Maureen Colclough

Care Quality

Commission HSCA Further Information

Citygate

Gallowgate
Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161
Mrs Jean Harkin Fax: 03000 616171

Assistant Coroner
Office of HM Coroner
County of Cheshire
West Annexe

Town Hall

Sankey Street
Warrington

Cheshire

WA1 1UH

emai to: as

16 October 2017

Our Reference: MRR1-4155695452
Dear HM Coroner
Ref: Maureen Ann Colclough

Re: Regulation 28 Report - Inquest into the death of Maureen Ann
Colclough

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
Maureen Ann Colclough. We are writing to you with our response to the matters
of concern raised in relation to Unique Care Services.

We note the legal requirement upon CQC to respond to your report within 56
days and thank you for granting CQC a four week extension to provide a
response.

Following the receipt of the Regulation 28 Report we held three internal
management review meetings to discuss the findings of the report and determine
what action CQC should take. We reviewed our records and found that the
Registered Provider had not notified us of the death of Maureen Ann Colclough
as legally required. This failure to report has been raised with the Registered
Provider and we will consider whether criminal enforcement action is appropriate.

1

We also agreed to conduct an inspection of the service, reviewing staff training in
the event of an emergency and also the oversight that is provided by |

Two inspectors visited the service on 11 September 2017 and 21
September. | have detailed some of our findings under your specific questions
below.

Background

The Registered Provider, TT wa: registered on 1 December 2014.
In May 2017, the Registered Provider moved location from Unique Care
Services, 19 Caldy Drive, Great Sutton, Ellesmere Port, Cheshire, CH66 4RN to
Stanlaw Business Centre, Unit C11 Stanlaw Abbey Business Centre, Dover
Drive, Ellesmere Port, Merseyside, CH65 9BF.

Unique Care Services was inspected on 17 and 24 October 2016. The service
was rated ‘inadequate’ in the Well Led domain, ‘requires improvement’ in the
Safe domain and ‘good’ in the Responsive, Effective and Caring domains. The
service was rated ‘requires improvement’ overall. We issued a requirement notice
for a breach of regulation 17 (good governance).

We inspected the service again in May 2017. The service was rated ‘good’
overall with ‘good’ ratings in four domains (Safe, Effective, Caring and
Responsive) and ‘requires improvement’ in the Well Led domain.

Coroner’s concerns
In relation to the specific matters of concern raised in your report:
4 Inadequate training of staff to recognise emergency situations.

During our recent inspection we found that all members of staff had received
basic life support training. This took place during August and early September
2017. The Registered Provider confirmed that additional classroom based
training has been provided to staff on 26 September and 3 October 2017.

We also noted that the two members of staff involved in the incident had received
training prior to the incident and one of them has subsequently received updated
training on emergency procedures. CQC is of the view that although the
Registered Provider has provided adequate training for staff in dealing with
emergency situations in response to the death of MC, the lack of training for
some staff prior to December 2016 and the delay in the provision of that training
put service users at risk at that time. Although the risk has been mitigated
whereby all staff have now had training, CQC considers that there had been a
system failure to oversee the management of the service.

2 Relying on presumptions when finding an unresponsive patient in a
serious situation.

CQc is of the view that carers relying on presumptions when finding an
unresponsive patient in a serious condition place that individual at high risk.
Whilst some of this risk has been mitigated as emergency training has been
provided for staff, more robust action by the Registered Provider is required with
regard to his oversight of the service.

Due to the concerns found during our inspection CQC is now taking substantive
enforcement action. In addition, the Registered Provider is required to provide
CQC with an action plan detailing how they intend to improve the care provided
to service users. Inspectors will continue to monitor the service to ensure that
service users receive safe and effective care.

A copy of the report detailing our findings will be available when published on our
website.

Should you require any further information please do not hesitate to contact me
on my telephone number
Yours sincerely

Head of Inspection

MEE. 2evistered Manager

Stanlaw Abbey Business Centre
Unit C11 Dover Drive

Ellesmere Port

CH659BF
uniquecareservices@hotmail.co.uk
0151 356 0426

Mrs. Jean Harkin
Assistant Coroner

Dear Mrs. Harkin:

| am writing in response to your request for Unique Care Services to provide details of
actions and proposed actions taken regarding your concerns after the passing away of
Maureen Ann Colclough.

We will always be open to new suggestions or information of how to continuously improve
the training that we provide for all employees at Unique Care Services.

In response to your concerns | have provided details of actions we have already taken since
the inquest took place as well as further steps that we have taken in an effort to prevent
future deaths.

e All employees have been notified and almost ALL have undertaken a revised
performance appraisal (regardless of any recent or up to date training) containing
specific information and questions relating to recognizing an emergency situation as
well as steps to take when finding an unresponsive service user.

e All new starters will be given the relevant information and must answer a series of
questions and show a satisfactory level of competence and understanding in
recognizing an emergency situation and responding accordingly. (Employees have
always been given this information in the past in the form of a handbook and have
been required to sign to confirm receipt)

« All employees of Unique Care Services have been made aware of that they MUST
attend an extra Emergency First Aid training course on either of the dates provided
and confirmed (Tuesday 26” September & Tuesday 37 October)

| sincerely hope that the actions and extra measures that we have taken prove to be
satisfactory for you report but please do not hesitate to get in further contact if there is
anything else you require from myself or any other employees.

Please allow me to state that we as a company have ALWAYS provided the relevant training
as well as promoting the options of many other training courses and qualifications even for
developing skills unrelated to Domiciliary Care.

I state this in relation to the unchallenged evidence provided by BE Gurins the
recent inquest. HE «ate that she had not been given the relevant first aid training.

This is a statement that | must declare false but was unfortunately made out of our hands.
We have since provided the Care Quality Commission with training records as well as
qualification certificates as evidence. When asked why ae had made such a
statement, she stated that she had not understood the question answered while under oath.
Unfortunately the matter remains unresolved as a. been on sickness leave for a
number of months since suffering a stroke and has not yet returned to work.

Sincerely

Registered Manager