Dear Mrs Hashmi, Regulation 28 Notice Dr Donald Stuart Clegg (Deceased) Ref: 64436 I write further to your letter and the Regulation 28 notice in relation to the inquest following the death of Dr Clegg: Firstly may I personally express my sadness at the loss of Dr Clegg and I send my sincere condolences to his family. Secondly I am disappointed that there are areas of our support which fell short of the high quality of care that we always aim to provide_ I would like to reassure you that the comments you have raised have been fully considered and it is my priority that we learn from these and continue to improve our practice: We have a culture internally of continual improvement and we are not afraid to challenge the we work: I have set out some further details below in response to your letter: Persona and Bury MBC
1. Communication and transfer of care between social services, the first placement and the final placement The comments raised relate to the inadequate communication between the care teams at Killelea (Bury Council) and Elmhurst (Persona), particularly given the complexities of Dr Clegg's circumstances: meeting has now taken place between the Persona Operations Director and the Business Manager responsible Intermediate Managed Care at Bury Council: It has been agreed that going forward and with immediate effect where a customer is being discharged from Killelea to Persona services, or vice versa, a representative from Persona will be included in a multi- disciplinary team meeting with the appropriate health professionals. I will ensure that this is monitored to see how it works in practice and whether we need to review additional methods to ensure we have the right level of communications between the respective teams: Persona Care and Support Ltd Grundy Centre Wellington Road BL9 9AH 0161 253 6000 info@personasupport org WWW personasupport orguk Company Registration Number: 09725580 NC Way 200 way for

Persona 2_ The process of assessment of care needs prior to admission was inadequate The established assessment process within Persona is for a Customer Relations Assistant to take the initial referral, capturing information via an Initial Assessment proforma. The Registered Manager would then make a decision on whether could meet the individual's needs and accept the referral, based on the information contained within the Initial Assessment: I must stress that the Registered Manager or their Deputy are the only individuals who would make a decision about whether to accept a referral and this would never be the decision of a junior member of the care or administration team: In light of the findings from this inquest we have reviewed the assessment process and we will be enhancing our approach to admissions: This involves the establishment of an additional post within our short stay services which will focus on admissions, ensuring that we obtain detailed information for the Registered Manager to allow them to make an informed judgement: This will also provide capacity for a face to face assessment or involvement in multi-disciplinary team meetings (as described at point 1) as required.
3. The Medicine Policy and/or staff training were inadequate and unsafe: The audit process was perfunctory As an organisation we are striving for 100% accuracy on our medication management: We are fully committed to improving our processes and have opened a dialogue with staff to obtain their views and to review medication management: Throughout the year we have undertaken a number of different forms of analysis to better understand how and why errors occur We have also reviewed the policies, protocols and training that we have in place: We have found due to the complexity of the services we deliver there is not "one-size-fits-all solution" and each service needs a tailored approach. An action plan is currently in place which we are actively progressing in order to improve performance: By way of summary the actions taken so far include: 3a. Investment in an Electronic Medication Administration System (EMAR) which is designed to improve accuracy and safety in respect of medication administration whilst also improving audit trails. This is being implemented at Elmhurst this week (w/c 24/9/18) and will be rolled out to our other short stay unit Spurr House in October
2018. 3b. On-going exceptional Board reporting on medication errors and progress against the medication action plan: 3c. Review and amendment of the medication policy to make it clearer for staff and to develop visual one page guides on certain key aspects of the policy: 3d. Review of our current medication training which we felt could be improved: We have therefore sourced an additional detailed and assessed training package which will be rolled out to staff imminently. 3e. Review and amendment of the self-administration assessments and protocols_ These now include a requirement to count medication weekly for people who are administering, and a mapping tool to allow the amount actually taken to be tracked against that which should have been consumed. 3f. Development of a comprehensive quality assurance framework (QA Framework)_ This has been completed in partnership with an external consultant: The work on the QA Framework has drawn current audit tools together to ensure that they are fit for purpose and all audits are meaningful, signed off by a more senior manager, and any actions are captured at scheme and organisational level in an Improvement Plan. This work has taken place across the summer months and is currently being rolled out in they self-

