Sidney Baker

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 
Fax: 03000 616171 

www.cqc.org.uk 

Coroner’s Office 
Greater Manchester West 
First Floor 
Paderborn House 
Howell Croft North 
Bolton 
BL1 1QY 

03/01/2020 

Care Quality Commission 
Our Reference: MRR1-8002398689  

Dear HM Senior Coroner 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Mr 
Sidney Clarence BAKER 

Thank you for sending CQC a copy of the prevention of future death report 
issued following the inquest touching on the death of Mr Sidney Baker. 

As you are aware the CQC local inspection team were not in attendance at the 
Inquest. To respond to the points you have raised in your report, we have 
reviewed your report, the information we held and have completed an inspection 
of the service in response. 

This response relates specifically to the points raised in your report. 

1.  There were no contemporaneous documents that dieticians or falls team 

referral had been made by the care home personnel in question. 

A comprehensive inspection of Barley Brook was carried out on the 8 and 9 
January 2020. As part of the inspection, we looked at people deemed at risk of 
malnutrition, or who had suffered unplanned weight loss and those at risk of falls. 
We noted appropriate referrals had been made to dieticians and the falls team as 
necessary. It was noted some referrals made had not been necessary, but had 
been completed as a precautionary measure, so professionals could make a 
determination about actions required, rather than the home. For example, despite 
unplanned weight loss, one person was rated as ‘low’ risk on the Malnutrition 
Universal Scoring Tool (MUST) and their BMI indicated they were obese, 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 however a referral had been made. This had been declined by the dietician for 
the aforementioned reasons.  

Based on the evidence noted during the inspection, processes were now in place 
and being followed to make timely referrals to professional as required. 

2.  There were concerns entries contained in Mr Baker’s care plan were 

incorrect, including vital information contained on his weight monitoring 
sheet. Furthermore, the general quality of record keeping was poor. 

As part of the inspection we reviewed the electronic care records of six people, 
all of whom had nutritional needs. We found people’s care plans and 
assessments contained varying amounts of out of date, contradictory or 
incomplete information. Overall, people’s needs had been captured, however 
care plans had not been clearly written, out of date information had not been 
removed timely, which meant information provided was contradictory. For 
example, one care plan stated a person ate a well balanced diet, had three meals 
a day, with pudding after lunch and tea, however also stated they had a very poor 
appetite. 

Documentation did indicate how often people required to be weighed, based on 
their MUST score and risk assessment and this guidance had been followed. 
Where any issues had been noted, action had been taken, including referrals to 
dieticians. 

We also identified issues with contemporaneous records relating to people’s 
personal care needs. Based on the records available, it was not possible to 
confirm people’s hair, nail and oral care needs had been met consistently, as 
these sections of the monitoring form had not been initialled by staff as 
completed. 

Audits and quality monitoring processes completed within the home and at 
provider level had failed to identify the record keeping concerns we noted. 

3.  I request you undertake a review to ensure staff receive the appropriate 

training on the issues identified above. 

As part of the inspection, we looked at staff training and support. A new training 
provider had been sourced and face to face training sessions were being 
arranged for all staff, to ensure they had the necessary knowledge and skills to 
carry out their roles safely and effectively. However, this had only recently been 
introduced which meant a large number of staff’s training was out of date. Overall 
training compliance within the home was at 67%.  

In accordance with CQC’s regulatory remit, we will be highlighting three possible 
breaches of the Health and Social Care Act 2008 (Regulated Activities) 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Regulations 2014 to the provider. These potential breaches relate to issues 
identified with record keeping, staff training and support and the providers quality 
monitoring processes. 

We will also be highlighting three possible breaches of the CQC Registration 
Regulations 2009. These potential breaches relate to failure(s) to submit 
notifications of incidents to the CQC without delay, in line with the above 
Regulations. The CQC will investigate these incidents and consider whether it is 
appropriate to take any enforcement action in relation to them.  

