Colm McCabe

Mrs Heidi J Connor 
HM Senior Coroner for Berkshire 
Reading Town Hall  
Blagrave Street 
Reading RG1 1QH 

Dear Madam Coroner, 

Inquest touching the death of Colm McCabe 
Response to the Regulation 28 Report to Prevent Future Deaths 

Thank you for your Regulation 28 Report dated 28 January 2022, subsequently re-issued on 31 January 2022, 
following the conclusion of the inquest into the very sad death of Mr Colm McCabe. This letter sets out the 
response to your Report. 

I know that you will share a copy of this response with the family of Mr McCabe and I would like to express 
my condolences for their loss. Please be assured that the safety of those in our care is our absolute 
priority. 

In your report, you raised the following matters of concern: 

1. A number of the policies referred to at the inquest were in fact already in place at the time of this
death.  Many of these were not followed.  I remain concerned about recruitment of staff, training of
staff, and appraisals of staff.

2. Whilst I was advised that a new management team is working at this care home, I remain concerned
about auditing of the effectiveness of this.  We heard evidence that auditing was taking place at the
time of this death, but this appears to have missed significant factors, including the fact that a 72
hour review was not carried out, that neither the 72 hour review nor any subsequent management
of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point
with the hospital, the GP or community diabetic nurses.
I heard evidence about investigations carried out by the home, and the fact that initial responses to
enquiries from the CQC suggested that the management had been appropriate.  I am concerned to
know to what extent care homes run by Four Seasons carry out full and candid investigations and
produce reports accordingly, and what training is given to managers in this respect?

3.

The Four Seasons Health Care Group (the Group) comprises a number of Registered Social Care Providers, 
and we recognise the importance of looking after the physical health needs of our residents, ensuring that 
our staff have the requisite skills, confidence and ability to provide high quality care. 

We  are  also  aware  that  it  is  extremely  important  for  us  to  operate  an  effective  auditing  system.  This  is 
supported by ensuring that our investigations into incidents are progressed in a timely manner and by way 
of an open, frank and transparent process involving all relevant stakeholders from an early stage.  

During the course of the inquest touching the death of Mr McCabe, 
 provided evidence to you 
about the immediate actions taken at a local level at The Berkshire Care Home .These actions were largely 
in response to the concerns raised both within the Group and by external stakeholders. As described to you, 
it was identified that the policies, due process and appropriate escalation of  actions as mandated by the 
Group had not been followed.  

Norcliffe House, Station Road, Wilmslow, Cheshire SK9 1BU  T: +44 (0) 1625 417800  F: +44 (0) 1625 417827  E: fourseasons@fshc.co.uk 

Four Seasons Health Care and brighterkind are part of the Four Seasons Health Care Group. 
Four Seasons Health Care Holdings Limited, Registered Office: Norcliffe House, Station Road, Wilmslow, SK9 1BU. Registered in England. Company number: 03806216 

 Following the inquest, we have received and carefully reviewed the Regulation 28 Report issued by you .We 
now write to give you assurance that further steps have been taken and actions implemented to address the  
matters  of  concern.  These  have  been  incorporated  into  the  ongoing  provision  of  care  services  at  The 
Berkshire  Care  Home  and  more  widely  across  our  business  as  part  of  our  approach  to  learning  and 
continuous quality improvement. 

Lessons learned and action taken to address the concerns raised by you are as follows: 

Policies, recruitment of staff, training of staff and appraisals of staff 

1.  The Group has introduced a “Policy of the Month” in order to raise awareness of company policies, 
practices and procedures. This is cascaded to all regional support teams and to homes via a weekly 
update by the Chief Operating Officer, with Home Managers cascading this to care home based 
team members during Daily Flash Meetings. The Group’s training platform has been improved to 
ensure  that  all  team  members  are  provided  with  relevant  training  that  reflects  the  Group’s 
policies,  practices  and  benchmarks.  The  platform  is  closely  aligned  to  current  statutory 
frameworks. All team members are guided through the principles and expectations of these as 
they complete each training module on the platform.  

Areas of training include: 

Essential  training  -  All  training,  including  statutory  and  mandatory  training,  that  the  Group 
considers essential for team members to complete to ensure safe and effective delivery of care 
and services.  

Statutory training - Training required by, or with a basis in, law or regulation.  

Mandatory training - Training specific to a role or roles, which the Group deems necessary for 
delivery of safe and effective care and services.  

Induction training - Essential training that is completed by team members when they start a new 
role so that they are quickly and confidently able to meet the needs and requirements of that role. 
For  new care home based team members, this is completed prior  to commencing  work  in the 
home;  for  new  office  based  team  members  and  for  care  home  based  role-changers,  this  is 
completed during the first eight weeks. Local induction includes an introduction and orientation 
to the local area of work, environment and day-to-day working practices.  