short stay during September and early October. We will work hard as a team to ensure it is embedded throughout the organisation. 3g. As medication in short stay services is particularly complex and busy we have reviewed the structure and are currently piloting having a Medication Co-ordinator role to provide more specialist knowledge and support in this area, as well as additional skilled capacity to undertake pharmacy and GP Iiaison and auditing: 3h. Review of the skills required by staff who administer medication has identified that there are skills around numeracy and attention to detail which had been underestimated in the previous job description and core attributes. These have now been added to job descriptions and will form part of the recruitment assessment in the future. 3i. Focus groups with staff are due to take place in early October 2018 to understand the challenges that they see in administering medication and any solutions which feel would improve their ability to perform consistently well in this area. We are also talking to other service providers to look at sharing best practice tips and tools 3j. In addition we have recruited a Compliance Manager (this is a senior appointment) who will be responsible for auditing medication. This post reports directly to me as the Managing Director. The post-holder commences on 1 October 2018.
4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in timely manner This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified: Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration: Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual's specific case in order to know when to seek further advice or involve medical professionals. This is an area that we need to further review and we have added it to our Improvement Plan and we will be taking it forward during October 2018.
5. Record keeping was inadequate and in parts incomplete Record keeping in social care has become an increasingly significant part of the role in recent years and as a result during 2017 we investigated a number of electronic care planning systems and in autumn 2017 purchased and began implementation of our chosen system Access Mobizio. Roll-out to Elmhurst took place in February 2018. It is now the case that all care planning is in the majority digital within short stay. The system allows real time recording, voice recording and more structured prompts which all contribute to improved record keeping: The QA Framework includes audits and spot checks of care records to assess the quality and accuracy of these. have identified that there is still further work to do with staff to continue to embed the approach and to drive a culture of improved record keeping: Part of this process included a series of staff workshops on the system and on person centred recording in general which took place during August 2018. Continuing to improve record keeping remains a high priority on our Improvement Plan for this service: We will look at ways to fully embed this throughout the organisation as we strongly believe it will significantly help with accuracy of record keeping: 6 There is no policy/protocol for observation/monitoring of service users when directed to do so by a medical practitioner they We

Having reviewed this area, we do not have an adequate system and protocol. This links closely to Point 4 (above). We will be developing a simple protocol for staff and an appropriate recording system for observations to sit alongside the training mentioned earlier. The new Compliance Manager will be tasked with this as an urgent action. Beyond the findings of your report I also wanted to take the opportunity to personally respond to the comment made about Persona representatives leaving court before the conclusion of evidence: I apologise on their behalf if this appeared in any way disrespectful or disinterested. This certainly was not the case and can be explained by the lack of experience in Coroner's of Court of these individuals. They believed they had been dismissed from Court and that it was appropriate for them to leave: We have recently developed a set of guidance around responding to Inquests, including what to expect when appearing as a witness. We are also exploring opportunities for Managers to observe cases at Coroners Court to increase their awareness of Court etiquette and confidence in this arena_ hope the contents of this letter provides you with satisfactory assurances that as an organisation, we are actively and continually learning and improving our practices to safeguard our customers from risk, harm or injury. In the event, that you require further information or have any follow up questions please do not hesitate to contact me on lor via email at

Dear Ms. Hashmi,

I am writing in response to your letter dated 9th August 2018. In my response I have included an overview of the discharge process from Killelea, what we are changing going forwards and also the rationale for the decision to discharge the late Dr Donald Clegg to a short stay placement.

Choices for Living Well bed based (Killelea) discharge process

Planning for discharge Planning for discharge commences upon a customer’s admission to Killelea. The MDT works closely with customers to facilitate safe and timely discharges from the Choices for Living Well bed based service.

The decision to discharge The decision to discharge a customer is made as an MDT, and involving the customer / family. Where a customer has been assessed as lacking the mental capacity to make a decision about discharge, the decision to discharge and discharge destination are made as a Best Interests decision.

For customers who have completed their period of rehabilitation or who are not able / unwilling to participate in rehabilitation a decision to discharge to an alternative setting will be made if they are not ready to return home. Department for Communities & Wellbeing

– Interim Assistant Director of Adult Operation

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Killelea, Brandlesholme Road, Bury BL8 1JJ 

For customers show are awaiting a package of home care, they may require a transfer to a short stay setting in the interim, as there is often is a high demand for beds at Killelea e.g. customers awaiting discharge form hospital. This decision is made as an MDT and professional rationale for not transferring to an interim bed are considered on a case by case basis by the management team e.g. customers with dementia, who may find an additional move unsettling.

The following actions are completed prior to discharge: Therapy staff confirm that equipment and adaptations that are essential for discharge are in place Transport arrangements are made – these may be with family/ friends, or depending on moving and handling needs, a wheel chair taxi or hospital transport may be required. Date and time of discharge agreed with the customer and family If the customer is to have a formal package of care at home or is transferring to a short stay setting or residential care, the date and time of discharge is agreed with all parties Arrangements are made for discharge of medications, and ensuring the appropriate documentation is taken with the customer e.g DNAR/ District Nurse file.

Handover of information/ transfer of care: GP, Chemist, District Nursing team, Continence Team, other involved services are informed of the discharge time and date

Onward referrals are made e.g. to the District nursing team to order pressure relieving equipment. Contact is made to ensure that the appropriate pressure

relieving equipment is in place e.g. air flow mattress prior to discharging the customer home/ alternative setting to help ensure a safe discharge.

