Marjorie Evelyne Keogh

Care Quality Commission

Care Quality Salone
Commission Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161
Fax: 03000 616171

www.cqc.org.uk

Mr D S Coutts-Wood
HM Coroner

The Town Hall

Town Hall Square
Leicester

LE1 9BG

4 February 2014

Re: Marjorie Evelyne Keogh
Dear Mr Coutts-Wood

Thank you for your letter of 4 December in which you wrote to us under the
provisions of Regulation 28 of the Coroners (Investigations) Regulations 2013 in
relation to the inquest into the death of Mrs Marjorie Evelyne Keogh.

We were extremely saddened by the news of the death of Mrs Keogh and the
circumstances surrounding it. We are also grateful for your report and for requiring
us to review what actions have and should be taken to prevent any reoccurrence of
such circumstances.

Please treat this letter as the formal response of the Care Quality Commission (‘the
Commission’) to your report.

In your report and pursuant to the requirements of Regulation 29 you require the
Commission to provide details of any action that we have taken or which we propose
to be take in response to the concerns highlighted in your report, or an explanation
as to why no action is proposed if appropriate.

We deduce from your report that your primary concerns arising from the Inquest into
the death of Mrs Keogh relate to the following issues:

1. The verification of compliance with building regulations, other relevant quality
standards and architects’ plans on the transfer of regulatory authority and
registration of providers between the National Care Standards Commission
(‘NCSC’), then the Commission for Social Care Inspection (‘CSCI’), and finally
then to the Care Quality Commission (‘the Commission’); and

2. The Commission's current and future intended practice in relation to these
issues with respect to new and pre-existing registrations with us.

in relation to both questions we feel that it would be useful to outline first how the
relevant regulatory frameworks have changed and developed since 1997.

Historic Regulatory Framework: 1997 to 2009

When Scraptoft Court was originally registered in 1997 the prevailing legislation was
the Registered Homes Act 1984 (‘RHA’) and the registration authority was Leicester
City Council. The RHA provided for a fundamentally different regulatory framework
from that currently in existence under the Health and Social Care Act 2008 (‘HSCA
2009"). In particular, ‘residential care homes’ were required to be registered as
distinct establishments, whereas under the HSCA 2008 residential care homes as
distinct establishments are not registered. Instead, persons are registered to provide
a regulated care activity at specified locations.

We assess that the RHA system was more directly concerned with the physical
environment and indeed the accompanying Residential Care Homes Regulations
1984 were more specific about what was required in respect of the physical
environment. The current HSCA 2008 is more focussed on the outcomes
experienced by the people using services, while the regulations that underpin those
outcomes are far less prescriptive about particular physical and/or environmental
requirements providing that those outcomes are met. The relevant regulations under
the HSCA 2009 are the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009.

It is our understanding that under the RHA regime there was no statutory duty on
registration authorities to check that care homes were compliant with building
regulations, architects’ plans or relevant British Standards. We understand that this
was then considered primarily a matter for planning departments of relevant local
councils. However we also understand that many registration authorities may upon
RHA registration have routinely checked for compliance with those regulations,
standards and plans. As well as being RHA registration authorities most Councils
were also planning authorities with responsibilities for planning and building control.
Accordingly, it appears that planning and building control checks were done
‘internally’ between council departments.

In having set out our understanding of the role undertaken by Local Councils in
respect of checking, at the point of registration compliance, with relevant buildings
regulations we are mindful that the Local Authorities themselves would have a
greater and more comprehensive insight into those practices.

We interpret that the Care Standards Act 2000 (‘CSA 2000’) enacted a similar
regulatory to that under the RHA. In particular, CSA 2000 provided for the regulation
of establishments. However, responsibility for regulating care homes was moved
away from local authority control to the NCSC, then and subsequently in 2004 to the
CSCI.

We understand that the NCSC initially carried out building control and/or planning
checks upon registration. However, by the time that CSCI came into existence
physical and/or environmental checks were being phased out in favour of a focus on
outcomes for people.

