Christine Neild

Salutem LD TopCo Limited & 
Salutem LD TopCo II Limited 
Minton Place 
Victoria Street 
Windsor  
SL4 1EG 

HM Senior Coroner 
Manchester South Coroner’s Court 

01/12/2020 

Dear Sirs,  

Inquest touching the death of Christine Rosemary Neild 

Regulation 28 Report Response of Meade Close Care Home 

Thank you for your letter dated 2 October 2020 enclosing the Regulation 28 Report to prevent 
future deaths signed and dated 2 October 2020 by HM Senior Coroner for South Manchester, 
Ms Alison Mutch OBE. The Report was also sent to The Care Quality Commission, Trafford 
Metropolitan Borough Council and NHS Trafford Clinical Commissioning Group. 

The Senior Coroner has set out her concerns at paragraph 5 of her report. She requires a 
response from Meade Close Care Home in respect of matter of concern (2):  

“2. There had been an earlier incident when Christine Neild had put a non-food 
item in her mouth. The carer did not escalate this and there was no further risk 
assessment”. 

The Coroner does not require a response from Meade Close Care Home in respect of the 
other matters of concern set out at Paragraph 5 of the Regulation 28 Report.  

Background 

Meade Close Care Home is a residential care home for adults with complex care needs. We 
aim to provide high levels of support to enable our residents to meet their personal goals and 
future  aspirations.  The  Care  Home  consists  of  two  bungalows,  each  bungalow  can 
accommodate  four  residents.  Each  resident  has  an  appropriate  bespoke  Care  Plan  to 
address their particular needs. We work in conjunction with healthcare professionals and the 
Council to make sure we are providing the highest levels of care possible.  

Christine Neild resided at Meade Close Care some between April 2016 and 31 January 2019 
when  she  sadly  passed  away.  Christine  had  complex  care  needs  which  were  carefully 
managed by Managers and Support Workers at Meade Close. She was diagnosed with a 
number  of  complex  conditions  including  Dysphagia  which  meant  that  she  struggled  to 
swallow.  
Her meals had to be blended to a specific consistency and one meal per day was bought into 
the service for her.  

 On  a  date  in  October/November 2019,  Christine  was  spending  time  with  her Sister, 

, at Meade Close Care Home. Her sister was removing gel nails and to do so she 
had  wrapped  Christine’s  fingers  in  cotton  wool  and  foil.  During  the  Inquest, 
  told  the 
court that she had been measuring up Christine’s bedroom for furniture and so she had left 
Christine alone whilst she went into her bedroom.  She was alerted to the fact that Christine 
had the cotton wool and foil in her mouth by a Support Worker and she immediately removed 
the item from her mouth. She referred to the incident as a “one off”.  

The Support Worker who witnessed Christine with the cotton wool and foil in her mouth did 
not report the matter to her senior colleagues or record it in Christine’s daily log. As a result 
of this the matter was not escalated and a risk assessment was not carried out. This was not 
in compliance with our policies and procedures.  

Actions taken and agreed 

As  a  result  of  the  concerns  raised  by  the  Coronial  investigation,  we  have  undertaken  the 
following:  

1.  Enhanced one to one supervision has been undertaken with the Support Worker involved 
in the incident when Christine placed a non-food item in her mouth. It is accepted that the 
Support Worker did not report or record the incident. During the supervision session, the 
details of the incident were discussed and the importance of reporting incidents of this 
nature. The Support Worker said that she was aware of the importance of reporting and 
the reasons why she should. She accepted that in no reporting the incident meant that 
the incident was not escalated and a risk assessment was not carried out. She is aware 
of the consequences of not reporting such matters. She was disappointed in herself that 
she had not done so. The Support Worker was advised of the appropriate ways to report 
incidents,  by  recording  them  in  the  residents  Daily  Log,  speaking  to  a  Senior  Support 
Worker and/or the Manager.  

2.  A staff meeting has taken place to discuss the issues raised by this case and specifically 
the risks of not reporting and recording incidents. It was agreed that all staff would have 
a recording and reporting training reset. 

3.  A review is being carried out of all staff inductions to make sure all staff members have 
received  the  same  level of  training.  It  has been  agreed  that  all  staff  will undergo  a  full 
Salutem induction. 

4.  All  staff  members  have  undertaken  a  Reporting  and  Recording  e-learning  module 
however as a result of the issues raised by this case all staff are required to retake the 
Reporting and Recording e-learning module to refresh their memories and make sure that 
their learning is up to date.  

5.  When residents are spending time with their families Support Workers are now required 
to ask the family member for a briefing of the time they have spent with the resident and 
to specifically ask whether anything arose during their visit that they think the Care Home 
staff need to be aware of. Support Workers must record the briefing in the resident’s daily 
log  and  escalate  any  matters  that  have  been  identified  as  a  risk.  We  are  preparing  a 
checklist of issues for Support Workers to go through with family members to make sure 
all relevant risks can be identified.   

