Robert Howell: Prevention future deaths report

“Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring. It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents. As such vital information to those responsible for providing care was often not provided.”

“Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care.”

“Evidence showed a lack of understanding about the falls policies in place.”

“It was acknowledged that the home did have procedures introduced since Mr [name redacted] death however it became evident that there was still a breakdown in communication and vital information was not being shared. There appeared to be a lacuna in what information should be passed to all staff and how confirmation of understanding was checked.”