By the end of its existence CSCI had ceased to check routinely compliance with
planning and/or building control requirements on registration. We understand that
those were regarded as being responsibilities of local authorities and providers
rather than the care regulator.

In conclusion, it is our assessment that it is unlikely that either the NCSC or the CSCI
checked that the original registration in 1997 included checks that Scraptoft Court
met Building Regulations or complied with the original architect’s plans or other
relevant quality standards.

Current Regulatory Framework

The Commission was established on 1 April 2009 by the Health and Social Care Act
2008 (‘the Act’). The Act introduced a single registration system which applies to
both healthcare and adult social services.

Once registered with the Commission, providers such as Scraptoft Court are
required to comply with conditions placed on their registration, as well as under the
Health and Social Care Act 2008 (Registered Activities) Regulations 2010 and the
Care Quality Commission (Registration) Regulations 2009 (‘the Regulations’). The
regulations set out the essential standards of quality and safety that service users
have a right to expect.

The Act also requires the Commission to publish guidance about compliance with
the requirements of the Regulations. The Commission has published “Guidance
about compliance, Essential standards of Quality and Safety” (‘the Guidance’) which
provides advice to providers about how and what they need to do to comply with the
Regulations in the form of outcomes and prompts. The Regulations implemented
under section 20 of the Act make particular provision with a view to securing a
service that is of an appropriate quality and secures the health, safety and welfare of
persons for whom any such service is provided.

Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010, which is assessed as Outcome 10 under the Guidance, has
particular relevance to your concerns relating to staircase furniture and is set out
below:

“Regulation 15: Safety and suitability of premises

The registered person must ensure that service users and others having
access to premises where a regulated activity is carried on are protected
against the risks associated with unsafe or unsuitable premises, by means of—

(a) suitable design and layout;
(b) appropriate measures in relation to the security of the premises; and
(c) adequate maintenance and, where applicable, the proper—
(i) operation of the premises
which are owned or occupied by the service provider in connection with
the carrying on of the regulated activity.

Prompts for all providers to consider

The following prompts relate to all registered providers except where care,
treatment and support is delivered in a person’s own home.

Ensure the premises are adequate

People who use services and others who work in or visit the premises can be
confident that in relation to design and layout, the provider:

Ensures the premises are suitable for the regulated activity.

Takes account of identified risks.

Meets the requirements of the Health and Safety at Work Act 1974 and
associated regulations and the Regulatory Reform (Fire Safety) Order
2005 and other relevant legislation.

Takes account of the safety needs of people who enter or use the
premises,

including the safety of children and other vulnerable people where they
are

permitted to enter.

Ensures that all safety precautions are in place and tested with regard to
all

specialist equipment and engineering systems that are physically fixed to
the premises.

Ensures the premises reflect Department of Health published guidance.

Lead effectively to manage risk about the premises

People who work, visit or use services can be confident that, in relation to design
and layout:

Where premises are altered or their use is changed, the continued safety
and suitability of the premises is assessed.

In relation to maintenance of premises and grounds, renewal and service
continuity:

There are clear procedures, followed in practice, monitored and
reviewed, which cover:

— how the premises are maintained

— the identification, assessment, management and review of risks
Plans are developed and implemented for the adaptation of the premises
in response to changes in:

— the needs of people who use services

— design, technical and operational guidance issued by appropriate

expert bodies

— how the service intends to provide regulated activities

— relevant legislation.

When the Health and Social Care Act 2008 came into force the move away from
prescriptive environmental requirements was further enshrined in the legislation.
Establishments were no longer required to be specifically registered and there is no
specific requirement in the Regulations concerning planning permission or building
regulations. Nor indeed are fire, food safety or environmental health standards
specifically and prescriptively incorporated into the Regulations.

