James Harris
21 Jul 2017 · Coroner Emma Brown · Birmingham and Solihull
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. resident not accompanied during mobilisation
“At the time of his fall one of his - had not read his care plan or risk assessments”
2. pain not addressed after fall
“Having fallen Mr [name redacted] complained of pain in his groin.”
3. inadequate record keeping
“Records of routine checks on residents are not made”
4. lack of registered manager
“The home is currently without a registered manager and has been for sometime”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr [name redacted] was checked hourly throughout following the fall there is no evidence that the checks were carried out”
Later report
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Responses
2017-0334-Response-by-Care-First-Class-UK.pdf ↗· Care First Class UK Limited
Stated action · within 72 hours of a service user arriving
“Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.”
2017-0334-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and”