Dear Sir, I write in respect of the Regulation 28 Report ("Report"), issued on 1 August 2025, following the conclusion of the inquest touching on the death of Mrs Margaret Medlicott. The Report raised the following concerns:
1. The resident whose actions caused Mrs Medlicott's fatal head injury had clear and recent history of unpredictable physical aggression towards his wife. The decision to admit that resident to the care home was made by a member of senior management without the clinical qualifications to assess whether the care home could meet his care needs and was in clear breach of a restriction agreed by the care home with Worcestershire County Council that no person was to be admitted who presented with "physically challenging behaviour". Despite having concerns about the decision to admit him, no member of staff at the care home felt able to raise or question that decision with senior management. There is therefore a concern that staff at the care home may not understand that it is their professional duty to question such decisions, and that the care home is not providing a working environment which encourages them to do so.
2. Despite being aware of concerns about the behaviour of both Mrs Medlicott and the other resident both before and shortly after their respective admissions to the care home, staff failed to complete proper risk assessment and care plans addressing the risks posed by each of them to themselves and to others. Those failures were accepted, but the inquest heard no satisfactory explanation as to why they might have occurred. There is therefore a concern that the staff concerned, and perhaps other staff at the care home, have not received proper training in how to carry out these important tasks. The response to this Report has been prepared in conjunction with senior management. To ensure each element of the concerns identified are addressed, I seek to respond under the following subheadings:
1. The Admission Decision.
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2. Staff Empowerment.
3. Risk Assessments and Care Plans. The Admission Decision: As raised and acknowledged during the inquest the admission of both residents occurred in the early days of the COVID-19 pandemic. During this time, the Home did not have the standard home management structure in situ - namely, a deputy manager and home manager -owing to unexpected absence and long-term sick. In response to this, the Home established an interim structure to manage admissions. This change occurred amongst the ever-changing landscape of COVID-19 guidance for Health and Social Care Providers. This interim structure is no longer in place and has not been for a significant period of time. All Home's within the organisation work to the following management structure: Regional Manager Home Manager Deputy Manager Senior Carers Care Assistants Kitchen Chef Activities Co- Ordinator Assistant Activities Assistant Hostess Administration Receptionist Domestic Team The Regional Manager sits within Head Office and is the direct contact for any of the Home's to escalate concerns to senior management. All admissions are overseen by the Home Manager and / or Deputy Manager. This means that no new resident is admitted without the knowledge and / or assessment of the Home Management Team. In terms of the admission process:
1. First contact with the Home is received from either Brokerage, Social Worker, Family or Friend. With this initial contact a brief description of the individual needs is gathered and input on a bed enquiry form.
2. The bed enquiry form is reviewed by either the Home Manager or Deputy Manager, and a preliminary decision to undertake further assessments is made. Essentially, we are asking if- whether on initial information provided - we feel that we can meet the individual's needs. In 2

some instances, it may be evident from the outset that we are not the appropriate home for the individual. For example, if they are more suited to a nursing care placement.
3. If - following a review of the bed enquiry form - we feel that we can meet the individual's needs, then a more fulsome assessment is undertaken. This is the preadmission assessment. This assessment compiles information from several sources, including social worker, hospital staff, GP, family, friend and any other professional body currently involved in the individual's care and treatment. This assessment will be completed either face to face, over the phone or via MS Teams, and seeks insight on:
a. Personal Information: name, preferred name, DOB, NHS number, current medical issues, current address, next of kin details.
b. Communication Needs: can the individual communicate verbally? Is it coherent or, due to their dementia, is it muddled? Do they have ways of expressing emotions or pain visually or verbally?
c. Behaviour Issues: what behaviours has the person displayed to date? What impact has this had on previous carers and the individual? Is the mental health team or memory clinic involved? Are they prescribed medications to help with these behaviours? Any triggers for challenging behaviour?
d. Continence: are they fully continent? Incontinent of just urine and able to indicate when they need to open their bowels? Doubly incontinent? Are they using continence aids?
e. Nutrition Needs: can the individual feed themselves independently or do they need support or full assistance? What are their likes and dislikes? What is their food preparation as per the IDDSI guidelines? Are they underweight, overweight, or within normal limits? Are they under the care of a dietician or speech and language team ?
f. Mobility: are they independently mobile with or without aids? Are they a high risk of falls? Have they had falls recently (within the last 12 months)? Do they walk with purpose or do they have a history of absconding?
g. Sensory Perception: any vision or hearing needs? Are they aware of their surroundings or have knowledge of where they are?
h. Skin Integrity: is their skin fragile? Do they have any pressure care concerns? Do they have any pressure areas that have broken down and need treatment? If they do, what grade is the wound and what is the current treatment regime? Are they able to reposition themselves or do they need staff to reposition at specified intervals?
i. Pain Management: what pain relief are they prescribed? Are they able to indicate that they are in pain either verbally or visually?
j. Oral Hygiene: do they have their own teeth? Do they have full dentures or part? What is their dental care regime? Have they seen a dentist? Can they brush their teeth themselves, or do they need full or part assistance? Are they compliant?
k. Footcare: are they diabetic with a regular appointment to see a Chiropodist? Do they have a regular Chiropodist? Do they have issues with their feet? Fungal nails? Long toenails etc?
l. Personal Hygiene Needs: do they need full assistance or are they able to wash themselves with guidance, support or independently? Do they have a history of self- s'