Under the current regulatory framework it remains the responsibility of providers to
ensure that the premises in which they carry on a regulated activity is fully compliant
with any relevant Buildings Regulations or British Standards. It is our interpretation

that the responsibility for enforcement with these regulations lies with Building
Control and/or Planning Departments in local authorities.

The Commission would and does check such compliance when it has information
that might indicate that people using or visiting a service may not be protected in the
way the regulation specifies.

At the point of registration with the Commission in November 2010 the Commission
did not specifically check whether Scraptroft Court was compliant with relevant
Building Regulations. The provider declared that they were compliant with the
Regulations and the provider indicated that no consideration was being given to
changes either in relation to the activities that they were to provide, or to the location
they were to be provided at, which would have resulted in a more detailed
assessment of their registration. The registration for Scraptoft Court was in effect a
‘like for like’ transition from the previous regime to the new one. Scraptoft Court was
adjudged compliant with the existing regulatory framework at the time of transition.
Additionally, there no information from either the provider or other sources to indicate
a risk to the people using the service or other relevant concerns about the service or
the provider, which would otherwise have prompted a more detailed analysis of
Scraptoft Court’s registration application at that point.

The Commission has inspected Scraptoft Court on five occasions since it was
registered under the Act in November 2010. We conducted three inspections in
2011, one in 2012 and one in November 2013. We attach a copy of each of those
reports to this response. During the course of three of those inspections we found
that the service was non-compliant with one or more regulations.

Non-compliance with Regulation 15 was assessed on one occasion, following the
inspection on 18 December 2012, and as set out at pages 10 and 13 of the Report
published on 6 February 2013. The Commission's concerns related to the carpeting
in the entrance hall, some communal areas and both the downstairs and upstairs
corridors of Scraptoft Court. Despite regular cleaning we assessed that this carpeting
retained an odour of urine. This carpeting was also heavily patterned and as such
was not suitable for people using the service who had dementia.

The provider replaced this carpeting and we found the service to be compliant with
the regulations at our last inspection in November 2013.

In terms of the Commission's registration policies and procedures, we are currently
reviewing our approach to registration. The contents of your Regulation 28 report
helps to inform that review. During the course of considering our response to your
Report we have consulted with the Head of Registration within the Commission. She
has confirmed that particular and detailed consideration is being given to the extent
to which the Commission should go beyond solely seeking a declaration at the point
of registration from a provider that they are compliant with relevant Buildings
Regulations and/or Planning regulations. That process of review is on-going.
However, at this stage the Commission’s plan is to undertake checks and seek
evidence to confirm a provider's compliance with building regulations as part of a
registration application where the provider seeks to accommodate people and where
the location is newly built or where building works have been undertaken

Thank you for raising this issue with us. We intend to share it with inspectors and
with other managers within the Commission as well the report informing our
intelligence and policy processes.

If you have any questions about this letter, please do not hesitate to contact 7
EE oc vi: cra! EE You can iso

make contact through our National Contact Centre using the details below:

Telephone: 03000 616161
Email: Enquiries@CQC.org.uk
Write to: Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA

Yours faithfully

Care Quality Commission
Encs

My Mil Limited, T / a  Scraptoft Court Care Home 
273a Scraptoft Lane,  Leicester.  LE5 2HT 

Tel/  fax:  0116 2431115 

HM  Coroner 
The Town  Hall 
Town  Hall  Square 
Leicester 
LEl  9BG 

Dear Sir/  madam, 

20  February 2014 

Re:  Regulation  28 report - Mrs Marjorie  Keogh 

1.  We  complete  a  needs  assessment  for  potential  residents  prior  to 
admission  to our homes  which  identifies  how  much  help and support a 
resident requires. 

A  Registered  Nurse  would  carry  out  the  needs  assessment  for  a 
resident who  required  nursing care.  A copy of Homes policy "Residents 
plans  of care"  (appendix  1)  and  our  pre-admission  assessment  pack 
(appendix 2) is enclosed. 

