James Delaney

Crystal Care Norfolk £ “

Wesley Greqo- OQ 7 Grefo- - Directors Crstal Care

The Ol Sawmill, 8 Town Corner, Hesinghan, Norwich, Norfolk NRIO SLZ.

T OU03 (S487 Meo OPKO3 063550 E: directors@erestal care. cbsuh

FAO: Jacqueline Lake, Senior Coroner Date: 07.08.2019
Coroners Service

Norfolk Coroners Court

Carrow House

301 King Street 8 AUG 2019

Norwich

NR1 2TN

Dear Mrs Lake

Your Insured Crystal Care ta Sapphire House Care Home
Inquest into the Death of James Delaney

| write to respond on behalf of Crystal Care (the Company") and Sapphire House ("the Home") to
the Regulation 28 report issued on 25 June 2019 following the inquest into the death of Mr James
Owen Delaney ("Mr Delaney"). The Company has carefully considered the report and the concerns
contained therein.

The company takes its responsibility regarding the care and health and safety of their service users
very seriously and were devastated to hear of the tragic death of Mr Delaney. We wish to offer our
sincere condolences, through your office, to the family and friends of Mr Delaney.

We address each matter of concern in order:

1. There are several general policies and procedures in place and individual documents relating
to service users. Whilst staff are now given ring-fenced time to read and understand those
documents on entering the home, the evidence is that the time is not set aside to refresh
themselves at regular intervals with regard to this information.

Due to the nature of the work carried out by the Company it is important that staff consider a
variety of information which is contained in the policy and procedure documents, and staff
handbooks. The Company have introduced a procedure by which staff are required to re-read
policies every six months of their employment.

The time allocated for staff to re-read and refresh policies is discussed with their Manager and
the timescale for completion is agreed during their supervision meetings. Each Manager will
allocate a specific date and time for this to take place and this will be transferred to the rota for
the specific home to ensure all staff on duty are aware that a specific staff member has an
allocated task and time set aside to achieve that task. The rotas have specific sections which
highlight daily activity, appointments, events and training. Managers check the staff signature
sheets on the policy/procedure documents after the allocated time to ensure the re-reading
has been actioned. The documents require staff to sign a signature list to confirm the date
they have read the policy.

Each home has a handbook for the following categories which contain policy and procedures
relating to that subject:

i. Service user handbook.
ii. Employee handbook.
ii. Health and safety handbook.

Each handbook now has a front sheet which highlights that staff are required to reread and
sign each policy and procedure to confirm their understanding on a six monthly basis. A copy
of the handbook front sheet for the health and safety handbook is attached herein for the
Coroner's consideration.

The policies are located in the staff office which is accessible to all staff and staff are
encouraged to refer to the policies and procedures throughout their employment in the event
they have any queries.

The procedures are also reviewed on an annual basis by the management team. In the event
that procedures are updated or amended, support workers are again required to reread these
policies meaning that there will be instances where support workers read policies more
regularly than six monthly.

2. The medication policy covering all medication, all service users, all homes within the Crystal
Care umbrella organisation provides a GP should be called if medication is not taken for 24
hours. Sapphire House staff have been sent an email requiring them to call a GP should a
service user refuse one dose of medication. This is not standard procedure across all homes
and could lead to confusion, particularly should staff transfer between homes and on new staff
joining who may not have access to the email.

The company has separated this concern into three sections in the hope it will assist:

i. The medication policy states that a GP should be called if medication is not taken for 24
hours.

On hearing the evidence of J during the inquest, she suggested that for specific conditions,
such as diabetes, she would expect to be informed within a 24 hour period. The Company has
subsequently amended the company wide medication policy to reflect the evidence a

A copy of the section relating to refusal of medication (section 33.12) is attached to this response for
the Coroner's consideration. The company wide medication policy now draws a distinction between
missed or refused medication for prescribed specific medical conditions such as epilepsy, diabetes
and angina against other more generic medication such as painkillers.

The company wide policy is now as follows:

If a service user refuses medication prescribed for a specific medical condition such as epilepsy,
diabetes, angina a staff member must contact 111 for advice after the first refusal. If there is a
deterioration in the service user's physical presentation whilst waiting for advice from 111 (for
example, the service user is less responsive, lethargic has difficulty breathing, refuses to take fluids
or starts to convulse) the staff member must contact 999.

If the service user is diabetic and they start to vomit following refusal of medication the staff member
is to contact 999. If a service user is epileptic and they start to convulse following refusal of
medication the staff member is to contact 999. The staff member should administer emergency
PRN medications in line with prescribed instructions whilst waiting for the emergency response
team.

If a service user has refused medication that is not prescribed for a specific medical condition for a
period of 24 hours the GP must be informed regardless as to whether the service user presents as
being well. if the GP is not contactable due to the refusal happening out of hours staff must contact
111 for advice and follow the operator's directives.

The responsibility for contacting 111 following a service user's refusal to take medication will be that
of the staff member who attempted to administer the medication. Each shift has a designated senior
on shift who is responsible for overseeing that staff have followed procedure correctly.

The Company has also introduced quick reference reminders which are attached to the MAR sheet
for specific service users. Examples of the quick reference sheets are attached herein for the
Coroner's consideration. These quick reference sheets direct the support worker to the medication
policy in the event of refusal of medication. These reference sheets are used across the Company
within all homes.

ii The practice at Sapphire House is not standard practice across all homes.

The company wide procedure has now been amended to reflect the advice given by | Ee
the instruction that had been given to Sapphire House staff. It is now standard practice across all
homes that medical assistance is sought on first refusal for specific medical conditions and with
non-specific medical conditions that the service user is observed more closely following the initial
refusal of medication.

By rolling out a new policy across all homes the Company are satisfied that all homes are adopting
the same standard practice and there ought not to be confusion between instructions given by
management.

iii There could be confusion with staff who transfer between homes due to the non-standard
procedures.

It is necessary from time to time for staff to transfer between homes or for the home to take on
agency staff, although this is not the preferred choice given the complexities of the service users
within the Company's care.

The Company have now created a checklist for staff who are either transferring between homes or
are otherwise unfamiliar with the home that they would be working with, e.g. agency staff or staff
covering a shift.

Staff are required to consider the checklist ensuring that they have read necessary policies and
procedures specific to the home that they are working in. Support workers are allocated 30 minutes
at the start of a shift to read persona! pen pictures for each service user, the Company considers
this is sufficient time given the small size of the homes.

The checklist needs to be signed both by the staff member covering the shift and the line manager.
It is also necessary for a specific member of staff to be named as mentor to the transferred support
worker so they can refer any queries they may have whilst on shift.

As there are many policies and procedures that are standard across the homes, in the event of staff
transfer support workers are asked to confirm that they have read the policies and procedures in
their original home and if this is the case they are not required to reread them in the home they have
been transferred to. Staff are only expected to review policies and procedures that differ between
the homes; these would be the service user specific policies only.

The Company is satisfied that the transfer process will ensure that staff are familiar with the service
users they are working with and also ensure the safety of staff as well as service users in the event
of transfers, covering of shifts or use of agency staff.

The Company does not take this incident lightly and has worked tirelessly to ensure this never
happens again and will continue to do so. Mr Delaney was a well-liked resident at the home and is
sincerely missed by many staff.

We hope the above is of assistance and that it addresses all of the issues raised in the Coroner's
report.

OG ty

Jenny and Wesley Grego
Managing Directors, Crystal Care