Dear Sirs, Inquest touching the death of Christine Rosemary Neild Regulation 28 Report Response of Meade Close Care Home Thank you for your letter dated 2 October 2020 enclosing the Regulation 28 Report to prevent future deaths signed and dated 2 October 2020 by HM Senior Coroner for South Manchester, Ms Alison Mutch OBE. The Report was also sent to The Care Quality Commission, Trafford Metropolitan Borough Council and NHS Trafford Clinical Commissioning Group. The Senior Coroner has set out her concerns at paragraph 5 of her report. She requires a response from Meade Close Care Home in respect of matter of concern (2): “2. There had been an earlier incident when Christine Neild had put a non-food item in her mouth. The carer did not escalate this and there was no further risk assessment”. The Coroner does not require a response from Meade Close Care Home in respect of the other matters of concern set out at Paragraph 5 of the Regulation 28 Report. Background Meade Close Care Home is a residential care home for adults with complex care needs. We aim to provide high levels of support to enable our residents to meet their personal goals and future aspirations. The Care Home consists of two bungalows, each bungalow can accommodate four residents. Each resident has an appropriate bespoke Care Plan to address their particular needs. We work in conjunction with healthcare professionals and the Council to make sure we are providing the highest levels of care possible. Christine Neild resided at Meade Close Care some between April 2016 and 31 January 2019 when she sadly passed away. Christine had complex care needs which were carefully managed by Managers and Support Workers at Meade Close. She was diagnosed with a number of complex conditions including Dysphagia which meant that she struggled to swallow. Her meals had to be blended to a specific consistency and one meal per day was bought into the service for her.

On a date in October/November 2019, Christine was spending time with her Sister,

, at Meade Close Care Home. Her sister was removing gel nails and to do so she had wrapped Christine’s fingers in cotton wool and foil. During the Inquest, told the court that she had been measuring up Christine’s bedroom for furniture and so she had left Christine alone whilst she went into her bedroom. She was alerted to the fact that Christine had the cotton wool and foil in her mouth by a Support Worker and she immediately removed the item from her mouth. She referred to the incident as a “one off”.

The Support Worker who witnessed Christine with the cotton wool and foil in her mouth did not report the matter to her senior colleagues or record it in Christine’s daily log. As a result of this the matter was not escalated and a risk assessment was not carried out. This was not in compliance with our policies and procedures.

Actions taken and agreed

As a result of the concerns raised by the Coronial investigation, we have undertaken the following:

1. Enhanced one to one supervision has been undertaken with the Support Worker involved in the incident when Christine placed a non-food item in her mouth. It is accepted that the Support Worker did not report or record the incident. During the supervision session, the details of the incident were discussed and the importance of reporting incidents of this nature. The Support Worker said that she was aware of the importance of reporting and the reasons why she should. She accepted that in no reporting the incident meant that the incident was not escalated and a risk assessment was not carried out. She is aware of the consequences of not reporting such matters. She was disappointed in herself that she had not done so. The Support Worker was advised of the appropriate ways to report incidents, by recording them in the residents Daily Log, speaking to a Senior Support Worker and/or the Manager.
2. A staff meeting has taken place to discuss the issues raised by this case and specifically the risks of not reporting and recording incidents. It was agreed that all staff would have a recording and reporting training reset.
3. A review is being carried out of all staff inductions to make sure all staff members have received the same level of training. It has been agreed that all staff will undergo a full Salutem induction.
4. All staff members have undertaken a Reporting and Recording e-learning module however as a result of the issues raised by this case all staff are required to retake the Reporting and Recording e-learning module to refresh their memories and make sure that their learning is up to date.
5. When residents are spending time with their families Support Workers are now required to ask the family member for a briefing of the time they have spent with the resident and to specifically ask whether anything arose during their visit that they think the Care Home staff need to be aware of. Support Workers must record the briefing in the resident’s daily log and escalate any matters that have been identified as a risk. We are preparing a checklist of issues for Support Workers to go through with family members to make sure all relevant risks can be identified.
6. A meeting was held on 23 October 2020 between the Manager of Meade Close,

and the Salutem Group Head of Talent and Development. During the meeting

discussions took place in respect of staff training and induction. It was agreed that all staff are to undertake refresher training in respect of Key working, Mental Capacity Act, Support planning/risk assessment, choking, recording and reporting, first aid and inductions. We attach a table detailing the actions agreed during the meeting.
7. We spoke to CQC over the telephone on 6 November 2020. During the call we discussed actions taken and action to be taken in respect to the concern raised by the Coroner.
8. We have carried out risk assessments for each resident, specifically in relation to the location of gloves, their access to them and any associate risk. For each resident we have considered the location of the gloves, both in communal areas and their personal bedroom and any risks that present for the individual resident. We assessed the precautions that are already in place and any further steps that need to be taken. A copy of the risk assessment has been placed in the individual residents Care Plan and the outcomes of the assessments have been communicated to all staff members. We will review the risk assessment every six months as a minimum if an issue arises that prompts an earlier review this will be carried out immediately.
9. We have carried out night time risk assessments for each resident. For each resident we have considered their sleeping pattern and for mobile residents we have considered the risk associated with them getting out of bed. We have assessed the precautions that are already in place and any further steps that need to be taken. A copy of the risk assessment has been placed in the individual residents Care Plan and the outcomes of the assessments have been communicated to all staff members. We will review the risk assessment every six months as a minimum if an issue arises that prompts an earlier review this will be carried out immediately.
10. We have completed a lessons learned log a copy of which we have shared with Trafford Metropolitan Borough Council for the comment. Conclusion We are sorry that it was necessary for the Senior Coroner to issue a regulation 28 report into the issue of reporting and recording at Meade Close and hope that our above mentioned actions satisfy the Coroner that we have taken her concerns seriously. We seek to reassure the Coroner that this was a one off incident. Having discussed Christine’s care with all staff members we can confirm that Christine had not been known to put non-food items in her mouth before or after this incident. Support Workers were knowledgeable with regards to reporting and recording incidents which would not be considered usual on a daily basis. However, as a result of the issues raised by the Coroner in this case, and as a reminder of the reporting and recording requirements, all staff members have received additional training with regards to identifying risks and then reporting and escalating the concerns in the appropriate way. All staff members have received training in respect of safeguarding adults and children, basic life support, first aid and reporting and recording of incidents.

