John Stanley Care Agency
Other
Disputed
The care agency disputes responsibility, stating that they were not informed of Mr. Lyons' swallowing difficulties or risk of choking by social services or family, and therefore could not supervise him adequately during mealtimes. (AI summary)
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REPORT FROM JOHN STANLEY'S CARE AGENCY John Stanley's Care Agency is contracted by the London Borough of Havering to provide domiciliary care in the community, on behalf of the council, We were commissioned by Havering Social Services to provide care and support to Mr Michael Lyons. Once we have agreed to take a referral from Social Services, the following process takes place: A completed Support Planning document is received from a named Social Worker This document contains the Service User'$ medical history and all personal details This document also contains a care diary, instructing what tasks are to be completed and the length of time allocated for each visit Prior to the commencement of any service, we are required to carry out our own full and detailed care needs assessment with the service user and if desired, family member/advocate also in attendance_ would like to answer the following issues which you have raised in your report: CIRCUMSTANCES OF THE DEATH When the agency were first engaged, information was provided to them about Mr Lyons' difficulty with swallowing: Part of the need for carers to attend Mr Lyons was to assist and supervise him with feeding: 1st April 2014: The support planning paperwork we received clearly states the tasks we are expected to complete_ Each morning call was for 30 minutes duration and the duties were to support Mr Lyons with shaving, washing and dressing in clothes of his choice Assist to the toilet; empty and clean urinal bottle. Support with making breakfast and carrying to the table. Leave a of cold drink to hand. There is no mention of Mr Lyons having difficulty swallowing or any mention of him needing supervision whilst he eats 3rd April 2014: In line with our company policies and procedures, we conducted our own care needs assessment and Mr Lyons' sister was in attendance. It is clearly stated on the front of our assessment form that no other health/social care professionals are involved in Mr Lyons' care at this time_ We have ticked the box 'difficulty with swallowing' , however the recommendation from the sister at the time of assessment was to try thickener in drinks for 2 weeks. It was not clearly identified where this information came from. (See Appendix 2) 14th April 2014: There is a hand written note in the file from Mr Lyons' sister, stating he has to have thickener added and instructions how to do this. Once again, it is not stipulated where this information stems from. There is no mention of a special diet or high risk foods. jug
10th September 2014; An additional Support Planning document was received from Havering Social Services requesting this agency provide a 30 minute lunch call, a5 a result of Mr Lyons being discharged from hospital, following a fall at home: The tasks were to assist him with toileting, prompt medication and support with a meal and hot drink There was no mention of Mr Lyons requiring supervision when eating: Mr Lyons had been assessed by a speech and language therapist (SALT) in April and June 2014. The SALT provided recommendations for the management of his swallowing difficulties and these included providing a list of high risk foods and advice that he should be encouraged to eat slowly; he should take small bites and his food should be cut into small pieces before serving: The list of high risk foods included toast: heard evidence from Mr Lyons' sister, who confirmed that she had telephoned the John Stanley Agency to confirm that a SALT assessment had taken place: She could not recall whether she gave any detail of the recommendations made by the SALT, during the call: She stated that she left the list of recommendations including the list of foods by the Blue Book understand that the Blue Book is the book used by the Agency carers. It would appear from her evidence that some Of the carers were aware of the need to cut up Mr Lyons' food. It is possible that Mr Lyons moved the recommendations and list. am however satisfied that the Agency were aware of the need to in place steps to protect Mr Lyons from the risk of choking (i) from the information provided to them at the outset of their involvement and (ii) as & result of the call confirming that a SALT assessment had taken place: This information regarding the SALT assessment was not passed on to this agency: There is documented on our computer system concerning a phone call having been received, which would have necessitated the need for the care plan to be changed. Had we been made aware of an assessment taking place and specific recommendations in place regarding Mr Lyons' food, we would have clearly listed this on our assessment paperwork and care plan and informed all carers who were involved in Mr Lyons' care at that time_ In addition, we would have contacted Social Services informing them ofthe change in Mr Lyons' needs and requested revised paperwork to reflect these changes and the need for extra time to complete the tasks. The increase for the morning call would have been required, as it is impossible to carry out all the personal care tasks already stipulated on the care plan and supervise Mr Lyons' eating within the 30 minutes allocated by Social Services We have no paperwork stipulating that Mr Lyons was at risk of choking and, therefore, needed to be supervised for all meals. Notwithstanding the risk of choking, the care plan for Mr Lyons provided only for thickener to be added to his orange juice. There was no provision for supervision during eating or for his food to be cut up: The reason we had made provision for thickener to be added on the care plan is because Iwas present during our initial assessment and made this request at that time. Ms Newson had also placed a hand written note in our Service User Home Notes Folder ('Blue Book' on the 14th April 2014,requesting thickener is added to the juice. There is no evidence documented to say this had been in place as a consequence of a report from a SALT assessment put nothing being put put
