Dear Madam This is a response to the Prevention of Future Deaths report made following the inquest touching the death of Margaret Elizabeth Douglas (referred to throughout as Elizabeth) and the “Matters of Concern” raised within your findings. My name is . I am a director of Minster Care Management Ltd, the parent company of Holcroft Grange and also registered NI for Holcroft Grange. I am a registered nurse (Mental Health) with the Nursing Midwifery Council -
- and hold an additional Specialist Practice degree in Community Mental Health Nursing (older person). I have operated in health care since January 2001 and as a registered nurse since 2005. May I first take this opportunity to offer my sympathies to the family of Elizabeth for the loss of their loved one during her stay with Holcroft Grange. I write to inform you of the actions taken in response to this report and provide reassurance regarding the concerns raised. I note in court, that the local authority stated that as a provider we could have put a 1-1 in place and then claimed back the monies later down the line. However, this suggestion is just not my experience or our company’s experience of working with local authorities and I can highlight several cases whereby we are pursuing funds for such cases via the courts. In response conclusion to point i of the Regulation 28 Report, which read as follows: “in the course of the inquest I heard evidence that by 05 September 2024 Holcroft Grange had already identified that they were unable to meet Elizabeth’s needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth’s needs and that they were unable to provide one to one care, Holcroft Grane accepted Elizabeth back into their care, following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided, creates a risk that future deaths could occur as a consequence of inadequate care and supervision. We understand that costs should not be a factor which determines the necessity of providing 1-1 care. Within the Croftwood Care portfolio of homes, any manager can contact me to seek support with navigating the difficulties in securing funding for clients such as Elizabeth.

Within our group of homes, we also have a clinical nurse who assists with ensuring that we meet the care needs of any residents who may have more complex presentations. We have made the further organisational changes in order to further embed this working practice:
1) All managers will be reminded of the need to communicate any difficulties they may have in managing a client with complex needs, to their area managers and then subsequently to our clinical nurse, Siobhan Christie, and/or myself. This also will include a specific agenda item being included in manager’s supervision checklists, circular communications and additional training.

2) By September 2025, all managers will have received “escalation” training directly from Area Managers. This will ensure they are able to confidently raise concerns directly to the Local Authority in cases where clients have been placed inappropriately or where the client’s needs rapidly become more complex. This training will be part of the induction process and then as part of annual supervision. This will also then be written in to our escalations policy.

3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance &support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not then be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.

In response to point ii of the Regulation 28 report which reads as follows: “In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English. The evidence given by those at Holcroft Grange was that they outsourced the provision of the one-to-one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and her complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech.

The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them, it poses a risk to their life.” In order to ensure that any staff engaged by Holcroft Grange have an appropriate understanding of residents’ care needs, we ensure that they have completed the International English Language Test (IELTS) exam. This forms part of our introductory checklists and paperwork prior to staff members working on our premises. Further, we have made the following improvements across our service Actions:
1) Our organisation will ensure that all overseas workers that attend our services via agencies have a competent understanding of the English language, both spoken and written. This will now be assessed by the person in charge of each shift to ensure that the command of the English language is good. Where it is deemed “inadequate” the staff member will not be allowed to work on site.
2) Our induction policy for agency workers will now form part of our compliance test undertaken by our routine internal monitoring teams. A monthly audit is carried out by area managers and the induction policy for agency workers will form a specific section within the audit documentation. This will provide assurances to our monitoring team that all agency staff have had sufficient opportunity to engage and read the relevant care plans for each resident they are caring for. Each agency carer will also have an induction through their own agency, before they are given an induction to the site and to the residents to be cared for, which will include time allocated to read specific care plans.
3) Handover of care between staff will be enhanced to ensure that any irregular staff ie Agency carers, have a written description of the issues and conditions that a person may exhibit. In addition to verbal handovers from the relevant staff members, written descriptions of the care plans will now be provided at the start of the shift. Information contained in the handover is also provided on handheld electronic devices that are given to all staff, and this information can also be easily updated at any given time. If you require any further information regarding any of the actions described above, please do let me know and I will be happy to assist.