The Kind Care Company
Action Taken
HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system. (AI summary)
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Dear Ms. Galloway,
Regulation 28 Prevention of future death report following inquest into the death of Robert Charles Rostron
I write in response to your letter of 11 July 2019 requesting written information and supporting evidence about action taken since the death of Mr. Rostron to reduce the risk of a similar incident occurring.
With regard to Four Seasons in particular, you will probably be aware that the Discharge to Assess service, where the incident occurred, is no longer being delivered. Whilst we continually work hard to reduce agency use, we also recognise that the reality of running care homes means that this remains a necessity to ensure that there are always sufficient staff available to support the needs of the people accommodated. We are required to pay a premium for nurse qualified staff in such circumstances, because of the assurances this provides in relation to training and fitness to practice to ensure their continued registration.
We, at HC-One, have been and remain committed to acting in whatever ways possible to ensure that we reduce the possibility of any recurrence of this incident and maintain the safety of all our Residents.
I will respond to each of your concerns in turn.
1. Agency nurses are still used, if necessary to lead a shift, when they have never worked on the unit before There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.
All agency staff are block booked as far as possible to maximise knowledge of HC-One standards and also individual Residents’ needs across individual homes.
It is still possible that an agency nurse might lead a shift at a home, but we have reduced the risk by reviewing and strengthening the Orientation booklet for agency staff, which is due for completion and distribution across the company by the end of October 2019.
2. An agency nurse might still be the only qualified member of the nursing staff on duty on the unit. It is possible that an agency nurse might be the only qualified nurse on duty, however this is much less likely now. Nevertheless, many of our homes operate with rigorously trained nursing assistants, who have completed NMC accredited training that includes medicine giving, which includes clarity on the need for there to always be two staff present when administering this medicine. In addition, an agency nurse is always supplied with contact details of other nurses working within the same home, senior managers outside of the home who are on call on a rota basis and available to offer advice 24 hours a day for seven days a week. Details of this are posted in the nurse station, which is included in the orientation booklet that both the agency nurse and senior staff member sharing are required to sign and a copy is kept on the agency nurses file at the home, as well as them being supplied their own copy for reference.
3. There is reliance upon a nursing qualification and agency providing the Agency Nurse regarding nursing ability, suitability and training. The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement. I have attached a copy of the checklist for your attention (Appendix 1). This negates any reliance on the nursing qualification by specifically ensuring we have verified training and qualifications. We stipulate the required nursing qualification on making the booking with the agency and the Home Manager has the facility to choose from a series of profiles and makes a positive choice of nurse who has provided evidence as having the necessary and appropriate registered general nursing qualification as a minimum.
Concerns 4 – 8: In this instance, the only induction to the Unit was by way of a Healthcare Assistant showing the Agency Nurse around on the morning of the shift. The agency nurse did not appreciate the relevance of the blood sugar level of 2.2. The agency nurse did not appreciate that no insulin should have been given in light of reading 2.2. The agency nurse did not know where the records were, the care plan for the patients or the relevant policies and procedures in place. The agency nurse did not know that it was policy of HC-One that insulin should only be given by him whilst a Nursing Assistant was present to check the dose. As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home. I have supplied a copy of our Administration of High Risk Medicines procedure (Appendix
2) as there is a relevant section regarding insulin, indicating the necessity for all insulin administration to be supported by two colleagues. This is covered in the checklist now because of the lessons learned from the agency worker deviating from the procedure. Operational colleagues overseeing this home crafted and completed a Home Improvement Plan for Four Seasons, which detailed many of the actions we had determined would both improve safety of Residents who required support with insulin administration and management and have attached an updated version (Appendix 3), which provides assurances around the completion of these actions and outcomes. Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix
4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised. The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.
I trust this information is helpful and offers the necessary assurances that we have taken the situation extremely seriously and continue to review and strive to make continued improvements in the best interests of our Residents.
Regulation 28 Prevention of future death report following inquest into the death of Robert Charles Rostron
I write in response to your letter of 11 July 2019 requesting written information and supporting evidence about action taken since the death of Mr. Rostron to reduce the risk of a similar incident occurring.
With regard to Four Seasons in particular, you will probably be aware that the Discharge to Assess service, where the incident occurred, is no longer being delivered. Whilst we continually work hard to reduce agency use, we also recognise that the reality of running care homes means that this remains a necessity to ensure that there are always sufficient staff available to support the needs of the people accommodated. We are required to pay a premium for nurse qualified staff in such circumstances, because of the assurances this provides in relation to training and fitness to practice to ensure their continued registration.
We, at HC-One, have been and remain committed to acting in whatever ways possible to ensure that we reduce the possibility of any recurrence of this incident and maintain the safety of all our Residents.
I will respond to each of your concerns in turn.
1. Agency nurses are still used, if necessary to lead a shift, when they have never worked on the unit before There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.
All agency staff are block booked as far as possible to maximise knowledge of HC-One standards and also individual Residents’ needs across individual homes.
It is still possible that an agency nurse might lead a shift at a home, but we have reduced the risk by reviewing and strengthening the Orientation booklet for agency staff, which is due for completion and distribution across the company by the end of October 2019.
2. An agency nurse might still be the only qualified member of the nursing staff on duty on the unit. It is possible that an agency nurse might be the only qualified nurse on duty, however this is much less likely now. Nevertheless, many of our homes operate with rigorously trained nursing assistants, who have completed NMC accredited training that includes medicine giving, which includes clarity on the need for there to always be two staff present when administering this medicine. In addition, an agency nurse is always supplied with contact details of other nurses working within the same home, senior managers outside of the home who are on call on a rota basis and available to offer advice 24 hours a day for seven days a week. Details of this are posted in the nurse station, which is included in the orientation booklet that both the agency nurse and senior staff member sharing are required to sign and a copy is kept on the agency nurses file at the home, as well as them being supplied their own copy for reference.
3. There is reliance upon a nursing qualification and agency providing the Agency Nurse regarding nursing ability, suitability and training. The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement. I have attached a copy of the checklist for your attention (Appendix 1). This negates any reliance on the nursing qualification by specifically ensuring we have verified training and qualifications. We stipulate the required nursing qualification on making the booking with the agency and the Home Manager has the facility to choose from a series of profiles and makes a positive choice of nurse who has provided evidence as having the necessary and appropriate registered general nursing qualification as a minimum.
Concerns 4 – 8: In this instance, the only induction to the Unit was by way of a Healthcare Assistant showing the Agency Nurse around on the morning of the shift. The agency nurse did not appreciate the relevance of the blood sugar level of 2.2. The agency nurse did not appreciate that no insulin should have been given in light of reading 2.2. The agency nurse did not know where the records were, the care plan for the patients or the relevant policies and procedures in place. The agency nurse did not know that it was policy of HC-One that insulin should only be given by him whilst a Nursing Assistant was present to check the dose. As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home. I have supplied a copy of our Administration of High Risk Medicines procedure (Appendix
2) as there is a relevant section regarding insulin, indicating the necessity for all insulin administration to be supported by two colleagues. This is covered in the checklist now because of the lessons learned from the agency worker deviating from the procedure. Operational colleagues overseeing this home crafted and completed a Home Improvement Plan for Four Seasons, which detailed many of the actions we had determined would both improve safety of Residents who required support with insulin administration and management and have attached an updated version (Appendix 3), which provides assurances around the completion of these actions and outcomes. Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix
4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised. The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.
I trust this information is helpful and offers the necessary assurances that we have taken the situation extremely seriously and continue to review and strive to make continued improvements in the best interests of our Residents.