If we  are  able  to  meet  the  needs  of the  potential  resident and decide 
to accept them  for admission,  risk assessments are completed 

We  complete risk assessments  to provide a  means  for taking the  more 
difficult decisions arising  from  what the  person  is able or unable  to do 
safely for themselves. 

Some  of what  is  planned  to  improve  the  residents  quality  of life  may 
involve their taking some risks,  for example,  improving and  maintaining 
mobility may require  the resident to walk rather than  use a wheelchair, 
which carries the risk of a fall. 

For  these  risks  we  assess  and  put reasonable  precautions put in  place 
to  minimise  the  risks.  We  try  not to err on  the  side  of risk  avoidance 
or totally  risk-averse on  behalf of our residents  as  it can  impose  a loss 
to quality of life. 

We  would  complete  a  risk  assessment  using  a  Premises  Internal  area 
risk  assessment  form,  if there are  any  risks  in  relation  to specific  areas 
in the home,  e.g.  is  there a risk  involved for the  residents occupying  a 
bedroom in the home that may be  upstairs.  Premises  internal area  risk 
assessment form (appendix 3) enclosed. 

MyMil Ltd 

Page 1 

 
 CQC  inspection  in  November  2013  shows  that the  care  home  is  fully 
compliant with  regulations  under the  Health  and  Social  Care  Act  2008. 
CQC  report (appendix 4) enclosed. 

2.  There  is  no  legislative  prescriptive  staffing  level  for  care  homes.  Our 
staffing  levels  are  based  on  needs  of residents;  we  care  for  residents 
with residential care  needs and  nursing  needs. 

This is the shift pattern for nursing and care  staff that we  have in  place 
for occupancy of 10 residential  residents and  20  nursing residents  (2 of 
these have one to one staffing periods)  in  February 2014: 

Registered  Manager/ Nurse - 40  hours per week daytime 
Registered  Nurse X 1 from 7am - 7pm 
Registered  Nurse X 1 from 7pm - 7am 
Residential  Manager/trainer - 32 hours per week 
Senior/Care staff x 6 from  7am -2.30pm 
Care  staff  x  1  from  7am  - 2.30pm  for  resident  requiring  one  to  one 
supervision 
Care  staff x  1 from  11am -2.30pm x  1 for resident requiring one to one 
supervision 
Senior/Care Staff x 6 from  2.30pm-10pm 
Care  staff x  2 from  2.30pm-10pm  for  2 residents  requiring  one  to one 
supervision 
Care staff x 2 from  10pm-7am 
Care  staff  x  2  from  10pm-7am  for  2  residents  requiring  one  to  one 
supervision. 

that  the  Regulation  and  Quality 
We  use  the  staffing  guidelines 
Improvement  Authority  (NI)  have  produced  as  guidance  us  in  our 
staffing calculations. 

This  example  is  taken  from  the  guidance,  however  we  only  have  20 
nursing  residents  and  the  remaining  10  are  residential  residents  that 
require lower staffing ratios,  so  we  are overstaffed at present. 

Example 1 - 30 bedded nursing home 

No of 
beds 

Time 
periods 

Staff/ 
Patient 
ratio 

Total 
no.  of 
staff 

No.  of 
Nurses 

No.  of 
C/A's 

30 

-

- -

-

-

8am-2om  1:5 
2Q_m-8~m 
8om-8am 

_1:6 _ 
1:10 

6 
5  -
3 

2 
_2 
1 

4 
_] 
2 

Total 
care 
hours 

36 
30 
36 

M"Mil I  trl 

 This  provides  a  total  of  102  available  care  hours  with  an 
average of 3.4 care hours per patient over 24 hour period with 
35% registered  nurses  and  65% care  assistants  over the  24 
hour period. 

