Robert Davidson

5)
Aver

Optimum Care Providers
Advocates of Person Centred Care

1 December 2016

Louise Hunt

Senior Coroner Birmingham and Solihull j 2ECEIVED

Coroner’s Court,

50 Newton Street, -2 DEC 2016
Birmingham,

B4 6NE BY:

Dear Ms Hunt,

Following your Coroner’s investigation and inquest into the death of Robert Arthur Davidson, the
jury concluded that Robert’s death was not an accident and was contributed to by neglect. During
the course of the inquest the evidence revealed a number of matters of concern. | have listed these
numerically below to correspond to each point you have raised, for clarity.

1. Health care staff had not been trained on basic process; the Health Care Assistant
(HCA) that was instructed to make the 999 call failed to demonstrate an awareness
that to obtain an outside line the caller must first dial ‘9’. Subsequently her attempt
to call emergency services was unsuccessful resulting in the nurse having to leave
the patient, whom was choking, to make the 999 call.

2. The RGN and HCA staff involved in the incident had not received training on the CPR
and the Choking Policy. They were unclear when to start CPR.

3. The two HCA’s involved had no experience or basic training before starting work as
HCA’s. They had limited understanding of conditions and processes and therefore
consideration needs to be given as to whether there should be a mandatory training
or minimum standards, which are objectively assessed, to ensure HCA’s have the
necessary skills and knowledge to undertake their role.

4. The deceased PICA behaviour was not highlighted or identified on his transfer
between care homes, therefore some direction from the governing body needs to
be provided to care homes to ensure essential information is provided and
highlighted when a patient transfers.

As a provider Avery Healthcare does have appropriate systems and documentation in situ to address
each of the above points.

For example, with reference to point 1. Avery’s orientation checklist would sufficiently provide
evidence of staff awareness regarding how to use the phone systems, how to utilise the nurse call
system, inclusive of emergency call bells and actions to take in an emergency.

Avery Healthcare Group
3 Cygnet Drive, Swan Valley
Northampton NN4 9BS

t: 01604 675566
f: 01604 674410

e: enquiries@averyhealthcare.co.uk
HealthInvestor "
Awards 2016 Residential care provider www.averyhealthcare.co.uk

of the year

With reference to point 2, Emergency first aid at work and basic life support training would provide
an appropriate level of training for staff.

With reference to point 3, Avery have a robust recruitment and induction process, inclusive of the
care certificate. This is to ensure that staff have the correct qualities and aptitude to fulfil the role of
an HCA within Avery Healthcare.

With reference to point 4, Avery's documentation pertaining to pre-admission assessment and
transfer of care is comprehensive and if completed correctly would indicate relevant clinical risk.

Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these
processes in place and where systems or processes were in situ they were often substandard. It
remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the
inquests findings an additional action plan and timetable for action has been implemented.

Kind Regards

Regional Manager

oO)

Care Quality ; oe
Commission See nformation

Gallowgate
Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161

HM Coroner Louise Hunt Fax: 03000 616171

HM Coroner's Court,
Coroner's Court

50 Newton Street
Birmingham

B4 6NE

21 December 2016

By Email to: coroner@birmingham.gov.uk

Our Reference Ai

Dear HM Coroner Louise Hunt

Ref: Robert Davidson
Re: Regulation 28 Report - Inquest touching on the death of
Robert Arthur Davidson

Thank you for sending the Care Quality Commission (CQC) a copy of the
Regulation 28 Report issued following the Inquest touching on the death of Mr
Robert Davidson. We are writing to you with our response to the matters of
concern raised in relation to Aran Court Care Centre and Jubilee Gardens.

CQC received a notification from the registered manager of Aran Court Care
Centre on 29 January 2016 notifying CQC of the death of Mr Robert Davidson on
27 January 2016, after he swallowed and choked on a viny! disposable glove. As
a consequence of receiving this information the CQC made further enquiries and
gathered information about the incident including Mr. Davidson’s care records.
CQC carried out a focussed inspection on 09 March 2016. At this inspection we
focused on how the people known to be at risk of choking were being supported.
We carried out a further comprehensive inspection at Aran Court Care Centre on
44 November 2016 in line with our inspection scheduling frequency. At this
inspection we looked to see if the provider had acted appropriately to address the

concerns raised during your inquest and were meeting the The Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 (“The Regulations’).

