Gunapathyammah Ragnanathan

16 ARROW SCOUT WALK, RUISLIP ROAD,  NORTHOLT, MIDDLESEX, UBS  6EE 

8th  May 2023 

TO THE  CORONER'S INQUEST-
REFRLECTION  ON THE ACCIDENT THAT HAPPENED TO THE  LATE  MRS GR. 
I have read the Coroner's record of inquest and the concern raised in the report and 
I make this  submission  in  response  to the  Coroner's  request.  Anywhere  I fail  to 
make  or  answer  to  specific  issues  raised,  this  should  not  be  deemed  as  an 
admission of any fact. 

I am conscious of the fact that the Coroner in the cause of this inquest, would have 
received lots of evidential submissions, therefore I apologise in advance if I attach 
any  evidence  that  the  Coroner  may  have  previously  seen,  which  therefore  is  a 
duplication. However, I have the following observation to make. 

An  additional  statement A5b,  submitted  by  a  family  member of the  Late  Mrs  GR, 
expressed the view that 4 days of the carer shadowing  the experienced carer was 
not sufficient.  In  the  past,  when  the  family  expressed  concerns,  we  have  always 
immediately  actioned any concerns raised  to meet the desired outcome. 

Occupational therapist assessment stated the Late Mrs GR was frail  and  unsteady 
but despite this report, Social Services over-looked the risk element and continued 
to press that one care assistant is needed to Care for Late Mrs GR. 

Social Services for some reason  under-estimated  Mrs GR's care  needs,  possibly 
because of their quest for financial saving. They ignored the risk posed to the client. 
I draw these facts from the records that the Late Mrs GR's care needs, when under 
the CCG,  was  provided  by two Carers.  However,  for some reason,  when the  Late 
Mrs GR care was taken over by Social Services, the provision of care was reduced 
to one carer to avoid charges that would have been  imposed on the Late Mrs GR 
to make partial contribution for her care.  I understand that Mrs GR expressed  her 
inability to pay,  because she only has her late  husband's pension  as  her income, 
and any such payment would impoverish her and diminish her quality of life. 

Mrs GR's care was assigned to my agency on 5TH  August 2020, to provide a total of, 
2hrs15min.  care  hours  a  day  (broken  down  in:  45mins  in  the  Morning  X1Care 
Worker, 30mins Lunch Visit X1Care Worker, Tea time Visit X1 Care Worker 30mins, 
and  Bed Time Visit X  1 Care Worker  30mins.  All these daily visits are X 7 Days a 
week. 

It was  known  by Social Services that the Late Mrs GR was 86  years of age,  with a 
desire to mobilise with her Zimmer frame. She was frail, and has health condition 

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 which affects her mobility, and had a previous fall in the past,  prior to LCM  taking 
over her care, which family did not disclosed this to us.  All these factors in her safe 
handling, which should  have involved 2 carers,  as stated  in the original NHS  care 
plan was ignored by her family and by social services, who again, in their quest  to 
cut costs, reduced  the number of carers from 2 to 1. 

Turning  now  to  our  training  programs  and  policies,  our  agency  has  training 
procedures  beyond  those  submitted  to  the  Coroner  at  this  inquest.  Please  see 
attached  correspondence with  our new Training  provider and  our new Policies & 
Procedures Consultants.  With  their support, these are  the  actions we  have put in 
place. The Coroner will  note that most of the training given to staff were  regularly 
assigned to an  external body, which includes training entrusted to Social Services 
training portals. We had a shadowing  procedure in place at the time of the accident. 
I accept that  it may  not have  been  entirely adequate,  but the accident of the  Late 
Mrs GR has exposed  the need for improvement. 

The seriousness of this accident prompted me to suspend  trading and  place LCM 
in  dormancy  to  enable  me  to  re-evaluate  our  entire  operation,  develop  decision 
for 
making  and  organisational  structure  with  a  service  development  blueprint 
future practice. 

ACTION  REQUIRED AND TAKEN TO  DATE 

There will be new management in place. I will step down in my role as Registered 
Manager. 