neglect? Do they prefer baths or showers? Do they use prescribed toiletries or off the shelf?
m. Sleep: what is their sleep pattern? Do they sleep or do they need medication to assist with their sleep? Do they require a bed set at a low level with crash mats and alarm mats? Do they need regular repositioning?
n. Social Care Information: what was their employment history, hobbies, interests, skills and abilities? Who is important them?
o. Further Information: any other information that the family, current carer or hospital can provide.
4. If - following completion of the preadmission assessment - the Home Manager and / or Deputy Manager (or in the absence of these parties, the Regional Manager) deem the Home to be a suitable placement for the individual then the requesting party (EG: Social Worker, Brokerage, Family, Friend) is informed of the decision and action is taken to arrange an admission date.
5. The information from the pre-admission assessment is transferred to PCS by either the Home or Deputy Manager and is utilised by the Care Team Leader's to complete the individual's first care plan and risk assessments. It is the expectation that care documentation will be available within 72 hours of the individual's admission to the Home, with any urgent care needs being captured within 12 hours of arrival. I note that, on most occasions, these urgent care needs are already within the PCS system by the time of the individual's arrival because of the pre-admission assessment. For example, If an individual had a nut allergy, this would be identified at the pre-admission assessment and immediately available on PCS as an alert to all Home Staff. These urgent needs would also be shared via the Home's WhatsApp Group and at the first stand-up meeting. Further, to ensure that those best placed to advise on a new resident's care needs are able to feed into the 72-hour care plan, a new standard operating procedure has been circulated to all Home's, requesting that the key care actions outlined in the 72-hour care plan are raised with the individual's representative for feedback. All attempted contact is to be documented. A person-centred plan should be completed within one week of the individual residing with the Home. This will develop as the Home's staff get to know the individual on a more personal level. Accordingly, when making the final admission decision, the Home Manager will be informed by:
1. Subject to the individual's funding status, a support plan from social services providing a breakdown of individual care needs from brokerage.
2. A completed internal pre-admission assessment form which includes the involvement of all interested parties, plus (where required) a face-to-face assessment. While the admission process is reliant on accurate information sharing, the Home's internal pre- admission process seeks to 'fact check' information and obtain its own insight into an individual's needs. It is only once all this information has been meaningfully considered that a final decision on whether the Home can safely provide care will be made. 4

