The Camphill Village Trust
Action Taken
The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and requested regular audits. (AI summary)
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Dear Sir Regulation 28 Report to Prevent Future Deaths write in reply to your letter dated 19 September 2013 addressed to Iconcerning the Inquest into the death of Daniel Onley: As requested provide details of action taken by the Camphill Village Trust (the Trust) to prevent future deaths in response to the matters of concern stated in your letter . The action the Trust has taken and proposes to take to prevent future deaths: Concern of_the_Coroner That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient. Improvements to_the safe administration of medicines in Trust services Audit of existing arrangements Between 15 2013 and 8 July 2013 internal audits were carried out in each of the Trust's nine communities to assess compliance against the requirements of CQC Essential Standards of Quality and Safety Outcome 9 (Management of Medicines): Where required, managers have acted upon any actions required to improve the safe administration of medicines in their service Patruns: The Duke' (f St Albans; The Lord Hastings Founder: Dr Karl Kinig The Camphill Trusl Limiled Is regislered Charily 232402 England Wales and non-prolil company limited by guarantee 539694 Englarid Walcs. Rcgistererl ollicc: Thc Kinglishur Offices_ Saville Street; Mallon, North Yorkshirc YOIZ 7V4. member of the Association of Camphill Communities Utllage May Villzge
Policy revision The Trust has completed an extensive review of arrangements concerning the handling of medicines and has implemented policy focused on the safe administration of medicines in its services. The Trust's Medicines Policy complies with the requirements of the Care Quality Commission regarding the management of medicines , and, guidance issued by the Royal Pharmaceutical Society on the safe handling of medicines in social care settings The purpose of the policy is to provide managers and staff with clear framework to ensure best practice when handling medicines and thereby to protect people who use the service from risks associated with the unsafe administration of medicines_ The policy lays out the safe and appropriate arrangements for staff to follow for the obtaining; recording; handling; safe keeping; administering and disposal of medicines, Future audit of arrangements Under the direction of the Trust's Operations Director, compliance checks will be carried out periodically (at least once every six months) to assess the quality of service delivery against the requirements of the Trust's Medicines Policy: 2 Concern of the Coroner There had been a failure to manage risks associated with Daniels management of his medication Improvements_to_the_manaqement of_risks associated with the_administration ofmedicines _in trust services The Trust's Medicines Policy lays out the actions managers and staff required to follow to ensure any risks associated with medicine taken by a person using the service are identified, clearly documented and acted on through written risk assessment (A) to identify any areas of risk the person is exposed to regarding the administration of any medicine they are taking: These risk assessments are required to be routinely reviewed every six months, or sooner if a person's prescription is changed or if any concerns come to light about any aspect of the safe management of medicines Examples of what could trigger a non-routine re-assessment could include an observed deterioration in person's health or wellbeing; concern that key are
person may not be taking their medicine as prescribed; evidence of lost or otherwise unaccounted for medicines a written mental capacity assessment (B) to determine the person's ability to safely manage any aspect of handling their medicines. These capacity assessments are required to be reviewed every six months, or sooner if person's prescription is changed or if any concerns come to light about any aspect of the safe management of medicines, and, On completion of (A) and (B), written description of the level of assistance person requires for the safe administration of their medicine is made and entered into the person's care record The Trust's Medicines Policy makes it clear to staff that all documentation relating to the administration of person's medicines must be current; clear, complete and correct. Regular training on the management of risks has been incorporated into the Trust's staff training plan: Future audit of arrangements Under the direction of the Trust's Operations Director, compliance checks will be carried out periodically (at least once every six months) to review the quality of risk assessment documentation, mental capacity assessment documentation and documented support provided to people using the service who take medicine 3 Concern of the Coroner The supervision provided to Daniel during the evening of Thursday June 2012 was not sufficient to safeguard Daniel's safety and wellbeing On 24 September 2013 managers were reminded in writing of the need to ensure that adequate and appropriate supervision commensurate with each person's assessed need is provided at all times in order to ensure the safety and wellbeing of all people using the service_ In the event of any unexpected shortfall in staff numbers or availability, managers are expected to ensure the adequacy and safety of the service through the provision of relief or agency staff. Specifically, with regard to arrangements in the Grange; i.e: the service where Daniel lived, the posts of General Manager and Care and Support Manager have been established and additional support staff have been appointed with the necessary competencies, knowledge, qualifications, skills and experience to ensure adequacy of staff cover and the safety of the service at all times 3 21st
Arrangements to ensure appropriate assistance is available to respond to any untoward Or emergency situation occurring between
10.00 pm and
7.00 am is provided in line with assessed need and any clearly documented funding authority expectations_ Future audit of arrangements The Trust's Operations Director will ensure that the adequacy of service staffing arrangements is reviewed periodically under performance and contract monitoring arrangements Other_Matters Disciplinary action Disciplinary action was taken against three individuals regarding their care and support of Daniel: 5 ComplaintsWhistle-Blowing Incident Reporting The Trust is committed to respond in timely and effective manner to any concern brought to its attention about its services_ Moreover, the Trust will continue to work constructively and positively with partner agencies and regulatory authorities to ensure the safety and wellbeing of people who use its services: This includes continuing to be open and transparent with statutory bodies on known;, or suspected, safeguarding concerns 6 Organisational _Learning The Camphill Village Trust Board of Trustees is committed to ensuring lessons are learned from this tragic incident and supports the Trust's senior managers in taking necessary steps to avoid a similar incident occurring in the future. The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines The introduction of such common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes The Trust also placed this matter before its Safeguarding Board (which is chaired by an independent person) for the Safeguarding Board's analysis ad comment in terms of reflective practice and organisational learning: At its meeting on 5 November 2013 the Safeguarding Board expressed view that it considers the concerns identified by the Coroner are being addressed and has the
