Action Plan for Bloomfield Dear Sir or Madam, We thought it might be useful to residents, potential residents, their relatives and friends to summarise our response to the Care Quality Commission s latest inspection report, published on the 22 nd of November 2016, setting out the actions we are taking to improve services at Bloomfield. We were grateful that the Care Quality Commission rated us good with respect to being caring. Their overall rating for the home was that it required improvement in three areas at the time of their inspection and was inadequate in one area, with an overall requires improvement rating. We value the Care Quality Commission s view of how we deliver care and recognise that we need to improve services at Bloomfield. We were pleased that the Care Quality Commission noted: People told us staff at the service were caring and we received positive feedback. People were treated with dignity and respect and we observed staff communicating with people in a caring manner. Staff understood the needs of the people they cared for and people's preferences were recorded to help support staff in delivering person centred care. There was a range of activities people could partake in and people were enjoying activities on the day of our inspection. They also recorded: People felt respected by the staff at the service and told us their privacy and dignity was respected. People and their relatives commented on the polite and friendly nature of staff. All of the people we spoke with felt they were treated with dignity and respect and that their privacy was respected by staff. We are already taking action to meet the Care Quality Commission requirements but we know that there are areas in which work is needed, and we want to reassure you that we are taking appropriate actions. We believe that setting out these actions will help everyone interested in care at Bloomfield to understand the inspection report and how we are improving the service we offer. Report findings and actions The Care Quality Commission asked us to ensure that we always report incidents investigated by the police to them. To ensure that we improve our reporting: The management team are now aware of the need to report any incident involving the loss of controlled drugs to the police, and subsequently to the Care Quality Commission. The management team will ensure that any accidents and incidents that require reporting
to the Care Quality Commission, Safeguarding and the Police are reported immediately. Incident and Accident reports will be brought to daily stand-up meetings for management awareness, discussion and action where necessary. Guidance on the statutory notification process has been discussed with our Heads of Unit through supervision and staff meetings. Senior nurses will be made aware of the process for reporting notifiable incidents to the Care Quality Commission, so that in the absence of the general manager or deputy manager they will be able to undertake reporting. Supervisions will be put in place for nurses to ensure any reportable medication errors are reported in a timely manner. Accident and incident reports will be reviewed through quality assurance processes undertaken by the Regional Director and support teams. The Care Quality Commission asked us to ensure that care planning is always appropriate to the individuals we support: To ensure that we improve our care plans: Staff are being reminded through meetings of the need to provide support in communal areas and to maintain safety checks for specific residents. We will recruit more staff for the units to enable a member of staff will be allocated on each shift to monitor lounges within specific units. The activities programme will be reviewed to include the activities organisers presence in communal areas during busy periods where care staff may be providing care in bedrooms or bathrooms. A documented review will take place of all resident s pressure relief requirements. Where residents require the use of alternating air pressure mattresses, the setting will be recalculated in line with their weights and this setting will be recorded in their care plan and on a label attached to the mattress pump. Through supervision and meetings, staff will be reminded of the need to check settings are correct on a daily basis and to record this check on repositioning charts. Carers have received training in the use of pressure relieving mattresses from Renray (our suppliers of these products). All residents or their representatives will be met to ascertain whether pain is experienced on a recurrent or occasional basis. Subsequently care plans pertaining to pain will be reviewed to ensure they reflect the cause and location of pain, whether analgesia is prescribed and the directions for use. Through clinical supervision, staff who handle medicines will be reminded of the requirement to monitor the effectiveness of prescribed pain relief. Initial and on-going assessments of pain will be undertaken utilising a recognised pain assessment tool. Through these actions resident s needs will be identified and care will be delivered in line with treatment plans.
The General Manager and Deputy Managers walking the floor, support team visits and quality assurance audits will include observation of communal areas and staff presence. As a part of the Resident of the day processes, reviews will take place at least monthly in regards to resident s pain assessments, their tissue viability status and the use of pressure relieving equipment. Where residents are deemed to lack capacity or require support we will involve their representative on an on-going basis to review their care needs and how we will meet these needs. The Care Quality Commission asked us to ensure that care is always provided in line with people s consent and with mental capacity legislation. To ensure that we improve our care practice: We will undertake a review of resident s records pertaining to mental health, the assessment of people s capacity, consent and associated best interest decisions. Care plans will be reviewed, and rewritten where required, in order to clarify resident s abilities to make decisions in regards to their care needs. Where residents have limitations on their ability to make decisions, care plans will identify their representatives, who will be consulted in support of their care requirements. This process of review will involve residents directly wherever possible (or their designated representative) and appropriate healthcare professionals. A review of all residents will be undertaken to establish where bedrails and recliner chairs are used, and where covert administration of medicines is sanctioned. Mental Capacity Assessments will be rewritten to specify what they pertain to, in particular whether this leads to a restriction or deprivation of liberty, (e.g., the use of bedrails, the use of recliner chairs, the delivery of personal care), or actions agreed as in someone s best interests, (e.g. the administration of medicines by covert means). Consent forms for the use of resident s photographs to ensure the safe delivery of care, (e.g., the safe administration of medicines), will be completed with the resident or their representative. These actions will ensure that care is delivered in resident s best interests, and wherever possible with their consent and agreement or following discussion with someone acting on their behalf. As part of Resident of the Day review, the Deputy Manager or General Manager will review the resident s care profile to ensure that the mental health care plan reflects the residents ability to make decisions or support required, as well as any practices undertaken in the individual s best interests or that restrict their liberty. The Regional Director and quality assurance processes will monitor care profiles to ensure that processes are maintained. The Care Quality Commission asked us to ensure that we always do everything possible to mitigate risks following an accident or incident and that we manage medicines safely.