We will carry out a further comprehensive inspection within 12 months, to ensure 
action has been taken and the provider is no longer in breach. Should this not be 
the case, we will consider further regulatory action. 

Finally,  our  records  show  we  were  not  notified  of  this  death  by  the  registered 
provider, as was legally required. This failure to report has been raised with the 
provider and we will consider whether criminal enforcement action is appropriate.  

Should you require any further information then please do not hesitate to get in 
touch. 

By email: 

By post: 

CQCInquestsandCoroners1@cqc.org.uk 

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Please include the reference number MRR1-8002398689. 

Yours sincerely 

Paul Wharton 
Compliance Inspector 

3

Coroner’s Action and Review Plan
Name of Home: Barley Brook_ Date: _05.12.2019___
Name of Resident: __Sidney Baker D.O.B__23.06.1928__________
Reason for Action to be Taken Summary of Action and Outcome
Summary of what happened
Point 1 – The home has in place Accidents and Incidents file which includes Falls and near misses. The file also
In light of the Coroners report into the death of Mr has an Action and Review with specific outcomes. The information within the file links in with Caredocs and
Sydney Baker, the areas highlighted from the report are the individuals care plan.
as follows have been followed up through a summary Once a fall has been logged (Depending of the severity), The home will follow the Local Authority Triage
and action plan. system (which notifications are located in the Managers office and the Communication Book), in other cases
symptoms of UTI are tested, a referral is done to the Physio and Moving and handling team (Falls Team). In
1. There were no contemporaneous documents that addition, families are contacted and kept up to date of the process.
a dietician or falls team referral had been made In addition, the Incidents are recorded within the file, and if necessary and where applicable notifications are
by the care home personnel in question. done to both the Safeguarding team and the CQC.
The Accidents and Incidents are monitored on a weekly basis by the Home Manager / Deputy Manager, and
2. There Were concerns that entries contained in additionally, as a Regional Manager I conduct a Monthly Home audit which includes overview of the
Mr Baker’s care plan were incorrect, including Accidents, Incidents and Safeguarding files.
vital information contained on his weight As a company we have Falls and Manual Handling training which is done both online and Face to Face by an
monitoring sheet. Furthermore, the general external provider. The Home also links in with Local Authority Tier Safeguarding training.
quality of record keeping was poor.
Point 2 – The home has in place Monthly Weights and Loss action file which identifies any residents currently
on weekly weights, this system links in with the Caredocs and Care plans. The weights are done and recorded
within a weights file which is kept up to date on a weekly/monthly basis by the Manager / Deputy Manager
and If a resident starts to lose weight, it is immediately highlighted and actioned. The information from this
file is then transferred over to the monthly audit file with Actions taken.
Referrals to Dietician and GP, and if necessary, SALT team. Families are notified and kept up to date with on‐
going progress. All the information is updated within the care plans which also include fluid charts and food
plans. Additionally, Anne‐Marie Peters (Compliance officer for Wigan Council) undertakes rigorous checks on
these areas on a monthly basis.
The Weights and loss file is monitored and audited on a weekly basis by the Home Manager / Deputy
Manager, in addition, as a Regional Manager I conduct a Monthly Home audit which includes an overview of
Coroner’s Action and Review Plan
Name of Home: Barley Brook_ Date: _05.12.2019___
Name of Resident: __Sidney Baker D.O.B__23.06.1928__________
the Weights and loss file as well as cross referencing care plan information to ensure the relevant data
matches.
The Homes training programme for staff include Fluids and Nutrition. In addition, we have recently taken on
board a new Training provider called QTA who will be providing SALT and MUST training.
All staff within Barley Brook undertake both online and face to face training to ensure the safe delivery of
care of which also includes the specific training on Manual Handling, Falls, and Person‐centred Care.
There are Rigorous auditing systems in place which cover all areas of the home to ensure that residents are
safe from Harm.
Care Plans on the Caredocs system are person centred and identify each individual need in order to meet the
care delivered. Care Plan Audits are conducted by the Home Manager. In addition, during my Regional
Managers visit on a monthly basis, I undertake care plan audits. As a Regional Manager I also have full access
to the Caredocs cloud system which allows me to have access all residents care plans within each of the
homes.
Resident Assessments are also done prior to admission by the trusted assessor to ensure the appropriateness
of a placement. This ensures that the Home can meet the needs of everyone that comes into the home.
Moving forward we will continue to ensure that we monitor all the current systems in place and ensure that
our residents remain safe from harm.
We take on board the recommendations and will ensure that all staff and Management remain vigilant in
their Care Delivery.
Name of Person Completing: Cos Zinonos
Job Title: Regional Manager – Rosewood Healthcare Group
Signed:

