This short podcast is on behalf of the West Sussex Safeguarding Adults Board and is about a Review in Rapid Time in relation to Darlington Court Care Home. This Review looked into the circumstances surrounding the deaths of 13 Residents and a wider outbreak of COVID-19 within the service.
The Review was completed within three weeks and provides a focus on organisational and systemic factors that impact on practice and, provides the opportunity for learning in a timely way.
Firstly, I would like to tell you a little about Darlington Court and the residents they support. Darlington Court is a care home which provides accommodation and care support for older adults including respite and end of life care. The care home residents include adults who have dementia.
At the time of the Covid-19 outbreak, during the second wave of the pandemic, there were 46 male and female Residents with varying support needs. At the time of the referral to our Board for a review, there were 7 open safeguarding enquiries in relation to concerns regarding the COVID-19 outbreak which impacted over 70% of Residents and a significant proportion of the staff team. Infections continued to spread from the first case in October 2020 up until the date of referral to our Board in December 2020.
The Review identified four key areas for learning:
Firstly, that ambiguous, inconsistent, and inaccurate information was not always clarified.
Secondly, that leadership and responsibility for obtaining information and for making decisions, was long-winded and insufficiently authoritative.
Thirdly, that the impact of resources, including operational pressures and the national context, are likely to have impacted on decision-making processes and practice.
And finally, that safeguarding concerns may have been avoidable and preventable.
The Review posed questions for the Board to take forward to gain assurance that the learning needed to improve practice and minimise the risk of similar situations reoccurring has been taken forward.
The Board have summarised these questions under three key areas:
The first is information sharing and multi-agency working: including the need to identify and remove barriers, develop a shared understanding of pressures, priorities and capabilities and to ensure that information shared with those that need it, is accurate and regularly updated.
The second is managing escalating concerns and crisis: including the need to identify escalating concerns and share these, to understanding and respond collectively, to rapidly appoint one person with the authority to lead a response and, the need to escalate concerns should there be a need to halt a process if this is ineffective or is exacerbating risk.
And, finally the third is considering the needs of Adults: including the need for onsite visits as opposed to telephone contact and, putting the needs of people who use services first during times of pressure and crisis.
The Board is focussed on taking forward and seeking assurance on the learning as a result of this Review. We therefore need staff across the partnership to take time to consider how the circumstances and the learning from the Review can influence and better inform your working practice.
To do this, we ask you to reflect on areas of learning from this Review, to support your practice to be current and to improve the experience and outcomes of the Adults we support.
Please do visit the Board website to view:
The accompanying learning briefing and full Review report;
And specifically, in relation to this Review: the information sharing guide and protocol, the escalation policy, the making safeguarding personal learning briefing, the pan-Sussex safeguarding policy and the adult safeguarding, roles and competencies for health care staff.
On our website you’ll also find useful links to all our safeguarding policies and procedures, information for professionals, and other Reviews and podcasts.
We thank you for your time to listen to this podcast today and, we appreciate you moving forwards with us to ensure the learning this Review makes a difference for those who we are supporting.