Beryl Simcock

FINAL 

RADCLIFFE MANOR HOUSE 
CARE HOME 

52 Main Road 
Radcliffe on Trent 
Nottingham 
NG12 2AA 

     25th August 2022 

In response to the coroner’s report of the Inquest 22 June 2022 and the Regulation 28 Notice 
issued subsequently, the trustees of Radcliffe Manor House commissioned a Health and Social 
Care consultancy company (Swift Management Services) to review the governance processes 
within the organisation in order to provide assurance that systems are in place and working as 
they  should  and,  where  appropriate,  make  recommendations  to  ensure  that  the  clinical 
governance  within  the  home  is  adequate  to  ensure  resident  safety,  transparency,  and 
compliance with best practice.  

A summary of the report is attached. (The full report contains details of the care plans of a 
number of residents from which they could be identified.) The main thrust of the report is that 
the paper-based care plan system currently used by the Home makes the identification of risk 
and  progression  to  mitigation  difficult,  and  this  has  not  been  helped  by  the  fact  that  risk 
two  major 
assessment  procedures  have  been  adapted  from  various  sources.  The 
recommendations of the report are: 

•  In order to improve care planning and record keeping, the Home should introduce a 
digital care planning system which will enable the linking of care plans to risk 
assessments; this digital system should also be capable of providing good quality trend 
analysis and facilitating point-of-care-delivery record keeping. 

•  In order to improve policy and procedure maintenance and also communication of 

changes, the Home should introduce an on-line total quality system that is 
subscription-based and maintained by the provider. This will mean staff have better 
access to policies and procedures and would be informed of changes automatically. 

The  trustees  are  currently  undertaking  a  procurement  exercise  in  relation  to  the  variety  of 
digital care systems available and we are evaluating a shortlist of two systems. Our aim is to 
have the system fully implemented for all of our residents by the end of this calendar 
year. 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
     
 
     
 
     
 
     
 
 
   
 
 
 
 
 
 
 
 FINAL 

On the advice of Swift Management Services, the trustees are also looking into acquiring the 
care-home-specific  total  quality  system  QCS,  which  is  easy  to  personalise,  has  an 
understandable format and readily navigable portal. This contains the basic set of audits to 
facilitate the primary audit process, thus reducing the risk of audits not being specific or being 
missed. This should also be in place by the end of this calendar year.  

In terms of improving communications with relatives with respect to falls and other 
significant incidents we have implemented several changes.  

•  The ‘falls protocol’ now explicitly includes a step to ensure relatives are informed and 

the care plans include communication sheets where this is formally logged. 

•  Family members are invited to participate in monthly reviews of the resident’s care 
plan where the resident themselves lacks capacity to do this. Where the resident has 
capacity, they are encouraged to involve family members in their review.   

•  Looking ahead, we will pay particular attention to the ability of the new care planning 
system we select to ‘prompt’ communication of significant events to relatives and to 
allow us to audit this process.  

Together, these actions should meet the concerns set out in the Regulation 28 Notice, but the 
trustees  are  aware  that  additional  effort  will  be  required  by  themselves  and  senior  staff  to 
ensure  that  these  operational  changes,  with  appropriate  training  and  implementation  of  an 
overarching  action  plan  and  risk  register,  continue  to  improve  clinical  governance  within 
Radcliffe Manor House. 

On behalf of the Trustees of Radcliffe Manor House

Clinical Governance Review  
Summary Report 
Radcliffe Manor House 

Introduction – Project Brief 
Following a coroner’s case in 2022, the clinical governance of the home known as Radcliffe Manor 
House was criticised. In particular, the regime for the preparation, updating and auditing of Care Plans 
was highlighted as in need of attention. Although some improvements were made at the time the 
original  ‘safeguarding’  was  raised  the  coroner  has  asked  for  further  evidence  that  the  Home  is 
addressing this issue. 

