Four Seasons Healthcare Group
Other
Action Taken
Four Seasons Healthcare details actions taken, including revising the policy for observations, undertaking reviews and audits, launching a revised incident reporting system (RADAR), simplifying the Root Cause Analysis function, and developing a bespoke training module for investigations. The group introduced mandatory training on diabetes awareness and management for all nurses. (AI summary)
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Dear Madam Coroner, Inquest touching the death of Colm McCabe Response to the Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 28 January 2022, subsequently re-issued on 31 January 2022, following the conclusion of the inquest into the very sad death of Mr Colm McCabe. This letter sets out the response to your Report. I know that you will share a copy of this response with the family of Mr McCabe and I would like to express my condolences for their loss. Please be assured that the safety of those in our care is our absolute priority. In your report, you raised the following matters of concern:
1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff, training of staff, and appraisals of staff.
2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses.
3. I heard evidence about investigations carried out by the home, and the fact that initial responses to enquiries from the CQC suggested that the management had been appropriate. I am concerned to know to what extent care homes run by Four Seasons carry out full and candid investigations and produce reports accordingly, and what training is given to managers in this respect? The Four Seasons Health Care Group (the Group) comprises a number of Registered Social Care Providers, and we recognise the importance of looking after the physical health needs of our residents, ensuring that our staff have the requisite skills, confidence and ability to provide high quality care. We are also aware that it is extremely important for us to operate an effective auditing system. This is supported by ensuring that our investigations into incidents are progressed in a timely manner and by way of an open, frank and transparent process involving all relevant stakeholders from an early stage. During the course of the inquest touching the death of Mr McCabe, provided evidence to you about the immediate actions taken at a local level at The Berkshire Care Home .These actions were largely in response to the concerns raised both within the Group and by external stakeholders. As described to you, it was identified that the policies, due process and appropriate escalation of actions as mandated by the Group had not been followed.
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Following the inquest, we have received and carefully reviewed the Regulation 28 Report issued by you .We now write to give you assurance that further steps have been taken and actions implemented to address the matters of concern. These have been incorporated into the ongoing provision of care services at The Berkshire Care Home and more widely across our business as part of our approach to learning and continuous quality improvement.
Lessons learned and action taken to address the concerns raised by you are as follows:
Policies, recruitment of staff, training of staff and appraisals of staff
1. The Group has introduced a “Policy of the Month” in order to raise awareness of company policies, practices and procedures. This is cascaded to all regional support teams and to homes via a weekly update by the Chief Operating Officer, with Home Managers cascading this to care home based team members during Daily Flash Meetings. The Group’s training platform has been improved to ensure that all team members are provided with relevant training that reflects the Group’s policies, practices and benchmarks. The platform is closely aligned to current statutory frameworks. All team members are guided through the principles and expectations of these as they complete each training module on the platform.
Areas of training include:
Essential training - All training, including statutory and mandatory training, that the Group considers essential for team members to complete to ensure safe and effective delivery of care and services.
Statutory training - Training required by, or with a basis in, law or regulation.
Mandatory training - Training specific to a role or roles, which the Group deems necessary for delivery of safe and effective care and services.
Induction training - Essential training that is completed by team members when they start a new role so that they are quickly and confidently able to meet the needs and requirements of that role. For new care home based team members, this is completed prior to commencing work in the home; for new office based team members and for care home based role-changers, this is completed during the first eight weeks. Local induction includes an introduction and orientation to the local area of work, environment and day-to-day working practices.
Additional learning and development - Learning and development that is based on a team’s/team member’s specific needs, identified either as knowledge gaps (information that employees need to know or understand but currently don’t), or skills gaps (actions that employees need to be able to carry out or perform but currently can’t). This is usually identified as part of the processes of supervision, annual appraisal or compliance (i.e. to meet the requirements of a particular service or local authority contract). It often leads to the development of personal improvement plans, which are regularly updated, reviewed and monitored.
Monitoring of compliance with training takes place at least monthly across all operational portfolios, reviewed by Managing Directors and Operational Managers to identify any corrective action where required. Compliance may be further assessed during internal and/or external audit. At The Berkshire Care Home work is continuing to support the development of the team and to recruit new team members with heavy emphasis on the need to follow systems and processes and to question practices which do not follow an agreed Multi-Disciplinary Team approach.
