Posted By Ian Blenkharn
You might like to consider reporting the incident to the local Council and Primary Care Trust, both of which have a responsibility in licensing, and you might take your complaint to the Healthcare Commission for further and more detailed investigation

Ian

Posted By Christopher
Martin

I was sorry to hear about this incident. At the risk of upsetting you, within the NHS there is a fair blame culture. This means that no individual is to blame (unless it suits them), but rather it is the entire teams responsibility. This will be viewed by the PCT as a learning exercise. There aren't that many places for elderly/confused people to be placed. Unfortunately, with the best will in the world accidents do happen, and where there is varied confusion, it can have an impact on the assessment of the nurse. There was no reason for the Care Home to reveal individual records to you, that would be covered by Data Protection. However, they should provide you with details of what training they provide to their staff, if you are a close relative.

I'm not sure how you came by the information of the key for the fire door, but I would have thought you could contact the local fire service.

I have investigated numerous incidents in hospitals, elderly care wards/rehabilitation units. There are numerous questions to ask, including, staffing levels (agency staff), patient demands of the ward, when last clinical assessment was undertaken. Changes in treatment. Staff training, staff knowledge of working with your relative. Number of incidents. How lessons have been learnt from such incidents. What action was taken following on from this incident, reports, etc. etc. Unfortunately, too many questions for me to post here.

Posted By Christopher
Hi Martin, what am I doing responding on a Saturday night!! Actually I'm writing a report and dipped into IOSH.

The Care Home is quite correct, all the patients details should not be left at the end of the bed. Notes are now kept in locked cabinets, generally in the office or the central station. As to whether the staff have read them or not, well if the patient is likely to be very long term, then it is likely that they may only be glanced at for potential changes. If there is ongoing treatment, then a more robust look will have been given. All actions taken on the patients care will be signed for. All the points that I have raised and others should be picked up by the organisations that you have identified.

I would suggest that you sit tight, and await the reports from those bodies to whom you have made representations. If it would help I am happy to review their reports and provide you with feedback. There will be no charge for this and anything read will be confidential.

However, the fire door does concern me. This does suggest that there is an absence of a safety culture. I would contact your local fire service. The patients are potential fatalities waiting to happen.

I will send you my email address seperately

Posted By CRT
Hi Martin.

sorry to hear about this unfortunate incident. In response to your posting, in my opinion it would be RIDDOR reportable, however, as previous postings on this forum have proven, injuries to people not at work and an accident arising out of or in connection with work are notoriously open to interpretation. The home may not have been aware of the need to report.
On the subject of enforcement, HSE are responsible for nursing homes, the LA env health are responsible for care homes, your posting does not indicate whether the home was providing "care" or "nursing care", this may explain the confusion with HSE.
As for the accident, whoever investigatates should look at care plans, staff training, staffing levels etc etc and arive at, hopefully, some conclusions.

Colin

Posted By jackw.
Hi, With regards to RIDDOR generally speaking the HSE do not want reports of incidents of "falling over" unless it is caused by something the care unit staff etc. have done or have not done to cause this: resident falling over a trailing cable left by a cleaner, on a wet floor not cleaned up by staff etc. Falls caused by frailty or a medical condition -- the HSE aren't interested. Whilst it appears that in this case the worker was at fault the care home may have decided that the fall was as a result of this persons frailty and not a failure by staff, systems etc. Care plans are not readily available to non staff, But they should be sufficiently detailed with a robust moving and assisting risk assessment and if the person has a mental issue: confusion dementia etc. a challenging behaviour risk assessment should also be completed, both to protect the resident and staff. Care staff should make them selves familiar with residents plan and each resident should have a key worker with more in-depth knowledge of them and thus able to brief co-workers. There should also be a daily log indicating any issues re a resident for each shift. This should be consulted by staff coming on shift at the changeover period. Re the door I would suggest a call to the fire service may help. Although this should have been highlighted and dealt with as part of the mandatory fire risk assessment for the home. With regard to the general care questions you should write to the regulating body making a complaint and request an investigation.

Cheers

Posted By jackw.
Hi sorry Colin, but that is the instruction from the HSE to us re falls in care homes: if it is because of frailty or a medical condition regardless of the injury they do NOT want it reported. Only if it is caused by something we have done or omitted that caused the incident/fall. Of course as i stated care plans must include risk assessments. But they are not in them selves risk assessments. The issue in this instance did the care worker/home contribute to the fall. I also indicated that the enforcing authority should be notified but they are not the HSE and you will find a reluctance from the HSE to get involved as they feel the registering/licencing authority are the ones to investigate and take action.

When we were the licensing authority we stopped admissions to many private providers because of the issues raised here. The Care Commission in Scotland are now responsible for registration inspection etc. With deference to the fire service on any fire safety issues. But remember care homes do/can not offer 1to 1 support for residents with mobility issues and thus there will unfortunately be falls by elderly frail residents.

Posted By Bob Thompson CMIOSH
I note all the points raised. and yes jack you are quite right hse do not want reports of accidents to residents /service users if it is down to medical condition/fraility etc. however if their is a causative factor then they do , it may be deemed that not following established moving and handling plans may well have been a causative factor. I have had expierience of one fatatility which resulted from a fall where it was not kown wether or not a person had fallen off of or getting onto a commode. The coroner said that the death was due to a fall ( not reportable) however there was a sugestion that a breach of procedure was implicated in this and at this point the HSE investigated .

regards Bob

Posted By CRT
Jackw.

i agree with your first comment, however, the original posting does intimate that the fall may have been caused because the person was left un-aided despite the care plan indicating that they had limited self supporting capability, yes she may have been frail, but, in my opinion, there have been failings (for what ever reasons) by care staff by not following risk control measures stated in the care plan. The investigating authority would establish whether there was a breach of Sec3, in my opinion, non-adhereance to a documented care plan would appear to suggest so.
Lets not forget what the original posting was about, lets not give opinions about what we think an enforcing authority may or may not do, what do we as safety practitioner think should happen ?

Colin

Posted By Ian Blenkharn
Martin

That would seem to be the very reason to consider an approach to the Healthcare Commission and/or the Commission for Social Care Inspection (the two will merge in 2008). The former, in particular, will examine the standards and quality of care, including if necessary a detailed investigation of the case.

There are certain formal steps that you must go through, that usually start with the Care Home's own complaints procedure etc. HCC staff will guide you through the process, appoint a case manager, and commission a detailed investigation and report if appropriate.

Ian

Posted By garyh
In situations like this I would always advise making your initial complaint IN WRITING (not by phone, not by email). Official bodies will usually respond more positively.

Posted By MariaW
It is my understanding (& our company training) that a fall resulting in a break or dislocation is RIDDOR & CSCI notifiable.
Falls resulting in a doctor being called out or a visit to A&E is CSCI notifiable.

Maria