Zinnia Healthcare
Other
Action Taken
Care plans now incorporate specific risk issues like falls, with monthly reviews and audits. Staff have been retrained and reminded to record incidents, and a new qualified nurse has been employed as Manager since February 2018. (AI summary)
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Head Office: Zinnia Healthcare Zinnia Healthcare Limited Suite 10, 792 Wilmslow Road, Didsbury; Yew Txee Manor Nursing Home Mzocbester: F.A.O. Nigel Meadows HM Senior Coroner 01-Feb-2019 HM Coroner's Office Manchester Area Exchange Floor The Royal Exchange Cross Street Manchster M2 7EF Re: Response to The Matters of Concerns (Regulation 28: Report to Prevent Future Deaths)
1. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise_ Care plans are now formulated to incorporate specific risk issues like falls; these are risk assessed and reviewed monthly: If a change had occurred since the last review, or occurs in-between this period, the risk is then assessed again with the new change(s) incorporated into the Residents care plan. Care plans are now audited to ensure reviews are done and the risks identified are managed appropriately. Initial care plans are created by the Manager/Business ManagerIRegistered Nurses using the pre- admission information gathered from the residentlrelativelprevious placement; and these are then extended and updated using further information identified after admission following further assessment of needs, risks and resident preferences and wishes Care plans reviewed by the Registered NursesiTeam Leaders/Business Manager and are overseen by the Manager on monthly basis are reviewed monthly or more often as needs change and are amended, resident wishes and preferences change, and families are kept aware of changes to treatment as appropriate
2. A failure to have appropriate daily observation records fully completed: In addition to staff been trained, they are reminded during staff meetings and one-to-one supervisions to record any incidentlaccident that occurs during their shift and to hand such over to the next shift: Staff member must be specific on the type of monitoring that they have undertaken following an incident or accident;
e.g. vital signs and physical examination of the Resident: are reminded that these must be recorded promptly and clearly_ 3 A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them_ From May 2018 several staff competency assessments have been completed. Also, supervision about record keeping have been completed The Manager has discussed with registered nurses how to access relevant information on NICE guidelines (including NICE Guidelines on head injury) , and these are available for staff to access at any time for reference Yew Trce Manor iS trading name of Zinia Healthcare Limited. Company Number: 02976391 Head Ollice Suite 10 792 Wilmslow Road Didsbury, Manchester MZO 6UG 0f 3 city are They having They
In addition to their professional training, all the nurses have access to a copy of the Clinical Procedures on the computer and a hard copy of The Royal Marsden Manual of Clinical Nursing Procedures both of which contain topics on falls prevention and what to do in the event of a fall and a falls protocol is in place and displayed for staff reference_
4. Failure to ensure sufficient numbers of adequately trained staff at all times Between August and November 2017, there was a home manager; deputy manager and nurse manager employed in the home, and registered nurses and care staff on duty 24 hours a day. The Directors have always strived to maintain sufficient numbers of adequately trained staff at all times_ The home now has in place staffing dependency tool to meet the assessed needs of the Residents monitored by the present manager: The Home Manager calculates the number of care and ancillary staff required in accordance with Resident needs to cover the relevant shifts. On occasions when any of our directly employed staff, for one reason or another; is not available, Manager, Deputy Manager, Business Manager, or most Senior staff on duty, calls one of the staffing agencies we use, to supply us staff in order that the absentee's role is covered. Agency staff profiles are always seen by the home before they come t0 ensure that their training is up to date to meet the assessed needs of the home: The home has embarked on extensive recruitment programme and have now recruited more registered nurses and team leaders who are nurses undergoing the IELTS to support the nurses and care staff: The Directors have sought and been granted Home Office sponsorship licence for the home in April 2018 to recruit nurses have since been on several foreign trips to recruit and prepare suitable candidates Some of the identified suitable candidates are currently preparing for both the IELTS and CBT tests_ The Directors sourced and procured a Mentorship update course for the Business Manager and Mentorship course for the Registered Manager and encouraged both to enrol: Both the managers have enrolled on these courses in preparation for the arrival of the newly appointed foreign nurses. Upon commencement at the home; each nurse will be mentored by both managers, undergo robust induction and training programme to ensure are suitably adapted and skilled to meet the needs of our Residents_ The home has implemented the use of a dependency tool provided by Manchester City Council (MCC). Dependency level is reviewed on monthly basis (or more often if required) with necessary adjustments made in the rota in accordance with the assessed needs of the Residents in-house and using the MCC tool. 5 . Failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents The home has through one-to-one supervisions, coupled with the Competency Assessments given clear guidelines to staff on when to seek medical help, also to refer to NICE guidelines for support: There is a file of NICE Guidelines available and accessible for all staff. The home has implemented a falls protocol chart for further guidance. This is available for all staff to access and reference at any time. Yew Tree Manor iS trading nanic of Zinnia Healthcare Limited. Company Vumber: 02976391 Head Ollice Suite 40 , 792 Wilnslow Road, Didsbury- Manchester MZO 6UG of3 the and they flow
