John Gregory

Care  UK  also  has  "How  to  Guides",  supported  by  the  wheelchair  user  manual, 
specifically  in  relation  to  wheelchair  safety  guidance  and  transporting  a  person  in  a 
wheelchair.  Copies of these guides are attached.  These guides are accessible to all 
staff  within  Muriel  Street,  and  outline  the  safety  checks  that  must  be  undertaken  to 
ensure the safety of residents, including the use of footplates and safety belts.  

Notwithstanding  this,  since  Mr  Gregory's  sad  death,  Muriel  Street  has  reviewed  the 
manual  handling  training  provided.    Following  this,  it  was  identified  that  the  training 
surrounding the use of wheelchairs could be strengthened.  Consequently, the training 
has been improved, and the manual handling training now includes a specific section 
on  wheelchair  safety  guidance.    This  includes  highlighting  and  working  through  the 
"How  to  Guide  –  Wheelchair  safety  Guidance"  (copy  attached)  during  the  training 
session.    Due  to  the  current  pandemic,  and  the  consequent  restrictions  placed  upon 
the  ability  to  provide  group  training,  Muriel  Street  has  undertaken  1:1  supervision  / 
training sessions with all staff members in order to go through the how to guide, and 
ensure staff are familiar with the expectations set out therein.  Further, there is now a 
laminated copy of this guide at every nurse's station to ensure that the guide is easily 
accessible.  Additionally, where a resident's care plan requires the use of a wheelchair, 
a hard copy of the guide is placed into that resident's care plan folder in their room.  

Muriel Street has also increased staffing levels since this incident, and there is now an 
increased  senior  presence  on  each  floor  with  a  senior  manager  (Deputy  Manager, 
Clinical  Lead  or  Care  lead)  based  in  each  nursing  office  and  the  addition  of  a  team 
leader who supports to carry out regular walk arounds of their floor / unit.  The result of 
this  is  greater  oversight  of  staff  activities  and  monitoring  of  residents  to  ensure  that 
residents' needs and safety are maintained. 

Muriel  Street  also  undertakes  specific  welfare  checks  upon  residents  at  regular 
intervals  throughout  the  day.    Previously,  whilst  such  checks  would  have  been 
undertaken during the day as part of other care provision (e.g. during meal provision, 
or regular repositioning), there would be no separate documentation during daytimes.  
Having reviewed matters, since April 2020, in accordance with Care UK policy  Muriel 
Street  has  now  ensured  that  the  welfare  check  sheets  are  completed  during  the  day 
alongside the other documentation ie food and fluid charts, activities log books, turning 
charts  and  daily  notes  in  addition  to  at  night  where  they  were  previously  completed.  
The  documentation  is  kept  in  the  resident's  care  plan  folder  in  their  room,  (together 
with  a  sample  completed  form  to  assist  and  guide  staff  on  how  to  complete  this 
documentation) and is now regularly audited by the Home Manager who now as part of 
the daily checklist undertakes a random audit of documentation every day in order  to 
ensure  that  these  checks  are  being  undertaken,  residents  are  being  properly 
monitored and the documentation is being completed to the expected standard across 
the home (details of documentation training are outlined below) 

2.  Being found inadequately dressed shortly before his transfer to hospital. 

Care UK and Muriel Street take the safety, welfare and dignity of residents seriously.  
To  this  end,  there  are  a  number  of  systems,  policies  and  guides  which  govern  and 
guide  staff  in  this  respect    We  attach  a  number  of  policy  documents,  together  with 
"How to Guides" and "Ways of Working" documents in support. 

In  relation  to  a resident's  clothing,  an  inventory  of  a resident’s  clothes  is  taken  when 
they  are  admitted  into  the  care  home  and  then  all  of  the  clothes  are  individually 
labelled.  The laundry room has named trays for each resident so that the clothes are 
returned  to  the  correct  resident’s  room.    In  addition  to  the  above,  there  is  also  the 

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 “Resident of the Day” process whereby every month a resident's care is reviewed as a 
whole.    This  includes  the  checking  of  wardrobes  and clothing  labels  to ensure that  a 
resident's clothing is in order. 

In order to ensure that a resident's dignity is preserved, there are a number of policies 
and guides in place, all of which re-inforce the need to ensure that a resident's dignity 
is  respected  and  observed  at  all  times.    Part  of  this  is  to  ensure  a  resident  is 
appropriately dressed and personal care training extends to checking that the clothing 
belongs to the correct resident and is appropriate for the conditions.  Whilst every effort 
is  made  to  encourage  a resident  and to  engage  with them  in this  aspect  of  personal 
care, there are times when a resident may be non-compliant.  In such instances, the 
expectation  as  set  out  within  the  policies  is  that  this  is  clearly  documented  and 
depending  upon  the  nature  of  the  refusal,  escalated  to  senior  colleagues  or  external 
healthcare providers (e.g. the GP) as appropriate. 

Staff  are  provided  with  training  on  this  matter  during  the  two  week  induction  training 
course, the content of which is attached, which includes person centred care, privacy 
and dignity and the training compliance report previously referred to.  The competency 
sign off sheet for personal care is also attached. 

Since this incident, the requirement to ensure that resident's are appropriately dressed 
was  specifically  discussed  during  the  daily  "Take  10"  meetings  for  senior  staff,  and 
during handovers when  all other staff would attend.  During these meetings, posters, 
which are now placed in each resident's wardrobe, outlining examples ways in which a 
resident  may  wish  to  be  dressed  depending  upon  the  weather,  drawing  upon  the 
circumstances  of  Mr  Gregory  as  an  example  of  an  unacceptable  standard  of  care.  
Further, staff were reminded of the requirement to document any issues with clothing 
(e.g. non-compliance) within a resident's care plan file. 

It is the firm intention of Muriel Street that all staff will undergo a personal care training 
refresher  course  once  the  current  pandemic  and  consequent  lifting  on  restrictions 
allow. 

Finally, as outlined previously, Muriel Street now has increased staffing levels and an 
increased  senior  presence  on  each  floor  /  unit  with  regular  walk  arounds  by  senior 
team members to ensure that the high standards expected by Care UK are being met.  

3.  Being  found  in  an  unconscious  state  without  any  apparent  staff  support  or 

monitoring. 

The  welfare  and  safety  of  residents  in  the  foremost  priority  of  Care  UK  and  Muriel 
Street.  As outlined above, the documentation of separate and regular welfare checks 
during the day are now in place at Muriel Street.  In order to support staff in this regard, 
the  need for  separate  welfare  checks  was discussed  and explored  at  both  the  "Take 
10" and handover meetings to ensure that all staff are aware of this new requirement, 
what is expected and how to complete the documentation fully and accurately.  It is the 
expectation that the welfare check documentation would be checked daily by a nurse 
in  order  to  ensure  that  any  matters  of  concern  are  noted  and  actioned  as  required.  
Additionally, as outlined above, this documentation is also regularly audited as part of 
the  Home  Managers  daily  checklist  to  ensure  such  checks  are  undertaken,  and 
documented appropriately. 

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 Also,  as  outlined  above,  Muriel  Street  has  increased  the  staffing  ratio,  resulting  in 
greater senior staff presence on each floor / unit, prompting greater and more effective 
oversight of staff and the monitoring of the welfare of residents. 

Additionally, since Mr Gregory's death, all nursing staff have undertaken a clinical skills 
workshop,  part  of  which  deals  with  the  identification  of  the  deteriorating  patient  and 
monitoring of the same, details of which are attached.  Part of this course deals  with 
the Restore2 deterioration tool which has now been rolled out at Muriel Street – details 
of which are below.  

Further,  Muriel  Street  has  also  undertaken  a  significant  amount  of  focussed  learning 
and training of both clinical and care staff in relation to the identification and escalation 
of a potentially deteriorating resident.  This has been done via the Significant 7 training 
package,  which  is  a  training  tool  developed  and  administered  by  NELFT  NHS 
Foundation  Trust.    The course  is  designed  to enable non-clinical  staff  to  identify  and 
act  upon  "soft"  signs  of  deterioration.    Broad  details  of  the  course  can  be  found  at 
https://www.nelft.nhs.uk/significant-7.    Since September 2019, the Home Manager at 
Muriel Street has become a registered trainer for the Significant 7 course, and all staff 
at Muriel Street have undergone the Significant 7 course.  It also now forms part of the 
induction training for new members of staff.  