Ms Rachel Syed 
HM Assistant Coroner,  
Manchester West 
HM Coroners Court  
Paderborn House 
Howell Croft North 
Bolton 
BL1 1QY 

Our reference:  SBaker/R28 
Your reference:  RRS/SBR/S.BAKER 
Please ask for: 
Extension: 
Direct line: 
Date: 

Joanne Willmott 
89451 
01942 489451 
27th January 2020 

Dear Ms Rachel Syed  

Sydney Baker - Deceased 

I write to you in response to your correspondence dated the 2nd December 2019 regarding 
Sidney Baker – Deceased, and the enclosed Regulation 28 report to prevent future deaths. 

Sidney Baker was a resident at Barley Brook, a residential care home delivered by the 
provider Rosewood Healthcare Group. Wigan Council purchase services from the provider 
on a spot purchase arrangement.  

Wigan Council is responsible for quality assuring the care homes delivering services within 
the Wigan borough. The Council has a team of Quality Performance Officers who perform 
proactive visits to services, which can be either announced or unannounced. They will also 
investigate any complaints and support any Section 42 safeguarding enquiries. 

The concerns identified in your Regulation 28 report closely reflect concerns highlighted 
and addressed during the Section 42 safeguarding enquiry and subsequent case 
conference. This being the case I would like to demonstrate that Wigan Council have acted 
in accordance with the Care Act 2014 to support the provider in making necessary 
changes. 

On the 12th August 2019 a case conference took place following the Section 42 
safeguarding enquiry. The outcome of this case conference resulted in the development of 
a protection plan which clearly defined Wigan Councils expectations regarding several 
aspects of the service delivery at Barley Brook, including those raised within the Regulation 
28 report. Wigan Council have monitored the service delivery against the documented 
actions to ensure that the concerns have been addressed.  

We write to assure you that such changes have led to improvements within the provider’s 
service resulting in better care and support and contemporaneous record keeping. 

Please reply to:   Joanne Willmott 
People Directorate: Children, Adults and Families,  
Wigan Life Centre, PO Box 100, WN1 3DS 
Phone: 01942 489454 
E-mail:  j.willmott@wigan.gov.uk  
 www.wigan.gov.uk   

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Between the 11th July 2019 and 16th January 2020, a total of 9 monitoring and support visits 
have taken place at Barley Brook. This involves the Quality Performance Officers from 
Wigan Council visiting the service and scrutinising service delivery and making 
recommendations to ensure that the service is not only compliant with the Care Quality 
Commissions regulations but that best practice and innovation is instilled into all areas. 

The concerns raised in the Regulation 28 Report are as follows: 

Concern 1:  There were no contemporaneous documents that a Dieticians or a Falls Team 
referral had been made by the Care Home personnel in question. 

Concern2:   There were concerns that entries contained in Mr Bakers care plan were 

incorrect, including vital information contained on his weight monitoring sheet. 
Furthermore, the general quality of record keeping was poor. 