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To align with Group training and policies, recruitment processes have been improved and all Departments are supported by the Group’s Recruitment Team. Additional learning and development needs are reviewed and addressed by Operational Managers once employment of the individual has commenced.
To support nurses with clinical practice and competence, the Group subscribes to The Royal Marsden Manual, with access available to all nurses at each of our homes. However, it is recognised that this resource has not been as widely used as was anticipated. Accordingly, communication has been and will continue to be cascaded nationally to remind Home Managers and Registered Nurses of the importance of this valuable resource, which is available as a point of reference and guidance 24 hours a day and accessible on various devices at each home.
The Group has reviewed and improved its supervision and appraisal process to provide a responsive and flexible framework that enables Home Managers to support their teams to give their best, develop and grow, and to manage the personal and professional challenges associated with working in the care sector. The improved process covers the areas of themed supervision, delivered on a one-to-one or group basis to provide a space for reflection and discussion about specific themes, cases or issues arising, whereby discussions encourage open dialogue and insight to enhance learning and improve practice. Observational supervision is now conducted as a supportive measure to review direct care practice and knowledge; should areas of improvement be identified during the observational session these are addressed with the employee. The process of clinical supervision relates to the delivery of professional standards, and the identification of specific training requirements to meet those standards. It is a requirement that an experienced and competent clinician who can demonstrate membership of an appropriate professional body must complete this.
Audit
2. Through reflection and review, it has been recognised that the Group Governance and Audit system was not utilised at The Berkshire Care Home in the way for which it was intended. The completion of the audit process is reliant upon human elements, namely the importance of understanding the process, an honest and accurate approach to completion and the ability to execute this through comprehensive and open reporting. Accordingly, work is now in progress with the Group Care Quality and Assurance Teams to develop and deliver bespoke training to all Home Managers on how to conduct and document an audit and evidence continuous improvement. Further to this, it is recognised that the completion of audits should not be the responsibility of one individual as this may result in a restricted overview without checks and balances. Accordingly, action has been taken to conduct audits via multiple sources, including completion by team members independent to the homes, promoting a validation approach to audits carried out. The review of data produced by audit has also been improved. Whereas previously if data indicated consistent high outcome scores, this was viewed as assurance that a home was compliant. A different approach is now adopted so that this is now interrogated further utilising an independent team member validation approach to obtain assurance as to the accuracy of the outcomes presented to the wider business.
During the course of the inquest, Ms gave evidence about 72-hour reviews, which were carried out, at The Berkshire Care Home. These reviews were introduced by Ms at a local level at The Berkshire Care Home, following the death of Mr McCabe and as an additional check as to compliance with process in response to the issues which became apparent following Mr McCabe’s death: they were not incorporated into the Group’s general policies applicable to the delivery of care at all homes. I am sorry for the confusion in this regard. Following consideration of the audit and other changes outlined in this letter it has not been considered necessary to implement 72 hour reviews as a standard process across the Group.
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However, a Care Plan Review tool has been introduced across the Group for use in all care homes; this is to be completed 5 days following admission and reviews the following areas:
Admission Assessment Consent documents and photographs. Medication on Admission Body Map Moving and Handling Assessment Falls Risk Assessment Choking Risk Assessment (to be completed within 2 hours of admission) MUST Risk Assessment (to be completed within 6 hours of admission) Waterlow Risk Assessment (to be completed within 6 hours of admission) Pain Assessment Wound Assessment Bed Rail Risk Assessment Self-Medication Risk Assessment (if applicable)
The review should ensure that care plans are underway, taking into account hospital discharge notes or other available information from external stakeholders as applicable. Operational Managers and our audit process will have additional oversight again to provide validation approach.
