Arnold Ward

INVESTORS.
IN PEOPLE

Part of the
Olea

Care
Group

Group Olfice:

Olea Care Group
20 Torkington Road:
Hazel Grove
Stockport SK7 480
T; 01619470874
F: 01614199783
W: oleacare.ca.uk

Registered Office:
Olea Care ltd

2fa Church Lane
Marple

Stockport SK6 62E

Company Number:
3047704

_ Olea Care Ltd
oe gon Road

Hazel Grove
Stockport SK7 4RQ

Telephone: 0161 456 8322
Head Office: 0161947 0874

y IK livingatfernlea.co.uk
: Ll

Alison Mutch
HM Senior Coroner
1 Mount Talbot Street

SKTaAG 07 FEB 2020
23/01/2020 HM CORONER
Dear Ms Mutch MANCHESTER S

Re: Your ref: 12108/CH

(hereby acknowledge receipt of your letter and report dated 16/12/19.

Since the incident concerning AFW we have arranged for all our Registered Nurses to
undertake third party wound management refresher training (either through a certified tissue
viability course or the NHS “React to Red" training course). We have also extended this
training to our care staff and to date 87% of the care team have undertaken the “React to
Red” training recommended by the Local Authority. This training has now been implemented
into our induction program for all new staff.

After discussions with the NHS Tissue Viability Nurse (TVN) we have adopted the NHS
wound management document within our Quality Management System to ensure continuity
between ourselves and NHS professionals.

During the time of the incident with AFW, the TVNs were in the process of transferring
teferrais from fax to email. They have acknowledged that there was a number of issues
around that time with referrals and follow ups. We have since changed our processes to
ensure all referrals to the TVNs are via e-mail or telephone followed up by a summary e-
mail. All referrals are followed up by a phone call the day after irrespective of urgency status
and prompts are placed in the diary and on a referral audit sheet for the care management
team to follow up.

After discussions with the GP it has been agreed that we will notify the GP of all referrals to
the TVN and wound management will form part of the weekly GP ward-round.

As part of our continual improvement strategy, the group has taken the decision to move
forward with the implementation of an electronic care planning system that uploads
information and photographs in real time. This will improve oversight and auditing and will
further improve our wound management processes.

For your information the Registered Nurses involved in this issue are no longer employed by
Olea Care Ltd.

If you require any further information, please do not hesitate to contact me.
Yours sincerely

_— —

eecVeeeveeneeeeee ba
where vou choose how to live vour life

NHS

Stockport

Clinical Commissioning Group

4th Floor
Stopford House
Piccadilly
Stockport
SK1 3XE

Tel: 0161 426 9900
www.stockportecg.nhs.uk

Your ref: 12108/CH
Our ref: STOCCG/SM

29 January 2020

Private & Confidential
Alison Mutch

HM Senior Coroner

1 Mount Talbot Street
Stockport

SK1 3AG

Dear Ms. Mutch,
Regulation 28 Report re: Arnold Fletcher Ward

| refer to your letter dated 16 December 2019 and acknowledge receipt of the Regulation 28
report in relation to this case.

Stockport Clinical Commissioning Group (CCG) commissions nursing care from nursing
homes in Stockport through a standard NHS contract. The contract sets out the required
operational standards; Schedule 6c of the contract refers specifically to pressure ulcers under
incident reporting procedures in addition to the local quality requirements.

The CCG, through these contractual arrangements, and through its quality and safeguarding
functions, has quality monitoring processes in place, which include serious incident reporting
systems and improvement monitoring. All investigations into serious incidents are quality
assured by the CCG to ensure that necessary actions are identified and implemented.

In considering this case you highlighted the following areas of concern:-

e Documentation in relation to the pressure ulcer failed to reflect the deterioration

e Delay in escalation to the specialist Tissue Viability Nursing Team despite clear signs
of deterioration

« Photographs were not used to track and document the progress of the pressure ulcer

e No evidence of a robust system to track the status of a referral to the Tissue Viability
Nursing Team

Actions Taken

e Record Keeping Review in response to the issue that documentation in relation
to the pressure ulcer failed to reflect the deterioration, and that photographs
were not used to track the progress.

