James Harris

pee ae

Care First Class UK Ltd

Bretby House St.Joseph’s Clifton House Cherry Lodge

253 Boldmere Road 46 Silver Birch Road 165 CliftonRoad 6 Manningford Road
Wylde Green Erdington Balsall Heath Druids Heath
Sutton Coldfield Birmingham Birmingham Birmingham

West Midlands West Midlands West Midlands West Midlands

B73 SLL B24 0AS B12 8SL B14 5LD

Tel: 0121 373 6562

18" August 2017

Ms Emma Brown

Area Coroner

Tel: 0121 373 0043

Birmingham and Solihull

50 Newton Street

Birmingham
B4 6NE

Dear Ms Brown

Tel: 0121 440 2089

Tel: 0121 430 5986

Re: Inquest on 21* July 2017 for the Mr James Albert Harris

Please find below the response to the coroners concerns at this inquest.

1)

2)

3)

4)

5)

Read and sign sheets have been implemented so that staff read and sign care plans
individually when residents are admitted to the home. The aim is that these are
completed in a timely manner within 72 hours of a service user arriving, and staff will
read and sign them the expectation being within one week. On point of admittance
information is given at handover three times a day so that staff are aware of needs
of a new resident.

Care plans and risk assessments are in place. Care plans stipulate if a resident
requires supervision on mobilising and staff do endeavour to be with residents when
walking. Unfortunately, some residents will not always wait for staff to assist and
therefore put themselves at risk. If staff observe a resident mobilising independently
and are aware that they should be accompanied then they will always assist.
Protocol for falls — this document has been given to all staff and a signed copy is kept
on their personnel file. This has also been made part of the induction protocol for
new staff.

Records of nightly checks are in place. This identifies when residents were checked
either hourly or two hourly at their request. This is then recorded on the night check
sheet and signed by staff on duty.

Residents who are complaining of pain would be offered analgesia if required. Staff
on duty can check Medication Administration Records to see if they are written up
for them and if they are able to administer them. If the person is not written up for
any pain relief, then staff would contact badger services or 111 for advice.

6)

7)

Care First Class UK Ltd

There is a manager in post at Cherry Lodge at present. HE cocs have
registration for another service and will register with COC in due course.

Staff are being spoken to individually at Cherry Lodge as to their understanding and
their roles and responsibilities in the event of any accident or incidents in the home.
Management staff are monitoring records that staff are completing and addressing
any issues arising from this.

The falls policy now forms part of the Staff member's supervision which is recorded.
This is to clarify the member of staff understands their role and responsibility and
what is expected when a service user has a fall. It will also be on the staff meeting
agenda as a lessons learnt.

Yours faithfully

Care First Class (uk) Ltd

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 
Fax: 03000 616171 

www.cqc.org.uk 

HM Coroner Emma Brown  
HM Coroner's Court, 
Coroner's Court 
50 Newton Street 
Birmingham 
B4 6NE 

13 September 2017                                                            

By Email to: coroner@birmingham.gov.uk 

Our Reference: ENQ1-4103996990 

Dear HM Coroner Emma Brown 

Ref:    James Albert Harris 
Re:     Regulation 28 Report - Inquest touching on the death of  

James Albert Harris 

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 
James Harris (‘Mr Harris’). We are writing to you with our response to the matters 
of concern raised in relation to Cherry Lodge Care Home (‘Cherry Lodge’).  

Brief Background 

Cherry Lodge is a care home without nursing operated by Care First Class (UK) 
Limited, and is registered to provide the regulated activity of accommodation for 
persons  who  require  nursing  or  personal  care  at  the  location  of  Cherry  Lodge 
Care Home from 26 August 2014.   

20170818 Reg 28 Response v5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The first comprehensive ratings inspection at Cherry Lodge was conducted on 17 
and 18 September 2015  where the service was rated as  ‘requires improvement’ 
with  a  breach  under  Regulation  13(5)  The  Health  and  Social  Care  Act  2008 
(Regulated Activities) Regulations 2014, (Safeguarding service users from abuse 
and  improper treatment).      A follow  up  inspection  was  carried  out  on  30 and  31 
August 2016 where the provider remained as ‘requires improvement’ but had met 
the  legal  requirements  of  the  breach  and  there  had  been  some  improvement  to 
the service.   

