Margaret Connor

Response: Coroners Report: Regulation 28: To Prevent Future Deaths.
From : The Heathers Nursing Home Bradwell Yarmouth.

Health and Social Care Act 2008. (Regulated Activities) Regulations 2009
and the Care Quality Commission Regulations (2009).

Compliance.

Prior to, during and since this event concerning Mrs M Connor, the
Heathers Nursing Home has, and continues to meet the regulated
standards as laid down in the act as stated and has remained compliant
with the ‘Essential Standards of Quality and Safety’ (Section 20)
Regulations of the Health and Social care Act 2008). This has included the
supply and maintenance of equipment and aids and adaptations used for
the benefit of residents and patients in the home. See previous
unannounced inspection reports for the home (December 2012, Oct 2013
and March 2014.)

Wheelchair management.

It has been the responsibility of nurses and care staff and included in the
policies and procedures of the home to ensure that any item of equipment
in use should be checked prior to immediate use to ensure that the
equipment in question is in full working order and ‘fit for purpose’. Where
a resident or patient with limited mobility has been assessed the use of a
wheelchair, on a regular basis or as part of their overall plan of care, the
key worker has the responsibility of ensuring all aids and adaptations are
in good working order and meeting the individual needs of the client.

Any problems or notable defects in the wheelchairs would be referred to
the maintenance /handyman. Where he was able to carry out a repair he
would do so recording the event. Otherwise the chair would be taken out
of commission and the external wheelchair specialists be asked to attend
the repair.

Reporting and recording

There are clear guidelines and instructions regarding the reporting and
recording of information about residents and patients. Care staff are
required to report to the senior carers or in the case of suspected illness
or injury directly to the trained nurse on duty. The information is recorded
in as much detail as possible and, depending on the severity of the
incident or illness, the trained nurse will make a judgement regarding the
immediate course of action and monitored throughout the next 24-72

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hours. Relatives or the designated next of kin are always notified of any
event affecting residents’/patients’ well being.

Information or contributions from relatives regarding the health and
welfare of residents or patients is always noted and recorded by nursing
staff.

Outcomes and Action

Although all the appropriate procedures and processes for the
management and safe handling of equipment is in place in the home and
monitored on a regular basis; it is acknowledged that this event has
highlighted the lack of attention to detail by the individual staff concerned
directly with this matter, and did not carry out the checking processes for
wheelchairs as directed by the management. They have also failed to
maintain good levels of communication as would be expected between
management and staff and as set out in their conditions of service and
code of contract.

As a direct outcome of this event and in response to your ‘matters of
concern’, the following action has been undertaken:

e All staff currently employed in the home have received updated
health and safety guidance and instruction regarding the use of
wheelchairs and their management.

e All staff have been directed to read / review each
resident’s/patient’s plan of care regarding their mobility and use of
aids and adaptations, including wheelchairs, to ensure they are
familiar with the written assessment and the equipment in use.

e All staff have been issued with a written directive from the Nurse
Manager giving clear instructions on the use and management of
wheelchairs (see attached 1).

The home currently has eleven wheelchairs in use, of which seven are in
use and four are held in stock. Six are new. Four chairs, although still
serviceable have been decommissioned as they were showing signs of
general wear. The wheelchairs in use have been issued with numbers and
allocated to rooms or /and residents and patients. It is intended that this
will improve the pracess of tracking the use of the chair and in the event
of any query or incident it should be possible to pinpoint the location and
identify the user.

The footplates for each of the chairs have been checked and correctly
fitted. The majority of them are now fixed, although they can be swung

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out of the way to allow the patient/resident to place their feet on the
floor. Staff directives issued recently now state that the plates must not
be removed.

The management will also be reviewing the current practice of allowing
relatives to use wheelchairs both in and outside the premises. The review
will look at ensuring that persons other than staff can safely manage and
manoeuvre the chair during use.

As well as the instructions to staff regarding the monitoring of
wheelchairs, they are also required to carry out safety checks before use.
All the wheelchairs in use will be checked each week by the maintenance
handyman. (see attached formats now in use (2 and 3).

All wheelchairs will be serviced every six months by the external
wheelchair specialists. Receipts and as before a written record will be
maintained.

Recording and reporting

A review of the process has been carried out and some minor changes
have been put into place with special emphasis on staff to record and
report all events at the time they occur. Carers must not delay passing on
the information to trained and senior staff.

Training

e All staff will undertake updated Health and Safety training sessions
to ensure they have a clear understanding about their role and
responsibility in maintaining the safety and well being of the
patients and residents especially when using equipment to support
their care.

e One of the visiting physiotherapists will be offering two training
sessions to the staff group covering the management of aids and
equipment and moving people with limited mobility. At the same
time -:

« The manager will be providing group sessions to carers on
understanding what is ‘referred pain’ and how it differs from ‘local
pain’, which is what is usually experienced and reported in the
event of a fall or injury. The manager will also be looking at ways
that staff can be advised on how to respond to complaints of pain
where there may not be corroborative evidence of a trauma having
occurred. This is work in progress and the instruction may take the

4 Heathers.MC.Coroners response.060614.JS

form of ‘what to do in the event of’ printed guide to ensure
consistency of action and care.

e Through the processes of supervision the staff will also be reminded
of their responsibilities to maintain good observation skills,
interpret and respond appropriately to non verbal cues, especially
physical expressions that may denote distress or and anxiety in
those residents and patients with limited cognitive awareness .

e The Manager and Quality Assurance Manager for the service will
also review the management / care staff and nurses’ interpersonal
skills to ensure the relationships with relatives and other health care
staff is open and professional.

e Staff at all levels will be reminded that they must maintain at all
times good standards of care combined with honesty and
professional integrity.

e The management team will also review how staff can be supported
and protected when dealing with challenging and inappropriate
behaviour, whether it is from patients, residents, relatives or
external health professionals.

The training will be completed within the next twelve months.

Registered Manager.

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Staff Directive: Appropriate use of wheelchairs

Guidance and instruction.

e Wheelchairs are currently allocated to designated rooms and meet
the assessed needs of the resident / patient.

e Wheelchairs are numbered for ease of identification and
whereabouts.

¢ Before using any wheelchair please carry out all safety checks ( see
format 3) .

e After use RETURN chair to designated room /resident. DO NOT
leave wheelchairs in any communal areas such as bathrooms
corridors or lounges. ALWAYS return them to the designated room.

« DO NOT attempt to remove footplates from wheelchairs.

e Please ensure that your knowledge regarding the accurate use of
wheelchairs and other aids and adaptations is up to date.

e Please ensure that you have completed all the ( refresher) Health
and Safety training sessions and that you can confidently and
competently assist people to move, transfer, appropriately and
safely.

Please report any faults immediately to maintenance/handyman and if
necessary remove the wheelchair from service.

Please note that ali wheelchairs will be checked once a week in house
and a record kept, and every six months by external wheelchair
services. To assist with this process please ensure the wheelchairs can
be located in their designated room.

Please ensure that you adhere to these guidelines and instructions as
directed in the interests of resident’s and patient’s safety and well
being. Failure to do so may lead to disciplinary action.

Please sign both copies to say that you have read and understood the
directive and will comply with the instructions. Return one copy to the
manager.

PriNt NAME...........seeeeseeereessseesseeseeees

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Heathers Nursing Home

Wheelchair Safety Maintenance Check

Allocated chair to:

Personal /Own Wheelchair YES/NO

Date

ON / OFF

Tyres accurate
pressure

Footplate in situ & in
use

Cushion /seat in place

Seatbelt in place &

Brakes fully functional |
fully operational |

Any comments:

Heathers Care Home

Carers Wheelchair Safety Checklist

Wheelchair checklist to be used each time a resident uses a wheelchair. Tick
in the box when the function has been checked and safe to use. If there is
any area of concern, do not use the wheelchair.

Allocated chair to: |

Date | Time| Brakes Tyres Footplates | Cushion | Seatbelt Sign
full accurate | insitu& | in place in place
functional | pressure use