Additional learning and development - Learning and development that is based on a team’s/team 
member’s specific needs, identified either as knowledge gaps (information that employees need 
to know or understand but currently don’t), or skills gaps (actions that employees need to be able 
to carry out or perform but currently can’t). This is usually identified as part of the processes of 
supervision, annual appraisal or compliance (i.e. to meet the requirements of a particular service 
or local authority contract). It often leads to the development of personal improvement plans, 
which are regularly updated, reviewed and monitored. 

Monitoring  of  compliance  with  training  takes  place  at  least  monthly  across  all  operational  
portfolios, reviewed by Managing Directors and Operational Managers to identify any corrective  
action where required. Compliance may be further assessed during internal and/or external audit. 
At The Berkshire Care Home work is continuing to support the development of the team and to 
recruit new team members with heavy emphasis on the need to follow systems and processes 
and to question practices which do not follow an agreed Multi-Disciplinary Team approach.      

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 To  align  with  Group  training  and  policies,  recruitment  processes  have  been  improved  and  all 
Departments  are  supported  by  the  Group’s  Recruitment  Team.  Additional  learning  and 
development needs are reviewed and addressed by Operational Managers once employment of 
the individual has commenced.   

To  support  nurses  with  clinical  practice  and  competence,  the  Group  subscribes  to  The  Royal 
Marsden  Manual,  with  access  available  to  all  nurses  at  each  of  our  homes.  However,  it  is 
recognised  that  this  resource  has  not  been  as  widely  used  as  was  anticipated.  Accordingly, 
communication has been and will continue to be cascaded nationally to remind Home Managers 
and Registered Nurses of the importance of this valuable resource, which is available as a point of 
reference and guidance 24 hours a day and accessible on various devices at each home.   

The  Group  has  reviewed  and  improved  its  supervision  and  appraisal  process  to  provide  a 
responsive and flexible framework that enables Home Managers to support their teams to give 
their best, develop and grow, and to manage the personal and professional challenges associated 
with working in the care sector. The improved process covers the areas of themed supervision, 
delivered on a one-to-one or group basis to provide a space for reflection and discussion about 
specific themes, cases or issues arising, whereby discussions encourage open dialogue and insight 
to  enhance  learning  and  improve  practice.  Observational  supervision  is  now  conducted  as  a 
supportive measure to review direct care practice and knowledge; should areas of improvement 
be  identified  during  the  observational  session  these  are  addressed  with  the  employee.  The 
process  of  clinical  supervision  relates  to  the  delivery  of  professional  standards,  and  the 
identification of specific training requirements to meet those standards. It is a requirement that 
an  experienced  and  competent  clinician  who  can  demonstrate  membership  of  an  appropriate 
professional body must complete this.  

Audit  

2.  Through  reflection  and  review,  it  has  been  recognised  that  the  Group  Governance  and  Audit 
system was not utilised at The Berkshire Care Home in the way for which it was intended. The 
completion  of  the  audit  process  is  reliant  upon  human  elements,  namely  the  importance  of 
understanding  the  process,  an  honest  and  accurate  approach  to  completion  and  the  ability  to 
execute this through comprehensive and open reporting. Accordingly, work is now in progress 
with the Group Care Quality and Assurance Teams to develop and deliver bespoke training to all 
Home  Managers  on  how  to  conduct  and  document  an  audit  and  evidence  continuous 
improvement. Further to this, it is recognised that the  completion of audits  should not  be the 
responsibility  of  one  individual  as  this  may  result  in  a  restricted  overview  without  checks  and 
balances.  Accordingly,  action  has  been  taken  to  conduct  audits  via  multiple  sources,  including 
completion by team  members independent  to the homes, promoting a  validation approach to 
audits  carried  out.  The  review  of  data  produced  by  audit  has  also  been  improved.  Whereas 
previously if data indicated consistent high outcome scores, this was viewed as assurance that a 
home was compliant. A different approach is now adopted so that this is now interrogated further 
utilising an independent team member validation approach to obtain assurance as to the accuracy 
of the outcomes presented to the wider business.  

During the course of the inquest, Ms 
 gave evidence about 72-hour reviews, which were 
 at a 
carried out, at The  Berkshire Care Home. These reviews were  introduced by Ms 
local level at The Berkshire Care Home, following the death of Mr McCabe and as an additional 
check as to compliance with process in response to the issues which became apparent following 
Mr McCabe’s death: they were not incorporated into the Group’s general policies applicable to 
the  delivery  of  care  at  all  homes.  I  am  sorry  for  the  confusion  in  this  regard.  Following 
consideration of the audit and other changes outlined in this letter it has not been considered 
necessary to implement 72 hour reviews as a standard process across the Group.  

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 However, a Care Plan Review tool has been introduced across the Group for use in all care homes; 
this is to be completed 5 days following admission and reviews the following areas: 

Consent documents and photographs. 

