Rebecca Begg

37, Station Road, 
Chesterfield 
S41 7BF 

Dear Dr Didcock, 

We refer to the prevention of future deaths report you issued following the conclusion of the 
inquest touching upon the death of Rebecca Begg.  

In addition to the below response, we enclose the action plan which was previously submitted to 
you in November. You will note that the actions and changes have all been implemented with the 
exception of some training courses that are yet to reach completion due to being on-line, long 
distance courses, and 
of the changes at Moorgreen and across Heathcotes more generally. 

 continues to have oversight of the implementation 

For ease of reference and clarity, we have used the topic headings provided in your report and 
responded accordingly: 

Failure to monitor compliance with care plans, and a lack of robust incident reviews – whilst 
welcome changes are planned with improved audit and monitoring, this is not yet fully 
implemented. 

Full incident reviews are implemented, the Registered Manager reviews and follows up each 
incident and formally documents whether any action is required post incident.  
The Clinical team (which is made up of a Clinical Director,  Head of Therapy, Mental Health Nurse 
and Assistant Psychologists), also have involvement in incident reviews now, and either have 
sessions with those involved (staff and people we support) to ensure the root cause is understood 
and different methods of support are offered or implemented to address any issues identified. Our 
internal governance and quality assurance procedures have been reviewed since the incident and 
the Quality Audit and the Monthly Provider visit both cover incident reporting. They also include 
reviewing and checking the quality of the reviews. In addition, they also check care plans and look 
for any changes made as a result of the incident. Physical items used to tie ligatures are now stored 
with the incident report, so that we can be sure what was used and how it was removed.  

As yet untested ‘observation level’ support plans. 

Several changes have been made in regards to compliance with care plans. An observation care plan 
has been formulated for each individual which includes information about that person, levels of 
observations they may require and why, when and who can implement the observations, how to 
undertake the observations and what process is followed to increase or decrease the observations. 
The decision to decrease observations is made by at least three members of the MDT (comprising of 
members of the Clinical team, Senior Operations team, the Registered Manager, Senior Compliance 
Managers.  At least one person involved in the decision making is from the Clinical team and the 

 
 review is documented and stored for future reference. The care plan is written in detail and provides 
staff with clear guidance on exactly what action to take. This process has been tested and used 
several times since being implemented. The whole process has been reviewed by the MDT and 
amended or adjusted as required. The observation changes have also been tested, as we are now 
able to review the CCTV following an event, which has been installed in proximity to bedroom doors 
(whilst ensuring privacy for those we support). Several audits have taken place to ensure staff are 
adhering to the observations in place and the frequency of them. 

A lack of inclusion of support workers in regular meetings about clients - it is these staff working 
each day with clients that can contribute to progress review and if necessary to a change in the 
support plans and/or risk assessments. 

Care plans are discussed within staff supervisions and staff meetings, we also hold care plan 
workshops. These workshops give the Registered Manager and staff members protected time to 
review care plans and make any amendments relevant or necessary. Any new staff member that 
begins employment now has an extended induction period of 6 full days. New staff are not signed 
off as competent to support people alone until the Manager has done a complete knowledge check 
specifically concerning people’s care plans, needs and high risk areas. Knowledge checks around care 
planning and risk areas are undertaken every 8 weeks at random to ensure that staff have a good 
knowledge of what people’s needs are and how to support them. Observations are also undertaken 
to ensure that staff are supporting people the way their care plans prescribe them to.  

No dedicated time for staff to read and digest care plans. 

Dedicated time for staff to be able to take time out to read or re-read care plans is highlighted on 
the handover sheet. Several periods of time are identified so that if one slot is missed the staff can 
pick the other ones. Care Plan Knowledge Checks are conducted frequently, and if gaps in knowledge 
are identified we ensure that people re-read care plans and have an understanding that we are 
satisfied with. Senior Management consider the outcomes of the Care Plan Knowledge Checks 
during quality checks to ensure that staff are implementing the appropriate care. People are 
discussed during staff members supervisions which enables us to further ensure that staff are 
supporting people correctly in accordance to their needs and the guidance provided. During the 
induction new staff members are allocated extra time to read care plans and are not signed off as 
competent until the Registered Manager is satisfied they have a good understanding.   

Lack of clarity regarding who can instruct for a room to be stripped following an incident of serious 
self-harm. 

The removal of risk items process has been reviewed. There are specific room searching care plans in 
place that provide clear guidance in terms of how to search, what to search for, how  to remove any 
risk items and when to do so. Staff at any level of seniority can make the decision to search (in line 
with policy). The room search policy has been amended and is currently in the peer review process. 
The detail of the policy is that we practice least restrictive methods, for example if someone requires 
a high level of observation (constant line of sight), then we will not remove belongings from people 
unless they request it or unless there is a specific need to. Detail of this is within the policy and 
specific care plans. The observation care plan has been considered as part of this process, and the 
level of observation can impact on the removal of risk items. Consideration has been given in terms 
of least restrictive practice for example, if someone is on constant eyesight or arm’s length 
observations, removing risk items wouldn’t be necessary. New policies describing observation levels 
and room searching have been developed and are incorporated within the care plans to ensure 

  
 
  
 
  
  
  
 consistent and safe working. The Registered Manager has spent time on night shifts with staff 
ensuring that they read and understand the support plans and new policies in the same way the day 
staff do. She has also worked shifts with them to observe practice and assure ourselves that they are 
following the guidance put into place. As previously confirmed, Team leaders are also on every night 
shift to ensure further oversight.  

Lack of a system for formalised contact with Nottinghamshire Healthcare NHS Foundation Trust 
(NHCT), including, if Heathcotes are unhappy about the response from the Mental Health teams, a 
means of escalation to NHCT senior team. 

Whilst we recognise the importance of this issue, it is beyond the power and control of Heathcotes 
to implement a system with Nottinghamshire Healthcare NHS Foundation Trust as they deal with 
numerous providers. Notwithstanding this, the changes we have made to our pre-admission process 
are designed to ensure that all appropriate documentation and knowledge is acquired before a 
resident moves into Moorgreen and will also ensure that the resident is registered with the 
appropriate professional bodies, such as the Community Mental Health Team before they move in 
should further assistance be required. 

Yours Sincerely, 

Director of Operations – North  
On Behalf of Heathcotes Group