Safeguarding Adult Review - Robert by Miriam

Working in partnership with the Family

2023-10-23 13:42:46 UTC

Kept a Relationship based work and made sure to keep the wider family (mainly his brother) well informed, as well as working in partnership with family who knew him best.
This links with PCF 2,3,4
Quote:
"His social worker had a great rapport with him which is reflected in the reflective conversations within this Review. Therefore, the key learning point here is the centrality of relationship-based work, informed by the understanding from those who knew him best, including his brother"

Keeping the support Risk assessed

2023-10-23 13:45:12 UTC

Made efforts and had evidence of making sure that Robert was always risk assessed. This links to PCF7
"Correctly assessed that the move would need to be planned thoroughly and
risk assessed"

Relocated Robert to sheepfold

2023-10-23 13:51:44 UTC

Social worker moved Robert from Harwich House after a change in management and leadership of the home which lead to his health deteriorated. This came from an assessment of how as the leadership of Harwich House changed as did the quality of care.
This links with PCF 8, the social worker worked to notice the adaptations and changes in organisation contexts and this meant that the social worker relocated Robert to Sheepfold.

"during the last 18 months of life his health deteriorated in a number of ways and this period of time will be considered in this Review."
" This move was due to multiple safeguarding concerns about the quality of care"

How he fractured his neck?

2023-10-23 13:52:27 UTC

And how do we miss a fractured neck?

How he was starved to death intentionally?

2023-10-23 13:53:19 UTC

And how long this was ignored?

How different members of a care home are able to assault each other?

2023-10-23 13:54:45 UTC

Why there is no measures in place to de-escalate fights?

How Care Plans and Eating and Drinking plans were not followed?

2023-10-23 13:55:44 UTC

Recommendation 1 - Multi-agency Working

wbjd2y7bdx — 2023-10-25 16:08:29 UTC

- Consider approaches to multi-agency working to include practice guidance for workforce
- Assurance of collaboration and inclusion of wider/independent care sector
- Assurance of its effectiveness
- Escalation process (both single agency and multi)
- Seek assurance from commissioning/provider organisations on supervision practice
- Seek assurance from statutory health and social care agencies regarding key working. (Should specifically ensure independent providers of care are integral to ongoing core planning)

Recommendation 2 - Safeguarding

wbjd2y7bdx — 2023-10-25 16:24:38 UTC

- Seek assurance that safeguarding enquiries for individuals who are in service are being managed under the Operational Framework for Provider concerns.

- Asked to ensure that personal safeguarding plan takes account the concerns raised for individual and relevant provider issues, risks and actions needed.

- Seek assurance that multi-agency Safeguarding procedures are being followed with reference to Police referrals when there is an allegation of a criminal offence.

Recommendation 3 - Workforce skills and knowledge

wbjd2y7bdx — 2023-10-25 17:00:55 UTC

- Seek assurance on arrangements for ensuring staff have necessary knowledge, experience and skills for meeting needs of adults with complex needs. (Should include consideration of bespoke individual training packages)

- Ensure there are agreed processes in place to support identification and escalation of deteriorating health conditions.

Recommendation 4 - Communication

wbjd2y7bdx — 2023-10-25 17:17:37 UTC

- Seek reassurance that providers have communication plans which ensure that info sharing with other agencies is easily accessible and person-centred.

- Effectiveness Schemes should be reviewed and whole system approaches applied

Areas of good practice reported in the review:

wbjd2y7bdx — 2023-10-29 21:50:24 UTC

The Learning Disabilities team worked well within the multi-disciplinary team
The psychiatry reviews were comprehensive
There was holistic application of the MCA
Were some holistic and person-centred wellbeing reviews
There was regular contact with family members
Was a high standard of safeguarding concerns from the Learning Disability team

Research based

2023-10-30 07:28:35 UTC

“his was well thought out and research based. Robert's Social Worker

correctly assessed that the move would need to be planned thoroughly and

risk assessed. Relocation of older people from one care setting to another is

recognised to be particularly stressful and to have adverse effects on health8

8 Castle N, Relocation of the elderly, Med Care Res Rev 2001

Robert's specific set of complex issues increased his vulnerability to morbidity

and mortality.”

If leadership wasn’t an issue would Robert have survived?

2023-10-30 07:29:57 UTC

If the issue lied within the organisation context then surely others would have died, could this have been prevented?

West Sussex:

he237 — 2023-10-30 08:15:05 UTC

"In West Sussex, we have sought assurance from the self-assessment process and case file audits and, highlighted the need for information sharing in our Reviews’ accompanying learning briefings and podcasts. We also, have two well established, monthly multi-agency subgroups. These are the Multi-Agency Risk Management where information is shared to manage risk of those with high risk and complex needs and, our Quality Assurance and Safeguarding Information which works to share and respond to risk with providers."

However there were things taken on board other local authorities:

he237 — 2023-10-30 08:15:53 UTC

For Example in Brighton and Hove:

he237 — 2023-10-30 08:17:54 UTC

"A Sussex Information Sharing Guide and Protocol has also been produced to support information sharing across Sussex in relation to safeguarding."