6. Failure to ensure adequate supervision and governance of all relevant staff: Supervision and competency assessments are conducted regularly with all staff in robust fashion, and this comprises all areas of needs of the Residents The home's policies and procedures are discussed during one-to-one meetings, supervisions and staff meetings: 7 A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made and how the governance of the Home was being managed and regular checking of the quality of all records now kept The Manager during the period of August 2017 to October 2017, her deputy and Acting Manager are no longer in our employment: We are taking legal advice on the disciplinary measures with regards to the nurse on duty on the 16th of November as she did not properly hand over the incident which occurred during her shift. There has been change in management: A new Manager who is also qualified nurse has been employed since February 2018. Changes to practice and procedures have been made: Manager's daily walk around; accident and incidents reviews, daily checks, Resident of the implementation, training of relevant staff is undertaken regularly and as when needed, internal documentation changed to online based, wider range of audits are now carried out: As Providers, we look at the Managers monthly care plan audits_ She carries out these audits in her capacity as the Manager and as professional nurse to ensure that they include accurate levels of details, treatments or adjustments to reflect any changes in care needs. We visit the home and discuss the resident's welfare regularly on the premises and over the phone and via e- mail When not on the premises, we are available via e-mail and phone for the Manager and other staff The above information has also been passed to and reviewed by our CQC inspector and we continue to work with the local authority and external consultants to improve our service for residents it meets with your expectations. However; should you require further information please do not hesitate t0 revert to uS Kind regards MI= Directors Zinnia Healthcare Limited Yew Trec Manor is trading name of Zinnia Healthcare Limited. Company Number: 02976391 Head Ofice Suitc [0. 792 Wilnslow Road. Didsbury. Manchester A2O 6UG 0f 3 being day hope
1. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise_ Care plans are now formulated to incorporate specific risk issues like falls; these are risk assessed and reviewed monthly: If a change had occurred since the last review, or occurs in-between this period, the risk is then assessed again with the new change(s) incorporated into the Residents care plan. Care plans are now audited to ensure reviews are done and the risks identified are managed appropriately. Initial care plans are created by the Manager/Business ManagerIRegistered Nurses using the pre- admission information gathered from the residentlrelativelprevious placement; and these are then extended and updated using further information identified after admission following further assessment of needs, risks and resident preferences and wishes Care plans reviewed by the Registered NursesiTeam Leaders/Business Manager and are overseen by the Manager on monthly basis are reviewed monthly or more often as needs change and are amended, resident wishes and preferences change, and families are kept aware of changes to treatment as appropriate
2. A failure to have appropriate daily observation records fully completed: In addition to staff been trained, they are reminded during staff meetings and one-to-one supervisions to record any incidentlaccident that occurs during their shift and to hand such over to the next shift: Staff member must be specific on the type of monitoring that they have undertaken following an incident or accident;
e.g. vital signs and physical examination of the Resident: are reminded that these must be recorded promptly and clearly_ 3 A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them_ From May 2018 several staff competency assessments have been completed. Also, supervision about record keeping have been completed The Manager has discussed with registered nurses how to access relevant information on NICE guidelines (including NICE Guidelines on head injury) , and these are available for staff to access at any time for reference Yew Trce Manor iS trading name of Zinia Healthcare Limited. Company Number: 02976391 Head Ollice Suite 10 792 Wilmslow Road Didsbury, Manchester MZO 6UG 0f 3 city are They having They