To  supplement  this,  since  April  2020,  Muriel  Street  has  also  rolled  out  the  Restore2 
deterioration  tool  (which  is  based  upon  the  NEWS2  system  commonly  used  across 
actual hospitals).  A copy of the Restore2 documentation is attached and is contained 
within  each  resident's  care  plan  file,  and  updated  monthly  by  a  nurse.    The  Restore 
tool assists staff members to be able to recognise the early signs that a resident may 
be  deteriorating  (as  per  the  Significant  7  course),  and  then  guides  nursing  staff  on 
appropriate escalation and frequency of monitoring if required to ensure a resident is 
provided with timely and appropriate medical intervention.  It should also be noted that 
the tool recognises that not all residents are the same, and therefore there is the ability 
to record additional signs of possible deterioration specific to a resident.    

The  Restore  2  system  is  a  paper  based  system.    In  order  to  seek  improvement,  the 
nursing unit at Muriel Street is part of a trial, involving a number of other organisations 
in  the  local  authority  area,  of  an  electronic  monitoring  system  called  Whazam.    This 
system  allow  staff  to  electronically  record  a  resident's  vital  observations  and  then 
calculates  a  NEWS2  score,  prompting  actions  as  necessary.    The  electronic  system 
also shares a resident's vital observations with local GP surgeries and if necessary the 
London Ambulance Service, to ensure speedy and effective transfer of vital information 
should the need arise. 

      4.  Monitoring a resident's oral fluid intake 

Care  UK  and  Muriel  Street  recognises  the  importance  of  ensuring  that  a  resident's 
hydration is carefully monitored.  There are a number of policies and guides in place to 
assist staff and highlight the importance of this aspect of care.   

In this case there are 2 specific areas of concern raised by the Coroner: 

Efforts to encourage residents to take oral fluids and escalation of concerns 
Care  UK  has  policies,  "ways  of  working"  and  "how  to  guides"  to  assist  staff  in 
supporting residents to take oral fluids and maintain hydration.  Copies of the same are 
attached.  You will see from these that there is a clear expectation that residents' oral 
intake is monitored and concerns over the same escalated and reviewed (for instance 

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 at  weekly  clinical  review  meetings).    Further,  in  the  event  of  more  acute  concerns  in 
relation to oral fluid intake, the matter should be raised with the visiting GP to consider 
and advise, as occurred in Mr Gregory's case. 

The    "ways  of  working"  and  "how  to  guides",  which  are  easily  accessible  by  staff, 
provide  information  and  guidance  on  the  importance  of  hydration  and  the  need  for 
some  resident's  to  have  repeated  encouragement  to  take  oral  fluids,  together  with 
suggested methods to encourage increased oral fluid intake.  The guides also highlight 
the  consequence  of  insufficient  hydration  and  checklists  for  action  in  the  event  that 
there are signs of dehydration. 

Since the death, Muriel Street has started and continues to educate staff of the need to 
encourage residents  with oral  intake  of fluids.   This  has  been  done  during  "Take 10" 
and  handover  meetings.    During  these  meetings  all  staff  have  been  advised  of  the 
reasons why encouragement of oral fluids is so important, followed by an explanation 
and  discussion  of  the  ways  of  working  and  how  to  guides.    Further,  hard  copies  of 
these  guides  are  now  included  in  the  resident's  care  plan  file  in  their  room.    This 
provides easier staff access to the guides and serves as a constant reminder to staff of 
the importance to encourage oral fluid intake. 

Additionally, once the current restrictions in place due to the pandemic are lifted, Muriel 
Street  will  be  undertaking  mandatory  dining  room  training  for  staff,  part  of  which 
provides  training  to  staff  on  the  need  to  encourage  residents  to  increase  oral  intake 
generally, as well as refreshing techniques / methods to encourage residents to do the 
same. 

