Eileen Walsh

Broadland View Care Home – Response to Regulation 28 
1.  A Night Working Policy was being prepared but this is still not completed some 3 years following Mrs 

Walsh’s death. 
I.  The Night Working Policy is a recent part of our continuous improvement and not part of the 

improvements 3 years ago. In our experience, it is not usual that a Care Home has a specific Night Work 
Policy. We chose to write this policy recently because of all the improvements that we have made over 
the last 3 years, and we wanted to consolidate all the work, where it related to Night Work specifically, 
into one policy.  

II.  Broadland View decided as a part of continuous Improvement to have some enhanced actions they 
could take, to bring together the learning and information that night staff specifically need, into this 
policy. 

III.  The main focus of improvement 3 years ago, was to implement a process that reduced the risk of wilful 

neglect by care staff, which was the Daily Notes Audit. 

IV.  When this audit was introduced, we investigated night observations across all residents and staff over a 

period of 12 months and it was only the one staff member that was prosecuted that falsified the records. 

V.  We still run this audit daily to ensure that no staff member pre-records observations. This written 
process was, and still is very successful, and has now become part of the Night Working Policy. 

VI.  The content of the Night Work policy is based on the Induction and training that Night staff have always 
had and information from policies on expected practice, so the information has always been in place. 

VII.  This tailored policy was uploaded onto the QCS system and added to the reading list for staff on 

01/08/2023, which was always its planned date for implementation. 

VIII.  Broadland view have a comprehensive policy and documentation electronic system in place (QCS) which 

is a long-standing external policy provider for care establishments. 

IX.  With the Daily Notes audits put in place immediately after the incident guidance was written for Care 

staff and Management on the recording expectations for night observations.  

X.  To clarify, the night work policy is an enhanced action that we took as part of our continuous 

improvement plans. 

XI.  The following existing forms were reviewed and included in the Night Working Policy and Procedure, as 

part of our consolidation exercise: 

Senior Task checklist 

-  Guidance for Daily Notes Audit - Care Staff 
- 
-  Handover Report 
Spot Check Form 
- 
-  Medication Observation Competency 
-  Observation forms x 6 

XII. The new alarm system has been installed, and the Night Working Policy has been updated to include 

this.  

2.  Evidence was heard that a new electronic system to monitor checks on residents was being sourced. This 

is not in place some 3 years following Mrs Walsh's death. 

I. 

The current Nurse call system was in place at the time of the incident and was regularly checked, 
however, the mat alarm in Mrs. Walsh’s room was reported as not working when the incident took 
place. The former Registered Manager, at the time of the incident, who was a very experienced care 
manager, was responsible for the alarms and their consistency to work and did not report that the 
system needed changing. 

II. 

Immediate actions at the time of incident 3 years ago: 

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  - Daily notes audit: to monitor and audit night observations 
 - Walkie Talkies: to enhance communication between staff and work in every area of the building 
 Further actions taken: 
 - additions made to ensure that staff limit the time in laundry/medication room 
 - Daily audit of handover, this includes call mats. 
 - 2nd line sampling of daily notes audit by the Care Manager 
 - If there is a discrepancy in the night checks, staff are required to explain why and complete an 
incident form around this. 

- Interim monitor system put into Laundry and Meds room so that alarms can be heard. 
- Alarms tested to ensure that they can be heard from all rooms. 

IV. 