CQC  Inspection  in  November  2013  shows  that the  care  home  is  fully 
compliant  with  the  regulation  under  the  Health  and  Social  Care  Act 
2008 

3.  Our Residents  Plans  of Care  policy  (appendix  1) outlines our objectives 
and  strategies,  in  relation  to  risks,  implementation  and  reviewing  care 
plans.  It outlines outlining staff's roles  in care  plan  process. 

Care  plans  reflect  the  differences  between,  what  the  person  can  and 
cannot do for themselves,  what they seek to do for themselves and  the 
daily  living  tasks  over  which  they  seek  or  need  help.  Each  person  has 
an  individualised  plan  of  care,  which  takes  into  account  significant 
nsks. 

Our Falls  Prevention  and  Risk  Assessment  Policy  (appendix 5)  which 
outlines  how  we  aim  to  balance  the  protection  of  residents  from 
risks  with the promotion of independence,  in  accordance  with  Dept. 
of  Health  guidance,  Independence,  Choice,  and Risk:  A  Guide  to 
Best Practice in Supported Decision Making. 

We  use  a fall  risk assessment tool/care  plan  which  is  widely used  in 
Leicester  hospitals  and  other  care  homes.  A  copy  of  which  is 
enclosed.  (Appendix 6) 

The  tool/care  plan  considers  the  "Place"  a  resident  is  cared  for, 
which  would  include consideration  about which  bedroom  a  resident 
occupied  and  where  it  was  located.  This  does  not  only  apply  on 
admission  but  it is  reviewed  each  month  or the  period  specified  on 
the care plan or when there is  a change of care need. 

Our  in  house  moving  and  handling  trainer  has  been  trained  by 
Leicestershire  County  Council  and  the documentation  she  uses  has 
been supplied by them for use. 

To  ensure  safety  and  to  maximise  residents  independence  and 
dignity we operate a minimal handling of residents whereby physical 
handling  is  or  lifting  of residents  is  minimised  or avoided  wherever 
possible. 

MyMil Ltd 

Page3 

 We  undertake  a  moving  and  handling  assessment  using  the  tool 
enclosed,  (appendix 7). A risk assessment form is  completed  for any 
of the tasks  identified on  the moving and handling assessment form . 
I  am  enclosing  copies  some  of  the  risk  assessments  templates 
(appendix 8 & 9) as examples. 

We  have  reviewed  and  changed  all  our  care  home  documentation 
over  the  past  3  years  and  we  have  received  a  lot  of  positive 
feedback from professionals. 

We  use a handover sheet each  day  to ensure  that all  information  is 
passed  between  shifts and  it highlights changes to care  plans and/or 
medication.  Staff sign  to say that they have attended the handover. 
(appendix  10) 

CQC Inspection in  November 2013  demonstrates that the care home 
is  fully  compliant  with  regulations  under  of  the  Health  and  Social 
Care Act 2008. 

4.  We  have  not  been  able  to  confirm  with  Building  Control  at 
Charnwood  Borough  Council  that the  balustrade  is  compliant to the 
required standard. 

They  did  ask  us  to  undertake  work  on  the  balustrade  after  the 
incident at Scraptoft Court,  which  we did. 

However,  they have  now  come  back  to me  and  state  that we  must 
obtain  a  report  from  an 
independent  surveyor  to  give  us  the 
information that you  require relating  to its compliance. 

We  have  therefore  now  commissioned  an  independent  surveyor  to 
address  this  and  will  forward  this  report  to you  within  the  next  28 
days. 

We  would therefore ask that the period for this  reply to be  extended by 
a further 28 days. 

Yours  faithfully. 

Director 

MyMil Ltd 

Page 4 

 
 MyMil Limited, T/a Scraptoft Court Care Home 
273a Scraptoft Lane,  Leicester.  LES  2HT 

Tel/  fax:  0116 2431115 

'iM Coroner 
The Town Hall 
Town Hall Square 
Leicester 
LEl  9BG 

Dear Sir/ madam, 

LEICESTER CITY & 
60UTH LEICESTERSHIRE 
CORu,.ERS DISTRICT 

I 

- 7 APR  2014 

3 Apr 

I 2014 

RECEIVED 

Re:  Regulation 28 report -Mrs Marjorie Keogh 

Further to your letter dated  1 April  2014.  Your letter states that I  requested  a further 
28 day extension, can  I  clarify that I  asked for a 21  day extension. 