The Group has recently refreshed its admissions policy to guide staff on the process required when dealing with planned, emergency, respite and intermediate care admissions. It also applies to re- admissions to the care home from hospital. In summary, upon receipt of a referral or enquiry, details about the person to be admitted will be taken and recorded on the Enquiry Management System in order to make an initial decision as to whether the home is able to adequately meet the person’s needs. Critically, staff have been empowered to decline an admission if it is identified that the home is not able to meet the person’s needs. The enquirer will be informed of this decision and the reasons why, and, where relevant, advice will be offered regarding alternative Group homes that may be able to provide a suitable placement subject to the needs and best interests of the individual. Pre-admission assessments will be carried out during a visit to the person in their current location (which may be their own home, another care home or in hospital) or over the telephone where a face to face visit is not possible and will be recorded using the Pre- Admission Document. The information obtained at the pre-admission stage will include everything that the home requires to ensure that the needs of the person can be met safely, and to ensure that there is continuity of care, treatment and support for the person. On admission, all needs assessments and risk assessments are completed using the information obtained at the pre-admission stage in conjunction with discussions with the resident or their representative at the home and the necessary care plans are generated. For respite care, each new period of admission will require a review of the existing pre-admission documentation with the resident or their representative to ensure that any new needs are planned for, that the placement remains appropriate and the home can safely meet the needs of the resident. The admissions process for an intermediate care patient journey is as follows: All relevant information will be gathered by the hospital, which will develop goals with the patient; On referral, a pre-admission assessment will be completed and a decision will be made to admit; If the care setting can accommodate the patient, admission will take place within 48 hours; and On admission, all relevant risk assessments will be completed, and the necessary care plans generated, as discussed and agreed with the Multi-Disciplinary Team.
Investigations
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3. The Group operates an incident management system via the RADAR platform; this is a fundamental change to the previous system DATIX, an incident management system commonly used in the sector and which was in use by the Group prior to April 2021. Whereas the DATIX system was controlled by the external program developers, which restricted our ability to invoke change when this was required to meet the needs of our business, the RADAR system allows for full participation and control to reflect Group practices and to enable positive change by the Group. Every incident reported has a designated workflow to guide and prompt team members as to the information required and notifications that may be required; these workflow steps are regularly reviewed to support improved reporting and investigation. A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the RADAR incident management system, workflow steps and effective completion of a Root Cause Analysis under sector standard principles and is delivered nationally across the Group. The training has been developed using a ‘lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation with a focus on openness and transparency, mirroring duty of candour principles. Areas covered include reasons why we have to investigate an incident; the four steps of effective investigation; and the correct method and terminology for completing an investigation. The training also encompasses interactive participation, where attendees review a case study and then discuss methods of investigation, identification of risk, causation, corrective action needed, how to write the investigation report and finally how to cascade lessons learned to the wider team.
Thank you for bringing your concerns to my attention. I hope that the detailed information provided in this response offers you assurance about both our systems and processes and the significant and continuing improvements we have made and will continue to make in order to mitigate risk to our residents.
We are sincerely sorry for the shortcomings in the care of Mr McCabe and are committed to ensuring that the improvements we have made are sustained both at The Berkshire Care Home and across our wider business.
1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff, training of staff, and appraisals of staff.
2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses.
3. I heard evidence about investigations carried out by the home, and the fact that initial responses to enquiries from the CQC suggested that the management had been appropriate. I am concerned to know to what extent care homes run by Four Seasons carry out full and candid investigations and produce reports accordingly, and what training is given to managers in this respect? The Four Seasons Health Care Group (the Group) comprises a number of Registered Social Care Providers, and we recognise the importance of looking after the physical health needs of our residents, ensuring that our staff have the requisite skills, confidence and ability to provide high quality care. We are also aware that it is extremely important for us to operate an effective auditing system. This is supported by ensuring that our investigations into incidents are progressed in a timely manner and by way of an open, frank and transparent process involving all relevant stakeholders from an early stage. During the course of the inquest touching the death of Mr McCabe, provided evidence to you about the immediate actions taken at a local level at The Berkshire Care Home .These actions were largely in response to the concerns raised both within the Group and by external stakeholders. As described to you, it was identified that the policies, due process and appropriate escalation of actions as mandated by the Group had not been followed.
2 | P a g e
Following the inquest, we have received and carefully reviewed the Regulation 28 Report issued by you .We now write to give you assurance that further steps have been taken and actions implemented to address the matters of concern. These have been incorporated into the ongoing provision of care services at The Berkshire Care Home and more widely across our business as part of our approach to learning and continuous quality improvement.
Lessons learned and action taken to address the concerns raised by you are as follows:
Policies, recruitment of staff, training of staff and appraisals of staff
1. The Group has introduced a “Policy of the Month” in order to raise awareness of company policies, practices and procedures. This is cascaded to all regional support teams and to homes via a weekly update by the Chief Operating Officer, with Home Managers cascading this to care home based team members during Daily Flash Meetings. The Group’s training platform has been improved to ensure that all team members are provided with relevant training that reflects the Group’s policies, practices and benchmarks. The platform is closely aligned to current statutory frameworks. All team members are guided through the principles and expectations of these as they complete each training module on the platform.