On 28 January 2017 CQC received a statutory notification from the  then deputy 
manager  of  Cherry  Lodge  advising  that  a  service  user (Mr  Harris)  had fallen  on 
26  January  2017  and  had  sustained  a  fracture  to  his  hip  as  a  result.    The 
notification advised that Mr Harris had slipped in the toilet and at the time of the 
fall  appeared  not  to  have  sustained  any  injury.    The  notification  continued  to 
explain that on 27 January 2017 Mr Harris complained to care staff of pain in his 
leg and the paramedics were called. Mr Harris was then taken to hospital and it 
was established he had a broken hip.  

On  receiving  this  notification  the  CQC  requested  additional  information  from  the 
deputy manager of Cherry Lodge on 1 February 2017.  We received a response 
on 6 February 2017 advising that this was the first time Mr Harris had fallen since 
his  admission  to  Cherry  Lodge  on  10  January  2017.  However  it  was  noted  that 
there had been a history of falls prior to his arrival to Cherry Lodge.  On request 
CQC received copies of the accident report, the daily records for Mr Harris from 
26 January 2017 and the night report for 26 January 2017.  However, not all the 
requested information had been sent to the CQC and as part of our assessment 
of  risk,  further  requests  for  information  were  made  to  the  deputy  manager  on  9 
February  2017  and  16  February  2017.  On  17  February  2017  the  CQC  received 
the  additional  information  requested  which  included  copies  of  Mr  Harris’  risk 
assessment, initial support needs assessment and a daily notes.  

In  accordance  with  CQC  processes,  we  considered  the  information  we  had 
available to us at that time (February 2017) to determine whether the service was 
meeting  the  The  Health  and  Social  Care  Act  2008  (Regulated  Activities) 
Regulations 2014 (“The Regulations”). Based on the information available to us at 
this time it was decided that no further action would be taken.  

On  2  March  2017  CQC  received  a  further  statutory  notification  from  Cherry 
Lodge,  advising  that  during  the  Registered  Provider’s  internal  investigation  into 
the  events  leading  up  to  Mr  Harris’  fall  there  had  been  allegations  made  by  a 
member of the care staff, that some statements provided by care staff around the 
time of the fall were not a true reflection of the incident.  These allegations were 
reported to the Registered Provider who then made a safeguarding referral to the 
Local Authority and a police investigation ensued.  It was during the course of the 
police investigation that the Registered Provider made CQC aware that Mr Harris 
had passed away in hospital on 3 April 2017 and his death had been referred to 
the Coroner’s Court. In light of the police investigation and additional information 

20170818 Reg 28 Response v5 

 
 
 
 
 
 
 the CQC had received, we revisited our assessment process.   As part of CQC’s 
assessment of risk the decision was made to wait for the outcome of the Coroner 
and  police  investigations’  before  deciding  if  we  needed  to  take  civil  or  criminal 
action. 

Further,  in  light  of  the  additional  information  above  and  as  part  of  the  CQC 
assessment  of  risk,  a  decision  was  made  that  the  date  of  the  next  scheduled 
inspection  of  Cherry  Lodge  would  be  brought  forward.    A  comprehensive 
inspection (‘the inspection’) took place on the 15, 17 and 22 August 2017.  In line 
with  the  CQC’s  inspection  processes,  the  findings  of  this  inspection  will  be 
published  on  the  CQC  website.    The  official  rating  of  this  inspection  cannot  be 
publicly reported on until the CQC have completed the entire inspection process.  
This includes the Registered Provider being given the opportunity to respond and 
challenge any factual inaccuracies they deem to be in the report.’    

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

1.  At  the  time  of  Mr  James  Harris’  fall  one  of  the  carer’s, 

,  had 

not read his care plan or risk assessments: 

The  Registered  Provider  is  responsible  for  ensuring  care  staff  are  competent, 
skilled and experienced and that they are appropriately trained as is necessary 
to  enable  them  to  carry  out  their  duties,  (Regulation  12  the  Health  and  Social 
Care  Act  2008  (Regulated  Activities)  Regulations  2014).The  Registered 
Provider  has  the  responsibility  to  ensure  care  staff  follow  service  users  care 
plans, and to make staff aware of the importance of knowing how to effectively 
and safely support service users and the appropriate actions to take by following 
a service users care plan. If care staff fail to read care plans there is a risk that 
they  will  not  provide  the  care  that  is  appropriate  to  a  specific  service  user  and 
thus putting that service user’s safety at risk.  

