Birchwood Care Home in Newbury tightens procedures after neglect was found to play a part in resident's death
A Newbury care home where neglect was found to have played a part in the death of one of the residents has tightened its procedures.
But a coroner has said there is still a risk of future deaths at the Birchwood Care Home and has highlighted the situation with the Care Quality Commission.
Frederick King, 78, died at the Royal Berkshire Hospital on September 9, 2021, having been admitted the previous day.
The cause of death was given as acute kidney injury caused by dehydration, and at an inquest earlier this month Jenny Goldring, assistant coroner for Berkshire, recorded a narrative conclusion, with a rider of neglect.
The inquest heard that Mr King, who suffered from vascular dementia, did not receive adequate fluids in the two days prior to his death. On September 7 he received 985ml and on the 8th 770ml, when the recommended level was 1,400ml.
The coroner said there was neglect because of Mr King’s high level of dependency – he could not feed or take fluid himself – the temperature outside at that time was 26-30 degrees, and his family’s concerns about his health were not recorded by staff.
In a Prevention of Future Deaths report Ms Goldring expressed concern about his fluid intake, the fact that the home’s records were inadequate and there was no manager at the home in the three days prior to his death.
During the hearing it was accepted that the record-keeping was inadequate but evidence was given that an electronic system had been introduced.
Complaints from families are now recorded, fluid records are checked daily and there is a full-time manager on the ground at the home.
The coroner said she was satisfied that improvements had been introduced, but went on: “However, these systems are only as good as the data inputted and the audits conducted, and this will need to be kept under review.
“I am therefore drawing the above matters to the attention of the Care Quality Commission, aware that there have been recent inspections."
The Commission has until January 10 to respond, but following an inspection in July this year it classed the Birchwood Home, which is owned by West Berkshire Council, as “in need of improvement”.
The report states: “The provider had not effectively addressed, monitored and mitigated the risks relating to the health, safety and welfare of service users or effectively sought and acted on feedback from people using the service to drive improvements.
“Risk assessments lacked sufficiently clear guidance to help staff mitigate risks for people.”
The inspectors also found “a significant number of medicines errors”.