III.  Medication is administered from a mobile secure medication trolley, and the only time that the 
Senior carer is in the Medication Room is to collect and return the trolley. They are instructed to 
have the door open whilst they collect and remove the trolley then close and lock it afterwards. 
Audits on controlled drugs and homely remedies is only completed when both management are on 
site ensuring that a senior member of staff is able to hear the alarm. Interim monitor system was 
installed into the medication room until the new monitoring system was fitted. 
Time spent in the laundry room is only a problem at night, as this is when the bulk of washing is 
done. Before staff enter the laundry room, they communicate the intention to do so via Walkie 
Talkie, then laundry trays are brought into the communal area on a laundry trolley. The laundry is 
then folded and sorted where alarms can be heard. Staff must radio to say that they are going into 
the laundry which will consist of loading/unloading the washing machine and driers, and then clean 
laundry is brought into the communal area to sort. When a staff member is in the laundry room, no 
other staff member will be on their break. This is managed by the senior carer. Interim monitor 
system was installed into the laundry room until the new monitoring system was fitted. 
New monitoring system: This is part of our continuous improvement plans. The Medicare system 
means that accurate recording of room checks, and response times will all be documented, and a 
detailed report can be obtained. There are sounders in all locations within the home ensuring that 
all staff can always hear the emergency alarms during their shift. 

V. 

3.  Evidence was heard that carers are responsible for work alongside caring for residents, including cleaning 
and laundry, A Night Tasks List was referred to as being “currently under review” and under the heading 
“Actions” was included “Implement revised night staff task list” in an investigation carried out by Adult 
Safeguarding in an Adult Safeguarding Record from 2022. As at the date of the inquest this document was 
not complete. There was no evidence as to what this List would include. 

I. 

II. 

III. 

IV. 

V. 

The Night Task checklist was reviewed, and the purpose was to determine whether the laundry 
would remain as part of Night work. It was decided that both laundry and kitchen tasks would 
remain on the task list, for night staff, as this is common practice in care homes to assist with the 
smooth running of the service, however doing these tasks must not have any impact on the care and 
support that the residents need during the night, as care and support takes precedence. 
The handover report includes reporting on laundry and kitchen tasks and handing over any 
unfinished tasks to the day staff where care and support duties have been the expected priority. 
The residents support and care through the night takes precedence and always has. It is the Senior 
Carers responsibility to carry out resident observations, calling on the carers if extra help is needed. 
The carers on duty prioritise personal care and supporting any residents nightly needs and 
preferences. They will only perform housekeeping duties if the shift allows. 
The checklist underwent further review prior to the implementation of the night work policy and 
procedure. 

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 4.  An investigation carried out by the Home found that records had been edited and some falsified by a 

member of staff. A statement made by the new Deputy Manager at the Home dated 14 July 2023 stated 
that only senior management could go into the system to edit existing records. Evidence was heard at the 
inquest from the Registered Manager who stated that care staff can access and edit the records. It is a 
concern that senior management are unaware the system can be edited as well as a concern that it is 
acceptable for staff to edit entries. 

V. 

III. 

IV. 

I. 
II. 

It was the former Registered Care Manager that gave evidence at the inquest. 
Care staff need to have edit rights on a resident’s care notes in order to record the work that they 
carry out. They will record their notes via the handheld devices that they carry on shift. 
However, they can only edit the care notes by going to the office and doing this via the computer, 
which is under the supervision of the Senior carer or the Management team. 
The reason that a member of staff could edit the notes at the time of the incident was because they 
were a Senior carer, and the member of staff whose login was used was also a trained Senior carer, 
so they had access to the computer at the time of the incident. 
The current Care Manager and Senior staff are fully aware of the edit functionality and access 
permission for care staff. 
The system CareDocs. is used throughout the health and social care sector, in many care homes, and 
the edit rights would be the same for those services.  
The former registered Care Manager and former Deputy also undertook daily audits of the system 
which were immediately put into place after the incident when they found that real time records 
could be found for the night observations. The Daily notes audits have been ongoing daily since the 
incident. We have found no edits made for night observations, except for the falsification of records 
by the member of staff that was prosecuted. 
 CareDocs were contacted asking about the function of being able to edit, their response was that 
this cannot be amended, if the edit function is removed from staff, they are not able to complete 
any record keeping. This is monitored by Seniors on duty, the Care Manager and Deputy. 
5.  Conflicting evidence was heard as to whether night staff are allowed to sleep during breaks whilst on night 

VIII. 