Areas of training include:
Essential training - All training, including statutory and mandatory training, that the Group considers essential for team members to complete to ensure safe and effective delivery of care and services.
Statutory training - Training required by, or with a basis in, law or regulation.
Mandatory training - Training specific to a role or roles, which the Group deems necessary for delivery of safe and effective care and services.
Induction training - Essential training that is completed by team members when they start a new role so that they are quickly and confidently able to meet the needs and requirements of that role. For new care home based team members, this is completed prior to commencing work in the home; for new office based team members and for care home based role-changers, this is completed during the first eight weeks. Local induction includes an introduction and orientation to the local area of work, environment and day-to-day working practices.
Additional learning and development - Learning and development that is based on a team’s/team member’s specific needs, identified either as knowledge gaps (information that employees need to know or understand but currently don’t), or skills gaps (actions that employees need to be able to carry out or perform but currently can’t). This is usually identified as part of the processes of supervision, annual appraisal or compliance (i.e. to meet the requirements of a particular service or local authority contract). It often leads to the development of personal improvement plans, which are regularly updated, reviewed and monitored.
Monitoring of compliance with training takes place at least monthly across all operational portfolios, reviewed by Managing Directors and Operational Managers to identify any corrective action where required. Compliance may be further assessed during internal and/or external audit. At The Berkshire Care Home work is continuing to support the development of the team and to recruit new team members with heavy emphasis on the need to follow systems and processes and to question practices which do not follow an agreed Multi-Disciplinary Team approach.
3 | P a g e
To align with Group training and policies, recruitment processes have been improved and all Departments are supported by the Group’s Recruitment Team. Additional learning and development needs are reviewed and addressed by Operational Managers once employment of the individual has commenced.
To support nurses with clinical practice and competence, the Group subscribes to The Royal Marsden Manual, with access available to all nurses at each of our homes. However, it is recognised that this resource has not been as widely used as was anticipated. Accordingly, communication has been and will continue to be cascaded nationally to remind Home Managers and Registered Nurses of the importance of this valuable resource, which is available as a point of reference and guidance 24 hours a day and accessible on various devices at each home.
The Group has reviewed and improved its supervision and appraisal process to provide a responsive and flexible framework that enables Home Managers to support their teams to give their best, develop and grow, and to manage the personal and professional challenges associated with working in the care sector. The improved process covers the areas of themed supervision, delivered on a one-to-one or group basis to provide a space for reflection and discussion about specific themes, cases or issues arising, whereby discussions encourage open dialogue and insight to enhance learning and improve practice. Observational supervision is now conducted as a supportive measure to review direct care practice and knowledge; should areas of improvement be identified during the observational session these are addressed with the employee. The process of clinical supervision relates to the delivery of professional standards, and the identification of specific training requirements to meet those standards. It is a requirement that an experienced and competent clinician who can demonstrate membership of an appropriate professional body must complete this.
Audit
2. Through reflection and review, it has been recognised that the Group Governance and Audit system was not utilised at The Berkshire Care Home in the way for which it was intended. The completion of the audit process is reliant upon human elements, namely the importance of understanding the process, an honest and accurate approach to completion and the ability to execute this through comprehensive and open reporting. Accordingly, work is now in progress with the Group Care Quality and Assurance Teams to develop and deliver bespoke training to all Home Managers on how to conduct and document an audit and evidence continuous improvement. Further to this, it is recognised that the completion of audits should not be the responsibility of one individual as this may result in a restricted overview without checks and balances. Accordingly, action has been taken to conduct audits via multiple sources, including completion by team members independent to the homes, promoting a validation approach to audits carried out. The review of data produced by audit has also been improved. Whereas previously if data indicated consistent high outcome scores, this was viewed as assurance that a home was compliant. A different approach is now adopted so that this is now interrogated further utilising an independent team member validation approach to obtain assurance as to the accuracy of the outcomes presented to the wider business.
During the course of the inquest, Ms gave evidence about 72-hour reviews, which were carried out, at The Berkshire Care Home. These reviews were introduced by Ms at a local level at The Berkshire Care Home, following the death of Mr McCabe and as an additional check as to compliance with process in response to the issues which became apparent following Mr McCabe’s death: they were not incorporated into the Group’s general policies applicable to the delivery of care at all homes. I am sorry for the confusion in this regard. Following consideration of the audit and other changes outlined in this letter it has not been considered necessary to implement 72 hour reviews as a standard process across the Group.