asked that regular audits are carried out to ensure continued safe practice and for the findings of these audits to be reported back to the Safeguarding Board: trust this letter provides reassurance that the Trust has taken appropriate action to prevent future deaths but please do not hesitate to contact me if further information or clarification is required:
Policy revision The Trust has completed an extensive review of arrangements concerning the handling of medicines and has implemented policy focused on the safe administration of medicines in its services. The Trust's Medicines Policy complies with the requirements of the Care Quality Commission regarding the management of medicines , and, guidance issued by the Royal Pharmaceutical Society on the safe handling of medicines in social care settings The purpose of the policy is to provide managers and staff with clear framework to ensure best practice when handling medicines and thereby to protect people who use the service from risks associated with the unsafe administration of medicines_ The policy lays out the safe and appropriate arrangements for staff to follow for the obtaining; recording; handling; safe keeping; administering and disposal of medicines, Future audit of arrangements Under the direction of the Trust's Operations Director, compliance checks will be carried out periodically (at least once every six months) to assess the quality of service delivery against the requirements of the Trust's Medicines Policy: 2 Concern of the Coroner There had been a failure to manage risks associated with Daniels management of his medication Improvements_to_the_manaqement of_risks associated with the_administration ofmedicines _in trust services The Trust's Medicines Policy lays out the actions managers and staff required to follow to ensure any risks associated with medicine taken by a person using the service are identified, clearly documented and acted on through written risk assessment (A) to identify any areas of risk the person is exposed to regarding the administration of any medicine they are taking: These risk assessments are required to be routinely reviewed every six months, or sooner if a person's prescription is changed or if any concerns come to light about any aspect of the safe management of medicines Examples of what could trigger a non-routine re-assessment could include an observed deterioration in person's health or wellbeing; concern that key are
person may not be taking their medicine as prescribed; evidence of lost or otherwise unaccounted for medicines a written mental capacity assessment (B) to determine the person's ability to safely manage any aspect of handling their medicines. These capacity assessments are required to be reviewed every six months, or sooner if person's prescription is changed or if any concerns come to light about any aspect of the safe management of medicines, and, On completion of (A) and (B), written description of the level of assistance person requires for the safe administration of their medicine is made and entered into the person's care record The Trust's Medicines Policy makes it clear to staff that all documentation relating to the administration of person's medicines must be current; clear, complete and correct. Regular training on the management of risks has been incorporated into the Trust's staff training plan: Future audit of arrangements Under the direction of the Trust's Operations Director, compliance checks will be carried out periodically (at least once every six months) to review the quality of risk assessment documentation, mental capacity assessment documentation and documented support provided to people using the service who take medicine 3 Concern of the Coroner The supervision provided to Daniel during the evening of Thursday June 2012 was not sufficient to safeguard Daniel's safety and wellbeing On 24 September 2013 managers were reminded in writing of the need to ensure that adequate and appropriate supervision commensurate with each person's assessed need is provided at all times in order to ensure the safety and wellbeing of all people using the service_ In the event of any unexpected shortfall in staff numbers or availability, managers are expected to ensure the adequacy and safety of the service through the provision of relief or agency staff. Specifically, with regard to arrangements in the Grange; i.e: the service where Daniel lived, the posts of General Manager and Care and Support Manager have been established and additional support staff have been appointed with the necessary competencies, knowledge, qualifications, skills and experience to ensure adequacy of staff cover and the safety of the service at all times 3 21st
Arrangements to ensure appropriate assistance is available to respond to any untoward Or emergency situation occurring between
10.00 pm and
7.00 am is provided in line with assessed need and any clearly documented funding authority expectations_ Future audit of arrangements The Trust's Operations Director will ensure that the adequacy of service staffing arrangements is reviewed periodically under performance and contract monitoring arrangements Other_Matters Disciplinary action Disciplinary action was taken against three individuals regarding their care and support of Daniel: 5 ComplaintsWhistle-Blowing Incident Reporting The Trust is committed to respond in timely and effective manner to any concern brought to its attention about its services_ Moreover, the Trust will continue to work constructively and positively with partner agencies and regulatory authorities to ensure the safety and wellbeing of people who use its services: This includes continuing to be open and transparent with statutory bodies on known;, or suspected, safeguarding concerns 6 Organisational _Learning The Camphill Village Trust Board of Trustees is committed to ensuring lessons are learned from this tragic incident and supports the Trust's senior managers in taking necessary steps to avoid a similar incident occurring in the future. The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines The introduction of such common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes The Trust also placed this matter before its Safeguarding Board (which is chaired by an independent person) for the Safeguarding Board's analysis ad comment in terms of reflective practice and organisational learning: At its meeting on 5 November 2013 the Safeguarding Board expressed view that it considers the concerns identified by the Coroner are being addressed and has the
asked that regular audits are carried out to ensure continued safe practice and for the findings of these audits to be reported back to the Safeguarding Board: trust this letter provides reassurance that the Trust has taken appropriate action to prevent future deaths but please do not hesitate to contact me if further information or clarification is required: