Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0335, written 19 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jun 2024 |
|---|---|
| Reference | 2024-0335 |
| Deceased | Maureen Woollen |
| Coroner | Tanyka Rawden |
| Coroner area | South Yorkshire (West) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Death of Maureen Alison Woollen (D.O.B. 24 September 1931, D.O.D. 31 October 2023)
Response to Regulation 28 Report to Prevent Future Deaths
Bundle of Additional Documentation
Document
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Document
Page No.
Prevention and Management of Falls Policy
Admissions Policy
Quality Assurance Audit
Quality Dashboard Metric
Service Report
1 – 4
5 – 6
7
8
9
Team Leader Monthly Monitoring Draft, July 2024
10 – 13
Weekly ‘Huddle’ Team Meetings, December 2023 – July 2024
14 – 49
Staff Training Completion Sheet
Deputy Good Practice Group Minutes, 2 July 2024
Lessons Learned, 21 June 2024
YAS Flow Chart
50 – 128
129 – 132
133
134
Falls Prevention Group Meeting Notes, 23 January 2024
135 – 139
Standard Operating Procedure – Actions Following Accident or
140 – 144
Fall
14.
Team Leader Monthly Monitoring Reports, October 2023 – March
145 – 160
2024
Prevention and Management of Falls Policy
This policy sets out a consistent approach to risk assessment and risk
management, the protocol to follow when a fall occurs, measures and
prevention and the means by which compliance with this policy will be
measured.
It is important that staff know how to manage the risk of falling in Sheffcare
services, how to deal with a fall when it happens and the methods by which
falls can be prevented.
SheffCare works in line with the CQC Care Framework, legalisation, and NICE
guidelines to enhance the quality of care provided for service users'.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
Regulation 12. The intention of this regulation is to prevent people from
receiving unsafe care and treatment and prevent avoidable harm or risk of
harm. Providers must assess the risks to people's health and safety during any
care or treatment and make sure that staff have the qualifications,
competence, skills and experience to keep people safe.
There are general duties placed upon employers to safeguard the health
and safety of employees and others (including residents, the public and
contractors) by Sections 2 and 3 of the Health and Safety at Work etc. Act
1974.
The Management of Health and Safety at Work Regulations 1999,
Regulations 3 and 5 and the associated Approved Code of Practice, require
employers to assess risks to the health and safety of both employees and
residents and to put into effect appropriate arrangements for health and
safety planning, organisation, control and review.
The Workplace (Health, Safety and Welfare) Regulations 1992, Regulation 12,
and the associated Approved Code of Practice establish an absolute duty
for floors to be suitable for their purpose (this includes adequate slip
resistance, evenness and slope). Floors must be kept free of obstructions and
any article or substance that may cause any person to slip, trip or fall.
Reviewed September 2023 – Director of Care & Operations
1
Regulation 13 requires measures to be taken to prevent any person falling a
distance likely to cause personal injury.
National standards and guidance relating to falls prevention and patient
care is recommended within the NICE CG161 Falls (June 2013) and Pathway.
The guidance published in June 2013 enhances the 2004 guidelines to
include recommendations about patients within inpatient settings.
https://www.nice.org.uk/guidance/cg161
NICE161 Clinical Guideline Falls: The Assessment and Prevention of Falls in
Older People.
• Older people in contact with health care professionals should be asked
routinely whether they have fallen in the past year and asked about
the frequency, context and characteristics of the fall.
• Older people reporting a fall or considered at risk of falling should be
observed for balance and gait deficits and considered for their ability
to benefit from interventions to improve strength and balance.
• Older people who present for medical attention because of a fall, or
report recurrent falls in the past year, or demonstrate abnormalities of
gait and/balance should be offered a multifactorial falls risk
assessment.
SheffCare aims to reduce the number of service users' falls which could result
in a serious injury and cause impairment to that person's general abilities,
needing effective pro-longed stressful treatment and rehabilitation for those
who have fallen. The risk of falling can never be completely removed but by
carrying out a falls risk assessment risk factors can be identified, and action
taken to remove or alter risk where possible.
On admission, all staff must follow any pre assessment advice/guidance.
All assessed aids must be in place and checked that they are in safe working order.
All aids are to be well maintained and kept in good working order, bed rails are to
Reviewed September 2023 – Director of Care & Operations
2
be checked in line with Central Alerting Systems guidance. Sensor mats and crash
mats are to be kept clean and stored safely when not in use.
A Falls Risk Assessment Form must be completed on admission and used in
conjunction with the Service Users Care Plan. This must be updated monthly or more
frequently as is required through the review process or as a result of a fall.
All falls must be recorded in the Accident Book and a Service Users' Falls Monitoring
Form must be completed and kept with the Service users Care Plan.
Person Centred Softwear data is to be analysed on a monthly basis by the
Registered Manager this will provide information which can be used to consider
measures to reduce further falls.
Registered Managers are to review falls data on a daily/weekly/monthly basis and
report on their findings within the PCS care notes, if there are any trends or patterns
or areas of concern these are to be referred to the GP for further review.
Registered Managers should also conduct a monthly quality assurance accident
monitoring form highlighting any issues or trends and any further action required.
Compliance with the policy is monitored through the monthly quality assurance
report submitted by the Registered Manager to the Head of Quality and
Improvement who reports monthly to the Board of Trustees.
If any individual staff highlight to have concerns over the number, frequency, type of
falls, they have sustained must be referred to their own GP for advice and guidance
& records updated accordingly. Referrals to the fall’s prevention team should be
actioned who can provide advice and guidance on fall’s management.
If any resident sustains an injury due to a fall immediate medial attention is to be
taken, a trained first aider is to review the resident, and if required seek medical
attention. Care notes are to be fully maintained on the action taken, advise
provided by whom and when is to be fully documented. If an ambulance is required
and goes over the allotted timeframe specified, or if the resident’s condition
Reviewed September 2023 – Director of Care & Operations
3
changes a 999 call is to be made to update on the resident’s condition or to inform
the ambulance service of the timeframe allocated on the initial call.
If a resident falls and there are no apparent injuries at the time, but staff then notice
injuries these are to be reported and medical attention sought. All care notes are to
reflect if a resident is injured and action taken to monitor and review the injury or
injuries.
Medications are to be reviewed by the GP and/or District Nurse due to the
increased risks of residents who are prescribed medication which can contribute to
the risk of falls. Residents who are prescribed Anticoagulation therapy as although
this treatment does not increase the resident’s risk of falling the outcome of the fall
could be more serious.
Training is provided for use of hoists and/or equipment this is overseen by the
Registered Manager.
Reducing the likelihood of fall’s by ensuring the environment is well maintained is
managed under Health and Safety audits.
“I STUMBLE” is recognised by Sheffield City Council, Yorkshire Ambulance Service
and Fall’s Prevention Team to be implemented within Sheffield care homes.
Appendix A.
“I STUMBLE” post fall audit can also be used to review actions and outcomes of a
fall. Appendix B.
. Appendices:
Reviewed September 2023 – Director of Care & Operations
i_stumble_audit_form.pdfiSTUMBLE.pdf4
Admissions Policy
Full information must be received in the Home prior to each person's admission e.g. full time
placement and respite placements. In the case of an emergency situation, the duty manager
must ensure that all basic relevant information is obtained and made available to the care
team and all such information should be received before or on admission.
Such information should include the following; the service user's full name, their date of birth,
address, NOK or carer, GP's details, medication details, name of the referring worker or their
Assessors details, with an outlined statement re the persons emergency.
The Registered Managers are responsible for ensuring that all prospective service users on
planned admissions have a completed Care Needs Assessment prior to or on their
admission.
It is the Duty/Shift Manager/Care Coordinator (if in post)/Registered Managers responsibility
to ensure that the home is able to meet the assessed emotional, social, nutritional (including
weight on admission), cultural and health care needs of the service user as required by Care
Quality Commission.
Such details must be completed and supplied by the Social Services representatives,
however for self funding service users; the Registered Manager must undertake a single
assessment, using the company's Self Funders Assessment Form. Where the individual is
self funding, a SheffCare Individual Placement Contract must also be completed. Section
3.1.2.3 Financial Procedure on Admission gives full details.
Prospective service users' should be presented with and asked to complete the Service
Users Guide/Contract of Care/Contract of Finance on before or at the time of their
admission, the Manager supporting that persons admission must ensure that Section Two
and Section Three are sent to the appropriate Service Users' finance Adviser.
It is the responsibility of the Registered Manager to ensure that all Service Users' nutritional
needs are assessed, documented on admission and there after monitored on a
daily/weekly/monthly basis. Fortified drinks are to be documented at all times. Training in this
regard must be provided to all appropriate staff.
All such information should be recorded on the individual's 'Service User Nutrition Screening'
form which can be found stored as part of the Service Users' Care Plan documents,
Team Leaders must take responsibility to ensure such information is documented and
reviewed Monthly, using the review form to evidence such action whilst ensuring up-dates is
passed on to the Senior Cook/Cooks and Care team.
Falls Assessments must be completed on admission, at this point we need to use the
information provided in the assessment document, if a resident presents with a falls history
this information needs to be transferred onto the electronic care records system, and there
after monitored on a daily/weekly/monthly basis.
Reviewed June 24 – Care & Operations Director
5
All history such as mobility needs, falls, health, medication, risk of wandering, overnight care
needs, level of support required with eating and drinking, choking risk are to be assessed
and considered at the point of admission for all types of admissions to the home.
Reviewed June 24 – Care & Operations Director
6
Quality Assurance Audits Sheffcare
Audit
Daily monitoring
Area report
Whole home report
Walk round
Accident monitoring
Care plan
Health and Safety
IPC
Kitchen
Medication
Frequency
Daily
Monthly
Monthly
Daily
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Responsible person
Team Leader
Team Leader
Deputy Manager
Manager
Manager
Manager
Manager
Manager
Manager
Manager
7
Quality Dashboard
Medication errors - harm
Medication errors - no harm
Falls
Choking
Pressure Care Gradient
Accidents* - residents
Accidents - staff
Safeguarding referrals
New S42 enquires in month
Ongoing open S42 enquires in the month
Closed S42 cases in the month
CQC notifications
Regulatory breaches
Duty of Candour reports
Hospital admission unplanned
Any placement at risk
Death of resident
Environment
External Inspections
Resident concerns
Complaints
All monthly QA audits complete
Compliments
IPC outbreak number of residents
DoLS
0
0
0
0
>0-1
0-3
0
0-3
0
1
0
0
>1
1
0
0
0
0
0
0
1+
0
All in place
Nurtition & Hydration-weight gain
Nutrition & Hydration-weight loss
>0-1kg
>0-1kg
Safeguarding
r
e
m
o
t
s
u
C
Compliments
and
complaints
1-2
>1
>2
4-10
1-2
3-5
1
2
1
1-2
1
1-5
1
1
>1
>3
>2
1 or more
>3
>11
>2
>5
>2
>3
>2
>1
>3
>2
>1
>5
>1
>2
>2
>1
Metric
* 3 or more falls is the reporting threshold for referrals
*Accidents refers to just accidents e.g. slips, trips, falls, not other incidents
* Needing to move resident out of the home
*Number of items required i.e. maintenance, repairs, tasks
* EHA, Fire Service, CQC, SCC
* 0 all complete
1-5
Waiting for outcome
of review
>1-2kg
>1-2kg
>6
Lack of follow up
from authority
>over 3kg
>over 3kg
* Denotes any type of outbreak
*Narrative on any red reporting
* Narrative for over 3kg weight gain
*Narrative for over 3kg weight loss
8 Jan-24
Feb-24 Mar-24
Apr-24 May-24
Jun-24
Jul-24
Aug-24
Sep-24
Oct-24
Nov-24
Dec-24
Outcomes
Medication errors - harm
Medication errors - no harm
Falls
Choking
Pressure Care Gradient
Accidents* - residents
Accidents - staff
Safeguarding referrals
New S42 enquires in month
Ongoing open S42 enquires in the month
Closed S42 cases in the month
CQC notifications
Regulatory breaches
Duty of Candour reports
Hospital admission unplanned
Any placement at risk
Death of resident
Environment
External Inspections
Resident concerns
Complaints
All monthly QA audits complete
Compliments
IPC outbreak number of residents
DoLS
Nurtition & Hydration-weight gain
Nutrition & Hydration-weight loss
PCS
Dining Experience
1
1
1
1
0
0
22
0
0
0
0
0
0
0
0
0
0
0
2
1
0
0
0
0
0
0
1
0
3
0
1
13
13
2
2
2
0
2
9
1
0
1
1
3
0
0
7
0
0
7
0
1
0
0
0
0
0
0
8
0
0
0
0
0
0
1
1
0
0
0
1
0
0
19
0
0
19
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
1
0
0
1
0
1
0
0
16
0
0
19
0
0
3
0
0
1
0
0
2
0
0
0
0
0
1
1
1
0
12
0
1
0
0
17
0
0
20
0
1
0
0
0
3
0
0
0
0
1
4
0
0
1
1
1
0
2
0
0
9 Team Leader Monthly Monitoring Draft July 2024
Month:
Corridor:
Resident Clinical Needs:
Falls: Please record all falls within the month individually and answer all the questions in detail.
Resident
Initials and
date of fall
Injury/mark
photographed
onto PCS?
Any
injuries/marks?
Witnessed or
unwitnessed
Medical
support
sought?
Body map
completed?
Family
Informed?
Comments
MUST: Please record any changes in MUST and/or +/- 2kgs of weight, include any high risk residents in detail.
Resident
Initials
Possible
cause known
MUST Score Amount of
GP Informed
and advice
Comments
Referral to
SALTs/Dietician
made
weight
lost/gained
Tissue & Skin Viability: Please record any pressure sores/skin tears/redness individually with detail.
Resident
Initials
Medical support
sought
Photographed
onto PCS
Description
of area/issue
Body map
completed
Family
informed
Treatment plan
recorded on
PCS
Comments
Infections/Illness: Please record any infections/illness individually with detail.
Treatment plan
Resident
on PCS
Initials
GP informed
and advice
Description of issue
Family
informed
Comments
10
Team Leader Monthly Monitoring Draft July 2024
Hospital Admissions: Please record any admissions in detail.
Resident
Reason for hospital visit
Date went to
hospital
Family informed Returned to
home
Comments
Resident Care and Wellbeing
Are residents actively participating in scheduled activities: Please record any issues with individuals being able to
participate and suggestions for improving this.
Resident
Suggestions to improve engagement
Activity and reason unable to attend
Are residents enjoying the dining experience and meals: Please complete a review of the meals each week and record your
thoughts and any resident feedback.
Week start
date
TL Feedback (Quality, flavour, presentation)
Resident Feedback
Resident daily checks: Please check that these checks are being completed and report on any missed checks or issues.
Area
Checked by
Any Issues
Area
Number in
use
Checked
by
Any
Issues
Number
in use
X
X
Hair Care
Nail Care
Clothing/Laundry
Toiletries
Commodes
Walking Frames
X
X
Oral Hygiene
Meals and
Hydration
Footwear/Footcare
Wheelchairs
Walking Sticks
Hospital Beds
X
X
X
11
Team Leader Monthly Monitoring Draft July 2024
Yes/No
Bed Rails
Records, Audits and co-production
Area
Have all incidents and accidents been
reported and documented on PCS
Have risk assessments been reviewed and
updated where necessary
Have daily care notes on PCS been checked
Has a resident meeting/consultation taken
place
Has any feedback from the resident or their
family been received this month
Health and Safety and Environmental Checks
Please record when all checks are being done and by who.
Any issues
Area
Number in
use
Checked
by/date
First Aid
Boxes
Bedding
Trolleys
Fire Alarm
Tests
H&S Audit
Wardrobes
and Drawers
tidy
Dining
rooms (inc
kitchen
areas) tidy
All repairs
identified
and reported
Pillows/Mattresses
Checked by
Comments/Actions identified
Number in use Checked
by/date
Any
issues
Area
Sluices
Nurse Call
Emergency
Lights test
Bedrooms Clean
and tidy
Lounges tidy
Bathrooms and
toilets clean and
tidy
12
Team Leader Monthly Monitoring Draft July 2024
Comments/Issues
Dates checked Checked by
Medications
Please record when checked and by who.
Area
MAR sheets checked
Any gaps in MAR sheets
Topical creams chart checked
Any gaps in topical cream charts
Medication room/trolleys cleaned weekly
Staffing
Please record detailed commentary including dates and who led the activity.
Area
Comments/concerns/actions
Number of huddles and topics covered
Any 1:1’s conducted
Training completed
How would you rate the team’s morale this
month (High, Medium, Low)
Summary
Please record any improvement actions, concerns or good practice to report to deputy/manager.
Signed
Dated
13
HUDDLE
Huddle Topic Falls
Date 5-10- 223
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
14 HUDDLE
Huddle Topic Falls
Date 4
12 23
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
Tao leode«vs o volor tool he above vs
+okq 0lace
15 HUDDLE
Huddle Topic Falls
Date H 1. 224-
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
S(£ lo nolor
16 HUDDLE
Huddle Topic Falls
Date 8- 2-244
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
17 Lesson Learned: 012
Sheffcare
Dear all,
Background: Resident experienced an unwitnessed fall and sustained injuries.
Extract of the findings:
During a period of respite care a resident experienced an unwitnessed fall resulting in hospital
admission via ambulance.
This matter was referred to the Social Care Ombudsman by the family and they have reached a
conclusion, their findings are for Sheffcare:
a) it does not overlook the need to prompt people to take fortified drinks and
documents this properly;
b) its staff have access to people's care plans and follow them when delivering
care;
c) care records are not misplaced after someone has left the care home.
What you as a Leader need to do next: Please ensure the following is implemented, as appropriate,
at your site:
1. Share lessons learnt of the incident in all Sheffcare homes to raise the awareness of this
incident
2. Review residents who are prescribed/taking fortified drinks and ensure that they are
prompted to take them and that this is documented correctly
3. Review that all staff have access to care plans (days and nights} and that these are followed
by undertaking reviews and observations of care practice
4. Review archiving processes within the home to ensure that records are kept safe and secure
5. Admissions policy reviewed to specify respite admission procedures
Assurance: Discussion in huddles, 1:1 meetings and staff meetings. Feedback to Head of Quality and
Improvement by 30" April 24 that the above actions are completed.
If anyone identifies additional learnings based on feedback of this matter, this is to be reported to
Head of Quality and Improvement.
Any questions, please do let me know.
Thank you for your continuing efforts to keep the people we support safe and happy.
Kind regards,
Lo
18 HUDDLE
Huddle Topic Falls
Date
)- 3- 2l
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an .infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
19 Dlaculon Held Wih
Con%en
elauel Wat ooobeof sle[p ad
eon nodal al p or otoll.iv
<bat not [dlg un m[ate» Deoo
6old
Any Action Required
20 HUDDLE
Huddle Topic Falls
Date 2% 3 --2L
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
21 HUDDLE
Huddle Topic Falls
Date 7-L-2Lu
Di
i
H ld With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or Is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
22 HUDDLE
Huddle Topic Falls
Date
l% --L -2A-
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
23 HUDDLE
Huddle Topic Falls
Date 6o -L,-2l4
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
24 HUDDLE
Huddle Topic: Quality Strategy 2023-2025
Date
1-S- l
Discussion held with
Content:
Sheffcare's Quality Strategy is the vision for quality from 2023-2025. This outlines how we
will be working towards achieving good quality outcomes for the residents and
organisation.
The quality metrics will be measured through audits and meetings.
A governance calendar of audits provides the organisation with qualitive and quantitative
data so we can inform and develop our homes.
Louise Beaumont will oversee the progress of the Quality Strategy and provide
feedback and updates
Any Action required:
For you to read the Quality Strategy and up to date Quality Assurance policy
For you to display The Quality Strategy-page 1 is the overview strategy on a page
For you to engage with the Quality Strategy through the quality assurance
processes and audits
25 HUDDLE
Huddle Topic Falls
Date 7-5-2L
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
26 Voad cw csa&s
u Hacflo
lesson Learned: 012
Sheffcare
Dear all,
Background: Resident experienced an unwitnessed fall and sustained injuries.
Extract of the findings:
During a period of respite care a resident experienced an unwitnessed fall resulting in hospital
admission via ambulance.
This matter was referred to the Social Care Ombudsman by the family and they have reached a
conclusion, their findings are for Sheffcare:
a) it does not overlook the need to prompt people to take fortified drinks and
documents this properly;
b) its staff have access to people's care plans and follow them when delivering
care;
c) care records are not misplaced after someone has left the care home.
What you as a Leader need to do next: Please ensure the following is implemented, as appropriate,
at your site:
1.
Share lessons learnt of the incident in all Sheffcare homes to raise the awareness of this
incident
2. Review residents who are prescribed/taking fortified drinks and ensure that they are
prompted to take them and that this is documented correctly
3. Review that all staff have access to care plans {days and nights) and that these are followed
by undertaking reviews and observations of care practice
4. Review archiving processes within the home to ensure that records are kept safe and secure
5. Admissions policy reviewed to specify respite admission procedures
Assurance: Discussion in huddles, 1:1 meetings and staff meetings. Feedback to Head of Quality and
Improvement by 30" April 24 that the above actions are completed.
If anyone identifies additional learnings based on feedback of this matter, this is to be reported to
Head of Quality and Improvement.
Any questions, please do let me know.
Thank you for your continuing efforts to keep the people we support safe and happy.
Kind regards,
27 HUDDLE
Huddle Topic Falls
Date 17.6.2u
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an .infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
Sf¢ Io eooxe +hey c«re ox(kin uxth 5eco
(S0Ys tkal ave a xk_ af Clls. (cdce core
lo@ea cuds ave mo <eck rd ore been
used .
Docexek ou {lls correc'\ cf (( deoils
28 HUDDLE
Huddle Topic Falls
Date 323-5- 24
Discussion Held With
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
±da long all about [rares end Us
<cl foot eor e kelp olevent (auks
loolc o to tog 5oo bevice ase 7y
rot use +tor (ham Docuro @ el7
seog ha. ran.
29 HUDDLE
Huddle Topic Falls
0ate 27-5-2l
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
Tclzed bl His saloect de
@klkcdg ua(tg skateg.2o2so=¢
about turd o documota0
30 HUDDLE
Huddle Topic Falls
bas I-%-2+
Di
i
H l Wi h
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an Infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
31 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: zz/6z
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
32
HUDDLE
Huddle Topic: Accessing medical tre
Date: au- ¢= . au
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
33 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 25.G Du
Discussion held with
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
lt ordersstxxl
c»ol egnect
34 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 34%- 2Lr
Discussion held with
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
35 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 21- % -24
Discussion held with
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
36 tkac\ cud dsces
m lido
lesson Learned: 012
Sheffcare
Dear all,
Background: Resident experienced an unwitnessed fall and sustained injuries.
Extract of the findings:
During a period of respite care a resident experienced an unwitnessed fall resulting in hospital
admission via ambulance.
This matter was referred to the Social Care Ombudsman by the family and they have reached a
conclusion, their findings are for Sheffcare:
a) it does not overlook the need to prompt people to take fortified drinks and
documents this properly;
b) its staff have access to people's care plans and follow them when delivering
care;
c) care records are not misplaced after someone has left the care home.
What you as a leader need to do next: Please ensure the following is implemented, as appropriate,
at your site:
1. Share lessons learnt of the incident in all Sheffcare homes to raise the awareness of this
incident
2. Review residents who are prescribed/taking fortified drinks and ensure that they are
prompted to take them and that this is documented correctly
3. Review that all staff have access to care plans {days and nights) and that these are followed
by undertaking reviews and observations of care practice
4. Review archiving processes within the home to ensure that records are kept safe and secure
5. Admissions policy reviewed to specify respite admission procedures
Assurance: Discussion in huddles, 1:1 meetings and staff meetings. Feedback to Head of Quality and
Improvement by 30" April 24 that the above actions are completed.
If anyone identifies additional learnings based on feedback of this matter, this is to be reported to
Head of Quality and Improvement.
Any questions, please do let me know.
Thank you for your continuing efforts to keep the people we support safe and happy.
Kind regards,
Louise
37 Huddle Topic: Accessing medical treatment -residents
Date:1-- 2+1
Discussion held wit
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
38 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date:
az/7/Z+
Discussion held with
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
39 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 3 7 22u
Discussion held with
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
40 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: -7- 2lt
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
41 MUDDLE
Hu«tee Tppie polo,Clocamont, (epork <n
+Haq ford re (dmckcs, boYunes
Dr
la
a
c
Vi
l .
Con@sn%
ha fclg any bras r arts
lo #lc oholo fo ors»'s oht
on olocmont, and fepoft to a
lean loaclor lo +le c look- lWon
cloclo ukak achon noecls halo
Any Action Required
42 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: «.1.2+
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
43 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date:
to/z/z9
Di
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
44 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 13--2\
Disc
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
45 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date:+--21
Content:
•
Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
46 HUDDLE
Huddle Topic Falls
Date 7% 7 -2u
Content
Monitoring falls and any patterns, is there something they are doing prior to
falling, do we think there could be an infection, has medication changed. We
need to be looking at what could be causing fall or is it un-preventable.
Ensure we are assisting those with poor mobility, checking their foot ware is
suitable and seeking advice where we need it via GP for referrals to Physio
and fall team.
Also documenting any changes and what has been do to help prevent falls.
Any Action Required
47 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: 7- 1-2l.