From a review of this case it is clear that record keeping was not of the standard | would
expect. | can confirm that staff at Fernlea Nursing Home now use photographs to track and
monitor pressure ulcer development. Initial photographs are taken once a pressure ulcer is
identified and the photographs are stored electronically on the nursing home system. Further
photographs are then taken on a regular basis to allow comparison and highlight deterioration
at an early stage. As a general rule photographs are taken every 2-4 weeks in line with
individual Risk Assessments and Care Plans. In circumstances where a significant change is
noted photographs are taken more frequently and referrals managed appropriately.

| am pleased to note that the nursing home has now adopted the Stockport NHS Foundation
Trust pressure ulcer monitoring form to ensure consistent and regular monitoring of pressure
ulcers.

Whilst this investigation has focused on an individual nursing home case, as the
commissioner of services for the Stockport population we re-issued the pressure ulcer case
review template to all Stockport Nursing Home Managers. The proforma asks the reporter to
consider safeguarding concerns and develop an Action Plan. The form is reviewed by the
CCG's Designated Nurse Safeguarding Adults and Quality Improvement Nurses. Cases can
then be escalated as a safeguarding concern (if not already raised) or discussed with the
quality team to determine if more targeted support such as ‘React to Red’ (pressure ulcer
prevention initiative) training is required.

e Registration Requirements in response to the issue that documentation in
relation to the pressure ulcer failed to reflect the deterioration

Registered nurses, midwives and nursing associates must comply with the Nursing and
Midwifery Council's professional standards that apply within their professional scope of
practice, which includes communicating effectively, keeping clear and accurate records
relevant to their practice. The CCG’s Designated Nurse Safeguarding Adults has developed
a two page guide to effective record keeping. This document was emailed to all Stockport
Nursing Home Managers on 24 January 2020.

The CCG/SMBC Quality Improvement Nurse is also going to share the guide and present it at
the Care Homes Forum in May 2020.

e Refresh of the requirements of the referral to Tissue Viability service process in
response to the issues of the delay in escalation to the specialist Tissue Viability
Nursing Team despite clear signs of deterioration, and No evidence of a robust
system to track the status of a referral to the Tissue Viability Nursing Team

The process of referral to the Tissue Viability Nursing has been reviewed and has now been
changed; Referrals to the tissue viability service are no longer submitted via fax. The referral
form now includes a prompt for nursing home staff to follow up any referral which is not
actioned within 2 working days.

It is now standard practice for Fernlea nursing home to ensure a read receipt is requested so
that the referring home can check to ensure that the e mail has been accessed / read by the
Tissue Viability Team. In addition a follow up telephone call is made to the service the
following day, irrespective of the pressure ulcer urgency status; during this call the date for a
visit from the team is confirmed and added to the nursing home diary.

The Quality Improvement Nurse is monitoring that this change remains embedded as part of
routine practice. | |

In addition, please note the additional actions to underpin the above changes

e React to Red Training
A training programme has been developed and rolled out across the Stockport Care Home
community. The training includes the nationally NHS recognised React to Red training for
pressure ulcer prevention within a care home environment. The training commenced in 2018
and | can confirm that since that time a total of 184 individuals from Stockport care homes
and domiciliary care agency have undergone this training.
In relation to Fernlea Nursing Home | can confirm that the home currently employs 4
registered nurses, all of whom have attended either React to Red or an alternative advanced
wound care training courses.

e Development of Nursing /Care Home Pathways

The Quality Improvement Nurse is also working with the Tissue Viability Nursing Service at
Stockport NHS Foundation Trust to develop a number of pathways for care homes.

e Escalation Processes
Any serious or thematic quality concerns relating to pressure ulcers are now escalated and
discussed at the Multi agency Quality Issues and Concerns meeting attended by members of
the CCG, SMBC, Public Health and CQC.

After reviewing the completed actions, | am satisfied that appropriate steps have been taken
in response to your findings.

If you require any further information please do not hesitate to contact me.

Yours sincerely

Case

Accountable Officer

Care Quality

Aaa HSCA Further Information
Commission Citygate

Gallowgate
Newcastle upon Tyne
NE1 4PA

| Telephone: 03000 616141
Alison Mutch OBE Fax: 03000 616171

HM Senior Coroner

HM Coroner Manchester South
Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

7 February 2020

Care Quality Commission
Our Reference: MRR1-8119778830

Dear HM Senior Coroner

Prevention of future death report following inquest into the death of Mr
Arnold Fletcher Ward

Thank you for the prevention of future deaths (Regulation 28) report issued
following the Inquest touching on the sad death of Mr. Arnold Fletcher
Ward.

We note the legal requirement upon Fernlea Care Home and the Care Quality
Commission to respond to your report within 56 days.

The registered providers of Fernlea Care Home are Olea Care Limited.

