Cole Valley Nursing Home
Action Taken
New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide strong leadership and governance is to commence employment at the Home before the end of April 2019. (AI summary)
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Dear Mr Bennett,
I write further to your “Regulation 28 Report to Prevent Future Deaths” dated 08th February 2019 and issued following the conclusion of your investigation into the death of Jean Mary Cutler at the end of an inquest on 25th January 2019. As noted, the inquest concluded that Ms. Cutler died from “a combination of natural causes, namely osteoporosis and an accidental fall”. It is also noted your concern arising during the inquest that “there is a risk that future deaths will occur unless action is taken”.
Paragraph five of your report cites “Coroner’s Concerns” as;
i) Cole Valley Nursing Home…cares for…residents who are vulnerable due to their age and physical and mental issues. ii) …the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; iii) …the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time…revealing the inadequacy of this as a safety measure…there remains a risk of vulnerable residents falling out of wheelchairs. iv) …the post incident investigation was inadequate and lessons have not been learned. v) The current falls Risk Management and Risk Assessment…continue to place reliance on the presence of a staff member to prevent falls…the falls risk assessment has not been adequately completed.
Cole Valley Nursing Home (hereinafter referred to as “the Home”) takes its obligation and duty to safeguard all persons entrusted into the Home’s care seriously and, after conclusion of the inquest and receipt of your report, has taken the following actions to rectify and address your concerns;
i) Over the previous six-month period the Home has experienced a rather unsettling period due to several managerial changes which resulted in a
lack of effective governance and oversight. To compound issues, staff had been instructed by previous management not to use lap belts due to the risk of strangulation. This, however, had not been explored through comprehensive risk assessment. On 23rd February 2019 the Home’s manager was removed from post (as a result of additional concerns being identified about the manager’s action(s) and inaction(s). The Home has sought and sourced a Consultant Advisor to support improvements within the Home and service provision with effect from 12th March 2019 – on an initial six-month contract. Part of his responsibility includes recruiting a competent and experienced permanent manager who will safeguard the interests of people living at the Home. A new competent, experienced and dynamic manager who will provide strong leadership and governance is to commence employment at the Home before the end of April 2019.
ii) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a “Low”, “Medium” or “High” risk rating (colour-coded Green, Amber or Red) and incorporate suggestions for risk management dependent on the level of risk identified. Risks will be recalculated on a (minimum) monthly basis (but sooner should an individual’s condition change i.e. through the contraction of an acute infection). Initial FRAs for people living in the Home were completed 03rd April 2019.
An anonymised sample Falls Risk Assessment is demonstrated as follows:
Page 9 of 9
v) All nursing and care staff working at the Home have been made aware of the new Falls Risk Assessments and Wheelchair Risk Assessments during handover and in staff meetings. The new risk assessments are available within each person’s care folder – which staff have access to throughout the 24-hour period. The protocol for ensuring lap belts are used when people use their wheelchairs (as specified within the new Wheelchair Risk Assessment) has been reiterated to all staff and appropriate use and implementation is monitored by members of the Home’s management team.
Cole Valley Nursing Home and its Directors accept and acknowledge the Coroner’s Concerns and believe that the control measures implemented by the Home serves to demonstrate how the Home and Cole Valley Care Ltd. have resolved said concerns - learning from both the inquest and the concerns detailed within your Regulation 28 report.
Assuring you of our continual commitment to learn and prevent.
I write further to your “Regulation 28 Report to Prevent Future Deaths” dated 08th February 2019 and issued following the conclusion of your investigation into the death of Jean Mary Cutler at the end of an inquest on 25th January 2019. As noted, the inquest concluded that Ms. Cutler died from “a combination of natural causes, namely osteoporosis and an accidental fall”. It is also noted your concern arising during the inquest that “there is a risk that future deaths will occur unless action is taken”.
Paragraph five of your report cites “Coroner’s Concerns” as;
i) Cole Valley Nursing Home…cares for…residents who are vulnerable due to their age and physical and mental issues. ii) …the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; iii) …the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time…revealing the inadequacy of this as a safety measure…there remains a risk of vulnerable residents falling out of wheelchairs. iv) …the post incident investigation was inadequate and lessons have not been learned. v) The current falls Risk Management and Risk Assessment…continue to place reliance on the presence of a staff member to prevent falls…the falls risk assessment has not been adequately completed.
Cole Valley Nursing Home (hereinafter referred to as “the Home”) takes its obligation and duty to safeguard all persons entrusted into the Home’s care seriously and, after conclusion of the inquest and receipt of your report, has taken the following actions to rectify and address your concerns;
i) Over the previous six-month period the Home has experienced a rather unsettling period due to several managerial changes which resulted in a
lack of effective governance and oversight. To compound issues, staff had been instructed by previous management not to use lap belts due to the risk of strangulation. This, however, had not been explored through comprehensive risk assessment. On 23rd February 2019 the Home’s manager was removed from post (as a result of additional concerns being identified about the manager’s action(s) and inaction(s). The Home has sought and sourced a Consultant Advisor to support improvements within the Home and service provision with effect from 12th March 2019 – on an initial six-month contract. Part of his responsibility includes recruiting a competent and experienced permanent manager who will safeguard the interests of people living at the Home. A new competent, experienced and dynamic manager who will provide strong leadership and governance is to commence employment at the Home before the end of April 2019.
ii) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a “Low”, “Medium” or “High” risk rating (colour-coded Green, Amber or Red) and incorporate suggestions for risk management dependent on the level of risk identified. Risks will be recalculated on a (minimum) monthly basis (but sooner should an individual’s condition change i.e. through the contraction of an acute infection). Initial FRAs for people living in the Home were completed 03rd April 2019.
An anonymised sample Falls Risk Assessment is demonstrated as follows:
Page 9 of 9
v) All nursing and care staff working at the Home have been made aware of the new Falls Risk Assessments and Wheelchair Risk Assessments during handover and in staff meetings. The new risk assessments are available within each person’s care folder – which staff have access to throughout the 24-hour period. The protocol for ensuring lap belts are used when people use their wheelchairs (as specified within the new Wheelchair Risk Assessment) has been reiterated to all staff and appropriate use and implementation is monitored by members of the Home’s management team.
Cole Valley Nursing Home and its Directors accept and acknowledge the Coroner’s Concerns and believe that the control measures implemented by the Home serves to demonstrate how the Home and Cole Valley Care Ltd. have resolved said concerns - learning from both the inquest and the concerns detailed within your Regulation 28 report.
Assuring you of our continual commitment to learn and prevent.