For customers having local authority commissioned support at home: Relevant information form the support plan is shared by the Brokerage team with care providers prior to discharge

For complex cases – care providers are encouraged to attend a moving and handling handover discussion with the therapy staff at Killelea The care agency/ setting is provided with contact telephone numbers for the Connect and Direct (CAD) Hub and the Out of Hours service.

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Killelea, Brandlesholme Road, Bury BL8 1JJ 

For customers having local author commissioned placement in a short stay setting, residential care or nursing care:

For complex cases – care providers are encouraged to attend a moving and handling handover discussion with the therapy staff at Killelea Arrangements are made for the provider to visit to complete their own assessment, as part of their admissions process For providers who accept referrals over the telephone, a copy of the social care assessment and support plan will be provided prior to admission The care agency/ setting is provided with contact telephone numbers for the Connect and Direct (CAD) Hub and the Out of Hours service.

For customers with complex health needs: Continuing Health Care screening is completed by the MDT at Killelea and assessments/ reports are requested from the District Nursing Team / Consultant Geriatrician to provide evidence for funding appropriate support for such customers , for example ‘Fast Track’ funding for a nursing placement.

For customers having a privately arranged package of support / placement: Arrangements are made with the provider to visit and complete their own assessment A copy of the social care assessment completed at Killelea is made available

The customer/ family is made aware of their right to a review from the local authority as required by the Care Act 2014

The care agency/ setting is provided with contact numbers for Bury Council should circumstances change/ additional input is required The care agency/ setting is provided with contact telephone numbers for the Connect and Direct (CAD) Hub and the Out of Hours service.

Following discharge Within 24 – 72* hours post discharge (*if discharged prior to the weekend)

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Killelea, Brandlesholme Road, Bury BL8 1JJ 

A safe and telephone call is made to check that the customer is settling in well back at home / care setting If any issues have arisen these will be addressed initially by Killelea staff and further action taken. This may be a follow up from Killelea staff e.g. a visit , or signposting to another service Contact telephone number are shared with customers and with care providers, The customer/ care provider will be notified that their caser will be reassigned to an alternative team for review and the contact telephone number for that team will be shared ( as well as the number for CAD// Out of Hours)

Self –discharge Occasionally, a customer will decide to self-discharge from Killelea A discussion takes place with the customer by a member of staff, to ensure that the customer is making an informed decision and to check that they are aware of any risks

Prior to discharge the customer will be asked to sign a disclaimer form The customer is provided with contact telephone numbers for the Connect and Direct (CAD) Hub and the Out of Hours service. If the customer is assessed as lacking the mental capacity to make this decision, consideration is given to where a DOLs application needs to be made. The decision to discharge and discharge destination would be made in the customer’s best interest, following the Best Interests process. Within 24 – 72* hours post discharge (*if discharged prior to the weekend) A safe and telephone call is made to check that the customer is settling in well back at home / care setting If issues have arisen, Killelea staff will make a professional judgement as to next actions, depending on the level of need/ risk e.g. signposting to another service or contacting the locality duty team.

Change to the discharge process

Following a review of the discharge process from Killelea we have made the following change:

For customers who are being discharged to a short stay placement at either Elmhurst or Spurr House we will arrange to invite Elmhurst or Spurr House staff to attend the discharge planning meeting at Killelea, so that they can meet the customer and assess if they are suitable for the service.

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Killelea, Brandlesholme Road, Bury BL8 1JJ 

Rationale for discharging Dr Clegg to a short stay placement

The allocated social worker for Dr Clegg, , arranged a discharge planning meeting with Dr Clegg and his son on the 10 January 2018. The Agreed actions included arranging for a home care provider to assess Dr Clegg’s needs for a private package of care

Ms. Barnes contacted a number of home care providers between 10th January and 24th January, however none had capacity to arrange to assess at that time, nor to provide a package of home care.

There was a very high demand for beds at this time, from both the hospital and the community. When a customer is ready for discharge but there is no support available to enable discharge to destination of choice, a move to a short stay placement may be required.

We have used Elmhurst on many occasions and have considered this to be a safe and appropriate placement setting to meet the residential care needs of customers, where a nursing placement is not required.

The proposed move to a short stay placement was discussed with Dr Clegg and his son on 24th January 2018 and this discharge arrangement was agreed.

Ms. Barnes followed the admission process for Elmhurst when booking the placement, and liaised with the relevant Occupational Therapist to refer for appropriate pressure equipment and ensured that this was in place before the discharge took place. also provided a copy of the social care assessment which detailed Dr Clegg‘s needs.