Treat with care

An investigation that showed the importance of proper staff training.

Fewer tasks carry more responsibility than the moving and transferring of frail elderly service users. This case study examines a situation where care home staff were not adequately prepared for the task of moving a resident and, because of this, she sustained injuries.

treatwithcareThe relatives of the lady complained that the service had failed to undertake suitable moving and handling assessment for their elderly relative.

As well as carrying out interviews, the investigators also examined the environment, viewed moving and handling equipment and checked the following documentation: personal planning documentation; the staff training matrix – Moving and Handling; and the care home’s accident record.

They also discovered that the injury happened as staff transported the resident across the room from bed to her wheelchair with a hoist. Staff said that this was not normal practice as they would normally have raised the resident from the bed, turned her and then lowered her in to a chair placed beneath her.

The accident record suggested that the resident’s head fell to the side during the transfer, causing her to make contact with the wardrobe. However, further information provided to the investigators by the staff raised concerns about the accuracy of the information contained in the home’s accident report.

Examination of the resident’s personal file, including Manual Handling Needs of Residents, Care Plan – Mobility, Risk Assessment Report Form – Falls, Risk Assessment Evaluation and Daily Progress Notes, revealed a lack of specific detail about how to move the resident safely and the documentation failed to identify the equipment staff should use for transfers.

The inspectors saw evidence that it was normal practice to use whatever slings were available for transferring the resident but the care plans did not provide any information about how to carry out a transfer other than to involve two members of staff.

The Care Inspectorate also found no evidence to suggest that staff had selected the specific equipment used to transfer the resident at the time of her accident as the result of an assessment.

The inspectors also noted that the service failed to notify the Care Inspectorate of the accident within 24 hours of it occurring.

The complaint was upheld and three Requirements were issued to the provider.

Lessons learned

Providers should ensure:

  1. Detailed moving and handling assessments are in place for each service user.
  2. Staff must be properly trained in moving and transferring procedures with the use of mechanical aids.
  3. Training should be refreshed with staff on a regular basis.
  4. All accidents and incidents are notified in accordance without delay in compliance with guidance published by the Care Inspectorate.