital (leaving staffing numbers unexpectedly depleted at the home) or where staff themselves are unwell and unable to attend work. By way of reassurance, our home managers are at liberty to contact their managers and seek authorisation to arrange for the attendance of ad-hoc bank and agency staff in the event that staffing numbers fall below requirement. Similarly, the on-call management system in place means that out of hours, a manager can attend the home and assist should it be difficult to secure the attendance of ad-hoc bank and agency staff. There is a low threshold for putting in place an additional member of staff in the event of there being any issues that may give rise to concern.
3. Internal review
Our operational management team have now had an opportunity to meet with our legal representatives following the Inquest and this meeting highlighted several salient points that were raised, not least the requirement for a review to be undertaken of this matter as you have outlined.
In respect of taking this review forward, our operational management team are to now closely consider the findings of your Inquest and other information made available about the tragic incident involving Mr Seaby. The review will assist the operational management team to draw out any salient themes and trends that still exist despite the overarching improvements made and the passage of time. A detailed action plan will be created and any significant learning points will be shared with colleagues at the home and also be shared more widely across Priory services as appropriate.
In respect of ensuring that there are proportionate reviews and investigations undertaken in response to serious incidents, I hope that you will be reassured to learn that:
3
The introduction of the Datix incident reporting system in Autumn 2019 has helped management colleagues to better monitor and respond to incidents and near misses. All serious incidents are ‘reported up’. Where necessary a meeting is held the next working day after a serious incident is identified with discussion held in respect of communication with family, staff support and investigation arrangements. Priory are recruiting an additional Investigations Officer to assist in undertaking reviews and investigations. Priory are in the process of adopting the Patient Safety Incident response Framework (PSIRF). This will assist Priory to better examine incident themes and trends and respond proportionately to incidents to achieve the most learning. We anticipate that PSIRF will be fully embedded across Priory Adult Care by Autumn 2023.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Peter Gary Seaby - Response to Regulation 28 Report
I write to you in response to the Regulation 28 Report dated Monday 27 February 2023. The report was issued following the Inquest touching the death of Mr Peter Seaby. You have raised two matters of concern that directly relate to The Oaks and Woodcroft Care Home and a further matter of concern relating to an aspect of governance within Priory Adult Care.
The responses to the matters of concern are as follows below. Please note that each concern has been raised and discussed directly with the management team at the home in order for them to reflect on the issues and take appropriate remedial actions.
1. The provision of care
You have raised a concern that staff operate an informal approach in respect of the delivery of care to residents at the home.
You will note that Priory Adult Care’s Director of Quality outlined in Inquest statement the enhancements that have been put in place at The Oaks and Woodcroft Care Home. The enhancements include: Having in place person centred support plans, handovers and one-page resident profiles. Arrangements to promptly report and review each incident and ‘near-miss’ incident. Systems to identify areas of improvement and lessons learned in response to incidents and ‘near- miss’ incidents. An overarching policy: OP47 Supporting Service Users with Swallowing Difficulties (Dysphagia) which is supplemented by a summary of the policy and ‘flash’ cards made available to staff at the home. Detailed individual resident swallowing / choking risk assessments. Systems to ensure robust handovers between outgoing and incoming shifts. Arrangements to ensure that residents are escorted to appointments with experienced staff who know the particular resident. A process for inducting and training colleagues with reference to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Competency assessments to be completed by staff to ensure that they can articulate the resident’s support needs and observation levels. An internal training team of experts to deliver emergency first aid at work training to colleagues across Priory Adult Care. This has helped to ensure that staff consider the risk of choking and the practical measures that can be put in place to reduce the risk. The introduction of ‘Nourish’, a bespoke electronic care records system enabling colleagues at the home to have quick and easy access to resident profiles and support plans. Nourish also assists the management team to check that effective support plans are in place.
2
There is an experienced and knowledgeable management team in place at The Oaks and Woodcroft Care Home. The team are supported by an effective central divisional management and compliance team who maintain a detailed oversight of the home and resident safety and welfare. Our view is that the home continues to operate safely and the residents are well cared for and supported.
We were however disappointed to learn that a witness, a current member of staff, gave evidence of care being delivered to residents in an ‘informal’ manner, despite the significant measures that we have in place at the home, some of which are listed above.
Since the Inquest we have offered support to the staff member and explored with her what meant by the term ‘informal’. We have asked her to identify the areas of day-to-day practice that feels would benefit from being made more precise. More widely, the staff team as a whole have been given feedback, as part of the debrief process, on the outcome and learning from the Inquest and have been asked for their views on resident care and what, if any, improvements need to be made. This exercise has resulted in some additional improvements having been made in terms of the process for allocation of roles, staff understanding their roles and responsibilities particularly at mealtimes and the process for staff handovers has been strengthened. We will continue to consult with, listen to and respond to staff at the home using, for example, the supervision process, staff meetings and colleague engagement surveys and continue to develop the service where improvement opportunities are identified.
2. Staffing levels
Our operational management team, together with the home management team, regularly review staffing levels at each of our homes, for example prior to the admission of a new resident and in response to the deterioration of a resident’s health. The operational management team have taken this opportunity to review staffing numbers again in response to your report, by consulting with the home management team, seeking feedback from colleagues at the home and reviewing resident support plans and considering resident needs. We are satisfied that staffing levels at The Oaks and Woodcroft Care Home are satisfactory, that staff are being effectively allocated to care for residents and that staffing numbers are sufficient to ensure that residents are safe and well looked after.
On a practical level, meal times are now undertaken in two sittings to enable closer supervision of each resident whilst eating and drinking.
We are aware however that it is impossible to take into account all eventualities for example, where a resident falls ill and needs to be escorted to hospital (leaving staffing numbers unexpectedly depleted at the home) or where staff themselves are unwell and unable to attend work. By way of reassurance, our home managers are at liberty to contact their managers and seek authorisation to arrange for the attendance of ad-hoc bank and agency staff in the event that staffing numbers fall below requirement. Similarly, the on-call management system in place means that out of hours, a manager can attend the home and assist should it be difficult to secure the attendance of ad-hoc bank and agency staff. There is a low threshold for putting in place an additional member of staff in the event of there being any issues that may give rise to concern.
3. Internal review
Our operational management team have now had an opportunity to meet with our legal representatives following the Inquest and this meeting highlighted several salient points that were raised, not least the requirement for a review to be undertaken of this matter as you have outlined.
In respect of taking this review forward, our operational management team are to now closely consider the findings of your Inquest and other information made available about the tragic incident involving Mr Seaby. The review will assist the operational management team to draw out any salient themes and trends that still exist despite the overarching improvements made and the passage of time. A detailed action plan will be created and any significant learning points will be shared with colleagues at the home and also be shared more widely across Priory services as appropriate.
In respect of ensuring that there are proportionate reviews and investigations undertaken in response to serious incidents, I hope that you will be reassured to learn that:
3
The introduction of the Datix incident reporting system in Autumn 2019 has helped management colleagues to better monitor and respond to incidents and near misses. All serious incidents are ‘reported up’. Where necessary a meeting is held the next working day after a serious incident is identified with discussion held in respect of communication with family, staff support and investigation arrangements. Priory are recruiting an additional Investigations Officer to assist in undertaking reviews and investigations. Priory are in the process of adopting the Patient Safety Incident response Framework (PSIRF). This will assist Priory to better examine incident themes and trends and respond proportionately to incidents to achieve the most learning. We anticipate that PSIRF will be fully embedded across Priory Adult Care by Autumn 2023.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.