To ensure that we improve our risk management: Through supervision and meetings, staff will be reminded of the need to complete accident and incident reports fully and promptly. These reports will be taken to daily stand-up meetings for the management team s awareness and for their review. The management team will undertake a supervision meeting with the Regional Director in regards to the completion of accident and incident forms. Accident and incident forms will be fully completed by the management team to show actions taken following the event, including who has been informed. A copy of the completed accident or incident record will be filed in the manager s office, with the original placed in the resident s records. A documented, monthly review of accidents and incidents will be undertaken by the General Manager and Deputy Manager to identify themes and trends, and where appropriate detail of how improvements are to be made. Where appropriate, Barchester Healthcare s duty of candour policy will be applied to reportable safety incidents, to evidence liaison with the relevant parties and to demonstrate learning from events. Controlled drug stock checks will be undertaken twice daily at handover. The completion of daily controlled drug checks will be confirmed to the General Manager or Deputy Manager as a part of daily stand-up meetings. A simple root cause analysis will be undertaken following any identified medication errors and learning outcomes will be identified and implemented. The service s Health and Safety Committee will review accidents and incidents each month to ascertain whether lessons can be learnt and whether action is required to minimise risks. The Regional Director will review Duty of Candour reports to ensure that where root cause analysis identifies areas for improvement the resulting recommendations are applied. The Care Quality Commission asked us to ensure that our care practice is in line with Mental Capacity Act legislation, following Best Interest processes To ensure that we improve in this area: An ongoing review will be undertaken of all residents to establish who is subject to an agreed Standard Authorisation or where an application has been made under the Deprivation of Liberty Safeguards. Following this review, the home s clinical governance database will be updated to ensure that it reflects current status for all residents. Where an application has been granted and restrictions or limitations have been approved care plans for mental health needs will be reviewed to ensure these restrictions are clear. Where past authorisations that have been granted have expired, the Local Authorities Deprivation of Liberty Safeguards team has been contacted and have been asked to review the resident s status, with new applications submitted where required.
The Deprivation of Liberty Safeguards team will be requested to advise on the processing of applications submitted where an assessment has not been carried out. Ongoing reviews will ensure that where restrictions are no longer necessary the Deprivation of Liberty Safeguards are withdrawn. The status of residents in regards to Deprivation of Liberty Safeguards will be included within handover sheets for staff awareness. Additional staff training on the Mental Health Act, Deprivation of Liberty Safeguards and Mental Capacity will be provided. Learning will be reinforced through on-going discussion, supervision and staff meetings. Accountability for change We are pleased that the Care Quality Commission rated our caring practice as good and noted that: People and their relatives were positive about the service they received. Many of the comments we received during the inspection were positive about how people felt safe and the staff that supported them. For example, one person commented, "I chose to come here, because it is close to where I lived and I had visited other people here and knew that it was a safe haven. It is like a hotel here, I feel safe and comfortable." Another person said, "I am settled here, it is lovely here, I am well looked after." One person's relative said, "My [service user name] is definitely safe here, their mood has lifted since being here, happy with everything," and: People and their relatives spoke highly of the effective care provided by staff at the service. People spoke highly of the care they received and told us they were supported by well trained and knowledgeable staff. One person we spoke with said, "(They are) Confident staff, they know what they are doing you can tell they are well trained." Another person told us, "I do not want for anything, they treat me right." A person's relative we spoke with said, "From my observations I think staff are very good, my [person's name] is very demanding and they deal with them well." We are working hard to ensure that we meet Care Quality Commission requirements for improvements and that we improve our working practices. We are monitoring our progress carefully, audited through regular visits from senior managers: our progress will also be monitored by the Care Quality Commission. As General Manager for Bloomfield these actions are accountable to me. If you would like to talk about any of the issues this raises I and my team would be pleased to do so. Sincerely, Julie Newsome-Cotterill, General Manager 22/11/2016