6.  A meeting  was  held on  23  October 2020  between  the  Manager of  Meade  Close, 

and  the  Salutem  Group  Head  of  Talent  and  Development.  During  the  meeting 

 
 
 
 
 
 
 discussions took place in respect of staff training and induction. It was agreed that all staff 
are  to  undertake  refresher  training  in  respect  of  Key  working,  Mental  Capacity  Act, 
Support  planning/risk  assessment,  choking,  recording  and  reporting,  first  aid  and 
inductions. We attach a table detailing the actions agreed during the meeting.    

7.  We spoke to CQC over the telephone on 6 November 2020. During the call we discussed 
actions taken and action to be taken in respect to the concern raised by the Coroner. 

8.  We  have  carried  out  risk  assessments  for  each  resident,  specifically  in  relation  to  the 
location of gloves, their access to them and any associate risk. For each resident we have 
considered the location of the gloves, both in communal areas and their personal bedroom 
and any risks that present for the individual resident. We assessed the precautions that 
are  already  in  place  and  any  further  steps  that  need  to  be  taken.  A  copy  of  the  risk 
assessment has been placed in the individual residents Care Plan and the outcomes of 
the assessments have been communicated to all staff members. We will review the risk 
assessment  every  six  months  as  a  minimum  if  an  issue  arises  that  prompts  an  earlier 
review this will be carried out immediately.  

9.  We have carried out night time risk assessments for each resident. For each resident we 
have considered their sleeping pattern and for mobile residents we have considered the 
risk associated with them getting out of bed. We have assessed the precautions that are 
already in place and any further steps that need to be taken. A copy of the risk assessment 
has  been  placed  in  the  individual  residents  Care  Plan  and  the  outcomes  of  the 
assessments  have  been  communicated  to  all  staff  members.  We  will  review  the  risk 
assessment  every  six  months  as  a  minimum  if  an  issue  arises  that  prompts  an  earlier 
review this will be carried out immediately.  

10. We have completed a lessons learned log a copy of which we have shared with Trafford 

Metropolitan Borough Council for the comment.  

Conclusion 
We are sorry that it was necessary for the Senior Coroner to issue a regulation 28 report into 
the  issue  of  reporting  and  recording  at  Meade  Close  and  hope  that  our above  mentioned 
actions satisfy the Coroner that we have taken her concerns seriously. We seek to reassure 
the Coroner that this was a one off incident. Having discussed Christine’s care with all staff 
members we  can  confirm  that  Christine had not  been  known  to  put  non-food  items  in  her 
mouth  before  or  after  this  incident.  Support  Workers  were  knowledgeable  with  regards  to 
reporting  and  recording  incidents  which  would  not  be  considered  usual  on  a  daily  basis.  
However, as a result of the issues raised by the Coroner in this case, and as a reminder of 
the reporting and recording requirements, all staff members have received additional training 
with  regards  to  identifying  risks  and  then  reporting  and  escalating  the  concerns  in  the 
appropriate way. All staff members have received training in respect of safeguarding adults 
and children, basic life support, first aid and reporting and recording of incidents.  

We hope that the Coroner will be satisfied that Meade Close is providing the appropriate level 
of  care  to  all  residents  whilst  trying  maintain  a  home  away  from  home  environment.  We 
highlight the comments made by Christine’s sister during the Inquest who commented that 
the staff at Meade Close Care Home were “amazing”.  

Please do not hesitate to contact us via our legal representatives, RadcliffesLeBrasseurLLP 
should any further information be required. 

Yours faithfully 

 
 
 
 Meade Close Care Home

ae TRAFFORD
2) COUNCIL

Private & Confidential

1st Floor
F.A.O: Alison Mutch Trafford Town Hall
Coroner's Court Talbot Road
1 Mount Tabor Street Trafford Council
Stockport M32 0TH

SK1 3AG

26 November 2020

Dear Ms. Mutch,

Re: Christina Rosemary Nield

—- ewrite-in=response--to-your- enquiry sent-to-us-on=2"_ October.2020-regarding.————
~~ Christine Rosemary Nield. + Met a ee ne SSS

You specifically asked us as the Local Authority and CCG to identify actions in
respect of the following statements:

4) During the course of the inquest evidence was heard that gloves were in
open and easily accessible locations throughout the home including in
rooms and the kitchen area. The inquest was told that this is standard
practice in care settings for people with learning disabilities even Where
residents do not have the insight into what items can safely be plated in
theirmouths. ~- |

|
We would like to assure! you that we have provided extensive guidance td our
providers of the safe {isage and disposa! of Personal Protective Equipment
(PPE). Following the olttome of Miss Neild’s inquest, we have reiterated this
message in our daily updates to our providers.