Falls Risk Assessment  
Choking Risk Assessment (to be completed within 2 hours of admission) 

  Admission Assessment 
 
  Medication on Admission 
  Body Map 
  Moving and Handling Assessment 
 
 
  MUST Risk Assessment (to be completed within 6 hours of admission) 
  Waterlow Risk Assessment (to be completed within 6 hours of admission) 
 
Pain Assessment 
  Wound Assessment 
  Bed Rail Risk Assessment  
 

Self-Medication Risk Assessment (if applicable) 

The review should ensure that care plans are underway, taking into account hospital discharge 
notes  or  other  available  information  from  external  stakeholders  as  applicable.  Operational 
Managers  and  our  audit  process  will  have  additional  oversight  again  to  provide  validation 
approach.  

The Group has recently refreshed its admissions policy to guide staff on the process required when 
dealing with planned, emergency, respite and intermediate care admissions. It also applies to re-
admissions to the care home from hospital.  In summary, upon receipt of a referral or enquiry, 
details about the person to be admitted will be taken and recorded on the Enquiry Management 
System in order to make an initial decision as to whether the home is able to adequately meet the 
person’s needs. Critically, staff have been empowered to decline an admission  if it is identified 
that  the  home  is  not  able  to  meet  the  person’s  needs.  The  enquirer  will  be  informed  of  this 
decision and the reasons why, and, where relevant, advice will be offered regarding alternative 
Group homes that may be able to provide a  suitable placement subject to the needs and best 
interests  of  the  individual.  Pre-admission  assessments  will  be  carried  out  during  a  visit  to  the 
person in their current location (which may be their own home, another care home or in hospital) 
or over the telephone where a face to face visit is not possible and will be recorded using the Pre-
Admission  Document.  The  information  obtained  at  the  pre-admission  stage  will  include 
everything that the home requires to ensure that the needs of the person can be met safely, and 
to ensure that there is continuity of care, treatment and support for the person. On admission, all 
needs  assessments  and  risk  assessments  are  completed  using  the  information  obtained  at  the 
pre-admission stage in conjunction with discussions with the resident or their representative at 
the  home  and  the  necessary  care  plans  are  generated.  For  respite  care,  each  new  period  of 
admission will require a review of the existing pre-admission documentation with the resident or 
their representative to ensure that any new needs are planned for, that the placement remains 
appropriate and the home can safely meet the needs of the resident. The admissions process for 
an intermediate care patient journey is as follows:  
  All  relevant  information  will  be  gathered  by  the  hospital,  which  will  develop  goals  with  the 
patient;   
 On referral, a pre-admission assessment will be completed and a decision will be made to admit; 
 If the care setting can accommodate the patient, admission will take place within 48 hours; and 
  On  admission,  all  relevant  risk  assessments  will  be  completed,  and  the  necessary  care  plans    
generated, as discussed and agreed with the Multi-Disciplinary Team.  

Investigations  

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 3.  The  Group  operates  an  incident  management  system  via  the  RADAR  platform;  this  is  a 
fundamental change to the previous system DATIX, an incident management system commonly 
used in the sector and which  was in use by the Group prior to April 2021. Whereas the DATIX 
system was controlled by the external program developers, which restricted our ability to invoke 
change when this was required to meet the needs of our business, the RADAR system allows for 
full  participation  and  control  to  reflect  Group  practices  and  to  enable  positive  change  by  the 
Group.  Every incident reported has a designated workflow to guide and prompt team members 
as to the information required and notifications that may be required; these workflow steps are 
regularly  reviewed  to  support  improved  reporting  and  investigation.  A  Root  Cause  Analysis 
function aligned to incident reporting has been simplified and improved with additional guidance 
and  prompts  to  support  team  members.    Furthermore,  the  Group  has  developed  a  bespoke 
training  module  to  guide  team  members  on  how  to  conduct  an  investigation;  this  is  directly 
aligned to the RADAR incident management system, workflow steps and effective completion of 
a  Root  Cause  Analysis  under  sector  standard  principles  and  is  delivered  nationally  across  the 
Group. The training has been developed using a ‘lessons learned’ approach and guides managers 
through the process of completing a timely, thorough and effective investigation with a focus on 
openness and transparency, mirroring duty of candour principles. Areas covered include reasons 
why we have to investigate an incident; the four steps of effective investigation; and the correct 
method  and  terminology  for  completing  an  investigation.  The  training  also  encompasses 
interactive  participation,  where  attendees  review  a  case  study  and  then  discuss  methods  of 
investigation,  identification  of  risk,  causation,  corrective  action  needed,  how  to  write  the 
investigation report and finally how to cascade lessons learned to the wider team.            

Thank you for bringing your concerns to my attention.  I hope that the detailed information provided in this 
response  offers  you  assurance  about  both  our  systems  and  processes  and  the  significant  and  continuing 
improvements we have made and will continue to make in order to mitigate risk to our residents. 

We are sincerely sorry for the shortcomings in the care of Mr McCabe and are committed to ensuring that 
the  improvements  we  have  made  are  sustained  both  at  The  Berkshire  Care  Home  and  across  our  wider 
business.  

Yours sincerely 

Director of Care Quality 
Four Seasons Health Care Group  

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