RegulaƟon 28 Report To Prevent Future Deaths Response to Coroners Concerns into the death of Ms. Susan Paley who passed away on 11th May 2024 at Hilltop Court Nursing Home, Dodge Hill, Stockport Background Harbour Healthcare is a family run care provider established in 2012. Hilltop Court is owned and operated by Harbour Healthcare, it is a Nursing Home offering nursing care for up to forty-six individuals living with demenƟa. Our philosophy is quite simple, we strive to provide an excellent standard of care to our residents, treaƟng them with complete dignity and respect. We like to call it, simply good care. Circumstances Of The Death Ms Paley was a resident at Hilltop Court Nursing Home and was significantly dependent on the care of others as a consequence of complex neurological problems which leŌ her with tremors, contractures and very limited mobility. Whilst Ms Paley had previously reported swallowing problems, the outcome of her most recent Speech and Language Therapy Assessment was normal meaning no modificaƟon was required to her diet. On 11th May 2024, a Healthcare Assistant had leŌ Ms Paley with a sandwich to eat in bed in her room. When around an hour later the same staff member returned to check on Ms Paley, she found her unresponsive. Whilst staff sought to assist Ms Paley and an ambulance was called, an aƩending paramedic confirmed she had died. A postmortem examinaƟon determined Ms Paley died as a consequence of:
1) a) Asphyxia.
1) b) Food bolus obstrucƟon. Ms Paley died having choked on food whilst eaƟng in her bed, Coroners Conclusion At the conclusion of the inquest, the coroner recorded a conclusion of Accident. Coroner's Concerns
1. Given Ms Paley's significant health problems and very limited mobility, it is a maƩer of concern that she had been leŌ in bed without a call bell to hand which she could easily reach should

she need to summon assistance; and
2. The Coroner is concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call bell, sensor-mats etc.) have them in place as indicated. Response to Concern 1 Given Ms Paley's significant health problems and very limited mobility, it is a maƩer of concern that she had been leŌ in bed without a call bell to hand which she could easily reach should she need to summon assistance; AcƟons Taken Harbour Healthcare uses the electronic care planning system Person Centered SoŌware (PCS) and this has been in use at Hilltop Court since 2022 a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly thereaŌer or in response to significant changes in the resident’s condiƟon. This was reviewed and updated in June 2024. b The outcome of the call bell risk assessment is then communicated into a care plan which details specific measures to ensure call bell devices, where in use, are working and within reach. c These specific measures, where appropriate, are then translated into planned care acƟons which are communicated to staff via handheld devices. These act not only to record the care delivered, but also to act as a reminder of care acƟons to be completed. Therefore, ensuring call bells are in reach and funcƟoning appropriately. These measures have been in place since the implementaƟon of PCS but have been revised and made more robust in terms of detailed Ɵme specific acƟons to support resident care. d The use of and response to call bells is already a feature of staff inducƟon and this has been reevaluated to ensure clear and comprehensive understanding amongst the staff team. e The above measures are being regularly reinforced during documented supervisions and staff meeƟngs. f Harbour Healthcare have currently upgraded the exisƟng call bell system to enable the use of more advanced, infra-red assisƟve technology. This work has now been completed. Response to Concern 2 The Coroner is concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call bell, sensor-mats etc.) have them in place as indicated. AcƟons As menƟoned above, Harbour Healthcare uses the digital care planning system PCS, and this has been in use at Hilltop Court since 2022

a The assessment of the requirements for specific aids is completed pre-admission and again on admission, thereaŌer these requirements are reviewed monthly or in response to significant change in the resident’s condiƟon. b Once again, the idenƟfied needs are cascaded into care plans and then translated through to planned care acƟons. This is then communicated to carers via their handheld devices. This acts as an aide-memoire. This system has been in place since the implementaƟon of PCS. c PCS is already part of staff inducƟon, and this has been strengthened by the addiƟon of a PCS training module completed by all staff using this system. d The above measures are being regularly reinforced and documented during supervisions and staff meeƟngs. All of the above measures are underpinned by the following Policies and Procedures. a Room Call Policy b Dementia Policy and Procedure c Use of Bed Rails Policy and Procedure d Pre-Admission and Admission Policy and Procedure e Person-Centred Care and Support Planning Policy and Procedure f CommunicaƟon Policy and Procedure g Training Policy & Procedure Regular oversight by the Regional and Quality Teams ensures that the home is operaƟng within the QCS Policy Framework.