Aran Court Care Centre is a care home with nursing operated by Avery Homes
RH Limited. The home has been registered to carry on the regulated activities of:
accommodation for persons who require nursing or personal care, diagnostic and
screening and treatment of disease, disorder or injury at the location of Aran
Court Care Centre from 02 March 2015. Prior to this Aran Court Care Centre was
operated by another provider.

CQC’s response to the specific concerns you have raised in the Regulation 28
Report are taken in turn and set out below:

1. Health care staff had not been trained on basic process as follows:

« Making 999 calls — to obtain an outside line caller’s needed to first
dial “9”. The health care assistant (HCA) instructed to make the 999
call, did not know this so the call was unsuccessful. The registered
nurse looking after the patient whilst he was choking had to make |
the 999 call resulting in her leaving the patient. :

e When to start CPR. The RGN and HCA staff had received no training
on the CPR and choking policy.

The concern is that staff was not trained in basic processes and therefore
not able to deal with emergency situations.

The registered provider is responsible for ensuring there are sufficient numbers
of suitably, qualified, competent, skilled and experienced persons deployed and
appropriately trained as is necessary to enable them to carry out their duties.
(Regulation 18, the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014). The provider should have procedures to follow in an
emergency and staff should be trained in these procedures. The CQC inspects a
provider’s compliance with the requirements of the Regulations during the course
of an Inspection.

During the course of the CQC focused inspection of Aran Court Care Centre on
09 March 2016, we found systems in place to ensure that nurses had training in
emergency first aid. Emergency First Aid at work training provides delegates
with an extensive first aid skill set so that they can identify incidents and manage
them appropriately, whether the patient is conscious or unconscious. The course
is designed to include first aid priorities, managing incidents, basic life support
(CPR), unconsciousness, control of bleeding, burns and scolds, recording and
reporting First Aid Priorities.

A system had been put in place so that all staff received the training they needed
and this ensured that there was always staff trained in first aid on each shift. Staff
were able to give us a satisfactory explanation and told us about the actions they
needed to take, and would take, in the event of a similar incident of choking.

At our inspection of the 14 November 2016 to Aran Court Care Centre, we
observed that at the shift handover staff were reminded of the need to dial ‘9’ for
an outside line. Staff spoken with confirmed their understanding of how to make
999 calls and what action to take in the event of a medical emergency.

The CQC provider guidance requires that when members of staff are registered
with a professional body, for example the Nursing and Midwifery Council (NMC),
and this is a requirement of their role, providers must ensure that nurses are
able to meet the requirements of the relevant professional regulator throughout
their employment, such as _ requirements for continuing professional
development. Where providers follow this guidance, registered nurses employed
will have the up to date skills and knowledge required to meet service users’
needs safely, including basic life support. During the 09 March 2016 inspection
we looked at the system that had been put in place to ensure that nurses had the
required training. At the inspection of 14 November 2016, we saw records that
showed what training people had received and were scheduled to receive.

On the 10 November 2016 we inspected Jubilee Gardens. All staff had received
first aid training commensurate with their role and all of the staff spoken with
knew how to respond to medical emergency, including how to make emergency
999 calls.

The two HCA’s had no experience or basic training before starting work as
HCA’s. They had limited understanding of conditions and processes.
Consideration needs to be given as to whether there should be mandatory
training or minimum standards, which are objectively assessed, to ensure
HCAs have the necessary knowledge and understanding to undertake the
role.

The Care Certificate was developed jointly by Skills for Care, Health Education
England and Skills for Health, and introduced on 01 April 2015. These Care
Certificate standards apply across both social care and health, and link to the
national occupational standards. The Care Certificate is designed for new HCA
staff, it also offers opportunities for existing staff to refresh or improve their
knowledge. The new standards encapsulated in the Care Certificate should
ensure that the health and social care workers have the required values,
behaviours, competences and skills to provide high quality, compassionate care.