As a result, the trustees have commissioned Swift Management Services Limited to carry out a review 
of the clinical governance processes within the organisation and to make recommendations to ensure 
that they are adequate to ensure resident safety, transparency, and compliance with best practice. 

Scope of the Review 
The trustees requested that we carryout a detailed review of residents’ records to ensure that care 
reflected within the care plan was implemented and there was a clear correlation between policy and 
procedure,  risk  assessment,  care  planning  and  review,  including  appropriate  escalation  to  outside 
agencies.  Also, that advice from outside  agencies was followed through in the care plans and  care 
delivery. The trustees asked that we review a sample of care documents in detail (30%).  

The review took place over two days on site at the Home, and the details of the findings are in the 
report entitled "Radcliffe Manor House Governance Review 2022".  

Introduction of the writer 
I am Robert York, and I am a registered general nurse. I have 39 years of experience in nursing, of 
which 22 years have been spent specialising in elderly care within the private sector. I work as a lead 
consultant within a Health and Social Care Consultancy. My experience within the industry has ranged 
from working as a Nursing Home Manager at numerous locations, Clinical Operations Director, and a 
Chief Executive Officer for a care home charity acting as the nominated individual accountable for care 
to the Care Quality Commission and board of trustees. 

I work daily with care homes and providers to address issues associated with care, compliance, and 
business  outcomes.  I  often  work  in  partnership  with  local  authorities  and  regulators  to  improve 
residents' standards of care and outcomes. This work includes reviewing care provision, implementing 
care plans, and teaching and assessing staff to provide evidence-based, individualised care. 

I act as an expert witness in criminal and civil cases, providing evidence on breach of duty relating to 
care for older people and care home issues. 

Overview of the Service 
The home is stand-alone, overseen by a board of volunteer trustees and managed on a daily basis by 
the registered manager. The registered manager confirms that the trustees are very supportive and 
hold a collective vision for the resident's well-being and the future of the home. 

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 Due to the home being a stand-alone operation, there is no direct line management of the registered 
manager from anyone with up-to-date clinical/care knowledge. The manager has no internal support 
to  keep  her  knowledge  up  to  date  or  opportunities  to  learn  from  best  practices  elsewhere  in  the 
organisation. Opportunities to keep up to date via networking events and other external training have 
also been limited during recent Covid-19 years. 

Most residents are privately funded on arrival to the home and others are supported by local authority 
funding  as  and  when  appropriate.  There  is  no  provision  for  the  delivery  of  nursing  care on-site or 
within the CQC registration. There is a mix of dependency levels in the home, from extremely low, to 
high.  In  some  instances,  some  residents  are  more  independent  than  would  be  expected  in  a  care 
home, but this is likely to be due to self-funding residents deciding to move into care at an earlier 
stage than would be the case if state funding was to be required. 

Where the home is now 
The original safeguarding was taken very seriously by the trustees and management team, and several 
initiatives (with the active involvement of the CQC and the GP) were immediately implemented to 
improve safety. These included: 

1.  New Falls Management Policy and Procedure 
2.  New Falls Management flow diagram 
3. 
4.  Enhanced linking between care plans and risk assessments, and incident reports. 
5. 

Improved referral processes to outside agencies such as the falls team. 

Improved management oversight of care plan documentation 

In our view the new systems in place have certainly protected residents and improved the outcomes 
for residents due to the early escalation of concerns concerning falls. Our detailed review of a sample 
of  the  care  records  showed  that  there  has  been  a  marked  improvement  in  incident  and  accident 
management at the Home since the August 2021 safeguarding was raised. 

However, falls are not the only risk to residents within a care home and whilst this was indeed the 
focus of the coroner's case, it should not be looked at in isolation from other risk issues. In the next 
section we highlight several areas of clinical governance which in our view require improvement.  

The Governance Process 
The  team  at  the  home  has  made  considerable  moves  towards  good  governance  structures  on  a 
resident-by-resident  basis  and  the  changes  made  show  there  is  now  a  pathway  for  escalation  to 
outside agencies. 