A failure of staff to read care plans and risk assessments is an ongoing risk, as a 
Registered  Provider  cannot  guarantee  that  even  if  care  staff  are  given 
appropriate  time  to  read  risk  assessments  and  care  plans,  that  they  will  then 
provide  care  in  line  with  these  documents.  However,  the  level  of  risk  can  be 
reduced if the Registered Provider has sufficient monitoring processes in place, 
such as regular spot checks, supervision and training.  

During the inspection, CQC inspectors spoke with seven members of care staff 
and noted that all seven possessed the requisite skills to perform their roles.  All 

20170818 Reg 28 Response v5 

 
 
 
 
 
 
 
 
   
 care staff we spoke with confirmed they had read service users care plans and 
risk assessments and that there were given ample opportunities to read them 

Following the inquest, CQC asked the Registered Provider what action they had 
taken.  The  Registered  Provider  informed  CQC  that  there  are  now  systems  in 
place  to  ensure  care  staff  read  care  plans  and  risk  assessments  of  service 
users.  The  Registered  Provider  ensures  that  staff  are  given  adequate  time  to 
read service users documents and care staff are required to  sign the signature 
sheets  on  each  of  the  care  plans  and  risk  assessments  to  confirm  they  have 
read  and  understood  these  documents.    CQC  checked  during  the  inspection 
visit and found these processes had been put in place to document when staff 
had read care plans and risk assessments .  Staff spoken with at the inspection, 
confirmed to us, they did read care plans and risk assessments and were given 
the opportunity to read them. 

2.  His care plan stipulated that he was at medium risk of falls and should be 
accompanied when mobilising yet he mobilised  to the bathroom from the 
lounge without assistance because the only member of staff present in the 
lounge  was  assigned  to  a  resident  requiring  one  to  one  observation  and 
therefore could not accompany Mr Harris. 

The  Registered  Provider  is  responsible  for  ensuring  sufficient  numbers  of 
suitably qualified, competent, skilled and experienced care staff are employed in 
order to minimise and reduce the risk of harm to service users, (Regulation 18 
the  Health  and  Social  Care  Act  2008  (Regulated  Activities) Regulations  2014).  
If there is a lack of care staff there is a risk that service users will not receive the 
level of support required to keep them safe from risk of harm.   

At the inspection CQC saw that there were sufficient numbers of staff during the 
day to support service users.  We discussed with the  Registered Provider how 
they  would  continue  to  ensure  this,  whereby  CQC  were  advised  they  used  an 
agency  with  regular  agency  staff  when  required.    We  were  also  provided  with 
evidence  that  the  Registered  Provider  had  an  ongoing  recruitment  drive  in 
progress to obtain more care staff.   

Following the inquest CQC asked the Registered Provider what action they had 
taken following the incident.  The Registered Provider advised that an additional 
shift had been created from 16.00hrs and 22.00hrs to provide additional support 
evening and night care workers.   At the inspection, we saw this was the case.  
In  addition,  the  Registered  Provider  also  informed  CQC  that  following  the 
inquest,  they  had  reviewed  their  initial  assessment  process  for  service  users 

20170818 Reg 28 Response v5 

 
 
 
 
 
 
 
 moving  into  the  home  on  a  short  or  long  term  basis.    Part  of  this  initial 
assessment  process  included  a  more  selective  approach  to  ensure  Cherry 
Lodge  had  appropriate  staffing  levels  and  staff  skill  mix  to  meet  service  users’ 
needs  safely  and  effectively.    The  responsibility  to  ensure  that  there  are 
sufficient  numbers  of  care  workers  available  at  all  times  to  support  service 
Provider. 
user’s 