Discussion held with
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
48 HUDDLE
Huddle Topic: Accessing medical treatment -residents
Date: e a2u-
D
Content:
• Seeking medical attention for residents
• Chasing up on ambulance call outs when given a timeframe for response times
Actions required
•
•
If any residents have an injury from a witnessed or unwitnessed accident, we seek
urgent medical attention at the time
If any residents have an injury which appears and is unknown, we seek urgent
medical attention when this is noticed
•
If we seek medical attention and are provided with a timeframe for an ambulance
to attend, we ensure that we chase the call to ensure that this does not lapse
• All of the above is to be documented in the PCS notes
49 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
FLEXEBEE
Palliative and End of Life
Care
13/6/2022
3/11/2022
20/3/2023
00:41:35
100
PASSED
Yes
HACCP Awareness
15/6/2022
11/3/2023
11/3/2023
00:06:46
12/7/2022
9/3/2023
16/6/2023
00:04:52
80
90
PASSED
Yes
PASSED
Yes
Autistic Spectrum
Disorder (ASD)
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
Learning Disability
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
12/7/2022
9/3/2023
16/6/2023
00:03:42
100
PASSED
Yes
12/7/2022
9/3/2023
19/6/2023
00:04:34
100
PASSED
Yes
12/7/2022
27/9/2022
11/3/2023
00:05:01
100
PASSED
Yes
12/7/2022
11/3/2023
11/3/2023
00:04:27
90
PASSED
Yes
12/7/2022
11/3/2023
11/3/2023
00:02:54
90
PASSED
Yes
12/7/2022
12/3/2023
16/6/2023
00:03:12
100
PASSED
Yes
12/7/2022
12/3/2023
16/6/2023
00:01:12
100
PASSED
Yes
12/7/2022
9/3/2023
16/6/2023
00:01:12
90
PASSED
Yes
12/7/2022
16/6/2023
16/6/2023
00:03:04
100
PASSED
Yes
12/7/2022
16/6/2023
16/6/2023
00:03:00
90
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
50 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
Learning Disability
Awareness
Autistic Spectrum
Disorder (ASD)
Awareness
Learning Disability
Awareness
Palliative and End of Life
Care
Palliative and End of Life
Care
Palliative and End of Life
Care
12/7/2022
16/6/2023
16/6/2023
00:02:07
100
PASSED
Yes
12/7/2022
16/6/2023
16/6/2023
00:18:34
100
PASSED
Yes
12/7/2022
9/3/2023
19/6/2023
00:02:05
90
PASSED
Yes
12/7/2022
19/6/2023
19/6/2023
00:02:35
100
PASSED
Yes
12/7/2022
19/6/2023
19/6/2023
00:04:29
90
PASSED
Yes
13/7/2022
4/8/2021
11/3/2023
00:08:34
100
PASSED
Yes
13/7/2022
3/11/2022
11/3/2023
00:04:11
90.9
PASSED
Yes
13/7/2022
16/6/2023
16/6/2023
00:03:18
81.81
PASSED
Yes
Allergen Awareness
13/7/2022
9/3/2023
19/6/2023
00:04:45
81.81
PASSED
Yes
Allergen Awareness
26/1/2023
19/2/2023
19/2/2023
00:10:14
81.81
PASSED
Yes
Autistic Spectrum
Disorder (ASD)
Awareness
26/1/2023
19/2/2023
19/2/2023
00:59:54
100
PASSED
Yes
Disability Awareness
26/1/2023
20/2/2023
20/2/2023
00:13:32
85.71
PASSED
Yes
Falls Prevention
26/1/2023
20/2/2023
20/2/2023
00:10:41
100
PASSED
Yes
Allergen Awareness
26/1/2023
17/10/2023
17/10/2023
00:23:00
90.9
PASSED
Yes
Autistic Spectrum
Disorder (ASD)
Awareness
26/1/2023
18/10/2023
18/10/2023
00:28:52
90
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
51 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Coronavirus Awareness
and Infection Control
26/1/2023
18/10/2023
18/10/2023
00:26:44
83.33
PASSED
Yes
COSHH Awareness
26/1/2023
19/10/2023
19/10/2023
00:24:32
Disability Awareness
26/1/2023
19/10/2023
19/10/2023
00:30:52
80
80
PASSED
Yes
PASSED
Yes
Palliative and End of Life
Care
26/1/2023
17/10/2023
21/10/2023
00:43:00
81.81
PASSED
Yes
Oral Health
26/1/2023
21/10/2023
21/10/2023
00:15:21
100
PASSED
Yes
Falls Prevention
26/1/2023
22/10/2023
22/10/2023
00:04:38
100
PASSED
Yes
Fire Safety CSTF Aligned 26/1/2023
22/10/2023
22/10/2023
00:28:49
90
PASSED
Yes
GDPR Awareness
26/1/2023
22/10/2023
22/10/2023
00:23:30
100
PASSED
Yes
HACCP Awareness
26/1/2023
22/10/2023
22/10/2023
00:31:03
26/1/2023
22/10/2023
22/10/2023
00:32:54
90
80
PASSED
Yes
PASSED
Yes
Learning Disability
Awareness
Manual Handling of
Inanimate Objects
Awareness
Moving and Handling of
People Awareness
Communication and
Record Keeping
Standard 1 –
Understand Your Role
Standard 2 – Your
Personal Development
Standard 3 – Duty of
Care
26/1/2023
22/10/2023
22/10/2023
00:28:18
100
PASSED
Yes
26/1/2023
22/10/2023
22/10/2023
00:22:03
26/1/2023
22/10/2023
22/10/2023
80
0
PASSED
Yes
PASSED
Yes
26/1/2023
22/10/2023
23/10/2023
00:02:09
83.33
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:17:37
83.33
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:20:44
83.33
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
52 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Standard 4 – Equality
and Diversity
Standard 5 – Work in a
Person Centred Way
Standard 6 –
Communication
Standard 7 – Privacy
and Dignity
Standard 8 – Fluid and
Nutrition
Standard 9 – Awareness
of Mental Health,
Dementia and Learning
Disability
Standard 12 – Basic Life
Support
Standard 13 – Health
and Safety
Standard 14 – Handling
Information
Standard 15 – Infection
Prevention Control
Standard 10&11 –
Safeguarding Adults and
Children
26/1/2023
23/10/2023
23/10/2023
00:29:38
83.33
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:20:35
83.33
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:08:36
100
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:06:37
100
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:19:49
100
PASSED
Yes
26/1/2023
23/10/2023
24/10/2023
00:02:13
83.33
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:15:09
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:12:21
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:05:36
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:08:46
83.33
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:45:32
83.33
PASSED
Yes
Care Certificate
26/1/2023
24/10/2023
24/10/2023
04:28:00
91.11
PASSED
Yes
Managing Challenging
Behaviour Positive
Behaviour Support
Mental Capacity Act and
Deprivation of Liberties
Awareness
26/1/2023
24/10/2023
24/10/2023
00:13:18
100
PASSED
Yes
26/1/2023
22/10/2023
25/10/2023
00:16:10
90
PASSED
Yes
Food Safety Level 2
26/1/2023
22/10/2023
26/10/2023
00:05:00
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
53 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Food Safety Level 3
26/1/2023
22/10/2023
26/10/2023
00:12:49
90
PASSED
Yes
Standard 10&11 –
Safeguarding Adults and
Children
26/1/2023
1/2/2023
7/2/2024
00:39:09
83.33
PASSED
Yes
Care Certificate
26/1/2023
7/2/2024
7/2/2024
01:39:00
91.67
PASSED
Yes
Food Safety Level 2
26/1/2023
7/2/2024
7/2/2024
00:30:04
Fire Safety CSTF Aligned 26/1/2023
7/2/2024
7/2/2024
00:06:21
GDPR Awareness
26/1/2023
7/2/2024
7/2/2024
00:08:01
90
90
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
Learning Disability
Awareness
Managing Challenging
Behaviour Positive
Behaviour Support
Manual Handling of
Inanimate Objects
Awareness
Mental Capacity Act and
Deprivation of Liberties
Awareness
Moving and Handling of
People Awareness
26/1/2023
7/2/2024
7/2/2024
00:04:39
100
PASSED
Yes
26/1/2023
7/2/2024
7/2/2024
00:04:28
100
PASSED
Yes
26/1/2023
7/2/2024
7/2/2024
00:02:16
100
PASSED
Yes
26/1/2023
7/2/2024
7/2/2024
00:03:54
100
PASSED
Yes
26/1/2023
7/2/2024
7/2/2024
00:08:42
80
PASSED
Yes
Oral Health
26/1/2023
7/2/2024
7/2/2024
00:02:31
100
PASSED
Yes
Palliative and End of Life
Care
Safeguarding of
Vulnerable Adults
Awareness
26/1/2023
7/2/2024
7/2/2024
00:04:42
90.9
PASSED
Yes
26/1/2023
7/2/2024
7/2/2024
00:54:44
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
54 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Dementia Care
26/1/2023
24/10/2023
24/10/2023
00:54:44
100
PASSED
Yes
Diet and Nutrition
26/1/2023
23/10/2023
23/10/2023
00:54:44
100
PASSED
Yes
Dignity, Privacy and
Respect
Emergency First Aid
Awareness
Equality, Diversity and
Human Rights
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
26/1/2023
23/10/2023
23/10/2023
00:54:44
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:54:44
100
PASSED
Yes
26/1/2023
23/10/2023
23/10/2023
00:54:44
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:54:44
100
PASSED
Yes
26/1/2023
24/10/2023
24/10/2023
00:54:44
100
PASSED
Yes
Person Centred Care
26/1/2023
23/10/2023
23/10/2023
00:54:44
100
PASSED
Yes
Safeguarding of
Vulnerable Adults
Awareness
26/1/2023
24/10/2023
24/10/2023
00:54:44
100
PASSED
Yes
Food Safety Level 2
11/3/2023
11/3/2023
11/3/2023
00:05:25
100
PASSED
Yes
Food Safety Level 2
11/3/2023
17/3/2023
17/3/2023
00:03:34
100
PASSED
Yes
Health and Safety
Awareness
11/3/2023
17/3/2023
16/6/2023
00:02:11
100
PASSED
Yes
Food Safety Level 2
11/3/2023
12/3/2023
15/6/2023
00:02:20
100
PASSED
Yes
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
11/3/2023
12/3/2023
15/6/2023
00:01:47
100
PASSED
Yes
11/3/2023
12/3/2023
15/6/2023
00:02:17
100
PASSED
Yes
Dementia Care
11/3/2023
12/3/2023
16/6/2023
00:02:29
80
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
55 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Equality, Diversity and
Human Rights
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
11/3/2023
12/3/2023
16/6/2023
00:02:23
11/3/2023
12/3/2023
16/6/2023
00:02:44
80
90
PASSED
Yes
PASSED
Yes
11/3/2023
12/3/2023
16/6/2023
00:02:38
100
PASSED
Yes
Food Safety Level 2
11/3/2023
12/3/2023
16/6/2023
00:02:25
100
PASSED
Yes
Food Safety Level 2
11/3/2023
12/3/2023
16/6/2023
00:02:36
100
PASSED
Yes
Infection Prevention and
Control Level 2 CSTF
aligned
11/3/2023
14/3/2023
16/6/2023
00:02:34
100
PASSED
Yes
Food Safety Level 2
11/3/2023
14/3/2023
16/6/2023
00:02:21
100
PASSED
Yes
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
Health and Safety
Awareness
11/3/2023
14/3/2023
16/6/2023
00:02:56
100
PASSED
Yes
11/3/2023
14/3/2023
16/6/2023
00:02:17
100
PASSED
Yes
11/3/2023
16/3/2023
16/6/2023
00:02:43
100
PASSED
Yes
Person Centred Care
11/3/2023
16/3/2023
16/6/2023
00:02:09
100
PASSED
Yes
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
11/3/2023
17/3/2023
16/6/2023
00:02:36
100
PASSED
Yes
11/3/2023
17/3/2023
16/6/2023
00:02:26
100
PASSED
Yes
Food Safety Level 2
11/3/2023
17/3/2023
16/6/2023
00:02:12
100
PASSED
Yes
Food Safety Level 2
11/3/2023
17/3/2023
16/6/2023
00:02:19
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
56 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Mental Capacity Act and
Deprivation of Liberties
Awareness
Mental Capacity Act and
Deprivation of Liberties
Awareness
11/3/2023
17/3/2023
16/6/2023
00:02:56
100
PASSED
Yes
11/3/2023
19/6/2023
19/6/2023
00:20:46
100
PASSED
Yes
Food Safety Level 2
11/3/2023
19/6/2023
19/6/2023
00:02:03
100
PASSED
Yes
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
Mental Capacity Act and
Deprivation of Liberties
Awareness
Mental Capacity Act and
Deprivation of Liberties
Awareness
Managing Challenging
Behaviour Positive
Behaviour Support
Mental Capacity Act and
Deprivation of Liberties
Awareness
Moving and Handling of
People Awareness
Moving and Handling of
People Awareness
Managing Challenging
Behaviour Positive
Behaviour Support
11/3/2023
19/6/2023
19/6/2023
00:05:01
80
PASSED
Yes
11/3/2023
19/6/2023
19/6/2023
00:05:10
100
PASSED
Yes
11/3/2023
19/6/2023
19/6/2023
00:03:00
100
PASSED
Yes
11/3/2023
19/6/2023
19/6/2023
00:04:04
100
PASSED
Yes
11/3/2023
16/8/2023
16/8/2023
00:06:33
80
PASSED
Yes
11/3/2023
16/8/2023
16/8/2023
00:05:53
100
PASSED
Yes
11/3/2023
16/8/2023
16/8/2023
00:05:31
11/3/2023
19/9/2023
19/9/2023
00:03:42
11/3/2023
19/6/2023
23/9/2023
00:02:49
80
80
80
PASSED
Yes
PASSED
Yes
PASSED
Yes
Emergency First Aid
11/3/2023
16/6/2023
24/9/2023
00:01:23
90
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
57 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Awareness
Fire Safety CSTF Aligned 11/3/2023
27/9/2023
27/9/2023
00:02:12
90
PASSED
Yes
Food Safety Level 2
11/3/2023
27/9/2023
27/9/2023
00:01:33
100
PASSED
Yes
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
Manual Handling of
Inanimate Objects
Awareness
Safeguarding of
Vulnerable Adults
Awareness
Communication and
Record Keeping
Communication and
Record Keeping
11/3/2023
27/9/2023
27/9/2023
00:27:32
100
PASSED
Yes
11/3/2023
27/9/2023
27/9/2023
00:01:40
100
PASSED
Yes
11/3/2023
27/9/2023
27/9/2023
00:04:02
100
PASSED
Yes
11/3/2023
27/9/2023
27/9/2023
00:02:16
90
PASSED
Yes
22/5/2023
9/11/2023
9/11/2023
00:31:07
100
PASSED
Yes
22/5/2023
7/2/2024
7/2/2024
00:03:22
Fire Safety CSTF Aligned 22/5/2023
13/2/2024
13/2/2024
00:15:12
COSHH Awareness
22/5/2023
13/2/2024
13/2/2024
00:01:29
90
80
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
Food Safety Level 2
22/5/2023
13/2/2024
13/2/2024
00:02:20
100
PASSED
Yes
Falls Prevention
22/5/2023
13/2/2024
13/2/2024
00:02:44
100
PASSED
Yes
GDPR Awareness
22/5/2023
13/2/2024
13/2/2024
00:02:54
80
PASSED
Yes
Moving and Handling of
People Awareness
Manual Handling of
Inanimate Objects
22/5/2023
13/2/2024
13/2/2024
00:01:34
100
PASSED
Yes
22/5/2023
13/2/2024
13/2/2024
00:06:08
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
58 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Awareness
Mental Capacity Act and
Deprivation of Liberties
Awareness
22/5/2023
13/2/2024
13/2/2024
00:02:01
80
PASSED
Yes
Allergen Awareness
22/5/2023
13/2/2024
13/2/2024
00:02:22
90.9
PASSED
Yes
22/5/2023
13/2/2024
13/2/2024
00:03:34
100
PASSED
Yes
22/5/2023
13/2/2024
13/2/2024
00:01:44
90
PASSED
Yes
22/5/2023
13/2/2024
13/2/2024
00:48:12
83.33
PASSED
Yes
22/5/2023
13/2/2024
13/2/2024
00:03:57
83.33
PASSED
Yes
22/5/2023
13/2/2024
22/2/2024
00:01:24
100
PASSED
Yes
22/5/2023
13/2/2024
22/2/2024
00:06:35
83.33
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:06:25
83.33
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:03:24
100
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:02:09
100
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:02:33
83.33
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:34:37
100
PASSED
Yes
Managing Challenging
Behaviour Positive
Behaviour Support
Autistic Spectrum
Disorder (ASD)
Awareness
Standard 2 – Your
Personal Development
Standard 3 – Duty of
Care
Standard 1 –
Understand Your Role
Standard 4 – Equality
and Diversity
Standard 5 – Work in a
Person Centred Way
Standard 6 –
Communication
Standard 7 – Privacy
and Dignity
Standard 8 – Fluid and
Nutrition
Standard 9 – Awareness
of Mental Health,
Dementia and Learning
Disability
Standard 10&11 –
Safeguarding Adults and
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
22/5/2023
22/2/2024
22/2/2024
00:01:37
83.33
PASSED
Yes
Yes
Deerlands
59 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Children
Standard 12 – Basic Life
Support
Standard 13 – Health
and Safety
Standard 14 – Handling
Information
Standard 15 – Infection
Prevention Control
22/5/2023
22/2/2024
22/2/2024
00:02:02
100
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:02:51
100
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:03:04
83.33
PASSED
Yes
22/5/2023
22/2/2024
22/2/2024
00:02:14
100
PASSED
Yes
Care Certificate
22/5/2023
22/2/2024
22/2/2024
02:55:00
92.22
PASSED
Yes
Disability Awareness
22/5/2023
13/2/2024
27/3/2024
00:10:44
90
PASSED
Yes
Palliative and End of Life
Care
Communication and
Record Keeping
Learning Disability
Awareness
22/5/2023
27/3/2024
28/7/2024
00:01:16
81.81
PASSED
Yes
22/5/2023
28/7/2024
28/7/2024
00:01:20
22/5/2023
28/7/2024
28/7/2024
00:01:57
90
90
PASSED
Yes
PASSED
Yes
Oral Health
22/5/2023
28/7/2024
28/7/2024
00:01:07
100
PASSED
Yes
Communication and
Record Keeping
5/6/2023
23/10/2023
25/10/2023
00:21:10
100
PASSED
Yes
Fire Safety CSTF Aligned 15/6/2023
25/8/2023
25/8/2023
00:03:35
Fire Safety CSTF Aligned 15/6/2023
24/9/2023
24/9/2023
00:03:55
90
90
PASSED
Yes
PASSED
Yes
Dysphagia Care
11/7/2023
22/10/2023
22/10/2023
00:44:20
100
PASSED
Yes
Diet and Nutrition
12/7/2023
16/8/2023
16/8/2023
00:06:44
Oral Health
12/7/2023
16/8/2023
16/8/2023
00:04:50
90
90
PASSED
Yes
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
60 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Oral Health
12/7/2023
16/8/2023
16/8/2023
00:09:56
90
PASSED
Yes
Oral Health
12/7/2023
16/8/2023
16/8/2023
00:03:36
100
PASSED
Yes
Diet and Nutrition
12/7/2023
16/8/2023
16/8/2023
00:02:53
100
PASSED
Yes
Diet and Nutrition
12/7/2023
23/8/2023
23/8/2023
00:13:36
100
PASSED
Yes
Oral Health
12/7/2023
23/8/2023
23/8/2023
00:18:48
90
PASSED
Yes
Diet and Nutrition
12/7/2023
25/8/2023
25/8/2023
00:15:46
100
PASSED
Yes
Diet and Nutrition
12/7/2023
25/8/2023
25/8/2023
00:03:26
90
PASSED
Yes
Oral Health
12/7/2023
25/8/2023
25/8/2023
00:10:12
100
PASSED
Yes
Oral Health
12/7/2023
25/8/2023
25/8/2023
00:02:53
Diet and Nutrition
12/7/2023
25/8/2023
25/8/2023
00:01:44
Oral Health
12/7/2023
25/8/2023
25/8/2023
00:05:10
90
90
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
Diet and Nutrition
12/7/2023
30/8/2023
30/8/2023
00:13:03
100
PASSED
Yes
Oral Health
12/7/2023
30/8/2023
30/8/2023
00:07:56
90
PASSED
Yes
Diet and Nutrition
12/7/2023
8/9/2023
8/9/2023
00:05:41
100
PASSED
Yes
Oral Health
12/7/2023
8/9/2023
8/9/2023
00:04:58
100
PASSED
Yes
Diet and Nutrition
12/7/2023
9/9/2023
9/9/2023
00:02:53
90
PASSED
Yes
Oral Health
12/7/2023
9/9/2023
9/9/2023
00:04:53
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
61 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Diet and Nutrition
12/7/2023
9/9/2023
9/9/2023
00:14:23
90
PASSED
Yes
Oral Health
12/7/2023
9/9/2023
9/9/2023
00:05:34
100
PASSED
Yes
Diet and Nutrition
12/7/2023
13/9/2023
13/9/2023
00:06:52
90
PASSED
Yes
Oral Health
12/7/2023
13/9/2023
13/9/2023
00:02:29
100
PASSED
Yes
Diet and Nutrition
12/7/2023
14/9/2023
14/9/2023
00:04:01
90
PASSED
Yes
Oral Health
12/7/2023
14/9/2023
14/9/2023
00:04:11
100
PASSED
Yes
Diet and Nutrition
12/7/2023
14/9/2023
14/9/2023
00:01:52
Diet and Nutrition
12/7/2023
14/9/2023
14/9/2023
00:02:41
90
90
PASSED
Yes
PASSED
Yes
Oral Health
12/7/2023
14/9/2023
14/9/2023
00:04:33
100
PASSED
Yes
Diet and Nutrition
12/7/2023
14/9/2023
14/9/2023
00:02:59
90
PASSED
Yes
Oral Health
12/7/2023
14/9/2023
14/9/2023
00:02:13
100
PASSED
Yes
Oral Health
12/7/2023
15/9/2023
15/9/2023
00:09:03
100
PASSED
Yes
Diet and Nutrition
12/7/2023
15/9/2023
15/9/2023
00:16:39
Diet and Nutrition
12/7/2023
18/9/2023
18/9/2023
00:02:13
90
90
PASSED
Yes
PASSED
Yes
Oral Health
12/7/2023
18/9/2023
18/9/2023
00:04:12
100
PASSED
Yes
Diet and Nutrition
12/7/2023
23/9/2023
23/9/2023
00:01:43
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
62 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Oral Health
12/7/2023
23/9/2023
23/9/2023
00:01:26
100
PASSED
Yes
Diet and Nutrition
12/7/2023
23/9/2023
23/9/2023
00:03:14
100
PASSED
Yes
Oral Health
12/7/2023
23/9/2023
23/9/2023
00:04:31
100
PASSED
Yes
Diet and Nutrition
12/7/2023
23/9/2023
23/9/2023
00:01:49
100
PASSED
Yes
Oral Health
12/7/2023
23/9/2023
23/9/2023
00:01:40
100
PASSED
Yes
Diet and Nutrition
12/7/2023
23/9/2023
23/9/2023
00:01:16
100
PASSED
Yes
Oral Health
12/7/2023
23/9/2023
23/9/2023
00:28:01
100
PASSED
Yes
Fire Safety CSTF Aligned 12/7/2023
24/9/2023
24/9/2023
00:39:29
90
PASSED
Yes
Manual Handling of
Inanimate Objects
Awareness
12/7/2023
24/9/2023
24/9/2023
00:01:17
100
PASSED
Yes
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:01:56
100
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:01:19
100
PASSED
Yes
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:02:02
100
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:15:15
100
PASSED
Yes
Oral Health
12/7/2023
14/9/2023
24/9/2023
00:01:46
100
PASSED
Yes
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:01:34
100
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:01:17
100
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
63 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:02:33
100
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:07:52
100
PASSED
Yes
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:02:52
100
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:01:59
100
PASSED
Yes
Diet and Nutrition
12/7/2023
24/9/2023
24/9/2023
00:01:58
90
PASSED
Yes
Oral Health
12/7/2023
24/9/2023
24/9/2023
00:01:29
100
PASSED
Yes
Diet and Nutrition
12/7/2023
27/9/2023
27/9/2023
00:02:30
100
PASSED
Yes
Oral Health
12/7/2023
27/9/2023
27/9/2023
00:03:16
100
PASSED
Yes
Diet and Nutrition
12/7/2023
27/9/2023
27/9/2023
00:03:17
100
PASSED
Yes
Coronavirus in Health
and Social Care
Mental Health
Awareness
12/7/2023
22/10/2023
22/10/2023
00:41:59
12/7/2023
22/10/2023
22/10/2023
00:15:13
Diet and Nutrition
12/7/2023
10/11/2023
10/11/2023
00:13:59
Diet and Nutrition
12/7/2023
7/2/2024
7/2/2024
00:05:43
Diet and Nutrition
12/7/2023
28/7/2024
28/7/2024
00:01:25
16/8/2023
2/8/2021
23/9/2023
00:02:14
90
90
90
80
80
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
PASSED
Yes
PASSED
Yes
PASSED
Yes
16/8/2023
4/8/2021
24/9/2023
00:01:55
100
PASSED
Yes
Equality, Diversity and
16/8/2023
4/8/2021
23/9/2023
00:01:46
100
PASSED
Yes
Equality, Diversity and
Human Rights
Equality, Diversity and
Human Rights
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
64 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Human Rights
Equality, Diversity and
Human Rights
Equality, Diversity and
Human Rights
Equality, Diversity and
Human Rights
16/8/2023
5/8/2021
24/9/2023
00:01:52
100
PASSED
Yes
16/8/2023
5/8/2021
23/9/2023
00:01:55
16/8/2023
29/7/2021
25/8/2023
00:02:15
90
80
80
PASSED
Yes
PASSED
Yes
PASSED
Yes
COSHH Awareness
16/8/2023
16/8/2023
16/8/2023
00:06:31
Communication and
Record Keeping
Moving and Handling of
People Awareness
Managing Challenging
Behaviour Positive
Behaviour Support
Equality, Diversity and
Human Rights
Emergency First Aid
Awareness
Health and Safety
Awareness
Infection Prevention and
Control Level 2 CSTF
aligned
Manual Handling of
Inanimate Objects
Awareness
16/8/2023
16/8/2023
16/8/2023
00:06:21
100
PASSED
Yes
16/8/2023
16/8/2023
16/8/2023
00:06:16
16/8/2023
18/8/2023
18/8/2023
00:05:25
80
90
PASSED
Yes
PASSED
Yes
16/8/2023
30/7/2021
18/8/2023
00:04:53
80
PASSED
Yes
16/8/2023
18/8/2023
18/8/2023
00:06:37
100
PASSED
Yes
16/8/2023
18/8/2023
18/8/2023
00:07:17
90
PASSED
Yes
16/8/2023
18/8/2023
18/8/2023
00:04:35
100
PASSED
Yes
16/8/2023
18/8/2023
18/8/2023
00:11:24
100
PASSED
Yes
COSHH Awareness
16/8/2023
23/8/2023
23/8/2023
00:12:46
Communication and
Record Keeping
16/8/2023
23/8/2023
23/8/2023
00:15:32
COSHH Awareness
16/8/2023
25/8/2023
25/8/2023
00:06:30
80
80
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
65 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
PASSED
(YES/NO)
HAS COURSE
BEEN
STARTED
(YES/NO)
MANAGER
NAME
SITE
NAME
Communication and
Record Keeping
Communication and
Record Keeping
Manual Handling of
Inanimate Objects
Awareness
Emergency First Aid
Awareness
Equality, Diversity and
Human Rights
Communication and
Record Keeping
Emergency First Aid
Awareness
16/8/2023
25/8/2023
25/8/2023
00:32:40
16/8/2023
25/8/2023
25/8/2023
00:07:02
90
90
PASSED
Yes
PASSED
Yes
16/8/2023
25/8/2023
25/8/2023
00:19:41
100
PASSED
Yes
16/8/2023
25/8/2023
25/8/2023
00:03:08
100
PASSED
Yes
16/8/2023
25/8/2023
25/8/2023
00:02:31
16/8/2023
25/8/2023
25/8/2023
00:03:51
80
90
PASSED
Yes
PASSED
Yes
16/8/2023
25/8/2023
25/8/2023
00:05:58
100
PASSED
Yes
Dementia Care
16/8/2023
25/8/2023
25/8/2023
00:01:47
16/8/2023
30/8/2023
30/8/2023
00:08:30
16/8/2023
30/8/2023
30/8/2023
00:06:21
100
PASSED
Yes
Communication and
Record Keeping
Emergency First Aid
Awareness
Moving and Handling of
People Awareness
Moving and Handling of
People Awareness
16/8/2023
30/8/2023
30/8/2023
00:16:06
16/8/2023
25/8/2023
1/9/2023
00:21:39
Food Safety Level 2
16/8/2023
1/9/2023
1/9/2023
00:44:35
80
90
PASSED
Yes
PASSED
Yes
80
80
90
PASSED
Yes
PASSED
Yes
PASSED
Yes
COSHH Awareness
16/8/2023
4/9/2023
4/9/2023
00:14:30
100
PASSED
Yes
Infection Prevention and
Control Level 2 CSTF
aligned
16/8/2023
4/9/2023
4/9/2023
00:37:27
90
PASSED
Yes
COSHH Awareness
16/8/2023
8/9/2023
8/9/2023
00:03:26
80
PASSED
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
Deerlands
66 USER NAME
USER
ID
COURSE NAME
COURSE
ASSIGNED
DATE
COURSE
START
DATE
COURSE
COMPLETION
DATE
COURSE
ACCESS TIME
(HH:MM:SS)
SCORE COURSE
STATUS
HAS
COURSE
BEEN
Text truncated at 80,000 characters — see the source PDF for the remainder.
1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Deerlands Residential Home, 48 Margetson Road, Parson Cross, Sheffield S5 9LS. CORONER I am Tanyka Rawden, HM Senior Coroner for the Coroner area of South Yorkshire (West). CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 6 November 2023 I commenced an investigation into the death of Maureen Alison Woollen. The investigation concluded at the end of the inquest on 18 June 2024. CIRCUMSTANCES OF THE DEATH Maureen Alison Woollen (born 24 September 1931) was discharged from the Northern General Hospital in Sheffield to Deerlands Residential Home in Sheffield on 2 October 2023. The S2A assessment identified she was a high risk of falls due to her underlying dementia and psychosis, her frailty, her limited mobility, the side effects of her medication and her previous falls. On admission to Deerlands residential home a falls risk assessment was not conducted. 4 On 3 October 2023 Mrs Woollen was heard shouting and was found on the floor in her room. She could not say how she came to be on the floor. Staff did not identify any external injuries and did not seek medical assistance. On 6 October 2023 a carer noticed a 'fresh big bruise and a lump on her right forehead and temple'. A team leader was notified and decided to call an emergency care practitioner. This call was not made. Between 6 October 2023 and 13 October 2023 there are no references to Mrs Woollen's facial injury in the care notes. On 11 October 2023 staff noticed a decrease in Mrs Woollen's food and drink intake. This was not recorded in the care notes and medical assistance was not sought. On 13 October 2023 a general practitioner was contacted due to concerns from Mrs Woollen's family and Deerlands Residential home that Mrs Woollen had experienced a recurrence of psychotic symptoms over the previous two days. A general practitioner attended on 13 October 2023 and found Mrs Woollen to be 'slumped in a chair'. He was told the facial bruising occurred on 9 or 10 October 2023. There are no incidents recorded in the care notes on those dates. Mrs Woollen was admitted to Northern General Hospital in Sheffield on 13 October 2023 and diagnosed with an intracerebral haemorrhage. She died in hospital on 31 October 2023 as a result of the intracerebral haemorrhage. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. The MATTERS OF CONCERN are as follows. - I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 August 2024 I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mrs Woollen. I have also sent it to Sheffield City Council who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 5 6 7 8 believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 19 June 2024 9 Signature Tanyka Rawden H.M Senior Coroner for South Yorkshire (West)
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
FAO Ms Tanyka Rawden HM Senior Coroner for South Yorkshire (West) South Yorkshire (West) Coroner’s Service, Medico-Legal Centre, Watery Street, Sheffield S3 7ES Sent by Email: T: E: Office: Our ref: Birmingham Your ref: TBC 13 August 2024 Death of Maureen Alison Woollen (D.O.B. 24 September 1931, D.O.D. 31 October 2023) Response to Regulation 28 Report to Prevent Future Deaths Dear Sirs We have been asked to assist Sheffcare in relation to the matters of concern raised in the Coroner’s Report to Prevent Future Deaths (PFD) dated 19 June 2024 raised under Paragraph 7 of Schedule 5 Coroners and Justice Act 2009. The PFD was addressed to Deerlands Residential Home, 48 Margetson Road, Parson Cross, Sheffield S5 9LS (“Deerlands”) which is the address at which Mrs Maureen Woollen was residing when she had an unwitnessed fall on 3rd October 2023. We attach a small bundle of documents which is referred to in this response. For the avoidance of doubt Sheffcare is the company that own Deerlands. Although we did not represent Sheffcare at the Inquest it is our understanding that the Learned Coroner considered several areas of concern which were: a failure to escalate matters and seek medical advice on 3rd October 2023 and subsequently a care worker noted on 6th October that Mrs Woollen had bruising to her face but did not seek medical advice about this either. There were also concerns about the lack of detailed risk assessment from the outset and that care notes were not completed adequately. Before dealing with the specific concerns, we thought it would be helpful to set out an overview of the current status regarding changes that have been made since the sad death of Mrs Woollen as well as the generic systems that Sheffcare have in place that are relevant. is the new Director of Quality and Care for SheffCare. was not in post at the time of Mrs Woollen’s fall, but since she took on the role of Director of Quality and Care, has been implementing changes and improvements at the service. She is a senior and very experienced member of the management team at Sheffcare having over 30 years’ experience in the private care sector. The service through , has taken the opportunity to consider wider matters arising from the inquest and although strictly not part of the PFD request, Sheffcare wish to document reassurance that it has Page 2 Our ref: Your ref: TBC reviewed its relevant policies and guidance including Falls and Risk Assessment and Admission Policy [see documents 1 and 2]. There is also stringent auditing at “root” level within the service and detailed reporting to the Board to track incidents and ensure compliance with various relevant regulations [see documents 3-6]. The Learned Coroner is aware that Mrs Woollen was admitted to Deerlands when her previous placement had stated that it could not address all of Maureen’s needs. This was after a fall for which she had been treated at hospital. On discharge she was subject to the S2A Pathway. This means that she needed to leave hospital as she was medically fit for discharge but that her initial placement with Sheffcare was for a period of assessment. Assessment of risk is dynamic, and it can take some time for an individual (especially with dementia) to settle in sufficiently for a baseline to be established so that person centred care can be fully implemented. The relationship between the service provider and the local authority, under the S2A Pathway is important. The Local Authority gleans information from the discharging Trust, and this is what the needs for admission into the private care provider’s service is based on. There is therefore significant reliance upon the Local Authority to provide the most up to date information although it is an essential part of the admission that the service conducts its own risk assessment on admission too. There must be liaison between the service and the local authority to ensure that the service can meet the individual’s needs – a decision which needs to be made prior to discharge. It is therefore paramount that all the relevant information is given by the discharge team. A further full assessment must be undertaken by the receiving service to ensure that the risks within that environment are noted and ameliorated. At a recent meeting between senior members of the management team of Sheffcare and the Local Authority a frank discussion on Risk Management and Incidents was undertaken. The service drew the Local Authority’s attention to the following: o Forms are often unreadable and filled with high-risk fall indications without detailed explanations. o There's a discrepancy between hospital and care home assessments, o Lack of information about patients' routines and history from the community is problematic. A senior member of the team at the Local Authority (RA) confirmed that over the next six months (July to December 2024) “efforts will focus on improving the S2A pathway, addressing identified issues, and preparing for a new model to be implemented post-April.” Page 3 Our ref: Your ref: TBC RA also confirmed that comprehensive information from the discharging hospital would be sought to enable better decision making around admission and to inform the risk assessment process. Finally, RA confirmed that he would be immediately responsible through the “Referral Workstream” for the implementation of a process for completing and transferring fall risk assessments from hospitals to care homes seamlessly. Whilst these matters are not a direct response to the concerns raised, Sheffcare is concerned to ensure that the Learned Coroner has other pertinent background information to evidence the proactivity and collaboration between the service and the Local Authority with the intention of reducing risk before admission to the service. It is anticipated that due to this enhanced reporting and more proactive relationship – service users’ risk will be assessed more accurately prior to joining the service. This will provide the service with a better understanding of the individual’s needs and enable staff to make appropriate provision for admission. The Registered Manager of the service is then responsible for carrying out a full risk assessment on admission. Staff are subject to training to recognise changes in risk and have clear information of how and when to escalate matters. Directly after the incident with Mrs Woollen, the service met with staff at Deerland and what is known as “huddles” were carried out [see document 7]. A huddle is an informal meeting at which matters to