As part of our ongoing scrutiny over this matter we plan to conduct bi-annual
audits with providers to, ensure that the new guidance is being adhered to. We
plan to monitor this u: 2 a specific audit tool and also to embed it i q our
annual quality review using a tool called an iTool which is specific to Trafford.
Once we have evidence that the practice is embedded it will move to the
standard review which is recorded within the iTool.

All adults who may be at risk of ingesting inedibles, are subject to individual risk
assessments, which include their capacity to understand the associated risks.
For adults who lack capacity to understand the decision in question, any actions
taken to safeguard the person will be undertaken in their best interests and in
accordance with Mental Capacity Act (2005).

As you are of course aware, the use of PPE is fundamental to ensure the health
and safety of all of our residents during the pandemic and needs to be
accessible at all times. We have consulted with our providers to see how we can
pragmatically manage the safe storage of gloves in particular.

The general feedback is that where the individual risk assessment is indicative of
a potential risk of ingesting inedibles, our providers assure us that they would
manage these instances in a variety of ways dependent on individual need,
including (but not exhaustively);

e Locked cabinets or key pad locked rooms
e Support Staff signing in/out low number of gloves to retain on their
person

RL AE a
=e Staff carrying hazardous: waste bags~ as opposed to“ hazard=binsin=

ee ee a a
people’s rooms to ensure safe & immediate disposal in accordance with
infection control measures

2) There had been an earlier incident when Christine Neild had put non-food

3

—

items in her mouth. The carer (family member) did not escalate this and
there was no risk assessment.

e have re-iterated to our providers, the importance that where any
idéntified/reported need (from any source) is to be intorporated into the person's
care delivery plan and escalated to the Registered Manager of the service. This
sop ensure that a risk assessment can be completed (where appropriate to do
so) and those providing the care are aware of the person’s support needs and
7 record any observations through caanieni recording and incident
reporting mechanisms.

The Provider in this instance has completed a lessons learned which has been
shared with their staff. This will be shared with our Provider Forum to ensure the
aes from this tragic case is shared across the Borough.

The inquest heard that in care settings such al this one for those with
learning disabilities there was no regular use of sensors to alert night staff
of a resident getting up and wandering. Staff relied on hearing a resident

2

Nett

getting up despite this being difficult if they were delivering care to another
resident.

Every adult with perceived care and support needs is assessed under the
appropriate legal frameworks afforded to the respective statutory agency; to
ensure that eligible assessed needs and outcomes are met. This holistic
assessment includes; the person’s views and wishes, relevant history, their
family/friends or representative's views and of course their needs for care and
support including any night-time associated needs. The needs assessment will
also incorporate the person’s mental capacity in relation to their care and
residence.

The assessment and subsequent support plan enables the Care Provider to
produce a person centred care delivery plan. This details how the person's care
will be provided and is individual to the supported person.

Assistive technology is an area which has advanced significantly over recent
years and in Trafford, we have a local offer to support our residents and
providers which includes the provision of bed/door sensors.

When meeting persons assessed needs, we must always ensure that we adhere

tothe appropriate legal frameworks. The prescriptive use of sensors could not.

~~“be routinely provided as there may be implications pertaining to a person's right —

to liberty (Art 5 ECHR) without a bespoke assessment of need and capacity.

Despite the above, we would expect that any individual identified night time
risk(s) are suitably risks assessed by the care provider with due consideration of
assistive technology as a less restrictive option to mitigating the perceived risk.

All of our Cafe Providers have been reminded to consider the exploration of
technblogical ‘solutions and risk assessment for any stipported person who is
knowh to leave their room during the night.

We hope our response is satisfactory for the issues raised, please dp not hesitate to
contact us should you require further clarification;

Yours Sigerely
i

| —_—

Services |

| Corporate sai baad \, Adult Social

Medical Director

CareQuality

Hraceh HSCA Further Information
Commission Cityaats
Gallowgate
Newcastle upon Tyne
NE1 4PA
Telephone: arp
HM Coroner Fax: 03000
Manchester South

Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

25 November 2020

Care Quality Commission (CQC
Our Reference:
Dear HM Senior Coroner

Prevention of future deaths report for Miss Christine Neild of Meade Close

Thank you for your Regulation 28, report to prevent future deaths issued following

— the inquest into the sad death of Miss Christine Neild on 21 September 2020. :

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. The !egislation that
governs this function is The Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014.