•  New training and assessment systems will be considered and implemented. 
•  Moving and  handling component to specifically include in testing  knowledge 

of safe Zimmer frame transfers, and how to respond to emergencies. 

•  New  policies  and  procedures  to  be  developed,  including  records  for 

shadowing and competency observations. 

•  An ongoing quality monitoring of training is to be implemented. 
•  New care plan and risk assessment format to be developed and implemented. 
•  Senior staff training  in  all  areas to be  redeveloped,  including  importance of 

• 

"new carer test" in Manual Handling. 
Induction training to include the importance of reporting when care plans are 
notusefuloroutofdate. 

•  Spot checks to include accuracy of the care  plan  and  assessments, suitable 

recording format to be implemented. (Electronic recordings). 

•  Office and senior staff training to include written communication skills. 
•  Management and  senior training to include "blame free"  culture and  duty of 

candour. 

•  Care planning and consent - Staff training in this area to be improved. 
•  Quality assurance and  governance - Calendar and  systems to be  developed 

and implemented. 

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 Moving  forward,  Lean  on  Me  Community  Care  Services  Ltd  has  taken  decisive  action  and 
requested that the CQC  place Lean  on  Me on  Dormancy Status. This was to allow me the time 

and space needed  to reflect upon the entirety of the Day-to-Day  operations of Lean  on Me as 
a result of  the accidental death of Mrs GR. 

In  future,  all  our staff training  needs  will  be  sourced  out to a Training Agency that  has  been 

suitably vetted by my Local Authority as their preferred training providers, so that the training 
needs of Lean  on Me are fully in line with  Skills for Care and CQC Standards of good practice. 

In this  response,  you will notice further action plans in  the email correspondence  I 
have  had  with  the  Local  Authority's  preferred  training  providers  dated:  February 
2023,  March  9th  2023,  March  1oth  2023,  March  13th  2023,  March 
2nd 
31 st  2023,  April  21 st  2013  and April  26th  2023. 

2023,  March 

3rd

Please see attached evidence of such  communication. 

You will notice that I have identified a wide range of training needs, which I believe  Lean On Me 
staff will benefit from, so that future care related accidents and incidents  will not occur under 
Lean On Me's watch. 

You  will also  notice a breakdown  of the Health  and  Social  Care  training courses  which  I have 
identified to be  beneficial to all  Lean  On  Me care  workers,  including the  Management Team; 
regardless of their previous experience, qualifications acquired  in care or in other professions. 

All  applicants  who  have  been  successfully  vetted  and  who  have  accepted  our  offer  of 
employment,  must attend all grassroots training courses Level 1 and Level 2 Induction Training. 
All staff must  work within Lean  On  Me's Policies and Procedures guidelines , which are in line 
with CQC standards of good practice,  at office level and in the field. 

You  will  notice  that  in  my  correspondence  with  the  training  providers,  a  breakdown  of the 
training durations - that is, the start and finish times - have been stated for each of the courses 

that they will provide to Lean  On  Me staff. It is in the best interests of Lean On  Me to adhere to 
these training  guidelines, working in close collaboration with the training providers,  because 
they are experts in care training. In addition,  as they are the Local Authority's preferred training 

providers, I believe that their training would  be up to date to reflect any changes  that may have 
occurred  in Skills for Care and/or the CQC as  a regulatory body. 

I have also requested specific areas of support from the training providers which I believe would 
benefit me and my team. I am grateful for the support that the training providers have given to 
me so far,  signposting where I can  access and  learn more about further training needs, so that 
all prospective staff of  Lean On  Me can  benefit from these  trainings. 

I am  committed to see  that all the  logistics  required for this agency are firmly on the ground 
while I am still in post. It is my responsibility to ensure that Managers, Field Supervisors, Care 

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 Coordinators, Quality assurance officers and  Field care workers, must all, again,  undergo the 
training  courses  starting  at  level  1  Induction  training,  and  level  2  Care  Award.  This  will  be 
followed by further training in "STRENGTH  BASED"  COURSES,  including "TRAIN THE TRAINER", 

so  that our field  supervisors,  care  coordinators, managers,  quality assurance  officers all  have 
the  knowledge  required  to support field  care  workers  when  they  require  additional  support 
from the office staff. 

