Agenda item

Briefing Note of the Executive Director of People

Simon Brake, Director of Primary Care Sustainability and Integration, Coventry City Council, Chair of the Review Board and Laurence Tennant, Independent Author of the Review Report have been invited to the meeting for the consideration of this item, along with David Watts, Coventry City Council.

The Scrutiny Board considered a briefing note of the Executive Director of People attached to which was the Executive Summary report which presented the findings of a Coventry Safeguarding Adults Board System Wide Review which followed the death of Mrs F in the spring of 2013. Appended to the summary report were the associated actions plans from both the review and the learning from the case.

Joan Beck, Chair of the Safeguarding Adults Board and Simon Brake, Chair of the Review Group attended the meeting for the consideration of this item along with Mark Radford, University Hospitals Coventry and Warwickshire Jamie Soden and Donna Reeves, Coventry and Warwickshire Partnership Trust and Glynis Washington, Coventry and Rugby Clinical Commissioning Group. The report was also to be considered by the Cabinet Member for Health and Adult Services at his meeting on 14^th December, 2015 and Councillor Clifford, Deputy Cabinet Member also attended the meeting.

Mrs F was 80 years old when she died and had been residing in a Coventry Nursing Home. She had chronic vascular disease which she was aware would be life limiting if she declined any surgical intervention. She received hospital treatment in relation to pressure ulcers. She was discharged from hospital and transferred to a care home where she could receive significant support from health care professionals. Whilst in the care home she developed tissue damage which became infected and was re-admitted to hospital. She died 5 days later as a result of the infection.

The Chair of the Safeguarding Adults Board expressed her condolences to the family, in particular to Mrs F’s granddaughter and apologised for the length of time that it had taken to reach this stage in the review process.

The summary report highlighted that a system wide review took place when a vulnerable adult had died or had been seriously injured or impaired, abuse or neglect was known or suspected and broader system issues were believed to have been a significant factor. The report set out the facts of the case, a summary and overall analysis and conclusions. A summary of the recommendations that applied to all agencies were highlighted along with those for the individual agencies. The action plans set out recommendations with actions required, gave target dates and appropriate lead officers as well detailing progress and expected outcomes.

The Board questioned those present on a number of issues relating to the circumstances of the case and responses were provided, matters raised included:

·  Clarification about the monitoring process for the quality and standards of care homes in the city

·  Concerns about the on-going financial viability of care homes in the current austerity climate and the introduction of the living wage

·  Whether there were any concerns about the viability of care homes in the city in light of press reports that national care home providers could withdraw services

·  Details about funding by the Council to care homes with financial difficulties

·  The use of regulatory tools where there were concerns about care homes and the support provided to those care homes that needed assistance from the Local Authority

·  Clarification about the improved reporting and treatment of pressure ulcers by the agencies involved

·  Further information on the progress of the action plans.

Particular discussion centred on the implications for Care Homes of the introduction of the living wage which was not funded by the Government.

RESOLVED that:

(1) The findings of the Serious Case Review and the recommendations, actions and progress in the action plans be noted.

(2) A report on the current state of care homes in the city be submitted to a future meeting of the Board.

(3) The Chair, Councillor Welsh, be requested to write on behalf of the Board to the Secretary of State for Health outlining the concerns raised about the financial pressure on Care Homes and concerns they may be exacerbated by the compulsory introduction of the living wage, which whilst welcomed is unfunded by Government. There is a concern that this unfunded pressure could lead to a potential reduction in quality of care and the health and safety of patients/residents.