We can confirm that the following actions have been taken to address both concerns as 
follows: 

Council’s considerations and investigation: 
Following Mr Baker’s death, several monitoring and support visits took place at Barely 
Brook. We considered a sample of referrals that had been made in respect of current 
residents. Wigan Council can confirm that the recording of referrals of any kind (including 
dietician and falls team, and referrals to the Later Life and Memory Team) has improved. 
Barley Brook has demonstrated they are now keeping contemporaneous records and 
documentation. 

Body map charts are now included in residents’ rooms to complete should an incident 
occur. This ensures body maps are contemporaneous and not completed retrospectively. 

Sending referrals via fax: 
Where a referral is sent via fax, the referral form is signed and dated at the point of 
submission. Following this a phone call is made to ensure that it has been received by the 
intended recipient. A copy is held on the individuals file and the action of a referral being 
made is appropriately documented in the persons health professionals log within the Care 
Docs system at the time the referral is confirmed as being received. It is the dietician 
service that requires referrals to come through via fax. Other supporting health services will 
accept referrals via email, in these instances a copy of the referral is printed off and held on 
the individuals care file and is complimented by adding to the the individual’s health 
professionals log.   

Such actions ensure a comprehensive chronological log of all health professional liaison 
and interventions. The Care Docs system contains several filters that can be applied by the 
person using it. This functionality assists the Registered Manager, Regional Manager and 
provides the aligned Quality Performance Officer with a platform that is easy to review and 
audit.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Safeguarding referrals:  
The Registered Manager has become more proactive in ensuring safeguarding referrals are 
submitted to Wigan Council, which includes falls, both witnessed and unwitnessed. If a 
person has fallen, witnessed or unwitnessed and no injury has been sustained the provider 
is still required to submit a Tier Two referral to their Quality Performance Officer.  

A referral will detail what has happened, the initial response to the incident and the plans 
put in place to mitigate the chances of reoccurrence. The Quality Performance Officer will 
then respond to the referral with any recommendations and further actions and look at 
previous referrals to identify patterns or trends. The requirement to comply with this process 
has been reinforced with the manager at Barley Brook to ensure comprehensive and 
consistent implementation.  

Unfortunately, the process had not been followed in Mr Baker’s case but the above 
demonstrates that steps have been taken to ensure this omission does not occur again. 

Wigan Council have offered training to the provider to support with this process. The staff at 
Barley Brook are due to receive “Tier Training” from Wigan Council which all staff will be 
taking part in. This will assist the staff moving forward in ensuring that referrals are made in 
a timely manner and incidents are recorded contemporaneously on a resident’s records. 
Wigan Council will monitor attendance at the training and the impact that this has on 
practice.  

The Registered Manager has demonstrated that they undertake a monthly falls audit to 
identify trends and patterns across falls that have occurred. Her review considers the time 
of day the falls have taken place, the activity taking place at the time of fall and location. 
Following this audit, the Registered Manager will consider the actions required, which may 
include a referral to the falls team. 

I can confirm that since the 24th June 2019 to present a total of seven referrals have been 
made specifically relating to falls which demonstrates the positive action taken and further 
understanding of the importance of record keeping.  

Weight monitoring and documentation: 
The Deputy Manager at Barley Brook is the person responsible for recording and 
documenting information regarding weight monitoring and management. All residents at 
Barley Brook are routinely weighed on a monthly basis. Weighing may take place more 
frequently if required by an individual’s care plan. The Registered Manager during a 
monthly audit routinely checks that weight monitoring is up to date and recorded 
appropriately. Documenting a new resident’s weight is also part of the admissions process. 
Should a person’s weight drop significantly, a referral will be made to the dietician team as 
appropriate when considering a resident’s MUST score. 

Wigan Council looked at a sample of care plans during support visits which took place on 
26.09.2019, 10.10.2019 and 16.01.2019.  Upon considering the plans, Wigan Council are 
satisfied that the provider uses the individual’s weight to inform their MUST score 
(Malnutrition Universal Screening Tool). This enables the Deputy Manager to identify and 
categorise a resident’s risk status as either low, medium or high. The Deputy Manager will 
make the necessary referrals and undertake the appropriate actions aligned to each score.  

