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I am the Managing Director of Sequoia CH Group Ltd (‘SCG’), the registered provider of Belle Green Court Care Home. I am submitting this Regulation 28 Report at the request of HM Coroner following the death of Mrs June Peel, who at the time of her death was a resident of Belle Green Court Care Home.

This report address the Matters of Concern identified by HM Coroner, namely;

1. There was a failure to record the injury from the body map in the daily communication records both on 3rd June and 6th June, and a failure to pass that information on at handover (or to document that the information had been passed on). This led to a period in which June was being turned on a 2-hourly basis with a displaced femur fracture.

2. There was a failure to recognise that medical attention was required for June from at least 3rd June 2022, notwithstanding all personal care being conducted by the healthcare assistants.

3. There was a failure to follow the care plan by the healthcare assistants. There has been no investigation done to identify whether this is a condoned or common practice within the home.

In this report I will explain, how Sequoia CH Group Ltd operates and provides care services, how we manage and oversee our care, how we have reflected on the incident that led to Mrs Peel’s deaths and improvements made since the time of the incident in June 2022. I would like to take this opportunity to again express on behalf of all the Directors how sorry we are that Mrs Peel sustained an injury whilst being cared for at Belle Green Court Care Home. I wish to offer my sincerest apologises to Mrs Peel’s family for the care failures that occurred. For the reasons I set out in this report, I strongly believe that Sequoia CH Group Ltd has learnt from this event and I am able to assure the Coroner and Mrs Peel’s family that changes have been implemented to ensure that our systems are more robust so that any failures identified are not repeated.

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The Coroner’s concerns relate to 4 areas of our practice in the care home:

1. Documentation and Recording
2. Communication between staff
3. Assessment of Injury and referral to external health care professionals
4. Staff performance and investigation of substandard performance.

Below I set out the review that we have undertaken and the action taken to ensure that our systems are robust to minimise the risk of future events.

BACKGROUND AND SUMMARY OF CARE DELIVERED

1. Mrs Peel (DOB 28.06.33. DOD 22.06.22) was admitted to the Home following her discharge from Barnsley District General Hospital (BDGH) on 24.03.22. Mrs Peel had been an inpatient at BDGH since 20.02.22, when she was admitted with wrist and leg pain following a suspected fall resulting from a stroke. Her admission to the Home was planned on a discharge to assess basis, whilst her family decided the plan for her long-term care needs as she was unable to continue to live independently at home due to a significant deterioration in her mobility and cognition.

2. Mrs Peel was dependant on carers for personal care and support. Whilst at BDGH, she had developed a number of pressure ulcers, and due to frailty and pain on movement she was cared for in bed. Any required transfers from bed required the use of a hoist. Mrs Peel was repositioned every two hours to support the healing of her existing pressure ulcers and to prevent further pressure areas from developing.

3. On 03.06.22, a senior carer noticed a hard lump on Mrs Peel’s left knee. At this stage there was no bruising. No assessment of pain was recorded.

4. On 06.06.22 an attending community district nurse was asked to review the lump. It is recorded that the nurse had no concerns.

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5. On 07.06.22, staff identified that there was bruising and swelling around the knee and a referral was made to the GP and 111. A GP visit took place on 08.06.22 and arrangements were made for Mrs Peel to be admitted to BDGH, where she was diagnosed with a fracture of the distal femur. Initially the fracture was treated with traction and surgery was undertaken on 10.06.22.

6. Mrs Peel was initially very poorly postoperatively requiring resuscitation. She made some improvements and plans were being made for her discharge back to the care home. Unfortunately, she deteriorated and sadly passed away on 22.06.22.

7. Concerns were raised in the Home and by staff at BDGH as to the cause of the fractured femur. A safeguarding investigation was undertaken by (who was the registered manager of the Home at the time of the incident). found that on
29.05.22, two members of staff had moved Mrs Peel from her bed to a weighing chair. The staff had failed to move Mrs Peel in accordance with the moving and handling directions set out in her care plan, that directed she should be moved from bed with the use of a hoist. All staff denied that Mrs Peel fell during the transfer. Whilst Ms Durham did not find evidence that the fracture was caused during the transfer, 2 members of staff were dismissed for gross misconduct for using an unsafe procedure.

