Lilian Shearing

Inquest of Lilian Shearing 13/09/2022 

Regulation 28 – Tanglewood Cloverleaf Care Home 

Training 
It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood 
homes  has  been  enhanced  significantly.  Throughout  the  pandemic,  work  has  been  ongoing  to 
continue to provide essential training. A new platform for e-learning was introduced which enabled 
team members, both newly employed and established, to access ongoing training throughout this 
period. There has been a continued focus on the importance of nutrition and hydration and how 
we support residents in all stages of their later life and what we can do in the event of the individual 
declining adequate nutritional and fluid intake  required to sustain life.  A care plan manager has 
been  employed  to  oversee  the  care  plans  and  content  in  all  homes  ensuring  the  standard  of 
documentation  is  consistent,  this  person  also  provides  training  to  all  care  teams  to  ensure  the 
process  is  understood.  Regular  audits  are  completed  for  each  home  with  action  plans  for 
completion where identified. These actions are followed up, checked for completion and verified. 
Policy & Procedure 
We have reviewed the content of the Nutrition & Hydration policy and amended the content to 
include current practice of monitoring and recording all intake (see appendix 1), how we support 
the  resident  who  may  be  reluctant  to  accept  food  and  fluids  especially  at  end  of  life,  and  the 
importance of recording if a resident declines assistance or intervention. What we do if a residents 
daily fluid target appears excessive and is not consistently achieved over a 7-day period and how 
we manage and record the discussions with the GP and family members in relation to this. 
Admissions to Tanglewood homes 
The outcome of Mrs LS inquest was discussed at a manager’s meeting on  27th September 2022, an 
overview was provided from the point of transfer to the home, we reviewed the pre-assessment 
information available to the home which was very comprehensive and the fact that two members 
of staff accompanied Mrs LS on the transfer to ensure information was relayed to the team at the 
home. 
We have set up the admission process over two time frames the first being 24-hours to complete 
key documents, this can be done using a pre-assessment document and additional information from 
family  members  – a  nutrition  &  hydration  assessment  is  included  – and  the  formulation  of  the 
remainder of the care plan within 7-days as this is a live document that will continually evolve. In 
addition  to  written  referrals  or  transfer  documents,  residents  and  their  families  are  actively 
involved  in  providing  information  which  enables  us  to  provide  consistent,  holistic  care  for  the 
individual. 
Daily oversight – all homes 
Each Tanglewood home completes a daily clinical oversight and operational report, this has been 
developed and implemented during the past year. It gives the Directors a complete overview of all 
allocated  services,  the  documents  are  saved  down  each  day  and  reviewed  by  the  registered 
manager of the home and the  regional manager, with actions carried forward to ensure nothing is 
missed (An example copy of this has been attached as Appendix 2). 
We have improved communication with family members by completing Resident of the Day records 
– this ensures we are contacting next of kin/POA to discuss the individuals wellbeing each month in 
line with this process. Changes to a person’s health is communicated to the family as soon as it is 
identified with additional information being added to the care plan. GP referrals are made through 
direct contact with the surgery or through Ask My GP. 
The resident of the day forms are checked and signed off daily by the Home manager and Regional 
Manager and any follow up is recorded. 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Ongoing regulatory visits to all homes by the Regional Compliance Managers 
Each Regional Manager has a portfolio of a maximum 4 homes, we are responsible for supporting 
the managers in all areas of compliance to ensure the standards and practices are consistent across 
the group. As part of the discussion and outcome surrounding the events prior to Mrs LS’ admission 
to the home and subsequent concerns relating to her condition prior to hospital admission we have 
very carefully considered lessons learned which we have taken forward as a group. 
Feedback has been given from a recent inquest on 12/10/2022 (WH – a late resident at another 
Tanglewood home) whereby it was commented on by the coroner about the recording of all fluids 
given and offered to the resident, it was evident from the records that even when refused – it was 
documented  –  this  is  a  direct  result  of  the  ongoing  focus  on  the  importance  of  recording  all 
incidences of acceptance and refusal of care interventions. 
Lessons learned 

•  On admission – ensure all information/transfer documents have been read and understood 
– staff are to complete 24-hour records and proceed with formulating the live care plan 
over the following 7-days as per process 

•  Ensure  that  any  risk  assessments  required  are  completed  to  ensure  minimal  risk  to  the 

person 

•  Ensure any daily charts required are activated from the admission date e.g., ADL’s, food & 

fluid intake 

•  Ensure that resident families/representatives are informed of any changes in their health 
promptly to enable them to visit the home or attend at hospital – staff to record all contact 
made 

•  Discuss  the 

information/documentation  available  with  the  resident  and/or  their 

representative to ensure all areas of concern are covered 

•  Ensure  ALL  communications/discussion  held  are  recorded  on  the  relevant  form  on  the 

electronic care plan system (iCare or PCS) 

•  Ensure that ALL referrals to external agencies are actioned and followed up timely with all 

communication recorded on the care plan system 

•  Ensure 

the  resident  and/or  their  representatives  are  kept 

informed  of  ALL 

requests/referrals including dates of appointments or visits 

•  Ongoing  face-to-face  staff  training  within  the  homes  to  embed  the  importance  of 

maintaining records and documentation to provide evidence of care provided 

•  Ongoing  staff training within  the  homes  to  ensure that  all  nutritional  and fluid  intake  is 
recorded even if declined as we are unable to force residents to take food & fluids if they 
refuse 

•  The provision of a Nutrition & Fluid Information Folder for each home which will be included 
in  home  meeting  discussion  and  available  for  team  members  to  access  for  future 
information, this will be added to as we move forward 

Outcomes 
We have identified the following as part of the review surrounding this review 

• 
• 

• 

Improved communications between homes and families/representatives 
Fewer complaints regarding care due to more frequent contact with families / 
representatives 
Improved record keeping and documentation – this is an ongoing process which includes 
all new & established employees 

•  Daily clinical oversight and resident of the day records have provided the senior 

management team with a clearer overview of all services 

Shared information 
All Tanglewood homes have received the information pack that has been submitted to the 
coroner as evidence of the progress that has been made and sustained during the past 3-years