As part of CQC’s regulatory role,/inspectors assess whether or not a provider is
meeting the needs pf people in a safe way. Inspectors make judgements from their
findings as to whether a servicd has mitigated the risks posed to people, for
example, physical tisks arising from existing health conditions and environmental
risks based on the surroundings in which they live. The CQC's website signposts
the-provider and registered manager to relevant guidance on how they can meet
our regulations and other related C= including approach to risk} |

As you are aware, ejmember of the'CQC local inspection team attended the Inquest.
This response relates specifically to the matters of concern raised in your report.

1. During the course of the inquest, evidence was heard that gloves were in
open and easily accessible locations throughout the home including in
rooms and the kitchen area. The inquest was told that this is standard
practice in jae settings for people with learning disabilities ile where |

|
1

residents do not have insight into what items can safely be placed in their
mouths.

Risk assessment processes should include risks common to residents as well as
risks specific to an individual, which may include the risk of a person falling out of
bed, needing help with bathing or moving around safely. This assessment should
include mitigating steps as to how to reduce the risk. Individual risk assessments
may be integrated into ‘care assessments’ or ‘support plans.’ There is an
expectation the provider considers the individual's needs and how these can be
met whilst keeping the person safe.

Although gloves were in open and easily accessible locations at Meade Close this
is not standard practice in care settings for people with learning disabilities, but
often determined by the dependencies of the people living in the home. Gloves are
worn by staff to protect people who receive support with personal care, have
medicines administered or when they require more clinical interventions, such as
suctioning or peg-gastrostomy care. Where people do not require that level of
assistance staff may not need regular access to gloves and therefore the storage
of these will differ accordingly.

—————-A-home's environmental. risk assessment-should-consider-the-safe-storage-and
use of personal protective equipment, including gloves: If. gloves ‘are to be worn’ by
staff. providing personal care, they should_be-easily..accessible,as.sterile as 9...
possible and stored appropriately to avoid cross contamination. A provider must
consider all the above when risk assessing the storage of gloves, whilst ensuring
that staff have rapid access to stock to manage the clinical needs of people with
specific health conditions or to respond urgently in the event of an emergency, as
was the case with Miss Neild.

2. There had been an earlier incident when Christine Neild had put non-food
items in her mouth. The carer did not escalate this and there was no further
tisk assessment.

As part of our ongoing monitoring role, the inspector has been ih contact with the
registered manager to explore lessons learned and changes in practice to prevent
this incident from happening to other people living at Meade Clbse. The provider

| has carried out an enhanced supervision with, the staff member who failed to
document ahd report the earlier incident, where Miss Neild plac@d non-food items

| inher mouth. The potential consequences of no} reporting and documenting such

! incidents in a person's support plan have been discussed with the wider staff team.
Staff will be refreshing their reporting and recording training and the provider is
reviewing the induction programme delivered to new employees to incorporate
these aspects.

Wewill choy the provider's compliance with the regulations on our next inspection
of the service using our key lines of enquiry|and in accordance with CQC’s
|

bein place during the night. Support-plans and corresponding risk assessments

regulatory remit, highlight breaches of regulation to the provider and/or registered
manager (‘registered person’) if warranted and ask them how they will make the
necessary improvements. This service is due to be inspected within the next 12
months, in line with the current rating of Good. CQC however, have recently
adopted a more risk-based approach to inspections and this date can change
should we receive negative intelligence or have further concerns and judge that
the service warrants more urgent scrutiny.

3. The inquest heard that in care settings such as this one for those with
learning disabilities there was no regular use of sensors to alert night staff
of a resident getting up and wandering. Staff relied on hearing a resident
getting up despite this being difficult if they were delivering personal care to
another resident.

The issue of using sensors to alert staff of residents getting up and moving around
during the night should be addressed in individual care risk assessments. If it is
known a person is inclined to do this and they are at risk of harm, control measures
should be considered. For example, bed or door sensors or a sensor mat in their
room. These are widely used in care home settings such as Meade Close.

From our observations of care planning documents and following discussions with
the:registered manager of the service Miss Neild did not require a sensor mat to

identified Miss Neild.was fully mobile during the day and on occasions at night and
was not at risk of harm. The inquest heard how Christine would sometimes seek
staff out at night as she liked to do this. Placing an alert mat on the floor when
someone is fully mobile can present as a trip hazard and becomes an additional
risk. Whatever method a service chooses to help keep people safe it must be the
least restrictive option, so people retain an element of control and independence
in their lives.

Where CQC identifies that regulations are not being met, we use our enforcement
powers to require improyements to be made. We cantinue to do this and will hare
key learning and practice points from the inquest into the death of Miss Christine
Neild with inspectors and registered persons.

| We hope that this response addresses your concerns. If this is not the case, ease
could you clarify any‘further details you require. |

Care Quality Commissidn North (Central) Region |

|