In addition to their professional training, all the nurses have access to a copy of the Clinical Procedures on the computer and a hard copy of The Royal Marsden Manual of Clinical Nursing Procedures both of which contain topics on falls prevention and what to do in the event of a fall and a falls protocol is in place and displayed for staff reference_
4. Failure to ensure sufficient numbers of adequately trained staff at all times Between August and November 2017, there was a home manager; deputy manager and nurse manager employed in the home, and registered nurses and care staff on duty 24 hours a day. The Directors have always strived to maintain sufficient numbers of adequately trained staff at all times_ The home now has in place staffing dependency tool to meet the assessed needs of the Residents monitored by the present manager: The Home Manager calculates the number of care and ancillary staff required in accordance with Resident needs to cover the relevant shifts. On occasions when any of our directly employed staff, for one reason or another; is not available, Manager, Deputy Manager, Business Manager, or most Senior staff on duty, calls one of the staffing agencies we use, to supply us staff in order that the absentee's role is covered. Agency staff profiles are always seen by the home before they come t0 ensure that their training is up to date to meet the assessed needs of the home: The home has embarked on extensive recruitment programme and have now recruited more registered nurses and team leaders who are nurses undergoing the IELTS to support the nurses and care staff: The Directors have sought and been granted Home Office sponsorship licence for the home in April 2018 to recruit nurses have since been on several foreign trips to recruit and prepare suitable candidates Some of the identified suitable candidates are currently preparing for both the IELTS and CBT tests_ The Directors sourced and procured a Mentorship update course for the Business Manager and Mentorship course for the Registered Manager and encouraged both to enrol: Both the managers have enrolled on these courses in preparation for the arrival of the newly appointed foreign nurses. Upon commencement at the home; each nurse will be mentored by both managers, undergo robust induction and training programme to ensure are suitably adapted and skilled to meet the needs of our Residents_ The home has implemented the use of a dependency tool provided by Manchester City Council (MCC). Dependency level is reviewed on monthly basis (or more often if required) with necessary adjustments made in the rota in accordance with the assessed needs of the Residents in-house and using the MCC tool. 5 . Failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents The home has through one-to-one supervisions, coupled with the Competency Assessments given clear guidelines to staff on when to seek medical help, also to refer to NICE guidelines for support: There is a file of NICE Guidelines available and accessible for all staff. The home has implemented a falls protocol chart for further guidance. This is available for all staff to access and reference at any time. Yew Tree Manor iS trading nanic of Zinnia Healthcare Limited. Company Vumber: 02976391 Head Ollice Suite 40 , 792 Wilnslow Road, Didsbury- Manchester MZO 6UG of3 the and they flow
6. Failure to ensure adequate supervision and governance of all relevant staff: Supervision and competency assessments are conducted regularly with all staff in robust fashion, and this comprises all areas of needs of the Residents The home's policies and procedures are discussed during one-to-one meetings, supervisions and staff meetings: 7 A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made and how the governance of the Home was being managed and regular checking of the quality of all records now kept The Manager during the period of August 2017 to October 2017, her deputy and Acting Manager are no longer in our employment: We are taking legal advice on the disciplinary measures with regards to the nurse on duty on the 16th of November as she did not properly hand over the incident which occurred during her shift. There has been change in management: A new Manager who is also qualified nurse has been employed since February 2018. Changes to practice and procedures have been made: Manager's daily walk around; accident and incidents reviews, daily checks, Resident of the implementation, training of relevant staff is undertaken regularly and as when needed, internal documentation changed to online based, wider range of audits are now carried out: As Providers, we look at the Managers monthly care plan audits_ She carries out these audits in her capacity as the Manager and as professional nurse to ensure that they include accurate levels of details, treatments or adjustments to reflect any changes in care needs. We visit the home and discuss the resident's welfare regularly on the premises and over the phone and via e- mail When not on the premises, we are available via e-mail and phone for the Manager and other staff The above information has also been passed to and reviewed by our CQC inspector and we continue to work with the local authority and external consultants to improve our service for residents it meets with your expectations. However; should you require further information please do not hesitate t0 revert to uS Kind regards MI= Directors Zinnia Healthcare Limited Yew Trec Manor is trading name of Zinnia Healthcare Limited. Company Number: 02976391 Head Ofice Suitc [0. 792 Wilnslow Road. Didsbury. Manchester A2O 6UG 0f 3 being day hope