HC One
Other
Action Taken
HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; CQC inspection evidenced significant improvements in the quality and safety of care. (AI summary)
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Dear Ms Gillespie, write to inform YOU of the actions taken at HC-One in response to Regulation 28 to prevent future death Following the inquest into the death of Mr. Goldby, we at HC-One, undertook a full review of the systems and processes in Stoneyford care home and our organisation: We allocated an Operational Project Manager, whose role is to support the review of SMART actions stipulated within the Home Improvement Plan to improve and sustain positive outcomes for Residents safety and well-being at the home This process enables the team in the home to make the changes without the additional administrative burden of managing the action plan and ensuring that there is robust follow Up and escalation for any issues that are evidenced to be 'off track with target. The Area Quality Director and Regional Quality Director attended Stoneyford and reviewed the care and support needs of each individual person accommodated and re-planned their care aS appropriate. The following actions were taken: Allocation of staff to and practical supervision of Residents whilst eating and drinking to assess any issues_ 2 Completion of the swallowing risk assessment with independent validation from another senior colleague to ensure accurate scoring and corresponding actions to mitigate risk are adhered to. This system remains in place with the Care Manager reviewing and signing off any updates: 3 All Residents whose assessment indicated having reached the appropriate threshold of need have been referred to the Speech and Language team (SALT) service via the GP for review- New referrals have also been actioned and follow-ups reviews have been planned by SALT- 2 existing Residents are due a review, which have been scheduled: The Care Manager taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support. This has been reported by all parties as very much improved, with greater clarity and swifter partnership working: HC-One 101325 351100 F 01325 351144 Correspondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH Registered in England and Wales: HC-One Limited, registration no. 07712656; Meridian Healthcare Limited, registration no. 01952719; HC-One Beamish Limited, registration no. 05217764; HC-One Oval Limited, registration no. 10257888; RV Care Homes Limited. registration no. 07417290. has
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5. All existing fluid/diet requirements SALT were shared with the whole team of colleagues working at the home. This includes the catering team, as well as housekeeping, care and nursing colleagues to ensure that as one team, the staff act as additional eyes and ears to protect Residents and prevent harm.
6. Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet_ As & result we have introduced new system of dining registers with quick reference guides, which were into place and help colleagues or any agency workers to reflect the handover documentation: These guides are reviewed every week, regardless if there are any changes, or immediately by the senior care staff, if any changes in a Resident's health or needs have been identified. There is a formal update process in place and this is discussed daily at the flash meeting with a prompted question within the documentation in case it is someone unfamiliar with the process who leads this meeting: The governance for this is managed by the care manager and then the area quality management team as a further check_ 8 The manager and staff at the home have implemented a Resident of the day' approach to care plan reviews which means that a designated Resident has their care and support needs reviewed every day to ensure any changes are reflected in updated care plans and shared with colleagues who support them: Any changes in need are reported monthly through to the clinical risk register, which is monitored by the Senior Turnaround Manager working at the home and the Area quality management Team We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone All colleagues working at the home have received supervision to support them with their working practices and which has led to the identification of any gaps in knowledge and sourcing of learning opportunities to support them in their roles Areas covered have included understanding Resident'$ needs, identification of changing needs, escalation processes, role profiles for each specific job, responsibilities and accountability, the vision and values of the organisation and the prioritisation of the delivery of high quality and kind care The hospitality specialist has supported the home and worked with colleagues working in the kitchen to implement and embed the policy and process that is required to be in place.
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HC The kind one care tompanr The Catering Manager in the home has developed their own review process for long term updates of diet notifications where Residents care needs haven't changed: The catering team have taken a proactive approach to the concerns raised: This process developed within Stoneyford will now form part of the governance strategy for managing the risk of choking across HC-One We recognise the seriousness of the issues raised by the death of Mr: Goldby and correspondingly have committed considerable resources to give ourselves, the Resident, family and external partners and regulators trust and confidence that we can ensure the safety of all of the Residents who currently reside within Stoneyford_ We continued, like many care providers, to find significant challenges in recruiting a stable nursing workforce and have addressed this through the cancellation of the regulated activity of nursing at this home: This is being processed by the CQC and will be completed when the final four nursing Residents are safely transferred to suitable alternative accommodation_ We believe this will reduce the acuity of the people accommodated at the home and the inherent risks associated in managing care with a lack of stability in the nursing team: Whilst this process is being managed we have sustained senior management cover at the home days a week to oversee the process. At this time there are 4 Residents currently requiring nursing care with expected safe discharge by end of June 2018 and subsequent closure of the nursing service. There is & registered manager in place who is & Senior Turnaround Manager and a newly appointed Care Manager whose background is in Residential care services As mentioned, this team has been working across 7 days/nights to ensure that the actions we have planned are being progressed and embedded with the care team: CQC completed a comprehensive inspection at the home on 24 and 25 April 2018 and the final report has since been published: The previous report the October inspection evidenced breaches on regulations around safe care and treatment of Resident, Need for consent, meeting people'$ nutritional and hydration needs, person-centred care and good governance_ The April report has evidenced that all of these issues have been satisfactorily addressed, there have been significant improvements in the quality and safety of care and support, there are no regulatory breaches and resultantly the home has moved out of special measures with an improved rating: We believe that this has evidenced that the team in the home have worked with the people care for and external professionals to achieve positive outcomes and is reflective that the actions have been achieved and that we continue to work towards ensuring the sustainability of all the learning; good practice and processes that have been refreshed at the home_ Ido hope that this response offers YOU sufficient assurance that we have acted with diligence_ thoroughness and commitment to ensure the appropriate lessons have been learned and
from they
HC The kind one care tompant necessary actions taken to reduce the likelihood of any repetition of the tragic circumstances that lead to the issue of this regulation 28 report.
