Jean Cutler

1. 1. vulnerable residents

   “Cole Valley Nursing Home is run a by a private company and cares for up to 45 residents who are vulnerable due to their age and physical and mental health issues”

2. 2. inconsistent use of lap belts

   “Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling”

3. 3. inadequate risk management

   “I heard evidence that following the incident the Care Quality Commission and Clinical Commission Group had requested from the nursing home copies of revised risk management documents. In my opinion this has led to the nursing home being given the impression their management of residents from falling out of wheelchairs is adequate”

4. 4. lack of restraint devices inside

   “However, the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time continues despite the incident on 5/10/18 revealing the inadequacy of this as a safety measure”

5. 5. inadequate post-incident investigation

   “The nursing home's internal investigation recognised as root causes of the incident a lack of internal knowledge and guidance, that the home has been through a hard time recently and it had impacted on the staff, that care plans did not give correct guidance to staff, and that management was unstable. However, the only post-action event listed was an 'incident debrief'”

6. 6. inadequate falls risk assessment

   “The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls”

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