Winifred Elliott

Care Quality

Commission HSCA Further Information

Citygate

Gallowgate
Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161

Dr Fiona J Wilcox Fax: 03000 616171

HM Senior Coroner Inner West London
Inner West London

Westminster Coroner's Court

65 Horseferry Road

London

SW1P 2ED

20 March 2017

Care Quality Commission
Our Reference:

Prevention of future death report following inquest into the death of Mrs
Winifred Elliott

Dear HM Coroner

Thank you for your letter dated 15 December 2016 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 Winifred Elliott.

Further to your report referenced above, we are writing to you with our response

_to the issues raised. Before addressing in turn each of the concerns set out at
section 5 of your report, we set out a background which | hope will assist,
providing context to the actions that we have taken.

Background

CQC was notified on 5 January 2016 of the injuries sadly suffered by Mrs Elliott
at Meadbank Care Home by the provider under Regulation 18 of the Care Quality
Commission (Registration) Regulations 2009. We were informed that Mrs Elliott
had been transferred to hospital and that a safeguarding alert had been
submitted to the local authority as there were concerns about how the injuries
had occurred. There were no ongoing concerns about the service at the time of
the incident and the lead inspector for Meadbank Care Home was in contact with
the home manager, the provider and local authority safeguarding team to ensure
that they were kept informed of the progress and outcome of the investigation.
Strategy meeting minutes dated 27 January 2016 were provided to CQC detailing

1

the steps the provider had taken to mitigate any further risks to people using the
service.

CQC carried out an unannounced comprehensive inspection of Meadbank Care
Home on 4 April 2016. During this inspection no concerns were noted in relation
to the moving and handling of people using the service and the service was rated

Good overall but Requires Improvement in the key question Safe as there were

some concerns about the administration of prescribed medicines.

A further unannounced focused inspection was carried out at Meadbank Care
Home on 2 September 2016 following the receipt of additional information from
Detective Sergeant (J Wandsworth CID in relation to his investigation
into Mrs Elliott's death. During this inspection we found that staff were trained in
how to safely transfer people and understood the moving and handling needs of
the people they were supporting.

We note that you identified the ‘matters of concern’ in your Report as
follows:

1. That information in relation to transferring residents has been removed
from display next to the resident e.g. from above their beds or inside their
rooms.

2. That the removal of such information has made it harder for busy staff to
access such information.

3. That as such, some residents may be being inappropriately transferred

and thus sustaining injuries that may cause to contribute to their deaths as

in this case.

That all homes should display as appropriate such information.

That the CQC should advise all residential homes that they should come

up with such a system and implement it forthwith.

6. That the CQC should inspect homes and confirm that such systems are in
place.

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

1. That information in relation to transferring residents has been
removed from display next to the resident

We have reviewed all of the reports written following our inspections of
Meadbank Care Home on 14 July 2011, 8 November 2012, 21 May 2013, 24
_ September 2013, 6 November 2014, 4 April 2016 and 2 September 2016 and
spoken with the lead inspectors involved in these inspections. We cannot find
any evidence that CQC at any time asked staff at Meadbank Care Home to

remove moving and handling guidelines for staff from display in people's
bedrooms. However, it is possible that a member of an inspection team brought
this to the attention of staff as a potential issue in relation to people's privacy and
confidentiality. We have drawn that conclusion as Regulation 10 of the Health
and Social Care Act (Regulated Activities) Regulations 2014 states that the
registered person is required to ensure the privacy of service users and
Regulation 17 states that people’s care records must be kept securely. Prior to
this Regulation 17(1) and 20(2) or the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010 may have been considered in relation to
this issue. These regulations were in force from 1 April 2010 until 31 March 2015.
Therefore it is possible that whilst assessing the provider in relation to these
regulations that an inspector advised staff to consider the implications of
displaying information in people’s bedrooms. CQC would not systematically
object to the display of moving and handling information in people’s bedrooms
but would expect that staff had considered people’s consent to this and what was
in their best interests.

2. Removal of information has made it more difficult for staff to access
this information.

The registered persons within care homes are required to ensure that staff have
access to the information they require to meet the individual needs of the people
they support which includes their moving and handling needs. This.includes care
plans and risk assessments and any guidance for staff to support them to meet
people’s needs appropriately and safely. Whilst it is accepted that information
should be easily accessible to enable staff to complete their roles effectively,
consideration must be given to the views of the person or their representatives in
relation to displaying information in people’s bedrooms to ensure their consent is
given for this. If people are unable to make this decision, a decision must be
made in their best interests in line with the Mental Capacity Act 2005. The two
inspections that took place of Meadbank Care Home following the death of Mrs
Elliott found that staff were aware of the correct moving and handling practices to
follow for the individuals they supported and the content of people’s care plans
and risk assessments.

3. Some residents may be being inappropriately transferred and thus
sustaining injuries that may cause to contribute to their deaths as in
this case.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014 require registered persons to provide care in a safe way for
service users which includes assessing risks to health and safety and doing all
that is reasonably practicable to mitigate such risks. It is not acceptable for staff
to transfer people without reviewing the information available in people’s care

plans and risk assessments to ensure that this is completed safely. It is expected
that staff who are working with people have access to these records in order to
guide them in the appropriate moving and handling techniques to transfer people
safely and this is assessed as part of our inspection methodology. .

4. That all homes should display as appropriate such information.

CQC has the statutory objective of performing its functions for the general
purpose of encouraging the improvement of health and social care services. This
is achieved by monitoring and inspecting services to ensure that they are
meeting the regulations. Providers develop ways of meeting the regulations that
are individual to the service and meet people’s individual needs. CQC as the
regulator does not have the power to insist that provider's meet the regulations in
a particular way. However, CQC does provide guidance for providers about how
to meet the regulations on our website which can be found here:
hitp://Awww.cac.org.uk/content/quidance-providers. Also we can ensure as part of
our inspections that staff have access to all of the information that they require to
meet people’s individual needs appropriately and safely and take action where
this is not the case. Care services find different ways of ensuring that care staff
have access to the information they need to provide people with safe and
appropriate care. For example, some services ensure that staff receive protected
time to read-and understand care plans and risk assessments and others keep
care plan folders in people’s bedrooms so that staff can access these easily for
each individual.

5. CQC should advise all residential homes that they should come up
with such a system and implement it forthwith

During the inspection process the inspection team will assess the performance of
the provider against the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014. As part of this process inspectors will assess whether or not
providers are providing safe care and treatment under Regulation 12. This will
include the assessment and management of risks associated with moving and
handling. As stated above CQC does not have the powers to insist on how
providers meet the regulations and therefore could not compel providers to
develop and implement systems for displaying moving and handling information.
However, CQC will assess the effectiveness of the systems providers have to
assess, monitor and mitigate the risks relating to the health, safety and welfare of
people using services and will take action against providers who fail to keep
people safe from avoidable harm.

6. That the CQC should inspect homes and confirm that such systems
are in place.

At all comprehensive inspections the inspection team will assess whether the
provider is meeting legal requirements under Regulation 12 of the Health and
Social Care Act 2008 (Regulated Activities) Regulations 2014 to ensure that
people are receiving safe care and treatment. This will include assessing staff
understanding of people's individual needs and access to information about
people’s needs as detailed in their care plans and any associated risk
assessments. CQC will take action in accordance with its enforcement policy
where providers are failing to provide safe care and treatment which includes the
failure to operate safe moving and handling procedures.

If you have any further questions or concerns, please do not hesitate to contact
us on the above number.

Yours sincerely

Head of Inspection (Adult Social Care) South east

(On behalf of
Head of Inspection (Adult Social Care) London)