Blenheim House Care Home
Other
Action Taken
The care home now requires that falls are recorded, and risk assessments are completed within 24 hours of any fall. Falls equipment audits have been taking place and more detailed accident and incident analysis has been included into the monthly accident audit. Pre-admission assessments are taking place in person when possible and The Berkley Care Group Training Manager is supporting Blenheim House with additional Falls Prevention Champion Training in Q2. (AI summary)
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RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FROM: Management Team, Blenheim House Care Home The MATTERS OF CONCERN expressed by the Coroner were as follows. – Evidence was given in relation to the Majesticare Falls Management Policy requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall Timely process for completing it Response
1. Further to the inquest onto the death of Mr Weston and the Report issued by the Coroner, the management team at Blenheim House have carefully considered the concerns expressed in relation to Mr Weston and have reviewed the Majesticare Falls Management Policy and Procedure.
2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response.
3. Monthly clinical and governance meetings continue to be held with the senior team, trends and patterns are identified in accidents and incidents audit from each month with monthly action plans in place. A weekly care review meeting is now also being explored to support this governance process.
4. Alongside care plans and risk assessments reviews during resident of the day, falls equipment audits have taken place in July, October and January by the Deputy Manager and the Home Manager. Daily walk round checks of equipment continue to take place.
5. In addition, more detailed accident and incident analysis has been included into the monthly accident audit.
6. Pre-admission assessments are now taking place in person when possible so that a proper assessment from a residential or nursing care perspective can be carried out. All residents at high risk of falls are identified at ‘high risk’ of falls prior to admission and the General Manager will seek the additional support of 1:1 care during required isolation period.
7. The Berkley Care Group Training Manager is also supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
1. Further to the inquest onto the death of Mr Weston and the Report issued by the Coroner, the management team at Blenheim House have carefully considered the concerns expressed in relation to Mr Weston and have reviewed the Majesticare Falls Management Policy and Procedure.
2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response.
3. Monthly clinical and governance meetings continue to be held with the senior team, trends and patterns are identified in accidents and incidents audit from each month with monthly action plans in place. A weekly care review meeting is now also being explored to support this governance process.
4. Alongside care plans and risk assessments reviews during resident of the day, falls equipment audits have taken place in July, October and January by the Deputy Manager and the Home Manager. Daily walk round checks of equipment continue to take place.
5. In addition, more detailed accident and incident analysis has been included into the monthly accident audit.
6. Pre-admission assessments are now taking place in person when possible so that a proper assessment from a residential or nursing care perspective can be carried out. All residents at high risk of falls are identified at ‘high risk’ of falls prior to admission and the General Manager will seek the additional support of 1:1 care during required isolation period.
7. The Berkley Care Group Training Manager is also supporting Blenheim House with additional Falls Prevention Champion Training in Q2.