William Tolen
Action Taken
Staff have received further supervision and training in relation to documentation, and instructions have been added to staff diaries. Staff have been requested that requests are stated clearly and that progress is recorded, and all nurses have discussed the need to enter details fully in the daily notes. (AI summary)
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Regulation 28 Report- Shawe Lodge- 16 November 2015
1. AlL have received further supervision and training in relation to documentation. This is process that in March and improvement is evident in current documentation, Instructions have been added to in relation to your specific concerns
2. Staff requested & visit from & private podiatrist in relation to & corn on Mr Tolen's right toe. There was no evidence of infection and the visit; although required, was not deemed to be of an urgent nature. It has been requested of all staff that failure to receive a response to & message left should be reported immediately to a senior member of staff; 3 The Clinical Manager's response to your concern about training Was intended to indicate that staff did not have training specific to podiatry requests. All nurses are aware of the procedure to follow should they have difficulty obtaining medical assistance. This support is available constantly through an established on call system within the home 4, Circumstances surrounding Mr Tolen'$ admission to hospital were discussed by management at the time and were deemed to have acted immediately and appropriately in relation to suspected cellulitis An investigation was carried out at the end of in relation to actions surrounding the discovery of possible cellulitis at the request of the Safeguarding Teancaod submitted to them on 2 June; Staff appear to have acted promptly on discovery of imflammation to Tolen's left lower leg and when visited by t was not considered to be in need of antibiotic treatment: Staff also acted promptly the next requesting further visit due to deterioration and suggesting transfer to hospital To date the outcome has not been received although we were informed that an inquest was to be held
5. The notes written by staff at Shawe Lodge did not indicate that Mr Tolen's nail had been removed. This was an made by the podiatrist; The subsequent investigation for safeguarding contained an error made by myself when attempting to decipher the shorthand and abbreviation used by the podiatrist; All visiting professionals have been advised that the home will not accept the use of abbreviation and our own staff have also been reminded of this.
6. The is used as a communication tool from one shift to the next Or as & reminder to themselves of what is required to be done the next As it is a document that relates to more than one resident details are kept to & minimum and should refer the reader to the resident's own notes_ would agree however that the notes are too brief and did not contain clear instruction Or request. Neither did contain clear explanation of progress to date. It has been requested of all staff that requests are stated clearly and that progress is recorded rather than ticking the message. The home does not have a GP visit book Or an MDT visit book: This information is on sheets at the front of the resident daily notes and is intended to provide a quick reference to previous visits thereby removing the need to read through weeks or months of daily reports These sheets should not; however; be used as & substitute for recording in the daily notes. All details should be entered in full in the daily notes with a brief explanation entered on the visit record. This been discussed with all nurses and is monitored regularly: 7 _ The podiatrist stated at the inquest that staff were available; and initially present; to help with persuading Mr Tolen to move to another location but that Mr Tolen refused. Mr Tolen was independently mobile and his reasons for not were down to choice rather than ability. Whilst Mr Tolen had no issue with his feet examined he became physically aggressive when it was suggested that he should move. staff = began staff May Mr day entry diary day: they kept being has being moving having `
8. The podiatrist made the decision to examine Mr Tolen's feet in the lounge but this is not the policy of the home whether Or not a procedure is planned. Staff have been requested to ensure that all intervention from any member ofthe MDT is carried out in the resident's own room; If this is not possible, for any reason; the appointment should be rescheduled 9 Staff from Shawe Lodge did not advise that Mr Tolen was subject to a DoLS authorisation. This claim was made by Mr Tolen's wife and confirmed by her friend. Staff the home disputed this claim but advised that, due to & between authorisations being requested and granted, could not confirm that one had never been requested without having access to his full notes which were not brought to the inquest This information was confirmed the next as requested. fron delay they day
1. AlL have received further supervision and training in relation to documentation. This is process that in March and improvement is evident in current documentation, Instructions have been added to in relation to your specific concerns
2. Staff requested & visit from & private podiatrist in relation to & corn on Mr Tolen's right toe. There was no evidence of infection and the visit; although required, was not deemed to be of an urgent nature. It has been requested of all staff that failure to receive a response to & message left should be reported immediately to a senior member of staff; 3 The Clinical Manager's response to your concern about training Was intended to indicate that staff did not have training specific to podiatry requests. All nurses are aware of the procedure to follow should they have difficulty obtaining medical assistance. This support is available constantly through an established on call system within the home 4, Circumstances surrounding Mr Tolen'$ admission to hospital were discussed by management at the time and were deemed to have acted immediately and appropriately in relation to suspected cellulitis An investigation was carried out at the end of in relation to actions surrounding the discovery of possible cellulitis at the request of the Safeguarding Teancaod submitted to them on 2 June; Staff appear to have acted promptly on discovery of imflammation to Tolen's left lower leg and when visited by t was not considered to be in need of antibiotic treatment: Staff also acted promptly the next requesting further visit due to deterioration and suggesting transfer to hospital To date the outcome has not been received although we were informed that an inquest was to be held
5. The notes written by staff at Shawe Lodge did not indicate that Mr Tolen's nail had been removed. This was an made by the podiatrist; The subsequent investigation for safeguarding contained an error made by myself when attempting to decipher the shorthand and abbreviation used by the podiatrist; All visiting professionals have been advised that the home will not accept the use of abbreviation and our own staff have also been reminded of this.
6. The is used as a communication tool from one shift to the next Or as & reminder to themselves of what is required to be done the next As it is a document that relates to more than one resident details are kept to & minimum and should refer the reader to the resident's own notes_ would agree however that the notes are too brief and did not contain clear instruction Or request. Neither did contain clear explanation of progress to date. It has been requested of all staff that requests are stated clearly and that progress is recorded rather than ticking the message. The home does not have a GP visit book Or an MDT visit book: This information is on sheets at the front of the resident daily notes and is intended to provide a quick reference to previous visits thereby removing the need to read through weeks or months of daily reports These sheets should not; however; be used as & substitute for recording in the daily notes. All details should be entered in full in the daily notes with a brief explanation entered on the visit record. This been discussed with all nurses and is monitored regularly: 7 _ The podiatrist stated at the inquest that staff were available; and initially present; to help with persuading Mr Tolen to move to another location but that Mr Tolen refused. Mr Tolen was independently mobile and his reasons for not were down to choice rather than ability. Whilst Mr Tolen had no issue with his feet examined he became physically aggressive when it was suggested that he should move. staff = began staff May Mr day entry diary day: they kept being has being moving having `
8. The podiatrist made the decision to examine Mr Tolen's feet in the lounge but this is not the policy of the home whether Or not a procedure is planned. Staff have been requested to ensure that all intervention from any member ofthe MDT is carried out in the resident's own room; If this is not possible, for any reason; the appointment should be rescheduled 9 Staff from Shawe Lodge did not advise that Mr Tolen was subject to a DoLS authorisation. This claim was made by Mr Tolen's wife and confirmed by her friend. Staff the home disputed this claim but advised that, due to & between authorisations being requested and granted, could not confirm that one had never been requested without having access to his full notes which were not brought to the inquest This information was confirmed the next as requested. fron delay they day