The Care Certificate clearly sets out the learning outcomes that should be

achieved whether this is through training or alternative learning and development
activities, There is a clear requirement for providers to demonstrate that staff has

3

been assessed in the workplace with regard to their competence and safety to
practice.
For example:

e Standard 11 of the Care certificate covers basic life support. The
expectation is that the learner will be able to carry out basic life support
and complete practical basic life support training that meets the UK
Resuscitation council guidelines.

e Standard 13 of the Care Certificate requires the learner to understand
procedures for responding to accidents and sudden illness, including the
procedures to be followed if an accident or sudden illness should occur.

CQC refers to the Care Certificate in the ‘Guidance for providers on meeting the
regulations. The Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014’. The guidance states, “That providers must have an induction
programme that prepares staff for their role. It is expected that providers that

- »employ healthcare assistants and social care staff support workers, should follow

the. Care Certificate standards to make sure new staff are supported, skilled and
assessed as competent to carry out their roles’. CQC therefore on inspection
looks to see if the provider's induction incorporates the Care Certificate
standards. If as an organisation the provider chooses on staff inductions to ask
staff to complete something other than the Care Certificate or not complete all of
the outcomes in the Care Certificate, they will need to demonstrate to CQC how
the induction meets the needs of the staff they employ and the needs of the
people they support.

At the Inspection of Aran Court Care Centre on 14 November 2016 we checked
to see that the induction training provided to new staff followed the Care
Certificate standards and we were able to see that it did. In addition information
provided by the. provider in the provider information return (PIR) showed that to
date nine: new staff had completed the Care Certificate induction standards
training.

At the inspection of Jubilee Gardens on 10 November 2016, we saw that new
staff complete induction training that incorporated the Care Certificate standards.
The provider's PIR also reflected that some new staff has completed the Care
Certificate induction standards.

The deceased PICA behaviour was not highlighted or identified on his
transfer between care homes. Some process or direction from the
governing body needs to be provided to care homes to ensure essential
information is provided and highlighted when patients are transferred.

CQC expects that providers should actively work with others, both internal and
external, to make sure the care and treatment remains safe for people using the
service. When people move between services or providers, Regulation 12(2)
(The Regulations) requires providers to undertake appropriate risk assessments
to make sure service users’ safety is not compromised. This includes when they
move between or to other bodies who may not be registered with CQC. At the
inspection on 14 November 2016 at Aran Court Care Centre, we looked at Avery
Homes RH Limited admission assessment document. This is the provider's
transfer document. Whilst we did not look specifically at Mr Davidson's transfer
document, we saw that if this admission document was completed appropriately
and with sufficient detail, the information needed to ensure that where people
were known to be at risk would be captured. This would enable the provider to
take appropriate steps to minimise this risk.

At the inspection of Jubilee Gardens on 10 November 2016, we reviewed the
provider's revised handover document, which is called a passport and if this
document was completed appropriately then the known risk to a person would be
recorded so that plans could be put in place to minimise these risk.

Should any further information please do not hesitate to contact me
on * iailieaeaaaasas ca

Yours Sincerely,

Cm

Head of Inspection
Adult Social Care Directorate

From David Mowat MP
% Parliamentary Under Secretary of State for Community Health and Care
AER

Department eeg Whitehall
of Health SWANS

Our ref: 1055494

Mrs Louise Hunt

Senior Coroner

HM Coroner for Birmingham & Solihull
Coroner’s Court

50 Newton Street

Birmingham RECEIVED]
B4 6NE 12 JAN 27

AN 2017 11" January 2017
Dear Mrs Hunt,

Thank you for your letter of 13" October 2016, following the inquest into the death of
Mr Robert Davidson. I was sorry to hear of his death and wish to extend my
condolences to his family.

The Department of Health acknowledges that improving the capability of the care
workforce through continued skills development is a vital investment in the future, and
helps other people to recognise social care as a skilled career option. The
characteristics of the workforce, including opportunities for learning and development,
have a direct relationship with the quality of the care that services users receive.