Recording of fluid balance and the accuracy of the same 
Clearly, part of ensuring a resident is taking sufficient oral fluid is to monitor oral intake 
via  the  fluid  chart.    Every  staff  member  attends  document  training  in  addition  to  the 
induction  training  when  they  join  the  care  home.      This  training  outlines  the 
documentation that staff are expected to complete and how to complete the same.   

Muriel Street has reviewed the fluid charts used and has introduced new fluid balance 
monitoring documentation – copies attached.  The new charts are clearer and enable 
details  of  a  resident's  input  /  output  to  be  recorded  in  more  detail.    Further,  staff  are 
now  instructed  to  document  when  the  re-attempt  to  provide  oral  fluids  to  ensure  that 
there is evidence of active encouragement. 

In addition to the balance chart, there is also a fluid target record chart which is to be 
completed.  This is completed daily and prompts active consideration by a nurse of a 
resident's  fluid  balance,  and  what  consequential  actions  are  required,  ensuring  a 
proactive  approach  to  a  resident's  oral  fluid  intake.    Any  concerns  are  discussed  at 
handover  meetings  with  the  clinical  lead.    Further,  if  there  are  lower  level  concerns, 
these are raised and discussed at the weekly clinical review meeting, in order to review 
the situation and decide upon future management. 

All  staff  members  have  been  trained  in  the  use  and  completion  of  these  new 
documents  via discussions  during  the Take  10  and  handover  meetings, during  which 
the  forms  are  gone  through  in  detail,  the  expectations  of  staff  made  clear,  and  the 
relevant  how  guides  provided.    The  how  to  guides  for  the  completion  of  the  chart  is 
also now included with the fluid charts contained in a resident's care plan file. 

In order to ensure that these new charts are being completed correctly,  all staff have 
been  the  fluid  balance  documentation  is  included  in  the  regular  random  audit  of 
documentation outlined above.  Recent audits have demonstrated that not only are the 

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 documents  being  completed  in  full,  but  there  is  also  now  documentation  of  repeated 
encouragement to take oral fluid. 

As  is  clear  from  the  above,  there  has  been  a  number  of  changes  made  since  the  death.  
Ordinarily  group  training  would  be  provided  in  order  to  re-inforce  the  improvements  made.  
However,  given  the  current  pandemic,  this  has  not  been  possible,  and  training  has  instead 
taken place in smaller groups.  Notwithstanding this, once the current restrictions have been 
lifted,  it  is  the  intention  of  Muriel  Street  to  have  full  group  training  on  the  following  relevant 
areas: 

  Manual handling – with the additional focus of wheelchair safety 
  Personal care – with an additional emphasis upon dress 
  Dining – with an additional emphasis upon encouraging oral fluid intake 
  Documentation  –  with  specific  reference  to  the  updated  welfare  checks  regime,  and 

the new documentation that has been introduced across a number of areas. 

Additionally,  Muriel  Street  would  usually  hold  regular  staff  meetings  /  lessons  learned 
sessions.    Again,  due  to  the  number  of  staff,  this  has  not  been  possible  due  to  the  current 
restrictions.  However, once such restrictions have been lifted, Muriel Street intend to have a 
series  of  group  staff  meetings  and  lessons  learned  session  during  which  the  issues  and 
concerns raised as a result of this case, and the changes made will be discussed in full. 

As outlined at the beginning of this response, Care UK and Muriel Street takes the safety and 
wellbeing  of  resident's  extremely  seriously,  and  has  in  place  a  robust  system  to  ensure  that 
the  high  standard  we  expect  are  met.    Nevertheless  we  also  seek  to  learn  and  continue  to 
improve.    We  are  therefore  confident  that  we  have  implemented  a  robust  series  of 
improvements,  which  will  result  in  greater  staff  understanding  and,  timely  and  appropriate 
response to the matters of concern highlighted.  

Yours sincerely, 

Muriel Street Registered Manager 

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