We hope that the Coroner will be satisfied that Meade Close is providing the appropriate level of care to all residents whilst trying maintain a home away from home environment. We highlight the comments made by Christine’s sister during the Inquest who commented that the staff at Meade Close Care Home were “amazing”.

Please do not hesitate to contact us via our legal representatives, RadcliffesLeBrasseurLLP should any further information be required.

Dear Ms. Mutch , Re: Christina Rosemary Nield write in response to your enquiry sent to uS on October 2020 regarding Christine Rosemary Nield: You specifically asked us as the Local Authority and CCG to identify actions in respect of the following statements:
1) During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area: The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have the insight into what items can safely be placed in their mouths: We would like to assure you that we have provided extensive guidance to our providers of the safe usage and disposal of Personal Protective Equipment (PPE): Following the oultome of Miss Neild's inquest, we have reiterated this message in our daily updates to our providers. As part of our ongoing scrutiny over this matter we plan to conduct bi-annual audits with providers to ensure that the new guidance is being adhered to. We plan to monitor this using specific audit tool and also to embed it inq our annual quality review using a tool called an iTool which is specific to Trafford. Once we have evidence that the practice is embedded it will move to the standard review which is recorded within the iTool. 2nd

All adults who may be at risk of ingesting inedibles, are subject to individual risk assessments, which include their capacity to understand the associated risks. For adults who lack capacity to understand the decision in question, any actions taken to safeguard the person will be undertaken in their best interests and in accordance with Mental Capacity Act (2005). As you are of course aware, the use of PPE is fundamental to ensure the health and safety of all of our residents during the pandemic and needs to be accessible at all times. We have consulted with our providers t0 see how we can pragmatically manage the safe storage of gloves in particular: The general feedback is that where the individual risk assessment is indicative of potential risk of ingesting inedibles, our providers assure us that they would manage these instances in a variety of ways dependent on individual need, including (but not exhaustively); Locked cabinets Or pad locked rooms Support Staff signing inlout low number of gloves to retain on their person Staff carrying hazardous waste bags as opposed to hazard bins in people's rooms to ensure safe & immediate disposal in accordance with infection control measures
2) There had been an earlier incident when Christine Neild had put non-food items in mouth: The carer (family member) did not escalate this and there was no risk assessment: We have re-iterated to our providers, the importance that where any identifiedlreported need (from any source) is to be incorporated into the person's care delivery plan and escalated to the Registered Manager of the service. This will ensure that a risk assessment can be completed (where appropriate to do so) and those providing the care are aware of the person's support needs and can record any observations through established recording and incident reporting mechanisms. The Provider in this instance has completed lessons learned which has been shared with their staff. This will be shared with our Provider Forum to ensure the learning from this tragic case is shared across the Borough:
3) The inquest heard that in care settings such as this one for those with learning disabilities there was no regular use of sensors to alert night staff of a resident getting up and wandering: Staff relied on hearing resident key her

getting up despite this being difficult if they were delivering care to another resident Every adult with perceived care and support needs is assessed under the appropriate legal frameworks afforded to the respective statutory_agency; to ensure that eligible assessed needs and outcomes are met: This holistic assessment includes; the person's views and wishes, relevant history, their familylfriends or representative's views and of course their needs for care and support including any night-time associated needs. The needs assessment will also incorporate the person's mental capacity in relation to their care and residence: The assessment and subsequent support plan enables the Care Provider to produce a person centred care delivery plan. This details how the person's care will be provided and is individual to the supported person. Assistive technology is an area which has advanced significantly over recent years and in Trafford, We have local offer to support our residents and providers which includes the provision of bedldoor sensors_ When meeting persons assessed needs, we must always ensure that we adhere to the appropriate legal frameworks. The prescriptive use of sensors could not be routinely provided as there may be implications pertaining to a person's right to liberty (Art 5 ECHR) without a bespoke assessment of need and capacity. Despite the above, we would expect that any individual identified night time risk(s) are suitably risks assessed by the care provider with due consideration of assistive technology as a less restrictive option to mitigating the perceived risk: All of our Cafe Providers have been reminded to consider the exploration of technblogical Isolutions and risk assessment for any supported person who is known to leave their room during the night: We our response is satisfactory for the issues raised , please dp not hesitate to contact us should you require further clarification;