In April 2015, the Government introduced the Care Certificate (as recommended by
Camilla Cavendish in her July 2013 review), which is helping to ensure that support
workers and their employers can deliver a consistently high quality standard of safe,
effective and compassionate care. It includes 15 standards and outcomes that health
and social care workers — in hospitals, care homes and people’s own homes — should
know and be able to deliver in their daily work. Regarded as ‘best practice’ for the
induction of new health and care assistants, it is also offering existing staff an
opportunity to refresh or improve their knowledge.

The Care Certificate standards include: Awareness of mental health, dementia and
learning disability; Basic life support; and Health and safety.

While not mandatory, all new healthcare assistants and social care support workers are
expected to attain the Care Certificate. It is a benchmark by which service providers
can demonstrate they meet Care Quality Commission ‘staffing’ and ‘fit and proper
persons employed’ requirements, and evidence of its use may be actively sought by
inspectors.

The Department is providing significant levels of funding to support training and
development for the care workforce. In 2016/17, DH will invest £12m through the
Workforce Development Fund which provides support to employers on modules and
qualifications for their workers in adult services in the private and voluntary sectors.

The Department is also continuing to work closely with our delivery partner, Skills for
Care, a partner in the sector skills council for social care, to improve the level of skills
of the adult social care workforce.

Skills for Care has developed a comprehensive suite of standards and qualifications to
help workers develop the skills and knowledge they need to support people who use

- services, including specialist pathways in dementia, diabetes, managing challenging
behaviour and learning disabilities.

As a government we take the safety of patients and quality of care very seriously.
Many measures have already been introduced to ensure providers improve standards -
including how the Care Quality Commission (CQC) assesses providers against the
new fundamental standards of safety and quality which care should never fail. CQC
has made unannounced inspections in November 2016 of both Aran Court Care Centre
and Jubilee Gardens Care Home.

Lam informed by CQC that its initial findings indicate that staff now have a better
understanding of what action to take in an emergency. However its assessment of the
findings following both inspections is still underway and, once completed, full
inspection reports will be published.

I hope this response is helpful and I am grateful to you for bringing the circumstances
of Mr Davidson’s death to my attention.

oo

DAVID MOWAT

Yours sincerely,

INHS

England

Room 6B7
Skipton House
London Road
London
SE1 6LH
0113 825 1120
Ms Louise Hunt
Senior Coroner
Her Majesty's Coroner for the City of Birmingham and the Borough of Solihull
Coroner's Court
50 Newton Street
Birmingham
B4 6NE

8" December 2016
Dear Ms Hunt,
Mr Robert Arthur Davidson (deceased)

Thank you for your letter 13" October 2016 enclosing your Regulation 28 Report which
follows investigation and inquest into the death of Mr Robert Davidson. On behalf of NHS
England | would like to express our sympathy to Mr Davidson's family.

It may be helpful, in replying to the Coroner's concerns, if | explain that Section 1H of the
National Health Service Act 2006 (as amended) (‘the 2006 Act”) created the National Health
Service Commissioning Board. The Board is more commonly known as NHS England. The
Board's functions and duties are set out in that both the 2006 Act as well as the Health &
Social Care Act 2012. The legal responsibility of NHS England is to commission healthcare
provision from third party healthcare providers. NHS England does not provide healthcare
itself. NHS England’s regulatory role is limited to that of primary care practitioners.

| have reviewed and considered the concerns set out in your report and your report and
address each as follows:-

During the inquest | heard evidence that Health care staff had not been trained
on basic process as follows:

e Making 999 calls — to obtain an outside line caller’s needed to first dial “9”.
The HCA instructed to make the 999 call did not know this so the call was
unsuccessful. The registered nurse looking after the patient whilst he was
choking had to make the 999 call resulting in her leaving the patient.

e When to start CPR. The RGN & HCA (Health Care Assistants) staff had
received no training on the CPR and choking policy.
The concern is that staff are not trained in basic processes and_ therefore
not able to deal with emergency situations.

Care organisations, including homes such as Aran Court Care Centre, are responsible for
the induction and training of their staff. This should include the use of the telephone in
emergency situations. Basic CPR training is a minimal expectation of those working in care
settings. It is the responsibility of the care home to provide this training and ensuring that
staff maintains their competence through regular updates. It may be necessary for the care
home to access training in the NHS to meet these requirements.