Registered 

remains 

with 

the 

3.  Having  fallen  Mr  Harris  complained  of  pain  in  his  groin.  The  homes 
‘Protocol for all Falls’ included that if the resident complains of pain in any 
part of  the  body  following a  fall  they  ought  not  to  be  moved  and medical 
attention  should  be  sought.  Medical  attention  was  not  sought  and  Mr 
Harris  was  returned  to  his  room.  The  three  carers  who  gave  evidence  at 
 all gave 
the inquest 
evidence  that  they  have  not  seen  the  document  entitled  ‘Protocol  for  all 
Falls’ prior to Mr Harris’ fall on the 26 January 2017, although 
and 
 were not found to be credible witnesses, 
was credible. Evidence of police investigations identified that the Protocol 
ought to have been clearly available for staff around the home as a result 
incident. 
the  CQC 
of 

issues 

raised 

prior 

 and 

this 

by 

to 

, 

The  Registered Provider has  the  responsibility  to  ensure  care  staff  are familiar 
with  their  internal policies,  processes  and  procedures.    If  care  staff fail  to  read 
the Registered Provider’s policies and procedures, for example the falls policy, 
the  risk  of  harm  to  service  users  is  increased  because  care  staff  may  not  be 
aware of what to do in the event of a fall and who they should contact.    

This  is  an  ongoing  risk  as  a  Registered  Provider  cannot  guarantee  that  care 
staff  do  read  and  understand  their  policies,  even  if  care  staff  sign  to  say  they 
have read and understood the policies.  This level of risk can be reduced if the 
Registered Provider has sufficient support mechanisms in place, such as regular 
supervision  and  training  to  ensure  care  staff knowledge  is up  to  date  and  care 
staff have a clear understanding about the actions they are expected to take in 
the  event  of  an  emergency.  It  is  important  to  note  that  care  staff  also  have  an 
individual responsibility to make sure that if they do not understand a policy this 
is  brought  to  the  attention  of  the  Registered  Provider  so  the  policy  can  be 
explained to them.   

During  the  inspection  we  asked  the  Registered  Provider  what  action  they  had 
taken in relation to Cherry Lodge’s falls policy and ensuring staff reviewed and 
understood  this.  The  two  care  staff  members  (
) 
had  been  disciplined  following  the  provider’s  internal  investigation  into  their 

20170818 Reg 28 Response v5 

 
 
 
 
 
 
 
 
 failure  to  follow  protocol  and  were  both  subsequently  dismissed  for  gross 
misconduct. 

Further at the inspection, each member of care staff that CQC spoke with was 
able to explain, in detail the protocol in the event of a service user having a fall.  
We saw evidence of the falls protocol being displayed in the staff room, the main 
office, a copy appeared in each staff members personnel file and each staff 
member had signed their own copies to confirm that they had read and 
understood their responsibilities in relation to this protocol. As mentioned above, 
during the inspection CQC inspectors noted that staff had received training in 
relation the falls policy and in moving and transferring people. In addition risk 
assessments for service users at high risk of falls had been reviewed and 
updated to reflect the falls protocol. 

4.  Mr  Harris  was  not  offered  any  analgesia  despite  his  reports  of  pain. 

Under  Regulation  12  of  the  Health  and  Social  Care  Act  2008  (Regulated 
Activities)  Regulations  2014  the  provider  must  ensure  that  service  users 
medicines  are  available  in  the  necessary  quantities  and  at  all  times  to  ensure 
that  the  risk  associated  with  medicines  not  been  administered  as  prescribed, 
this would include medicines available for pain relief.  

The  Registered  Provider  had  a  system  to  ensure  that  service  users  received 
their  prescribed  medication,  including  medicines  prescribed  on  an  as  required 
basis.  However,  individual  care  staff  had  not  followed  the  provider’s  protocol 
when Mr Harris complained of pain. The policy of the Cherry Lodge was not to 
offer or keep homely remedies on the premises.  This means,  if a service user 
required  pain  relief  not  already  prescribed  by  a  GP,  a  care  worker  cannot 
administer the medicine.  In such an event, the Registered Provider’s protocol is 
to call for assistance either through 111 or 999.  Cherry Lodge  is not a nursing 
home  and  as  such  care  staff  do  not have  the  necessary  clinical  skills to  make 
judgements  about  people’s  health,  or  the  risk  associated  with  administering 
medication that had not been prescribed. 

