Elsie Brown

There was no falls risk assessment nor bed rails assessment in place for Mrs Brown;, nor was her mental capacity assessed Mrs Brown's care plan was incomplete_ unsigned, undated and never reviewed, despite Mrs Brown from her bed on 8 March 2015. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails There was a lack of clarity as to where the responsibility for an initial bed rails assessment lay.
5. There was an insufficiently robust auditing process, in that the omissions were not identified by Langwith Lodge nor by Your Health Ltd Brown's fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested, A member of staff who had responsibility for record making could not effectively and independently do so due to poor literacy skills That the night time provision of two staff members to cover the main Lodge and two to cover the Horton Suite (two separate but joined buildings) was not seen as a minimum requirement t0 ensure the health and safety of residents when at least one resident in each building needed the assistance of two carers but that from falling Mrs only three were regularly rostered for the night shift:
9. Handovers were not regarded as integral to the staffs paid shift and were informal and unpaid