Mary Walker

Belong

Central Office
Pepper House
Market Street

fe WY Nantwich
. _ Cheshire
CW5 5DQ

27 April 2016

www.belong.org.uk

H M Coroner’s Court
Paderborn House
Howell Croft North
Bolton

BL1 1QY

Dear Ms Lomax

| acknowledge receipt of your letter dated 21 April 2016 and the Regulation 28
Report to prevent future deaths.

The report confirms that the conclusion of the inquest was that the cause of death of
Mary Walker who resided in Belong Wigan, was natural causes namely
bronchopneumonia.

| note the Coroner’s matters of concerns and would like to provide my response:

1. At the inquest there was no specific evidence about what was revealed during
the night checks. The global summary stated the times of the checks but there
was no information about the resident’s condition during the checks.

| have noted that the report provided a general summary of the resident's condition
during the night and therefore it was difficult to determine the exact time of her
deterioration. This was a breach of the organisation’s ‘Safe Management of records’
procedure.

Actions taken:

° Refresher training has been provided by the management team to all staff in
Belong Wigan, on the ‘Safe management of records’ policy and procedures
with an emphasis on the importance of accurate recording of progress against
dates and times.

e Meetings have been held with all senior staff to identify the uses of an
approved audit tool to ensure sure safe and correct procedures are being
followed.

° Nurses are required to follow policy and procedure and will record any
professional advice and direction provided within the customers’ individual
records.

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2. During the inquest we failed to provide you with clarity about the procedures.
that are used by Support Workers to escalate health concerns.

Actions taken:

° All Support Workers have been reminded of the correct procedures to follow
and how to seek advice from outside professionals for non-nursing customers
in their care, when they need to escalate health concerns. This is incorporated
into the care practice training for all staff, to include staff induction,
supervision, life plan review and audit.

| trust that my response will provide you with the reassurance that we have reviewed

and communicated our procedures following the Coroner's concerns over the death

of Mary Walker, and therefore improved the safety of our practice.

Yours sincerely

Wound

— Director

Belong

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 03000 616161 

Her Majesty’s Coroner 
Manchester West 
H M Coroner’s Court 
Paderborn House, 
Howell Croft North, 
Bolton, 
BL1 1QY 

BY EMAIL 
16 June 2016 

Your ref:  
Our ref: 

MARY WALKER – Deceased, Prevention of future death report 

Dear HM Coroner  

We  are  writing  in  response  to  the  21  April  2016  Regulation  28  Prevention  of  Future 
Death  Report  issued  by  Alison  Mutch,  Assistant  Coroner  to  Belong  Central  Office, 
Pepper  House,  Market  Street,  Nantwich,  Cheshire  CW5  5DQ  and  to 

, CQC Inspector, Bolton Wigan and Salford Team following the Inquest into 

the death of Mary Walker.  This letter is the CQC’s response to the Report issued to 

. 

Following  receipt  of  this  Report  we  held  a  management  review  meeting  to  look  at  the 
information we held in relation to this case. At this meeting we took the decision to: 

 

firstly,  undertake  a  comprehensive  ratings  inspection  at  Belong  Wigan  Care 
Village  where  Mary  Walker  resided  prior  to  her  unfortunate  death  and  to 
specifically  look  at  actions  the  provider  had  taken  in  response  to  the  Report 
findings; and 

  secondly,  to  request  copies  of  the  documentation  you  held  so  we  could  also 

consider if we needed to undertake a criminal investigation. 

As  you  are  aware  from  1  April  2015  CQC  is the lead  enforcement  body  for  health  and 
safety incidents in  the  health  and  social  care  sector.  As  Mary Walker’s  death  occurred 
after  1  April  2015  CQC  considered  when  undertaking  its  inspection  whether  further 
investigations or criminal enforcement were appropriate.  

We noted the response provided to you by the registered provider, CLS Care Services 
Limited  known  as  Belong  on  27  April  2016.  In  light  of  this  response  it  was  not  felt 
necessary for CQC to contact the registered provider to request written confirmation and 

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 evidence  of  the  action  they  have  taken  to  date  following  this  death  and  any  additional 
action  they  intended  to  take  in  response  to  the  prevention  of  future  death  report. 
However, we did consider the response sent to you during the course of proceedings as 
part of the comprehensive inspection we undertook.  

We undertook an inspection at Belong Wigan Care Village across two days, the 06 and 
16  May  2016.  We  found  steps  had  been  taken  by  the  provider  to  respond  to  the 
concerns identified in the Regulation 28 report. The detail relating to this can be found in 
the ‘safe’ and ‘well led’ sections of the report.  

We found a flow chart for unexpected changes in health had been developed and given 
to every member of staff and was displayed within each household at the service. On 
the 2nd day of the inspection all the night staff were spoken with, and all were able to 
describe the procedure that was in place. 

We  found  that  a  night  time  record  sheet  had  been  introduced.  The  record  was  time 
specific and was completed by staff as people's care and support needs were met. This 
meant clear and concise records were now being maintained throughout the night, which 
enabled management to illicit information regarding people's health and care needs  and 
the specific time at which things had occurred. We spoke to 11 night staff who confirmed 
the records had been implemented immediately following the issue being identified. 

As a result of our inspection we have provisionally rated the service as ‘good’ subject to 
the factual accuracy process. The report of our inspection is currently in draft form.  

We  have  provided  this  draft  report  as  an  attachment  to  this  letter  as  a  disclosure 
permitted  under  S.79  of  the  Health  and  Social  Care  Act  2008.    We  would  respectfully 
request that this draft report is not widely published at this time.  We will publish a final 
report of our inspection as soon as it is possible for us to do so.   

Thank  you  for  providing  us  with  disclosure  during  the  Coronial  investigation.  We  can 
confirm that following our inspection and a review of these documents we do not intend 
to  undertake  further  investigations  in  relation  to  the  death  of  Mary  Walker  or  the 
provision of regulated activities by CLS Care Services Limited.  

Yours sincerely, 

Head of Inspection 

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