VII. 

VI. 

shift. 
I. 

II. 

Staff working at night are referred to as Waking Night Carers which means that they are not allowed 
to sleep on shift. 
However, if a waking night staff takes a break, authorised by the senior carer, then this is their own 
downtime. They can choose to nap in that break as long as they are contactable in an emergency, 
and they are back on the floor at the expected time. 

III.  Waking Night Carers are not allowed to sleep whilst on shift, however what they do in their 

downtime is their decision. If they are struggling and feeling tired, then they are to inform the senior 
ensuring they get the correct support. 
This information is part of Night staff Induction but is also in the Night Working Policy. 
The Care Manager and Deputy continue to complete 2 to 3 spot checks a month. 
 Managers will work part or full night shifts periodically to observe working practices of night staff 
and give them support. 
 The Night Work Policy is available in the staff area. It is also uploaded to the QCS policy system 
where staff have access to all policies. 

IV. 
V. 
VI. 

VII. 

VIII.  Managers discuss the new Night Work policy at staff meetings. 

IX. 

Staff receive practical training in Safeguarding and whistleblowing to ensure they are confident in 
reporting any member of staff that is found sleeping when they should not be. 

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 6.  The warning alarms requiring immediate response cannot be heard in all places at the Care Home. It is 
understood walkie-talkies have been introduced for use by all staff, but this adds in another step to be 
taken by staff before the alarm is responded to. 

I. 

The areas identified where warning alarms may not be heard are the Medication Room and Laundry 
Room. At the Inquest there was mention of alarms not being heard from Rooms 1 & 2, by former 
employees working at the time of the incident. 

III. 

II.  Medication Room: The new monitoring system is now in place and prior to this medication was, and 
still is administered from a mobile secure medication trolley. The only time that the Senior carer is in 
the Medication Room is to collect and return the trolley. They are instructed to have the door open 
whilst they collect and remove the trolley then close and lock it afterwards. Audits on controlled 
drugs and homely remedies in the medication room are only completed when both management are 
on site ensuring that a senior member of staff can hear the alarm. Also, an interim monitor system 
was installed into the medication room until the new monitoring system was fitted. 
Laundry Room: The new monitoring system is now in place and prior to this, the laundry room was 
only a problem at night, as this is when the bulk of washing is done. Before staff enter the laundry 
room, they communicate the intention to do so via Walkie Talkie, then laundry trays are brought 
into the communal area on a laundry trolley. The laundry is then be folded and sorted where alarms 
can be heard. Staff must radio to say that they are going into the laundry which will consist of 
loading/unloading the washing machine and driers. Clean laundry is then brought into the 
communal area to sort. When a staff member is in the laundry room, no other staff member will be 
on their break. This is managed by the senior carer. Also, an interim monitor system was installed 
into the laundry room until the new monitoring system was fitted. 
Rooms 1 & 2: this was only raised at the Inquest, but the current Care Manager reported that the 
alarms can be heard in this area. She has since tested to ensure this and the alarm from could be 
heard from rooms 1&2, prior to the new monitoring system being fitted. However as additional 
precaution, sounders have been placed near these rooms ensuring that the emergency can be 
heard. 

IV. 

7.  The Director of Training and Operations referred to the Incident Investigation carried out internally and 
found that PIR sensors were not in use in Mrs Walsh’s room at the time of her fall. PIR sensors were 
referred to in witness evidence and also in Mrs Walsh’s Daily Care Notes. It was found at the inquest a PIR 
sensor was in Mrs Walsh's room at the time of her fall and the PIR sensor did not sound an alarm as 
required in the Care Plan, at the time of Mrs Walsh’s fall. It is a concern this investigation did not read Mrs 
Walsh’s Care Notes before reaching this conclusion when concerns that the PIR sensor did not sound could 
have been addressed. 

I. 

II. 

III. 