For completeness, Haresbrook Park Care Home, has successfully completed the recruitment of a Deputy Manager. Following the completion of a six-month probationary period, this individual will be able to support in the admission, and general management, processes. Staff Empowerment: QCS, an external provider, produces all of the Home's policies. The contract includes the routine review, update and distribution of the documents to ensure they remain in line with regulations, care standards and internal expectations. The Policies include Raising Concerns, Freedom to Speak Up and Whistleblowing Policies. These are all fit for purpose and are available to all staff on the electronic policies and procedures platform. The platform also produces a reading list for all managers to outline which staff have engaged with the Policy. Any staff failing to review the policies will be reminded of their importance and their professional obligations to consider, and adhere, to the documentation. Any continued shortfalls will be escalated. The importance of speaking up - either formally or informally -continues to be promoted throughout the organisation:
1. New starters are provided with the Whistleblowing Policy in their handbooks.
2. The relevant contact numbers for Whistleblowing are displayed throughout the Homes, including in staff rooms. The flyers include contact numbers for 1) internal escalation, 2) external escalation - CQC and Whistleblowing Helpline.
3. It is a standing headline topic in all Home's daily stand-up meetings.
4. Home Manager's operate with an open-door policy. To further empower staff to speak up, at the beginning of each shift, the team leader and / or senior will ask whether any member on shift wishes to raise any concerns. This may include a care concern, personal concern or practice concern. Any concerns raised will be noted on the staff allocation sheet with the intention of either addressing and / or escalating them by the end of the shift. If no concerns are noted, this is also documented. At the conclusion of the shift, it is the expectation that the team leader and / or senior will personally ask each member of staff whether there were any concerns noted on shift which they would like to raise. The concerns are documented and managed according to the nature of the concern. For example: if an individual's care needs amending, this will be raised at handover with the next shift and the care documentation updated. If no concerns are noted, this is also documented. As an organisation, I feel that we have provided all levels of staff with the appropriate tools to express
- and if necessary, escalate - concerns. Risk Assessments and Care Plans: The Home is now benefitting from a fully integrated electronic care system, namely PCS (Person- Centred Software). The maintaining of care documentation, including risk assessments, in one place allows for one point of reference for all members of staff. Alongside complete care plans and risk assessments, all staff can see:
1. Summary Sheet: this highlights all key areas of care and risk for an individual resident. 5

2. Plan Care Day Sheet: this instructs care staff in relation to tasks (for example: repositioning, welfare, medications, weight, fluid) that need to be completed for an individual. If staff do not complete these tasks, the system generates a 'red flag' which can be seen by all staff on duty, including management. Further, the Home's Manager and Deputy Manager has access to the PCS desktop which provides an overview of all its residents care delivery, including any red flags. This quickly identifies to a manager any areas which urgently need to be addressed at hand over and / or the daily stand-up meeting. When generating care documentation, the Care Team Leaders and / or Seniors will start by completing risk assessments. These are a tick box exercise which result in the generating of a generic care plan. For example: if an individual is deemed to be at high risk of falls, a generic care plan will be generated suggesting ways to mitigate this risk. It is the role of the Care Team Leader and / or Senior to personalise the care plan by using information obtained at pre-admission stage and then in getting to know the individual. All staff are trained on PCS at their induction. This training is conducted by review of videos and use of the system in 'TUTOR' mode. As a business, all staff are required to complete mandatory training through an online training portal. This training supports staff in knowing how to capture the care needs to be documented. Subject to the nature of the training, these need to be renewed on either an annual or bi-annual basis. If a staff member is deemed to be falling short of expected standards, then they will be directed to recomplete the training. The mandatory training modules include living with dementia, MCA and DoLS, person centred care, health and safety, and safeguarding adults at risk. The required training includes communication, documentation and reporting, positive behaviour and support, and leadership and management. Alongside the training modules, the organisation's compliance manager is working to generate a routine PCS training schedule. The nature of the electronic system means that it is constantly updating and creating new processes to support the safe delivery of care. The intention is to conduct a six- monthly interactive seminar at each Home in which every member of staff will be taken through the updates and the organisations expectations on how they will be utilised. Haresbrook Park Care Home will be the first Home to receive this training on 25 September 2025. Each Home conducts its own internal audits on care documentation. Each Home Manager is responsible for managing how its Home completes its oversight. At Haresbrook Park Care Home, the Care Team Leaders are responsible for overseeing the care plans on their unit. Every month, they will be required to conduct an audit on a sample of care plans on the alternate unit. The results of these audits will be shared with the Home Manager who will compose an action plan to be addressed by the next month's audit. The Care Team Leaders are also responsible for conducting random spot checks on both documentation and on the floor care. To ensure organisation oversight, the organisation's compliance manager is completing a full audit of all Homes care documentation. This was completed for Haresbrook Park Care Home on 22 August
2025. The results have been shared with the Home Manager and all staff will be addressed at a mandatory Home-wide meeting on 24 September 2025. Beyond organisation oversight, the audit has allowed the compliance manager to obtain each Home's baseline and then work to generate an 6

the appropriate training, tools and governance to routinely complete robust documentation . However, where there are lessons, these are being utilised to generate an audit schedule which burrows down to understand the core of the issue and provide a foundational fix. Thank you for allowing us this opportunity to reflect. Chief Executive Officer 7