The provider location registered with CQC is located at 20 Torkington Road,
Hazel Grove, Stockport, SK7 4RQ. The provider is registered for the following
regulated activities:

Accommodation for persons who require nursing or personal care
Treatment of disease, disorder or injury

The role of the CQC & Inspection methodology

The role of the Care Quality Commission (CQC) as an independent
regulator is to register health and adult social care service providers in
England and to inspect whether or not the fundamental standards are being
met.

Our current regulatory approach involves inspectors considering five key
questions. They ask if services are Safe; Effective; Caring; Responsive;
and Well Led. Inspectors use a series of key lines of enquiry (KLOEs) and
prompts to seek and corroborate evidence and reassurance of how the
provider performs against characteristics of ratings and how risks to people
are identified, assessed and mitigated. Sources of evidence for the KLOEs
can be found on our website along with our KLOEs and characteristics of
ratings.

The regulatory framework includes providers being required to meet
fundamental standards of care, standards below which care must never fall.
We provide guidance to providers on how they can meet these standards
(Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014).

Fernlea Care Home was inspected by CQC on 13 May 2019 and the
comprehensive inspection report was published on 5 June 2019. The provider was
rated Good overall across all our five domains; Safe, Effective, Caring, Responsive
and Well Led.

Since the last inspection in May 2019 CQC had not received any information of
serious concern in relation to this care home and the next comprehensive
inspection was scheduled for December 2021. At the time of the inspection CQC
was not aware of the circumstances of Mr Ward's case or subsequent death.

This response relates to the concerns expressed in your report that:

e Within the home the forms used did not capture the deterioration of the
pressure ulcer or require detailed monitoring/use of photographs to track
its progress. This meant that the significant and steep deterioration was
not recognised and escalated at an early opportunity to the Tissue Viability
nursing team for expert wound management input. As a result the type of
wound dressings Mr Ward required were not utilised/available.

e \thad been captured in the notes that there had been a referral to the
Tissue Viability Nursing team in October 2018. There was no system in
the home to chase up the team after a number of weeks had elapsed and
there had been no response. The inquest heard that even in non-urgent
cases the Tissue Viability Nursing team would contact a home requesting
support in at least 10 days and more quickly in an urgent case.

The matters of concerns which arose from the preventing future deaths report were
reviewed by CQC and a decision was made to undertake an unannounced,
focused inspection of the Fernlea Care Home. This was because the concerns
indicated that the registered provider may have been/may still be in breach of the
following fundamental standards:

Regulation 12 (1) Care and treatment must be provided in a safe way for service
users

Regulation 17 (1) Systems or processes must be established and operated
effectively to ensure compliance with the requirements in this Part (Part 3 of the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).

The inspection commenced on the 27 January 2020. The inspection team
consisted of an inspection manager and a lead inspector. The inspection was
focused on two specific key questions; Is the service effective? and Is the service
Well Led? Within the context of each domain our inspection team focused on the
specific areas of concern raised in the report. We particularly looked at people’s
pressure ulcer management and management oversight of the home.

In addition, the registered provider had not submitted a statutory notification to us
in respect of Mr Ward’s pressure ulcer, as required under Regulation 18(2) of the
Care Quality Commission (Registration) Regulations 2009. Failure to notify is a
statutory offence and we looked at whether there were other incidents that had
occurred where the registered provider had failed to notify us. We will consider
further enforcement action regarding this matter in due course.

Initial findings from the inspection have been fed back informaily to the registered
manager. Whilst the inspection team could see that some measures had been put
in place to mitigate future risks to people using the service, we were not satisfied
at this stage that the systems were sufficiently robust. The inspection further
highlighted some additional lines of enquiry and following further management
reviews on 28 January and 4 February 2020 a decision was made to extend our
initial focussed inspection into a full comprehensive inspection. On completion of
the inspection we will review the evidence and if we identify breaches in the
regulations we will take appropriate and proportionate action in line with our
enforcement policy.

The inspection report will be published in due course and we are happy to provide
a copy of the report to HM Coroner.

Finally, CQC proposes to make further enquiries as to the circumstances of Mr
Ward's treatment prior to his death. As you are aware from 1% April 2015 the
Commission has lead responsibility for investigating and where appropriate
prosecuting breaches of fundamental care standards contained within the Health
and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes

a failure to provide safe care or treatment resulting in avoidable harm or a
significant risk of exposure to avoidable harm.

If you have any further questions or require further information please do not
hesitate to contact us quoting the reference| number MRR1-8119778830

Yours sincerely

= 5 =

Adult Social Care North West,