IV. 

The Director of Training and Operations (DTO) is not an employee of Broadland View Care Home 
(Medicare corporation) and is a remote worker, for another business. 
The DTO of Careskills Academy questioned the PIR Sensor in their statement for the inquest because 
the former Care Manager, employed at the time of the incident, was unsure whether there was a 
PIR sensor in Mrs Walsh’s room, which became known during the inquest preparation. It would have 
been the Care Managers responsibility to ensure that the correct sensors and alarms are in place for 
each resident and have knowledge of which sensor alarms are used by each resident.  
The DTO from Careskills Academy was asked at the time of the incident to guide the Deputy 
Manager in an investigation of CareDocs to ascertain whether night staff had recorded their 
observations correctly as there were questions being asked about the length of time that Mrs Walsh 
was on the floor, at the time of the incident.  
The Deputy Manager, employed after the incident, found that real time entries were also recorded 
with the night observation times in a report from the back end of the system and based their 
investigation on this, then sent their findings and evidence to the DTO of Careskills Academy who 

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 V. 

VI. 

VII. 

looked at all the evidence submitted and wrote a summary report of their findings, based on the 
evidence given to them.  
The investigation evidence that was presented at the time determined that there had been 
falsification of records in the CareDocs system for the night observations carried out.  
The DTO of Careskills Academy referred to only the alarm mat not working in their summary report 
as this was a finding from an incident report submitted with the Deputy’s evidence. There was no 
evidence submitted to them that mentioned a PIR Sensor. 
The DTO of Careskills Academy did not have access to CareDocs and therefore would not have seen 
whether a PIR Sensor was mentioned in the care plan. They were only involved in looking at the 
evidence pulled from the system regarding night observations and balancing this against staff 
incident reports, which mentioned that the alarm mat did not sound. 

8. 

 (8a) The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs 
Walsh’s death, and raised similar concerns as raised during this inquest, including: 
a) Safeguarding concerns had not always been appropriately identified and referred 

I. 

II. 

The Safeguarding concerns referred to involved one member of staff. The Care Manager apologised 
on the day of inspection and notifications rectified.  
The Care Manager questioned the Inspector because medication errors referred to were proven to 
be ‘near misses’ so no errors were made and therefore this was the reason that a safeguarding was 
not made. The inspector said that ‘near misses’ must also be raised as safeguarding, which is not 
something that is usually done. We would like to reiterate that the medication in question was 
successfully and safely taken by residents. 
This member of staff had given poor personal care on one shift which was addressed and did not 
happen again. The manager apologised for not raising a safeguarding on this occasion and this was 
subsequently done.  
This member of staff was suspended after the medication near misses, investigated, then dismissed 
and reported to the Disclosure and Barring Service, before the CQC inspection took place. 
(8b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days 
later. 
I. 

IV. 

III. 

On the day of inspection, a sensor mat was found to be faulty and changed immediately, as is normal 
practice. The Care Manager had not done their daily walk round of the service where they test the 
sensor mats, because of the arrival of the CQC Inspector. 
It is common in care that senor mats can become faulty or stop working, and there is a process in 
place for testing and replacing them. For the mat in question there had been a fault recorded on 
27.01.2023 where the mat and the box had been replaced on the 28.01.2023 by the maintenance 
team.  
On the daily checks recorded by the seniors, the mat was then reported as working until 10.02.2023 
when there was a fault mended by Maintenance. The mat was reported as working every day from 
10.02.2023 up until the inspection on 20.02.2023. It was working on 19.02.2023 when tested which 
was the day before the inspector arrived. 
Sensor mats are checked 3 times a day, once by the day senior, once by the night senior, which is 
recorded on the Senior Task Checklist and then again by the Care Manager/Deputy on their daily 
walk round. The Maintenance team alarm checks have now been increased from Monthly to Weekly. 
If mats require changing, they have always been documented either on the senior task list, the 
managers walk round, or the maintenance checklist, dependent on who changes the mat. This 
information is also handed over on the handover report. If the call point is faulty then extra checks 
will be completed on the resident that night until maintenance are on site to repair, it. 
The Handover Report has regularly been reviewed and updated. Call mats are included on the 
handover report. Staff are required to change at the point of failure, and if the call point is damaged, 

II. 

iii. 

iv. 