2, The 2 HCA’s had no experience or basic training before starting work as
HCA’s. They had limited understanding of conditions and processes.
Consideration needs to be given as to whether there should be mandatory
training or minimum standards, which are objectively assessed, to ensure
HCA’s have the necessary knowledge and understanding to undertake their
role.

Health Care Assistants (often referred to as nursing assistants or support workers) have
traditionally received training from their employer. This has caused a variation in standards
of practice across the country. The recent introduction of the National Care Certificate,
developed jointly between Health Education England and Skills for Health, is a set of
standards that social care and health workers stick to in their daily working life. The new
minimum standards should be covered as part of induction training of new care workers.
The Care Certificate was developed jointly by Skills for Care, Health Education England
and Skills for Health.

3. The deceased PICA behaviour was not highlighted or identified on his transfer
between care homes. Some process or direction from the governing body
needs to be provided to care homes to ensure essential information is
provided and highlighted when patients are transferred.

It is essential that information is communicated between organisations when a patient is
transferred. In this case between Jubilee Gardens and Aran Court Care Centre. Had Aran
Court Care Centre been aware of Mr Davidson’s condition they would have been aware of
the need for additional, possibly 1:1, care. The commissioning organisation should be
satisfied that the organisation to which Mr Davidson was being admitted were able to meet
his care needs. The care home will be registered with and regulated by the Care Quality
Commission, to whom this Regulation 28 report has also been sent, and they may wish to
comment in respect of this issue.

1 am grateful to you for highlighting this matter to NHS England and trust that, in so far as
remedies are within our powers, NHS England has endeavoured to address the issues
raised by you.

Yours sincerely

Chief Nursing Officer
England

[->>--- PRIORY

Pe
Director of Risk and Safety
Priory Group
Fifth floor
80 Hammersmith Road
London, W14 8UD
Tel. 020 7605 0923
Email:

Your reference: 112694 — Robert Arthur Davidson (LH/AS)
Friday 21 October 2016

Mrs Louise Hunt

Senior Coroner: Birmingham & Solihull Areas
50 Newton Street

Birmingham, B4 6NE

Private and confidential

Dear Mrs Hunt
Re. Robert Arthur Davidson Deceased

I write to thank you for your report dated Thursday 13 October 2016. You have made your
report under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations
28 and 29 of the Coroners (Investigations) Regulations 2013.

Your report is in response to the matters of concern identified during the inquest concerning
the death of Mr Davidson who had been a resident at Jubilee Gardens Care Home from 20
March 2015 until his discharge to another care home Aran Court Care Centre on 3 April
2015. Our understanding is that Mr Davidson died on 27 January 2016.

We have considered your report at length and understand that you have raised three
matters of concern. The particular matter of concern which is relevant to the actions of
Jubilee Gardens Care Home is the third:

e The deceased PICA behaviour was not highlighted or identified on his transfer between
care homes. Some process or direction from the governing body needs to be provided to
care homes to ensure essential information is provided and highlighted when patients
are transferred.

Whilst we understand that you have directed this matter of concern to be dealt with by the
governing body (which we take to understand either the regulator the Care Quality
Commission or the Department of Health or NHS England) we hope that you will be
reassured by the actions that we intend to take in respect of this matter.

These actions are as follows:

«This incident and the lessons learnt from it i.e. to ensure effective communication at the
point of a resident’s transfer or discharge to another provider will be raised in a
forthcoming issue of our quarterly Safety 1* bulletin which is shared across all of our
Amore Care Homes.

« We will also highlight the requirement for our home staff to complete Form AM32
Transfer Discharge record. This form is completed in accordance with Policy AM27
Admission, Transfer and Discharge (July 2016). The form contains prompts for staff to
record key information such as PICA behaviour. The completed form is then provided to
staff at the receiving organisation at the point of the resident's transfer or discharge.

We do hope that you will feel reassured by these actions. Please note that we are happy to
provide you with copies of the documents outlined above if this would be of benefit to you
and other parties involved in this matter.

Yours sincerely

Director 5 ack and Safety