4 | P a g e
However, a Care Plan Review tool has been introduced across the Group for use in all care homes; this is to be completed 5 days following admission and reviews the following areas:
Admission Assessment Consent documents and photographs. Medication on Admission Body Map Moving and Handling Assessment Falls Risk Assessment Choking Risk Assessment (to be completed within 2 hours of admission) MUST Risk Assessment (to be completed within 6 hours of admission) Waterlow Risk Assessment (to be completed within 6 hours of admission) Pain Assessment Wound Assessment Bed Rail Risk Assessment Self-Medication Risk Assessment (if applicable)
The review should ensure that care plans are underway, taking into account hospital discharge notes or other available information from external stakeholders as applicable. Operational Managers and our audit process will have additional oversight again to provide validation approach.
The Group has recently refreshed its admissions policy to guide staff on the process required when dealing with planned, emergency, respite and intermediate care admissions. It also applies to re- admissions to the care home from hospital. In summary, upon receipt of a referral or enquiry, details about the person to be admitted will be taken and recorded on the Enquiry Management System in order to make an initial decision as to whether the home is able to adequately meet the person’s needs. Critically, staff have been empowered to decline an admission if it is identified that the home is not able to meet the person’s needs. The enquirer will be informed of this decision and the reasons why, and, where relevant, advice will be offered regarding alternative Group homes that may be able to provide a suitable placement subject to the needs and best interests of the individual. Pre-admission assessments will be carried out during a visit to the person in their current location (which may be their own home, another care home or in hospital) or over the telephone where a face to face visit is not possible and will be recorded using the Pre- Admission Document. The information obtained at the pre-admission stage will include everything that the home requires to ensure that the needs of the person can be met safely, and to ensure that there is continuity of care, treatment and support for the person. On admission, all needs assessments and risk assessments are completed using the information obtained at the pre-admission stage in conjunction with discussions with the resident or their representative at the home and the necessary care plans are generated. For respite care, each new period of admission will require a review of the existing pre-admission documentation with the resident or their representative to ensure that any new needs are planned for, that the placement remains appropriate and the home can safely meet the needs of the resident. The admissions process for an intermediate care patient journey is as follows: All relevant information will be gathered by the hospital, which will develop goals with the patient; On referral, a pre-admission assessment will be completed and a decision will be made to admit; If the care setting can accommodate the patient, admission will take place within 48 hours; and On admission, all relevant risk assessments will be completed, and the necessary care plans generated, as discussed and agreed with the Multi-Disciplinary Team.
Investigations
5 | P a g e
3. The Group operates an incident management system via the RADAR platform; this is a fundamental change to the previous system DATIX, an incident management system commonly used in the sector and which was in use by the Group prior to April 2021. Whereas the DATIX system was controlled by the external program developers, which restricted our ability to invoke change when this was required to meet the needs of our business, the RADAR system allows for full participation and control to reflect Group practices and to enable positive change by the Group. Every incident reported has a designated workflow to guide and prompt team members as to the information required and notifications that may be required; these workflow steps are regularly reviewed to support improved reporting and investigation. A Root Cause Analysis function aligned to incident reporting has been simplified and improved with additional guidance and prompts to support team members. Furthermore, the Group has developed a bespoke training module to guide team members on how to conduct an investigation; this is directly aligned to the RADAR incident management system, workflow steps and effective completion of a Root Cause Analysis under sector standard principles and is delivered nationally across the Group. The training has been developed using a ‘lessons learned’ approach and guides managers through the process of completing a timely, thorough and effective investigation with a focus on openness and transparency, mirroring duty of candour principles. Areas covered include reasons why we have to investigate an incident; the four steps of effective investigation; and the correct method and terminology for completing an investigation. The training also encompasses interactive participation, where attendees review a case study and then discuss methods of investigation, identification of risk, causation, corrective action needed, how to write the investigation report and finally how to cascade lessons learned to the wider team.
Thank you for bringing your concerns to my attention. I hope that the detailed information provided in this response offers you assurance about both our systems and processes and the significant and continuing improvements we have made and will continue to make in order to mitigate risk to our residents.
We are sincerely sorry for the shortcomings in the care of Mr McCabe and are committed to ensuring that the improvements we have made are sustained both at The Berkshire Care Home and across our wider business.