Holdingham Grange Nursing Home
Action Taken
Holdingham Grange Nursing Home investigated the circumstances around a resident's fall, finding sufficient staffing levels were in place, staff receive training, and no summons to the inquest were received. They have reviewed all falls risk assessments and are working with OTs, and falls training is available for all staff. (AI summary)
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2 11 1 r:~"O . LvL HOLDINGHAM GRANGE INVESTIGATION REPORT RE The late Donald Elliott (DE) 17.08.30 BACKGROUND Mr Elliott was admitted to Holdingham Grange, from another care home, in August 2018 in order to be nearer to his wife; who lives in Sleaford. DE was at a high risk of falling; which was highlighted in the risk assessment and an appropriate care plan was developed. He walked with a frame but frequently tripped over his feet and his frame. He used a wheelchair for distances. He had a sensor mat next to his bed to alert staff when he was up, which he agreed to. Other than that staff observed him as was normal in the course of the day. He was able to use his call bell and, although forgetful, he did ring most of the time. He was never funded for or deemed that he required 1-1 observation. He was funded for nursing care. He was visited by his wife most days. He came up for meals into the dining areas and socialised with others. He had capacity to make decisions about where he wanted to go and what he wanted to do. He was sometimes confused to time and place but was easily reassured and re orientated. He lived on the Nursing unit initially, as this was the only unit that was open. He moved onto the dementia unit when it opened on 7th January 2019. At that time the staff ratio was 2 staff to 4 residents in the day and 1 carer and nurse floating at night, (3 residents were residential and 1 was nursing). CONCERN Coroner raised some questions which required a response by April 8th 2020 : Staffing levels on both days, when Mr Elliott to confirm we had sufficient suitably trained staff Why 2 staff called to attend the inquest did not attend If staff received support, supervisions and appraisals to enable them to carry out their roles and responsibilities. INVESTIGATION METHODOLOGY
• Care records
• Interviews with staff present during incident
• Rotas
• Allocation sheets
• Resident occupancy sheets
• Accident reports FINDINGS
24.01 .19 There were two staff on duty during the day and one carer and a 'floating' nurse at night. There were four residents on the unit.
31.01 .19 There was a registered nurse and an agency carer on the unit when he fell. Staff to resident ratio was 2-4 at the time of the fall. The fall was witnessed by the carer who did not see him hit his head. He was checked over by the nurse who was giving medication at the time. The investigation has demonstrated that there were sufficient, suitably qualified, staff on duty on 24.01 .19 and 31 .01 .19 to meet the needs of the residents occupying the home at the time. Agency staff on duty at the time had received appropriate training through their agency; which was evidenced within the contract with them. The same agency staff attended the home to maintain continuity.
24.01 .10: Staffing levels during the day included; the Registered nurse manager, a registered nurse and 4 care staff and an activities person in the day and one registered nurse and two care staff at night. The total number of residents in the home on the 24.01 .19 were 27. Eight of which required nursing care and the remaining required social and personal care. 31 .01.19: Staffing levels on this day were I registered nurse manager, 2 nurses and 9 carers and an activities person, one carer being on induction day, and the second nurse was supernumery for care planning a ratio of 1-3, and 1 nurse and 2 carers at night, a ratio of 1-8 28 residents were in the home in total 8 requiring nursing care and the remaining social and personal care DE had not been assessed as requiring 1-1 care therefore usual observations and checks were undertaken. Staff complete training before commencing employment. During the probation period a full induction is completed and supervision is provided. Staff with prior care experience are employed where possible. No summons was received by the manager or any other staff to attend the inquest. Please accept our apologies as none of the staff would knowingly not attend . . Actions: We have reviewed all our falls risk assessments we work in partnership with OTs to discuss suitable equipment and this is ongoing and falls training is available for all staff. Registered Manger 27 .03.2020
• Care records
• Interviews with staff present during incident
• Rotas
• Allocation sheets
• Resident occupancy sheets
• Accident reports FINDINGS
24.01 .19 There were two staff on duty during the day and one carer and a 'floating' nurse at night. There were four residents on the unit.
31.01 .19 There was a registered nurse and an agency carer on the unit when he fell. Staff to resident ratio was 2-4 at the time of the fall. The fall was witnessed by the carer who did not see him hit his head. He was checked over by the nurse who was giving medication at the time. The investigation has demonstrated that there were sufficient, suitably qualified, staff on duty on 24.01 .19 and 31 .01 .19 to meet the needs of the residents occupying the home at the time. Agency staff on duty at the time had received appropriate training through their agency; which was evidenced within the contract with them. The same agency staff attended the home to maintain continuity.
24.01 .10: Staffing levels during the day included; the Registered nurse manager, a registered nurse and 4 care staff and an activities person in the day and one registered nurse and two care staff at night. The total number of residents in the home on the 24.01 .19 were 27. Eight of which required nursing care and the remaining required social and personal care. 31 .01.19: Staffing levels on this day were I registered nurse manager, 2 nurses and 9 carers and an activities person, one carer being on induction day, and the second nurse was supernumery for care planning a ratio of 1-3, and 1 nurse and 2 carers at night, a ratio of 1-8 28 residents were in the home in total 8 requiring nursing care and the remaining social and personal care DE had not been assessed as requiring 1-1 care therefore usual observations and checks were undertaken. Staff complete training before commencing employment. During the probation period a full induction is completed and supervision is provided. Staff with prior care experience are employed where possible. No summons was received by the manager or any other staff to attend the inquest. Please accept our apologies as none of the staff would knowingly not attend . . Actions: We have reviewed all our falls risk assessments we work in partnership with OTs to discuss suitable equipment and this is ongoing and falls training is available for all staff. Registered Manger 27 .03.2020