All  office Management staff, field  supervisors, field  Care workers who wish to take 
extra  training  in  Specialist courses  as  CPD  for  their own  learning,  will  equally  be 
encouraged and supported to take the advantage of these courses. 

There  will also be  ongoing Refresher courses that are  Mandatory for all Staff to attend as  the 

need  arises 
performance monitoring  will be implemented. 

including  Continuous  Professional  Development  (CPD)  courses.  Ongoing 

Lean on Me  will also source out further training in Leadership and Management qualifications 
for those  Management staff, who have not yet acquired such  qualifications. This will be linked 
with the volume of clients we have acquired, that can  enable us to sustain training support for 
of our staff, who are happy to acquire further skills in Health & Social Care. 

Lean  on  Me  will  ensure  that  incentive  opportunities  are  made  available  and  are 
given  to  our  most  committed  care  workers,  who  have  demonstrated  their 
commitment.  working very well with the clients we have. Loyalty incentives will be 
awarded  as  an  additional  bonus  to  those  care  workers  who  have  demonstrated 
loyalty to Lean on Me through  "thick and thin". 

Again, I will no longer be actively  involved in the day-to-day activities of Lean on Me Agency. As 
soon as I am satisfied that all the Logistics of Lean On Me are firmly in place. 

I  have  recently  recruited  7  management  personnel.  The  7  applicants  already  have  acquired 

more  than  5  years'  experience  working  in  Health  and  Social  Care.  One  has  Leadership  and 
Management qualifications in care, and has been earmarked as a future Manager, because she 
has  worked  as  a  Registered  Manager for a  large  Care  provider  in the  past.  Another possible 

manager has Adult Nursing  qualifications from Massachusetts USA,  and  is  currently doing UK 
NMC adaptation. He  has also acquired  other qualifications in the USA:  A bachelor's degree in 
public health  and  an  NBA  master's  degree  in  business  administration . I have two field 
care  supervisors  with  over  10-years  previous  care  experience,  including specialist  training 
courses acquired when they worked in  other Care provider organisations. 

This being said, we are still  recruiting  all who are interested to work with Lean  On  Me - Care 
workers and  field Care Supervisors. Our goal is to have a good number of field care supervisors 
who are  competent to work alongside  care  workers  during their field  shadowing training, so 
that they can  appraise their performance in the field and decide if the new care worker is fit to 

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 continue as  a care worker or not. For those care workers who have not acquired RQF,  they too 
will be supported to enrol in RQF courses. 

Although we have recruited 7  management staff, we still have a long way to go to reach 

our desire number. The current number of 7 staff,  will not  make business sense to 
pay  for  their  training,  because  the  training  provider  has  informed  us  that  the 

maximum number of  staff cannot exceed 12 attendees in any given course. 

BELOW  ARE  CONTACT  DETAILS  OF  THE  TRAINING  PROVIDERS  AND  THE  CONSULTING 
AGENCY THAT WE  HAVE CONTRACTED  TO  SUPPORT US  ON AN ONGOING BASIS. 

(1). FIRST RESPONSE TRAINING COMPANY,

  Ealing  Council  also  uses  First  Response  Trainers  as  one  of their  vetted 

providers. 

(2).  CQC  EXPERTS  has  provided  all  new Policies  and  Procedures  that  are  required  to run  an 
effective and efficient  Health & Social Care  Service. 

. They  have  supplied 

over  600  new  care  documents  to  Lean  On  Me,  including  over  100  Policies  and  Procedures, 
available on request. Lean  On Me now has complete A -Z Policies and Procedures in place. 

As we do not have any service users whose care needs involve regulation 9 Regulated  Activities . 
we are attaching to you a blank copy of our new FIELD  SHADOWING FORM. 

I  hope  the  attached  information  is  helpful  to  enable  you  to  consider  how  I  have  seriously 
reflected on this accident, to prevent accidents or incidents from happening in the future. 

Sincerely 

(Registered Manager) 

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