External Review into care at Brackenridge for identified residents December
2013
A summary
Prepared as part of Brackenridge’s commitment to more open and proactive communication
with the users of the services, their families and other stakeholders,
In September 2013 serious concerns about care at Brackenridge Estates Limited (BEL) were
expressed to the CEO of Brackenridge by GP Dr Peter Wilkinson with whom a number of the clients
of BEL were enrolled. This prompted the Ministry of Health to carry out an issues based audit. Dr
Wilkinson alleged that two Brackenridge residents may not have died last year if early nursing
assessments had been made.
The Brackenridge Board and management commissioned a separate independent review of the care of
the three residents who died in mid 2013. The objectives of the review were:
1. To identify how the physical healthcare needs of these residents were identified, assessed
and responded to within the Brackenridge care framework.
2. To assess whether the identification, assessments, and responses were adequate.
The review was confined to the care received by the three specific residents within the context of the
Brackenridge environment, and the systems and processes used by Brackenridge in relation to care
and support for them.
The reviewers noted that the model of residential support at Brackenridge, as per the Ministry’s requirements,
is a social care model rather than one of healthcare provision. This model of care does not adequately
recognise the co-existing physical health problems faced by a significant proportion of this population.
The review team
also noted that
throughout the review, very positive comments were made about
Brackenridge staff, and in particular the care and attention shown through residents’ last days as staff
remained in attendance with residents at hospital, often in their own time.
The reviewers concluded that
“the identification, assessment and response to these residents’
physical healthcare needs could be considered adequate within the Brackenridge care framework.”
However, a number of key concerns and areas for improvement were identified regarding:
Organisational structure, roles and responsibilities / accountability
Access to health services
Professional nursing issues
Consistent policy implementation
Leadership visibility
Speed of response to incidents
Communication across health settings
Implementation of the IABA Multi-element Model around Challenging Behaviours.
1
Recommendations for the Brackenridge management and Board were made by the review team
aimed at addressing these concerns and implementing improvements.
A number of recommendations have already been implemented at Brackenridge, and the
management team and Board have agreed a plan to address the issues raised in this report as well
as the findings of the Ministry of Health Audit carried out in late 2013. Implementation and monitoring
of that action plan is well underway.
Key themes identified by the review team, and recommendations
a. Organisational structure, roles and responsibilities / accountability
Recommendation
That the senior management team undertake a thorough stock take of all roles, and ensure all
team members are aware of their responsibilities and performance expectati
ons.
b. Access to health services
Recommendations
Advice should be sought on a Memorandum of Understanding or similar with GPs who provide
services to Brackenridge residents, to define the level of service expected and clarify
Brackenridge’s obligations as a service provider.
Review policies and procedures around accessing health services, concurrent to
consideration of the role of registered nurses at Brackenridge.
It is noted that Brackenridge has already taken steps to develop further education on the
signs and symptoms of physical illness and required steps if a resident is unwell.
Individualised ‘crisis plans’ be developed with the GP for residents with known health risks
which list the steps to be taken if they become unwell. They should be made accessible to all
staff and reviewed regularly.
c. Professional nursing issues
Recommendations
Clinical and professional leadership responsibilities should be clearly defined across the
organisation.
The Physical Wellbeing policy should be reviewed and how nursing oversight of al residents’
physical wellbeing is to be achieved should be considered.
The “Registered Support Worker” position description should be reviewed to be consistent with
Registered Nurse competencies, with a separate position description for Enrolled Nurses.
A Direction and Delegation policy should be developed
A professional development programme for RNs should be developed and successful
achievement of all requirements
of the CPIT Health Assessment paper should be a
requirement for all RNs.
d. Consistent policy implementation
Recommendations
Quality Management needs a comprehensive review, ensuring all policies and procedures
reflect current accepted best practice, and are communicated to all staff.
Staff attendance at training should be addressed to ensure attendance meets expectations.
The internal audit programme should be reviewed to ensure it provides a robust means of
ensuring policy is implemented in accordance with requirements to ensure quality.
Staff responsibilities for implementing policy should be highlighted as a key performance area.
Standardised documentation should be considered.
e. Visible leadership
Recommendations
The daily / weekly oversight by senior management on an ongoing basis needs further
consideration.
Weekly onsite meetings of senior management to discuss all residents’ progress could be
considered as a means of ensuring physical wellbeing needs are identified, referrals to
appropriate team members such as Behaviour Support Coordinators are instigated, etc.
Make better use of collegial provider networks nationally to determine a best practice means
of ensuring visible and effective leadership in this setting.
f. Responding to incidents
Recommendations
Implementation of the computerised system of reporting should be monitored to ensure
increased responsiveness to incident reporting, and timely investigation.
Multi-disciplinary involvement in incident investigation should be considered for example GP,
Behaviour Support Coordinators, etc.
g. Communication across health settings
Recommendations
In identifying GPs to work with Brackenridge in the future, those able to access a shared
electronic record and/or Collaborative Care Management System etc could be considered to
ensure timely access to appropriate information to guide their care and treatment decisions.
h. Implementation of the IABA multi-element model around challenging behaviours
Recommendations
Consideration should be given to the full implementation of the IABA (Institute for Applied
Behaviour Analysis) multi-element model for people supported by Brackenridge who present
serious challenging behaviours. This would include a full comprehensive assessment and review of
existing care at Brackenridge for identified residents.