HC kind one tare tomparut
5. All existing fluid/diet requirements SALT were shared with the whole team of colleagues working at the home. This includes the catering team, as well as housekeeping, care and nursing colleagues to ensure that as one team, the staff act as additional eyes and ears to protect Residents and prevent harm.
6. Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet_ As & result we have introduced new system of dining registers with quick reference guides, which were into place and help colleagues or any agency workers to reflect the handover documentation: These guides are reviewed every week, regardless if there are any changes, or immediately by the senior care staff, if any changes in a Resident's health or needs have been identified. There is a formal update process in place and this is discussed daily at the flash meeting with a prompted question within the documentation in case it is someone unfamiliar with the process who leads this meeting: The governance for this is managed by the care manager and then the area quality management team as a further check_ 8 The manager and staff at the home have implemented a Resident of the day' approach to care plan reviews which means that a designated Resident has their care and support needs reviewed every day to ensure any changes are reflected in updated care plans and shared with colleagues who support them: Any changes in need are reported monthly through to the clinical risk register, which is monitored by the Senior Turnaround Manager working at the home and the Area quality management Team We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone All colleagues working at the home have received supervision to support them with their working practices and which has led to the identification of any gaps in knowledge and sourcing of learning opportunities to support them in their roles Areas covered have included understanding Resident'$ needs, identification of changing needs, escalation processes, role profiles for each specific job, responsibilities and accountability, the vision and values of the organisation and the prioritisation of the delivery of high quality and kind care The hospitality specialist has supported the home and worked with colleagues working in the kitchen to implement and embed the policy and process that is required to be in place.
The from put fully
HC The kind one care tompanr The Catering Manager in the home has developed their own review process for long term updates of diet notifications where Residents care needs haven't changed: The catering team have taken a proactive approach to the concerns raised: This process developed within Stoneyford will now form part of the governance strategy for managing the risk of choking across HC-One We recognise the seriousness of the issues raised by the death of Mr: Goldby and correspondingly have committed considerable resources to give ourselves, the Resident, family and external partners and regulators trust and confidence that we can ensure the safety of all of the Residents who currently reside within Stoneyford_ We continued, like many care providers, to find significant challenges in recruiting a stable nursing workforce and have addressed this through the cancellation of the regulated activity of nursing at this home: This is being processed by the CQC and will be completed when the final four nursing Residents are safely transferred to suitable alternative accommodation_ We believe this will reduce the acuity of the people accommodated at the home and the inherent risks associated in managing care with a lack of stability in the nursing team: Whilst this process is being managed we have sustained senior management cover at the home days a week to oversee the process. At this time there are 4 Residents currently requiring nursing care with expected safe discharge by end of June 2018 and subsequent closure of the nursing service. There is & registered manager in place who is & Senior Turnaround Manager and a newly appointed Care Manager whose background is in Residential care services As mentioned, this team has been working across 7 days/nights to ensure that the actions we have planned are being progressed and embedded with the care team: CQC completed a comprehensive inspection at the home on 24 and 25 April 2018 and the final report has since been published: The previous report the October inspection evidenced breaches on regulations around safe care and treatment of Resident, Need for consent, meeting people'$ nutritional and hydration needs, person-centred care and good governance_ The April report has evidenced that all of these issues have been satisfactorily addressed, there have been significant improvements in the quality and safety of care and support, there are no regulatory breaches and resultantly the home has moved out of special measures with an improved rating: We believe that this has evidenced that the team in the home have worked with the people care for and external professionals to achieve positive outcomes and is reflective that the actions have been achieved and that we continue to work towards ensuring the sustainability of all the learning; good practice and processes that have been refreshed at the home_ Ido hope that this response offers YOU sufficient assurance that we have acted with diligence_ thoroughness and commitment to ensure the appropriate lessons have been learned and
from they
HC The kind one care tompant necessary actions taken to reduce the likelihood of any repetition of the tragic circumstances that lead to the issue of this regulation 28 report.