MATTERS OF CONCERN The care agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014 We were aware that Mr Lyons had difficulty with swallowing a5 a consequence of his sister Jinforming us during our risk assessment. Our paperwork states that 'no other health/social care professionals are involved in Mr Lyons' care at this time. There is no information documented that we have been informed that a SALT assessment had taken place. There was no evidence that the care agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking As we were unaware that a SALT assessment had taken place, consequently we were unaware that there was a requirement for Us to cut up Mr Lyons' food. The care plan received from Social Services on 10th September which asked us to in an additional visit for lunch, made no reference to the fact that Mr Lyons' now needed to be observed whilst eating: Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23r September confirmed that she was not aware that food needed to be cut up. If that is the case, that information was never passed on to this office. All the log sheets (in the Home Notes Folder) from Zth April 2014 to 22n September 2014,have been audited and there is no documented evidence that food had been cut Up, or that care workers have waited until he had finished his food, It would also appear that toast was Mr Lyons' preferred choice of breakfast, as it is mentioned on numerous occasions_ AIl care workers are instructed to offer choice and respect service users' wishes. If a list of high risk foods had been available then ALL care workers would have been informed and the care plan and risk assessment would have reflected this. The care plan did not provide a management plan to protect Mr Lyons from the risk of choking: The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. The care plan did not specify food should be cut up and Mr Lyons should be supervised a5 we had not been made aware that a SALT assessment had taken place and that there were recommendations in place. In our initial assessment on 3rd April 2014, it is clearly stated other health/care professionals involved' At no time had there been any mention from Social Services that Mr Lyons is at risk from choking so should, therefore, be supervised at meal times If this information had been made known to us then we would have contacted Social Services and requested extra time, as it is impossible to support Mr Lyons with shaving, washing ad dressing in clothes of his choice, assist to the toilet; empty and clean urinal bottle, support with making breakfast and carry to the table, leave a jug of cold drink to hand and supervise him whilst he ate_
5. The care plan was dated 10th September 2014. The information from the SALT was available at the time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment: Our care plan dated the 10th September 2014,has the lunch visit entered, however, the tasks are not listed. We received paperwork from Social Services requesting an increase in care in the form of a put "no
lunch visit for Mr Lyons, as a direct result of him being discharged from hospital, following a fall at home: In fact, our Reviewing Officer had telephoned in order to make a appointment to complete the revised care plan, to include a lunch call: She was informed by husband that she was at the hospital with her other brother who was unwell: It was agreed with her that we would start the lunch call as per the instructions from Social Services, which were to assist Mr Lyons with toileting, prompt medication and support with a meal and hot drink The Reviewing Officer tried again to contacth however, the brother who was ill; had sadly passed away and asked if we could postpone the meeting until after the funeral, which we naturally agreed to, under the circumstances It is important to make clear that at no time whatsoever, had we been informed by either Havering Social Services or (that Mr Lyons was at risk of choking or in need of supervision whilst eating: Registered Manager
20.03.15 very
10th September 2014; An additional Support Planning document was received from Havering Social Services requesting this agency provide a 30 minute lunch call, a5 a result of Mr Lyons being discharged from hospital, following a fall at home: The tasks were to assist him with toileting, prompt medication and support with a meal and hot drink There was no mention of Mr Lyons requiring supervision when eating: Mr Lyons had been assessed by a speech and language therapist (SALT) in April and June 2014. The SALT provided recommendations for the management of his swallowing difficulties and these included providing a list of high risk foods and advice that he should be encouraged to eat slowly; he should take small bites and his food should be cut into small pieces before serving: The list of high risk foods included toast: heard evidence from Mr Lyons' sister, who confirmed that she had telephoned the John Stanley Agency to confirm that a SALT assessment had taken place: She could not recall whether she gave any detail of the recommendations made by the SALT, during the call: She stated that she left the list of recommendations including the list of foods by the Blue Book understand that the Blue Book is the book used by the Agency carers. It would appear from her evidence that some Of the carers were aware of the need to cut up Mr Lyons' food. It is possible that Mr Lyons moved the recommendations and list. am however satisfied that the Agency were aware of the need to in place steps to protect Mr Lyons from the risk of choking (i) from the information provided to them at the outset of their involvement and (ii) as & result of the call confirming that a SALT assessment had taken place: This information regarding the SALT assessment was not passed on to this agency: There is documented on our computer system concerning a phone call having been received, which would have necessitated the need for the care plan to be changed. Had we been made aware of an assessment taking place and specific recommendations in place regarding Mr Lyons' food, we would have clearly listed this on our assessment paperwork and care plan and informed all carers who were involved in Mr Lyons' care at that time_ In addition, we would have contacted Social Services informing them ofthe change in Mr Lyons' needs and requested revised paperwork to reflect these changes and the need for extra time to complete the tasks. The increase for the morning call would have been required, as it is impossible to carry out all the personal care tasks already stipulated on the care plan and supervise Mr Lyons' eating within the 30 minutes allocated by Social Services We have no paperwork stipulating that Mr Lyons was at risk of choking and, therefore, needed to be supervised for all meals. Notwithstanding the risk of choking, the care plan for Mr Lyons provided only for thickener to be added to his orange juice. There was no provision for supervision during eating or for his food to be cut up: The reason we had made provision for thickener to be added on the care plan is because Iwas present during our initial assessment and made this request at that time. Ms Newson had also placed a hand written note in our Service User Home Notes Folder ('Blue Book' on the 14th April 2014,requesting thickener is added to the juice. There is no evidence documented to say this had been in place as a consequence of a report from a SALT assessment put nothing being put put
MATTERS OF CONCERN The care agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014 We were aware that Mr Lyons had difficulty with swallowing a5 a consequence of his sister Jinforming us during our risk assessment. Our paperwork states that 'no other health/social care professionals are involved in Mr Lyons' care at this time. There is no information documented that we have been informed that a SALT assessment had taken place. There was no evidence that the care agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking As we were unaware that a SALT assessment had taken place, consequently we were unaware that there was a requirement for Us to cut up Mr Lyons' food. The care plan received from Social Services on 10th September which asked us to in an additional visit for lunch, made no reference to the fact that Mr Lyons' now needed to be observed whilst eating: Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23r September confirmed that she was not aware that food needed to be cut up. If that is the case, that information was never passed on to this office. All the log sheets (in the Home Notes Folder) from Zth April 2014 to 22n September 2014,have been audited and there is no documented evidence that food had been cut Up, or that care workers have waited until he had finished his food, It would also appear that toast was Mr Lyons' preferred choice of breakfast, as it is mentioned on numerous occasions_ AIl care workers are instructed to offer choice and respect service users' wishes. If a list of high risk foods had been available then ALL care workers would have been informed and the care plan and risk assessment would have reflected this. The care plan did not provide a management plan to protect Mr Lyons from the risk of choking: The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. The care plan did not specify food should be cut up and Mr Lyons should be supervised a5 we had not been made aware that a SALT assessment had taken place and that there were recommendations in place. In our initial assessment on 3rd April 2014, it is clearly stated other health/care professionals involved' At no time had there been any mention from Social Services that Mr Lyons is at risk from choking so should, therefore, be supervised at meal times If this information had been made known to us then we would have contacted Social Services and requested extra time, as it is impossible to support Mr Lyons with shaving, washing ad dressing in clothes of his choice, assist to the toilet; empty and clean urinal bottle, support with making breakfast and carry to the table, leave a jug of cold drink to hand and supervise him whilst he ate_
5. The care plan was dated 10th September 2014. The information from the SALT was available at the time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment: Our care plan dated the 10th September 2014,has the lunch visit entered, however, the tasks are not listed. We received paperwork from Social Services requesting an increase in care in the form of a put "no
lunch visit for Mr Lyons, as a direct result of him being discharged from hospital, following a fall at home: In fact, our Reviewing Officer had telephoned in order to make a appointment to complete the revised care plan, to include a lunch call: She was informed by husband that she was at the hospital with her other brother who was unwell: It was agreed with her that we would start the lunch call as per the instructions from Social Services, which were to assist Mr Lyons with toileting, prompt medication and support with a meal and hot drink The Reviewing Officer tried again to contacth however, the brother who was ill; had sadly passed away and asked if we could postpone the meeting until after the funeral, which we naturally agreed to, under the circumstances It is important to make clear that at no time whatsoever, had we been informed by either Havering Social Services or (that Mr Lyons was at risk of choking or in need of supervision whilst eating: Registered Manager
20.03.15 very