celebrate as well as concerns are raised directly with staff. The incident with Mrs Woollen was discussed and staff were reminded of the policies in relation to falls risk, documentation, and escalation it has also been part of their mandatory training and discussed in supervisions. [see document 8]. The importance of maintaining care notes was discussed at the Deputy Managers’ meeting on 2 July 2024 [see document 9]. Sheffcare already have sophisticated Person-Centred Software, but this does not appear to have been used effectively at the time of Mrs Woollen’s care. Sheffcare has now improved the training sessions which already focus on the importance of keeping timely and accurate care notes by incorporating within the existing training real and anonymised scenarios to reinforce to staff understanding. The software includes training around ensuring a falls risk assessment is completed on admission. Falls (witnessed or otherwise) must be documented in the Person-Centred Care system and there is a monitoring and tracking section in the notes. This is audited. Refresher training has been rolled out at all Sheffcare homes to include the completion of assessments prior to admission to the home and the importance of making detailed Person-Centred Software entries and maintaining daily care notes. The roll out of this refresher training was completed on 31 Page 4 Our ref: Your ref: TBC July 2024. It is now a continuing feature of regular updating training. The training programme is reviewed and reported upon every month. The training matrix is attached [see document 8]. Subsequent to Mrs Woollen’s fall, there has also been a complete review spearheaded by Louise of the Quality Assurance Systems for the Person-Centred Care systems which links care plans and risk assessments automatically this is audited [see document 3]. There is a three-tier approach to quality auditing headed by the Team Leader, Deputy Manager and Registered Manager who undertake quality audits which then inform the monthly quality dashboard report. [see document 4]. There has been further focus on the process at Team Leader level to capture whether falls and requirement for medical attention is being escalated appropriately. The auditing also includes analysis of whether care notes are properly updated. This review was completed on 8 July 2024. In addition, the Registered Manager and Deputy Manager QA now incorporate management checks on the Person-Centred care system and daily care notes are sampled to promote good record-keeping principles. This gives further quality assurance and the end of the roll out of this new part of the services oversight will be completed by 31 August 2024. The governance of Quality Assurance processes is kept under review by the Executive team and Quality Committee. Reporting at Director level to the Board is in place and includes all areas of risk management. Director home Quality Assurance visits were introduced in May 2024. A Lessons learned briefing was issued on 21 June 2024 to all homes to ensure that this matter was discussed across all the teams [see document 10]. held a Deputy Managers’ meeting on 2 July 2024 and issued notes for all the homes to ensure a generic approach and focus on, the process for completing body maps and taking photographs of any injuries or marks. Updated guidance on ensuring correct and robust use of body maps. This was completed on 12 July 2024 [see document 9]. met with Care Plan Coordinators on 16 July 2024. The Care Plan Coordinator role and remit is to upload the PCS notes from assessment and ensure that all assessments are undertaken. They support the operational management team in building care plans on PCS and ensure care plans are kept under close review. The meeting focussed on ensuring that falls risk assessments are in place prior to admission or on admission day, along with care plan review processes. is undertaking an analysis of PCS falls assessment data, which will provide additional reassurances that all residents have falls risk assessments in place and any additional information around the management of falls is appropriately reviewed. The Initial findings will be presented at the 22 August 2024 Quality Committee meeting, and this will be completed by 31 August 2024. The admissions policy was reviewed and updated on 1 July 2024 to further outline that falls risk assessment are to be completed prior to or on admission to Sheffcare homes. This will include a Page 5 Our ref: Your ref: TBC person’s falls history and associated risks which could increase the risk of falls along with any falls which occur during the residency within a Sheffcare home. The falls prevention policy was reviewed and updated 1 July 2024 to reiterate the procedure for completing first aid checks on a fallen resident and referring to medical attention, also to ensure that any injury/injuries are monitored and reviewed within the care notes [see document 1]. The updated admissions policy and falls prevention policy were sent to Registered Managers and Deputy Managers on 1 and 3 July 2024 for them to read and to familiarise themselves with the changes, and to update their staff teams [see document 9]. Unannounced visits have been undertaken by the Head of Quality and Improvement and the Director of Quality and Care provide additional assurances and visibility to the team. Following these visits, a review is being undertaken to include any observations and learning arising. Increased due diligence of referrals was discussed with managers on 24 July 2024 at the managers’ meeting and a frank discussion regarding referrals which arise, with limited information, or areas of assessment which identify possible areas of risk a new due diligence process has been implemented (see comments regarding the Local Authority involvement above). There is now oversight by the Executive team of any inquests providing further opportunity to undertake thematic reviews that may require additional oversight or action, including any relating to HR, health and safety or financial investment. Mrs Woollen’s case (and the improvements and learning from it) will be discussed on 22 August 24 at the Quality Committee meeting. This will include the outcome of inquest, the PFD, actions put in place and a review of progress. The service has been in direct contact with CQC and updated on all improvements made. In short there has been a significant overview by Sheffcare in relation to the quality of services, risk assessment and training. Specific matters of concern from PFD No process in place to ensure medical attention is promptly sought for residents who require it, Please see the above regarding the Person-Centred care system. Further, all staff at the service receive basic training in relation to life support and falls management. All staff are aware of how to contact the local GP, when to escalate and when to call 111. Staff are aware that if in doubt then 111 should be called for further advice [see document 11]. Page 6 Our ref: Your ref: TBC That care notes are not fully utilised – especially for recording of injury and incidents. The Person-Centred Care system as stated above has a section for specific recording of injury and incidents. Staff have received refresher training and there is ongoing audit being undertaken. Please see response above Falls risk assessments are not being conducted on admission. A complete risk assessment including falls risk assessment is undertaken by the Registered Manager on admission in accordance with the new policy [see documents 1 and 2]. As stated previously, the care notes are subject to spot checks to ensure compliance. In addition to the huddles and cascading of information through managers, this is discussed at staff supervisions. We do hope that this response will go some way to reassure the Learned Coroner that Sheffcare has taken its responsibilities very seriously. It has been gravely concerned at the issues that were identified by the Learned Coroner and has used this opportunity to undertake a complete review under the supervision of the Director of Quality and Care. If the Learned Coroner seeks clarification of any of the issues raised, then please contact Sarah Knight ( ). Yours faithfully Legal Director Weightmans LLP
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