At the inspection CQC found that following the inquest the Registered Provider 
had taken steps to reinforce this protocol with all care staff and that a number of 
care workers had completed their basic life skills/first aid training.  Following the 
Registered  Provider’s  internal  investigation  into  the  incident,  the  two  care 
workers on duty at the time of Mr Harris’ fall were disciplined and dismissed for 
gross  misconduct. The  care  staff  we  spoke  with  at  the  inspection  all  explained 
the correct process to follow should a person, not prescribed pain relief, start to 
experience pain. 

20170818 Reg 28 Response v5 

 
 
 
 
 
   
 5.  Records  of  routine  checks  on residents are  not  made.  Therefore whilst it 
was asserted that Mr Harris was checked hourly throughout following the 
fall  there  is  no  evidence  that  the  checks  were  carried  out,  by  whom  and 
what was found. 

The Registered Provider has a duty to ensure processes are followed to protect 
service users from the risk of harm, which includes monitoring the checks made 
on  service  users  were  conducted  and  reviewing  the  records  of  these  checks.  
The  care  staff  at  Cherry  Lodge  were  aware  that  they  should  have  recorded 
when checks were made on Mr Harris.  However, the Registered Provider has 
the  overall  responsibility  to  ensure  there  are  appropriate  processes  in  place 
which  should  ensure  regular  monitoring  checks  are  made  on  people  and 
accurately recorded. 

At the inspection we asked the Registered Provider what action they had taken 
following the incident.  The internal investigation had found the care workers had 
not  followed  the  processes  that  were  in  place  at  the  time,  and  had  been  later 
dismissed for gross misconduct.  Since the incident the Registered Manager has 
re-introduced  night  spot  checks  which  will  take  effect  from  September  2017.  
The  spot  checks  will  be  unannounced  and  will  be  conducted  by  the  manager 
and  deputy  manager,  and  will  include  checking  to  ensure  care  staff  are 
accurately  recording  when  service  users  are  monitored,  including  the  time  and 
details  of  the  check.    The  responsibility  to  ensure  that  the  service  has  the 
appropriate  checks  and  processes  in  place  remains  with  the  Registered 
Provider.  

At  the  inspection  all  of  the  care  workers  informed  CQC  that  they  did  conduct 
checks  on  service  users  regularly  to  ensure  they  remained  safe  and  that 
appropriate records of these checks were kept.   

6. The  home  is  currently  without  a  registered  manager  and  has  been  for 

sometime. 

A  Registered  Manager  is  essential  in  providing  staff  with  leadership,  guidance 
and  support;  hence  it  is  a  condition  of  the  registered  provider’s  registration  that 
they have a Registered Manager in post.   

The  previous  Registered  Manager  commenced  employment  at  Cherry  Lodge  in 
July 2016; suffered a period of sickness in December 2016 and returned to work 
in January 2017. However, the Registered Manager later resigned in May 2017. 

20170818 Reg 28 Response v5 

 
 
  
 
 
 
 
 
 The Registered Provider made attempts to recruit a Registered Manager and an 
offer was made to one applicant to start in June 2017 but they then later declined.  
At the inspection it was confirmed that a new manager had been in post at Cherry 
Lodge since 14 July 2017, and CQC were advised that they were in the process 
of applying for registration.  CQC will monitor this application and the provider has 
been  made  aware  that  failure  to  have  a  registered  manager  places  them  in 
breach of their registration and could result in criminal enforcement action.  

Should  you  require  any  further information  please do  not hesitate  to  contact me 
on Tel:

Yours sincerely 

Head of Inspection  
Adult Social Care Directorate  

“Guidance for providers on meeting the regulations. Health and Social Care Act 
2008 (Regulated Activities) Regulations 2014(Part 3) (as amended) 
Care Quality Commission (Registration) Regulations 2009) (Part 4) (as 
amended)” 

This  document  sets  out  our  guidance  to  providers  on  meeting  all  of  the  HSCA 
regulated activity regulations. 

Enforcement Policy 

20170818 Reg 28 Response v5