The Proprietor Cc: Social Services Inspector
INCIDENT REPORT
To: The Proprietor cc: Social Services Inspector cc: Health Authority Inspector
Introduction
The purpose of this report is to analyse the causes of the incidents which lead up to, and resulted in, the death of a resident at your home, Mrs X. The report will further draw conclusions from the incident, and will make several recommendations to assist in the prevention of such an incident occurring again in the future.
Account of the incident
Mrs X was an elderly resident who suffered from osteoporosis – a condition which causes the bones to become fragile and brittle.
On the day in question, it appears that a Care Assistant employed by yourself, had cause to restrain Mrs X, and did so by “pulling her shoulder”. …show more content…
Each one is detailed as follows:
1. On said occasion, it was reported that Mrs X was poking a fellow resident with a stick. This behaviour was deemed to be inappropriate, and Mrs X was restrained by a Care Assistant, who “… pulled her shoulder”.
2. It has been reported that it is common practice in the home for care staff to use physical means, to restrain or redirect residents, however none of the care assistants appear to have received any training in this regard.
3. It is not clear whether or not there were any senior staff, or supervisors, present when the incident occurred.
4. The care assistant made a verbal report of the incident to yourself as Proprietor.
5. A written report was subsequently prepared by yourself, and in it there was a suggestion that the care assistant lost his temper with the resident. This suggestion was subsequently denied by the care assistant, and it is unclear whether or not the care assistant had seen, and was given an opportunity to discuss, the contents of the report.
6. It is not clear whether any formal incident reporting procedures …show more content…
Social Services should be able to assist with the provision of a copy of their guidelines for good practice on the use of restraint in residential care for adults.
• It is further suggested that you prepare your own guidelines which can be displayed in staff areas and distributed to staff.
This should be an integral part of all future staff training and retraining/refresher programmes.
Staff Supervision (Obs. 3)
• It is recommended that a staffing review is carried out to ensure that junior and/or inexperienced staff are supervised by a senior member of staff at all times.
• It should also be pointed out that as proprietor, you have a duty of care to familiarise yourself with the day-to-day activities of staff (and residents), as you may be held accountable for them.
(This point should be reiterated due to the fact that (as pointed out in Observation 2), physical restraint is viewed as “common practice” in the daily running of the home, despite the fact that this is contrary to the home’s regulations.)
Incident Reporting (Obs. 4, 5, 6)
• It is recommended that a full review of incident reporting procedures are carried
To: The Proprietor cc: Social Services Inspector cc: Health Authority Inspector
Introduction
The purpose of this report is to analyse the causes of the incidents which lead up to, and resulted in, the death of a resident at your home, Mrs X. The report will further draw conclusions from the incident, and will make several recommendations to assist in the prevention of such an incident occurring again in the future.
Account of the incident
Mrs X was an elderly resident who suffered from osteoporosis – a condition which causes the bones to become fragile and brittle.
On the day in question, it appears that a Care Assistant employed by yourself, had cause to restrain Mrs X, and did so by “pulling her shoulder”. …show more content…
Each one is detailed as follows:
1. On said occasion, it was reported that Mrs X was poking a fellow resident with a stick. This behaviour was deemed to be inappropriate, and Mrs X was restrained by a Care Assistant, who “… pulled her shoulder”.
2. It has been reported that it is common practice in the home for care staff to use physical means, to restrain or redirect residents, however none of the care assistants appear to have received any training in this regard.
3. It is not clear whether or not there were any senior staff, or supervisors, present when the incident occurred.
4. The care assistant made a verbal report of the incident to yourself as Proprietor.
5. A written report was subsequently prepared by yourself, and in it there was a suggestion that the care assistant lost his temper with the resident. This suggestion was subsequently denied by the care assistant, and it is unclear whether or not the care assistant had seen, and was given an opportunity to discuss, the contents of the report.
6. It is not clear whether any formal incident reporting procedures …show more content…
Social Services should be able to assist with the provision of a copy of their guidelines for good practice on the use of restraint in residential care for adults.
• It is further suggested that you prepare your own guidelines which can be displayed in staff areas and distributed to staff.
This should be an integral part of all future staff training and retraining/refresher programmes.
Staff Supervision (Obs. 3)
• It is recommended that a staffing review is carried out to ensure that junior and/or inexperienced staff are supervised by a senior member of staff at all times.
• It should also be pointed out that as proprietor, you have a duty of care to familiarise yourself with the day-to-day activities of staff (and residents), as you may be held accountable for them.
(This point should be reiterated due to the fact that (as pointed out in Observation 2), physical restraint is viewed as “common practice” in the daily running of the home, despite the fact that this is contrary to the home’s regulations.)
Incident Reporting (Obs. 4, 5, 6)
• It is recommended that a full review of incident reporting procedures are carried