Cole Valley Nursing Home
Action Taken
The nursing home has implemented a new post falls protocol folder, a new manager’s report/handover for nurses, and a Daily Walkabout Form. They have also promoted an RGN to Deputy Manager and implemented a new daily task folder for nurses to complete audits. (AI summary)
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Cole Valley Nursing Home 326 Haunch Lane, Kings Heath, Birmingham, B13 0PN
Prevention of Future Deaths Notice Response 24th May 2021
To whom it may concern
1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.
2. The Manager has reviewed current documentation regarding post falls reporting and observing. The manager agrees that post documentation protocols was not substantial and did not accurately reflect the observations that took place on the day, so has implemented a new robust post falls protocol folder for the nursing team. This is allocated in one place and therefore nurses can easily access documents. This protocol now gives guidance and clear directions to follow. This protocol also has a NEWS chart that is included within this pack and a timed observation log post fall. Regarding the previous fall, the manager has reviewed archived documentation but is unable to locate any documentation to support the reported proceeding fall on or around the 15th October
2021. The manager has spoken to about this concern. said he was extremely nervous about this situation and had many anxiety attacks before attending Coroner’s Court. stated he that he panicked throughout the questioning and was not completely sure about the fall around this time. The manager has however, implemented a new manager’s report/handover for nurses to complete daily and every night. The manager to review handover daily. A Daily Walkabout Form is also in place. This identifies if there has been any accidents or incidents in the last 24 hours and what actions have been done, such as evaluating care needs of the individual involved. Cole Valley Nursing Home has promoted an RGN to Deputy Manager with supernumerary time to assist the manager with audits and action plans, supervisions and implementing and monitoring documentation to aid continuous improvement of the Home. The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor care plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness. Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person- centred care and avoidance of missed evaluations in the future. Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices. A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day). This system has proven to be successful so far as anomalies have already been identified and action plan has been updated to reflect the service improvement plan
3. The manager has identified the failings of the court orders to supply documentation. has stated that this was not intentional and genuinely upset that she misunderstood the reports sent.
She now understands the importance of reading these reports thoroughly and sending requested documentation as a matter of urgency. has now returned to Cole Valley Nursing Home full time and will remain at her primary home to ensure that these measures are maintained to a high standard and ensure emails are checked daily and respond more efficiently.
Nominated Individual
Prevention of Future Deaths Notice Response 24th May 2021
To whom it may concern
1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.
2. The Manager has reviewed current documentation regarding post falls reporting and observing. The manager agrees that post documentation protocols was not substantial and did not accurately reflect the observations that took place on the day, so has implemented a new robust post falls protocol folder for the nursing team. This is allocated in one place and therefore nurses can easily access documents. This protocol now gives guidance and clear directions to follow. This protocol also has a NEWS chart that is included within this pack and a timed observation log post fall. Regarding the previous fall, the manager has reviewed archived documentation but is unable to locate any documentation to support the reported proceeding fall on or around the 15th October
2021. The manager has spoken to about this concern. said he was extremely nervous about this situation and had many anxiety attacks before attending Coroner’s Court. stated he that he panicked throughout the questioning and was not completely sure about the fall around this time. The manager has however, implemented a new manager’s report/handover for nurses to complete daily and every night. The manager to review handover daily. A Daily Walkabout Form is also in place. This identifies if there has been any accidents or incidents in the last 24 hours and what actions have been done, such as evaluating care needs of the individual involved. Cole Valley Nursing Home has promoted an RGN to Deputy Manager with supernumerary time to assist the manager with audits and action plans, supervisions and implementing and monitoring documentation to aid continuous improvement of the Home. The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor care plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness. Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person- centred care and avoidance of missed evaluations in the future. Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices. A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day). This system has proven to be successful so far as anomalies have already been identified and action plan has been updated to reflect the service improvement plan
3. The manager has identified the failings of the court orders to supply documentation. has stated that this was not intentional and genuinely upset that she misunderstood the reports sent.
She now understands the importance of reading these reports thoroughly and sending requested documentation as a matter of urgency. has now returned to Cole Valley Nursing Home full time and will remain at her primary home to ensure that these measures are maintained to a high standard and ensure emails are checked daily and respond more efficiently.
Nominated Individual