However, in our view there are further areas that need attention. We found that: 

•  The process is limited regarding policy and procedure compliance with best practices and the 
Home is overly reliant on the registered manager to keep these up to date. There is a potential 
risk that policies and procedures are not updated in a timely manner. 

•  Although the manager has implemented a falls management policy and had personalised it to 
the  home  it  was  evident  from  the  care  plans  reviewed  that  this  policy  was  not  yet  fully 
embedded into the organisation's culture as the care plans did not always correlate with the 
policy. 

•  The policy folder itself is difficult to navigate as there is no division of policies to make finding 

policies easy. 

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 •  There  was  a  form  of  trend  analysis  on  a  resident-by-resident  basis.  However,  this  did  not 
translate into an organisation-wide action plan, and there was no evidence of staff learning 
from incidents and accidents. 

•  Care  plans  were  present  but  these  were  not  personalised  and  information  from  external 

agencies did not always get reflected in the care plans. 

•  There  was  no  formal  delegated  responsibility document from Trustees to ensure that they 
were involved in clinical governance and that boundaries and escalation expectations were 
set. 

•  The manager  undertook  audits  but these served more as a review of individual care plans 
rather than a means to improve practice across the home. The audits completed were not 
based  on  compliance  with  the  organisation's  policies.  The  audits  acted  as  a  review  of 
documents, with no measure of outcomes against best practice guidance. 

•  The home would benefit from becoming a learning organisation with a no-blame culture to 

promote reported incidents and lessons learned.  

Whilst there is a significant need to improve clinical governance, at no point during the visit was it 
considered that residents did not receive kind care.  

Recommendations 
The Home has made significant advances since August 2021. In addition, the Home has a dedicated 
manager who appears to have a good relationship with the staff, residents and trustees which makes 
implementing new governance systems and creating a learning environment much more achievable. 

Our specific recommendations are therefore: 

1.  To  improve  policy  and  procedure  maintenance  and  communication  of  changes  the  Home 
should implement an online total quality system provided by subscription and maintained by 
the  system  provider.  Staff  will  have  better  access  to  policies  and  procedures  and  will  be 
automatically informed of changes as ‘best-practice’ in the care sector continues to evolve.  

2.  To improve care planning and record keeping the Home should implement an electronic care 
planning system. If the correct system is purchased, it will prompt the linking of care plans to 
risk assessments, will enable good quality trend analysis and facilitate point of care delivery 
record keeping. 

3.  To  improve  the  understanding  of  clinical  governance,  trustees  and  senior  staff  should 

undertake training and implement an overarching action plan and risk register. 

Conclusion 
The  board  of  trustees  and  the  registered  manager  are  committed  to  making  sustainable 
improvements. They have already made significant improvements in the management of falls and the 
overall clinical governance of the home. 

There is a group of long-serving dedicated staff who know the residents well and provide kind, caring 
care but do not have the best tools to ensure that the care they provide is following best practices and 
based on risk management. In our view the implementation of training and electronic systems will 
assist the process of embedding learning, risk management and escalation to outside agencies. 

The arena within health and social care, particularly relating to clinical governance, risk mitigation and 
escalation pathways to external agencies, came about after the mid-Staffordshire enquiry known as 
the Francis report published in February 2015. The report changes the focus and management within 

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 health and social care dramatically. For all care homes with long-standing staff teams, the impact and 
importance of this report may not have been fully understood. 

The use of risk ratings, risk registers, action plans, evidence of actions and reviews of effectiveness 
such as audits and policy reviews are all essential elements of good governance. 

Recent events have been the catalyst for change and in our view if the recommendations we set out 
are accepted and acted on then these will ensure that ‘clinical governance’ at the Radcliffe Manor 
House is fit for the future.  

Director 
Swift Management Services Limited 

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