Health oversight

he237 — 2023-10-30 08:23:51 UTC

Not being diagnosed with fractured Neck

"Difficulties in recognition/management of pain"

failure to diagnose and prevent "Inanition"

"significant conditions contributing to death, but not related to the disease or condition causing it: II cognitive impairment schizophrenia"

Staff skills and Knowledge

he237 — 2023-10-30 08:26:38 UTC

Lack of leadership, and or a change in leadership caused Roberts health concerns to be overseen or ignored.

This also relates to how a lack of communication causes delays in response to such health concerns.

the staff not knowing the signs or how to deal with Robert's complex needs contributed also.

Staff in the care home not always effectively documenting or communicating changes in presentation both behaviourally and from a physical health perspective so key health professionals were not fully cited.

GP

he237 — 2023-10-30 08:27:30 UTC

Psychiatrist

he237 — 2023-10-30 08:27:51 UTC

LD Nurse

he237 — 2023-10-30 08:28:11 UTC

Learning Disability Nurse

SALT

he237 — 2023-10-30 08:28:34 UTC

Speech and Language Therapists

And his care team at Harwich House

he237 — 2023-10-30 08:28:48 UTC

He had a Health Management Plan, a Hospital Passport and a person-centred “My Plan”.

he237 — 2023-10-30 08:28:51 UTC

Social Worker

he237 — 2023-10-30 08:50:39 UTC

And his care team at Aspen Lodge in his young adult years

he237 — 2023-10-30 10:12:58 UTC

Person-centred

he237 — 2023-10-30 10:14:26 UTC

Robert would have benefited from a person-centred approach, throughout his care, instead of what the care home were no longer able to supply

How long was he starved, until he developed the condition he died of?

he237 — 2023-10-30 10:15:24 UTC

Achieve-together team

he237 — 2023-10-30 10:16:11 UTC

Was he subject to assault because he couldn't see or speak?

he237 — 2023-10-30 10:23:36 UTC

Medical staff at Worthing Hospital

he237 — 2023-10-30 10:30:40 UTC

Prior to the change in leadership, Robert was doing well.

he237 — 2023-10-30 10:34:26 UTC

Robert

2023-10-30 10:35:19 UTC

Today we will be talking about a 61 year old named Robert who lived in a care home for 10 years.

We will be discussing the background of Roberts care, what could've been done better, services involved, what went well, our role as a social worker and learning from this.

Robert was described as a vibrant man who enjoyed social events and activities and was said to enjoy his time in the care facility before covid.

Robert suffered from depression schizophrenia and a learning disability. he also was registered blind.

With Robert further being mostly non verbal his brother illustrates in the report his care needs and quality of life

why was Natural causes the cause of his death on death certificate?

he237 — 2023-10-30 10:38:58 UTC

Inconsistent application of the multi-disciplinary care plan.

he237 — 2023-10-30 10:40:02 UTC

LD nurses and team showed strong evidence of advocating for Robert

he237 — 2023-10-30 10:41:34 UTC

Unqualified care staff

he237 — 2023-10-30 10:42:34 UTC

Registered Manager

he237 — 2023-10-30 10:46:57 UTC

The manager didn't know much about he care plan?

Horsham medical staff

he237 — 2023-10-30 10:51:00 UTC

West Sussex Safeguarding Adults board

he237 — 2023-10-30 10:53:21 UTC

West Sussex Police

he237 — 2023-10-30 10:57:40 UTC

Due to assault he faced in care home from other residents

Adult Social Care

he237 — 2023-10-30 10:57:52 UTC

lack of documentation

he237 — 2023-10-30 10:59:28 UTC

the unqualified staff were not able to document Robert's needs or symptoms causing delays in treatments

Robert was Blind and non-verbal

he237 — 2023-10-30 11:01:53 UTC

Unqualified staff were unable to communicate with Robert about his issues, fears or dislikes

Church Services

he237 — 2023-10-30 11:04:04 UTC

How quickly situations can change

he237 — 2023-10-30 11:06:04 UTC

How a decision seemingly unrelated to Robert can impact him so much?

he237 — 2023-10-30 11:06:56 UTC

known to be prone to fall

he237 — 2023-10-30 11:14:21 UTC

yet was left alone on several occasions

Care Plan-not followed repeatedly

he237 — 2023-10-30 11:14:49 UTC

Teenage years

2023-10-30 11:18:04 UTC

Robert began experiencing difficulties in secondary school and struggled with the transition

He was admitted to hospital at 14 and suffered from a traumatic set of investigations from doctors who were "perplexed" by him

Despite these investigations no real diagnosis was given to him

Mid 1980's diagnosed with schizophrenia and was moved to Aspen lodge where he was described as happy and fulfilled with finding out his special interests

11 years later Robert was further moved to Harwich house, with his brother describing him with a love for shopping, attending church and arts and crafts

There was a good relationship between the carers at Harwich house and Robert with full engagement

Robert was also able to choose Greece as his holiday destination

Multiple safeguarding concerns from Harwich house with improvement for quality control- confusing. Manager unsure of his plan

Unfortunately Robert lost his mother which significantly impacted him

February 2021 Robert moved to a different care home in which his health declined and he sadly passed away. his family were allowed to be there for his final days