The referral and documentation processes have improved. 

 
 
 
 
 
 
 
 
 
 After considering a sample of care files during support visits, Wigan Council can confirm 
that the provider has also undertaken other actions such as revised the supplementary care 
chart. This is used to monitor an individual’s food and fluid intake. The charts are completed 
first-hand by the care staff that have been supporting individuals with mealtimes and is 
completed after each meal to ensure that records are both factual and contemporaneous.   

The charts do not simply say ‘ate full meal’ or ‘drank two cups of tea’. It is specific in the 
amounts eaten and drank and includes guideline intake amounts. Other supplementary 
care charts have been reviewed also including but not exclusive to positional changes.  

The recording of any care delivery or significant events is now performed by the individuals 
delivering the care and support. Records are no longer solely updated by Senior Carers on 
site. This reduces the risk of inaccurate record keeping and ensures the recording of 
information is contemporaneous as the records are updated at the time incidents and 
events occur by the person who is witness to the event or incident.  

All care staff now have access to the online Care Docs system used by the service and 
each staff member has their own log in details. 

Entries are both digitally stamped with the persons log in ID, time and date.   

During Wigan Council’s support visits on 26.09.2019, 10.10.2019 and 16.01.2019, several 
care plans were analysed, and Wigan Council can confirm that record keeping has 
improved due to the above actions being taken and implemented. 

During our support visits to the service we have considered a sample of the monthly care 
plan audits performed by the Registered Manager. These audits show that weights are 
being monitored and recorded appropriately. The Regional Manager also audits a sample 
of care plan files during their monthly visits to the service. The above ensures a triple 
layered approach to quality assurance and scrutiny of practices within the service.  

Wigan Council consider that the above actions demonstrate the provider’s commitment to 
ensuring contemporaneous record keeping is consistent and care plans accurately reflect 
the care that an individual requires.  

Training: 
We visited the provider on 16 January 2020 and scrutinised the training programme at 
Barley Brook. Wigan Council recommended that the provider sources training for all staff in 
both effective record keeping and dementia and nutrition. Wigan Council consider that such 
training is necessary to ensure that all staff team members recognise the importance of 
good record keeping, their role within this and the what the consequences of poor record 
keeping can be. The training in relation to dementia and nutrition will provide staff with a 
deeper understanding in order to deliver a more person-centred service. The training will 
provide learning such as how dementia can affect a person intake including managing 
weight loss, changes in food taste and preferences that can occur and methods in which to 
increase a person’s intake. The response to these recommendations will be monitored by  
Wigan Council to measure the uptake and impact that learning has had on service user 
experiences.  

Conclusion 

 
 
 
 
 
 
 
 
 
 
 
 Moving forward Wigan Council will continue to monitor, support and constructively 
challenge the service delivery within Barley Brook to ensure that individuals residing within 
the services do not share the experiences of Mr. Sidney Baker.   

Specifically, we will continue to monitor the changes that have taken place as detailed 
above. This includes monitoring the effective record keeping and ensure that referrals made 
in a timely manner to supporting health professionals are effective.  

We will be coordinating bimonthly monitoring visits aligned with the visits of the Regional 
Manager for the next six months; this will ensure that the quality and positive steps taken 
continues. 

The Care Quality Commission have recently inspected the service. The inspection report 
has yet to be published but upon publication we will review its content and scale our 
support to the service accordingly.  

I have endeavoured to provide you with as much detail as possible regarding both actions 
already taken and actions to be performed moving forward but should you require any 
further information or have any questions regarding the above please do not hesitate to 
contact me.  

Yours sincerely 

Joanne Willmott 
Director of Homes and Communities 
Wigan Council