The above summary is documented in the following records:

03.06.22 – Wound care plan ‘Hard Lump near knee cap. No bruising’. (Senior Carer)
06.06.22 (12.55pm)– DN Communication Record ‘June’s Left Knee, the DN was asked to look at it but wasn’t concerned by the lump’. (Senior Carer)
08.06.22 (03.00 am overnight shift 07.06.22/08.06.22)- Daily Communication Record. June was settled in bed at start of shift. Staff noticed June has an injury on her left knee. Staff contacted 111/999 and they have said that they are referring it to her GP which should be out today 08.06.22.
07.06.22 ?[Incorrect date should be 08.06.22] – GP Communication Record ‘Contacted Clara from GP surgery regarding my call to 111 over a hard lump on June’s left knee. said they had sent a referral through from 111. said that she could put June on tomorrows list if

4 it was urgent to contact I-heart. I spoke to (Manager) who said it was ok for GP to visit tomorrow. (Senior Carer).
08.06.22 – Daily Communications Record – 2 hourly turns were maintained but June was crying out in pain so she refused on some occasions. Good fluid intake.
08.06.22 – Daily Communication Record – June has had poor diet and fluids this afternoon however is talkative when staff came to see her. She has had a visit from the doctor about her query dislocated knee (see care plan) she has also had her pad changed.
07.06.22 [? Incorrect date should be 08.06.22]– Wound care Plan – ‘Bruising on left knee (query dislocation).
09.06.22 [? incorrect date should be 08.06.22]– GP Communication Record- ‘GP practitioner from 111 came to see June about her left knee. GP did June’s obs and rang for a[n] ambulance as she believes that June may have dislocated her left knee due to her left side weakness’

Other professionals made the following corresponding entries:

06.06.22 DN Record (14.20pm) – Wound care left calf wound care haematoma right shin, wound care lacerations left foot.

08.06.22 – (17.45pm) GP Record: History ….a senior carer has noticed a bony lump on Friday [03.06.22] during the night when she was on night shift, was handed over to day staff……… Obvious deformity of the left knee, bony tenderness +++ on the outer aspect, bruising over the area (care staff report only started with bruising yesterday) movement restricted due to previous CVA, normal colour of the lower limb no signs of infection.

Summary of Findings The records demonstrate that staff identified the change in Mrs Peel’s condition on 3 June 2022 when a hard lump was identified by a senior carer. At this stage there was no bruising. There is no documentation as to whether Mrs Peel was in pain. On 6 June 2022, Mrs Peel was seen by the District Nurse. Staff record the District Nurse reviewed the lump when dressing wounds on her leg and the District Nurse had no concerns. The District Nurse made her record of the visit over and an hour after the visit and did not reference the review of Mrs Peel’s

5 knee. On the night of 7 June 2022, the swelling worsened with bruising and a referral was made to 111 and Mrs Peel was assessed by the GP on 8 June 2022.

My review of the documentation demonstrates that although staff asked the DN to review Mrs Peel on 6 June 2022, she was not referred to the GP/Paramedics until the early hours of 8 June 2022.

Mrs Peel’s records did not contain sufficient detail and there were some records where the dates had not been or had not been correctly recorded. Accordingly, it is difficult to clearly track the care provided to Mrs Peel. The records were not robust enough to evidence the care pathway and decisions that were made by staff.

I have reviewed the Matters of Concern and considered our policies and procedures, documentation, communication processes, training, auditing and governance in order to identify any organisational improvements that can be made.

REVIEW UNDERTAKEN AND ACTIONS IMPLEMENTED

A: POLICIES AND PROCEDURES As a regulated provider we are required to have written policies and procedures that cover all aspects of service delivery. The Company subscribes to Croner – I. This is a well-regarded service providing policies and procedures for use in care homes. Croner - I provides detailed policy templates which are designed to be compliant with the regulatory requirements. We review and amend the draft policies to ensure that they are relevant for the Home. Some, or all of the policies are reviewed during Care Quality Commission (CQC) Inspections. No issues or concerns have been raised by the CQC regarding the quality of the policies in use. A copy of the CQC’s last inspection report can be reviewed at this link.

04565de9996b?20220622120000

We currently have circa 130 policies in use.

6 I have reviewed the policies relevant to the Matters of Concern. The Home already has in place policies on;

• Moving and Handling
• Falls Prevention and Risk Assessment
• Use of Hoists
• Record Keeping
• Care and Support Plan
• Training
• Accident and Injury
• Supervisions and Competencies
• Auditing and Auditing Processes
• Whistleblowing
• Escalation Policy

These policies are robust and provide clear guidance to staff regarding our expectations for record keeping, communication, using safe moving and handling techniques, delivering care in accordance with resident care plans and seeking medical assistance. The policies also provide clear guidance to the management team on auditing the quality of the records and assessing staff performance to ensure that the expected standards are met. We review the policies annually to ensure they remain in date.

