Dear Coroner, Thank you for your recent correspondence regarding matters at The Meadows. Please find below Cardinal Healthcare’s formal response.

Organisational Governance, Structure and Responsibilities Cardinal Healthcare operates within a mature and comprehensive governance framework designed to safeguard the safety, wellbeing, and dignity of all individuals in our care. Every staff member is employed under a clearly defined job description outlining their duties, delegated responsibilities, and accountability structures. All clinical and care staff maintain registration with the relevant professional and regulatory bodies to ensure lawful, competent, and ethical practice. Our governance systems incorporate:  A comprehensive policy framework encompassing clinical care, safeguarding, risk management, medicines management, incident reporting, infection control, and quality assurance.  A structured audit programme, including monthly internal audits and periodic independent audits, ensuring adherence to organisational standards and regulatory expectations.  Operational protocols and supervision systems that provide consistent oversight of staff performance, regulatory compliance, and safe practice.  Mandatory training and competency reviews, aligned with the Care Act, CQC Fundamental Standards, and applicable professional codes of conduct. Since its inception, Cardinal Healthcare has relied on these systems to maintain high-quality care and a safe, well-governed environment for all residents.

Findings Related to The Meadows Our internal investigations identified that the management team at The Meadows did not adhere to established Cardinal Healthcare policies and procedures. These departures from expected standards constituted a significant breach of organisational governance and leadership responsibilities. As a result:  The Home Manager was placed into disciplinary proceedings for failing to uphold policy, maintain effective oversight, and ensure compliance with organisational expectations. The Manager subsequently resigned during the disciplinary process. Cardinal HC Ltd Paramount House 1 Delta Way, Egham Surrey, TW20 8RX Tel: 01932 253 403

 Following the Manager’s departure, temporary oversight was delegated to the Clinical Lead. However, the Clinical Lead did not demonstrate the transparency, accountability, or cooperation required in such a role. Their conduct was inconsistent with organisational protocols and contributed to operational deterioration within the home.  Staffing levels remained above dependency needs for more than a year, and all amendments to staffing were made in consultation with the Clinical Lead at the time. Notably, no reports were produced or documented by the home regarding recurrent falls for the resident later admitted to hospital in February 2025. In the interests of transparency and to support the Coroner’s understanding of the wider context, Cardinal Healthcare considers it relevant to note that this was the second care home in which the Clinical Lead concerned had been associated with serious governance failures involving the provision of misleading information to the provider. Whilst we do not seek to speculate on future conduct, our experience gives rise to a reasonable concern that similar risks could arise in any future appointment if appropriate oversight is not exercised. We sincerely hope that this is not the case. In order to assist your office fully and to ensure that any regulatory considerations are informed by a complete picture, we have attached a copy of the individual’s previous employment reference, which documented concerns of a similar nature and which, regrettably, were not appropriately escalated and policies not followed at the point of recruitment by the Manager and the Operational Manager. Cardinal Healthcare retains copies of the relevant correspondence.

Additionally, the Operational Manager, who held responsibility for governance oversight at The Meadows, did not maintain sufficient supervisory control. This failure contributed materially to the decline of the service and caused significant organisational harm. The Operational Manager has since left Cardinal Healthcare prior to disciplinary proceedings. These events were deeply regrettable and do not reflect Cardinal Healthcare’s values, systems, or long-standing commitment to high-quality, safe care.

Commitment to Quality, Learning, and Improvement Cardinal Healthcare has consistently prioritised the provision of a safe, caring, and well-governed environment. In response to the issues identified at The Meadows, we have strengthened our systems further, including:  Enhanced internal audits, ensuring continuous compliance and improvement.  Policy updates and targeted staff re-training, informed by incident learning and emerging best practice across the sector.  Strengthened recruitment and HR protocols, including rigorous reference checks and improved verification of prior employment concerns.  Revised governance and reporting structures, with increased senior-level quality oversight. The organisation has also issued a formal notification to the Care Quality Commission (CQC), the Local Authority (WCC), and the Integrated Care Board (ICB) outlining concerns regarding their oversight of the home, which we believe was neither unbiased nor conducted in a supportive manner and appeared instead to reflect a predisposition towards closure.

These measures reflect Cardinal Healthcare’s enduring commitment to learning, accountability, and continuous improvement. The lessons from The Meadows have been taken seriously, and we have used this experience to reinforce our organisational resilience and strengthen the quality of care we provide. Cardinal Healthcare remains dedicated to its mission to be a leading healthcare provider within the community—delivering compassionate, safe, and dependable care to every resident we support. Should your office require any further information or clarification, we remain fully at your disposal.