The information that you  require to make the decision  is as follows: 

1.  In the matter of concerns (section 5,  Reg.  28 report) 4,  it  asks "Is the staircase at 
Syston  Lodge compliant with the requirements  referred to". 

I  have  not  been  able  to  get  this  information  from  Chamwood  Borough  Council 
Building  Control  Dept.,  who  signed  the  building  off  when  the  care  home  was 
completed  in  1998 as I  have been told they no longer have records ava ilable. 

On  the advice of our Solicitor we  have commissioned a structural engineer to help us 
address  this.  I  returned  to  work  on  the  26th  March  2014,  the  structural  engineer 
came out last week and I  am  awaiting correspondence from him after this visit. 

2. 
March 2014 so was off from this date. 

  has  been  off sick  since  16  February  2014.  I  had  surgery  on 

5th

3. 
resume work after this. 

 sick certificate is  for 2 months,  it is not known if he will  be able to 

4.  The outstanding  matter needed  to  be addressed  by  a director;  we were  involved 
with the building  and  registration  of the care  home in  1998 and  need to ensure that 
the question asked  is answered. 

Yours faithfully. 

Director 

My Mil Ltd 

 
 
 MyMil Limited, T/a Scraptoft Court  Care Home 
273a Scraptoft Lane,  Leicester.  LES  2HT 

Tel/  f~0ll6 2431115 
.,., 
,,  ··•cf/ 
~ 

r 
C(A. 

..£ _ ~SiG_Ify & 
It:.._-_;;,  D,{}SH1f?f

Flier 

HM  Coroner 
The Town Hall 
Town  Hall  Square 
Leicester 
LEl  9BG 

Dear Sir/ madam, 

14  4PR lON 

10 April  2014 

Re:  Regulation  28 report -Mrs Marjorie Keogh 

In relation to the remaining question  (4) relating  to the stairs at Syston  Lodge 
  knows that the same company who supplied the 
Residential  Home. 
balustrading at Scraptoft Court supplied  Syston  Lodge  Residential  Home. 

The  balustrading  at Scraptoft  Court  has  been  found  not to  comply  therefore 
we feel  that the balustrading at Syston  Lodge is  not compliant. 

We  have  instructed  a  Structural  Engineer  to  look  into  this  and  make 
these 
recommendations 
recommendations once we  receive his report. 

they  comply.  We  will  undertake 

to  ensure 

Please  do  not  hesitate  to  contact  me  should  you  require  any  further 
clarification . 

Yours faithfully 

Keg.  Off c.e  We'>twood  ouse, 78 LOughboroi.g!l Road, Quorn,  Le1ce~tcr~h1re,  LE!L BDX 
Cor1pany Reg11,t•at1on  lllo  7180927 
D1·ecto1,;:  Di:ie;h Gokarn,  Heleri Appleton 

 
 
 MyMil  Limited, T/a Scraptoft Court Care Home 
273a Scraptoft Lane, Leicester. LES 2HT 

Tel/ fax:  0116 2431115 

HM Coroner 
The Town Hall 
Town Hall  Square 
Leicester 
LEl 9BG 

Dear Sir/ madam, 

19 September 2014 

Re:  Regulation 28 report -Mrs Marjorie Keogh 

Further to my letter dated 3 July 2014. 

Please  find  enclosed  a  copy  of the  summary  of the  report that was  undertaken  by 
our commissioned  Structural  engineer in  relation  to the balustrading at Syston  Lodge 
Residential  Home. 

Yours faithfully. 

Director 

MyMil Ltd