Action Taken Whilst the policies are robust, we cannot be assured that staff delivered care to Mrs Peel in accordance with the policies. Accordingly, we have taken the following action,

1. We have added further information to some of the policies to provide more detailed and specific guidance to staff, please see below.

2. We have also introduced specific guidelines for staff regarding action that they are required to take in the event of a resident presenting with symptoms suggestive of an injury. (Referral for Medical Attention policy – see below).

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3. We have formalised the process for staff reviewing our policies. Staff are required to read the policies relevant to their area of practice before being signed off as competent to work without supervision and staff are required to review these annually. We now maintain a record of staff undertaking the required policy reviews.

4. We have introduced a learning exercise of ‘Policy of the week’ where staff are required to review a specified policy in depth and the policy is discussed at staff meetings.

5. The Manager now undertakes supervisions with staff around their knowledge of the policies.

6. If staff fail to follow the guidelines set out in the policy, they will be required to undergo further training or supervision as appropriate and may be subject to disciplinary action.

B: DOCUMENTATION AND RECORDING All staff are required to make a comprehensive record of any care intervention and any communication with external professionals. Staff are trained to look for changes in presentation, signs of illness and injury, and report and record this.

I identified that the documentation around Mrs Peel’s injury was not as robust as it should have been, specifically,
• There appear to be dates recorded incorrectly.
• The names of the external professionals providing advice was not recorded.
• When the small lump was identified on 03/06/22, it was not recorded in the daily communication record, it was not photographed, no pain assessment was carried out and there was no instruction for follow up review.
• Staff did not document a follow up plan.
• Staff did not reference the small lump in the handover document.
• There was no record of ongoing review and assessment of improvement or deterioration.

8 Action Taken Although staff received training and guidance on record keeping during their induction, we have policies in place that set out the action that is expected of staff and records are also audited regularly to ensure that staff are meeting the required standards, the documentation was not of the required standard. Accordingly, we have implemented the following changes:

1. We have prepared a recording keeping guide which has been distributed to all staff which sets out the principles of record keeping and expected standards. (Please see attached).

2. All staff are required to review our policy relating to record keeping and the record keeping guidance.

3. The record keeping guidance is displayed throughout the home to as a reference guide and reminder for staff.

4. Staff receive training on record keeping on induction and supervisions will be carried out throughout the year.

5. The quality of record keeping is reviewed regularly by the management team as part of the weekly and monthly audits. The Manager also undertakes spot checks on documentation.

6. If staff fail to meet the required levels of recording keeping, they will be provided with further training and supervisions.

C: COMMUNICATION BETWEEN STAFF We have identified that the communication between the staff teams was not robust. The Senior Carer who identified the lump on 3 June 2022 recorded the lump on a wound chart but failed to record this in the daily communication record. They also failed to record this in the written handover record and therefore we could not determine whether all staff were made aware of the lump.

9 Effective communication between staff is central to the delivery of consistent and effective person-centred care. Our policies make it clear about the information that must be communicated between staff to ensure the effective delivery of care.

Action Taken We have taken the following action to ensure information is effectively communicated across the team;

1. All staff are required to document key information in accordance with our record keeping guidelines set out above.

2. Care staff are required to report any changes/concerns to the senior carer on shift. Both the carer and senior carer are required to document their concerns and review of the resident. The senior carer is responsible for ensuring that the care plan is updated if any specific care needs/follow up are required.

3. All relevant information must be recorded in the daily records and the written handover record so that we can be assured that staff are handing over the relevant information to the next team.

4. The senior carer who receives the handover is responsible for communicating information to the carers about the residents who they will be responsible for that shift.

5. At the beginning of each shift, all carers are required to review the daily communication records and the wound plans for the residents who they will be responsible for during that shift and sign to say that they have read the daily communication records from the previous week, the wound chart and the GP communications record.

6. The Manager reviews the handover record every day to ensure that the records are robust and key information is included. The Manager signs of the report to evidence that it has been reviewed.

10 D: ASSESSMENT OF INJURY AND REFERRAL TO EXTERNAL HEALTH CARE PROFESSIONALS Concerns were raised by the Coroner that there was a delay in referring Mrs Peel for medical attention from at least the 3 June 2022 when the lump was first identified and this resulted in Mrs Peel continuing to be repositioned when she may have had a displaced fracture.

The records are not sufficiently robust to evidence the Senior Carers rationale for not seeking immediate medical attention when the lump was first identified on Friday 3 June 2022, and waiting for the DN to attend and review on Monday 6 June 2022. I can only deduce that this was because of Mrs Peel’s presentation the Senior Carer exercised her judgement that medical assessment could wait until after the weekend, however the records do not record any plan or reasons for the delay in asking for Mrs Peel to be assessed.

Action Taken We have implemented a new policy ‘Referral for Medical Attention’. Staff must not exercise their judgement as to whether urgent referral/ treatment is required or whether assessment can be delayed. The policy requires that

1. Any resident who presents with
1.1. a change in health condition,
1.2. a deterioration in condition, or
1.3. presents with any physical changes (however minor and whether or not they are indicative of an injury)

will be referred to the GP/111/999 with a request for a clinical assessment as soon as reasonably practicable after the concern is identified.

2. At the time of referral to the GP/111/999, the Senior Carer will request instructions from the external health professional as whether any specific care interventions should continue pending the clinical assessment. For example, whether staff should cease repositioning the resident.

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3. A record of the deterioration/injury will be made in accordance with the record keeping guidance.

4. A record of the referral will be recorded in the daily communication record and External Professionals Communication Record, with details of the information provided to the external health professional.

5. Any guidance given by the external health professional will be recorded in the GP communication record.

6. The care plan will be reviewed an updated as necessary.

7. Any guidance and follow up instructions given will be recorded in the handover record.

8. The Manager will be made aware of any referrals to external professionals and any follow up required.

E: STAFF PERFORMANCE AND INVESTIGATION OF SUBSTANDARD PERFORMANCE. Following Mrs Peel’s injury an investigation was carried out by the Home Manager. She identified that two members of the care team failed to follow Mrs Peel’s care plan and used an unsafe moving and handling technique. The staff members were dismissed for gross misconduct. The staff members had received the appropriate training and had acted contrary to this training. On my review, I identified that the Manager did not document that she had undertaken a review of practice across the Home to determine whether the poor practice of these two staff members was systemic, whether there were any issues with training across the service that needed to be addressed, and whether staff had observed poor practice and if so, why this had not been raised as an issue.

Poor individual performance can occur in any workplace setting, but I acknowledge in a care setting this can place people at risk of harm. We seek to provide the highest quality of care to all our residents by ensuring that the staff we employ have the appropriate skills and resources available. We seek to achieve this through:

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• Recruitment: We recruit staff who have the appropriate qualities to be a carer and who demonstrate honesty and integrity.
• Resources: We have detailed policies and procedures that staff can refer to for guidance on our expectations to meet our standards of care and delivery and the processes that should be followed across all aspects of service delivery.
• Training and Development: We offer training to develop staff and training is ongoing. All staff are required to undertake mandatory training at specific intervals (annually/biannually depending on the course). Following training, staff are assessed as being competent. If staff fail to undertake their training within a reasonable period set by the manager, they are removed from the rota until the training is complete. Staff receive 4 supervisions a year and an appraisal. The supervisions can be tailored around areas where the manager has identified further training or development is required.

Action Taken
1. Staff have received updating training on care planning and record keeping. (Please see details above) and manual handling.

2. Staff have reviewed all key policies and procedures relevant to their practice. This is an ongoing annual requirement for all key policies.

3. The Manager has commenced a tracker of all accidents and incidents which requires a high-level analysis to assist identifying any patterns or concerns.

4. Any incident/accident that identifies poor staff practice will lead to a review/assessment of practice across the staff group. The outcome of this assessment will determine the further action that is required; for example – refresher training, review of policies, supervisions, competency assessments.

5. Issues of safe manual handling, delivery of care and care recording are addressed as a standing items at each team meeting to ensure that safe practice is engrained.

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6. The Manager undertakes a daily walk around which includes observation of staff practice.

7. All staff have reviewed the Whistleblowing Policy and Safeguarding Policy, and are required to familiarise themselves with their duties to report poor practice.

F: AUDITING AND GOVERNANCE The Home operates a range of quality assurance systems to monitor and improve the service. These are used to identify areas for improvement. When issues are identified, action is taken to make improvements. We have incorporated the actions detailed in this report to ensure there is a continuous approach to improving care.

ENCLOSURES: Enclosed is a copy of the updated Record Keeping Policy which includes the Record Keeping Principles at Appendix A.

Copies of policies referred to are available on request.