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 v. 

vi. 

vii. 

then additional checks will be required, and if it is a busy night the on-call manager will be asked to 
come in to support the home or put in an additional member of staff to help with the extra checks. 
Night spot checks continue and have always been part of the Care Manager’s practice. This is now 
recorded on the managers monthly reporting sheet, and on the night shift audit. Testing sensor mats 
is also part of the managers spot checks. 
There is always a stock of spare mats for replacement and the current Care Manager has sourced a 
more robust type of mat that does not require sticking down as they are naturally non-slip. 
Faulty mats are replaced immediately and if the call point is found faulty then observations are 
increased to every 30 mins until fixed. Staff are aware to notify the management team when the 
replacement mats are running low. 

viii.  A new monitoring system has been installed to further enhance the Nurse Call system already in 

place. This has added sensors for staff to actually login when they enter a resident’s room, and the 
system also connects to the sensor mats already in place. The manager will be able to check call 
response times more accurately, and observations that take place in real time physically. This 
information can be pulled up on a daily report, at this moment in time it is also being cross 
referenced with the notes being input onto CareDocs, ensuring that timings are the same or in 
proximity. 
Staff have been and continue to be trained on how to use the new system, and feedback has been 
positive. 

ix. 

(8c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified, and 
effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of 
harm. 

i.  This incident relates to one member of staff on one night shift and is the same member of staff 

referred to in section 8(a) of this report.  

ii.  The member of staff in question came with two excellent references which did not give any reason 

to give cause for concern at the time. The member of staff upon starting at Broadland View 
presented as keen to learn, and enthusiastic in their role, was involved and person-centred with the 
residents, and up until the delivery of poor personal care and concerns with medication practice 
there had been no reason to be concerned about their performance.  

iii. After this incident, the staff member was supervised and observed on all medication procedures 

until suspended and finally dismissed. Training, working, suspension and dismissal was over a period 
of 5 weeks. During this time, they did not work every day and had a period off sick, where they were 
hospitalised. When they returned to work after the period of sickness, they did not lone-work and 
were observed by management before being suspended and subsequently dismissed. 

iv. Managers continue to complete 2 to 3 spot checks a month. Managers will work part or full shifts to 
observe working practices of staff. Managers discuss the Night Work policy at staff meetings and a 
copy is available in the staff area. Staff are confident to follow the whistleblowing policy and 
Safeguarding is discussed at all staff meetings. Staff receive practical safeguarding and 
whistleblowing training with scenario-based exercises. 

v.  As part of lessons learnt, the Staff Induction Record has undergone another review and additional 

observation reports for staff have been implemented. 

vi. The Care Manager will refer staff that have been dismissed sooner to the Disclosure and Barring 

Service, if appropriate and did this in November 2022 when a longstanding member of staff block 
booked too many observations after they had taken place. 

(8d). Recent audits carried out by the Home had not identified concerns found by the CQC 

i.  Daily notes audits are carried out daily and pick up in real time when observations are entered. On 

the day of inspection, the CQC Inspector asked to see the night spot checks, which were shown. This 
is a record of what happened at that moment in time when the Manager appears unannounced in 

Page 6 of 7 

 
 
 
 the service. However, it is the Daily Notes Audit that evidences what happens during every night 
shift, but when offered the CQC Inspector refused to look at these. In the Inspection Report there is 
confusion over the name of the report and their terminology used which we addressed with the CQC 
in our representations following the Inspection. The CQC refused to change the terminology. 

ii.  The medication audits picked up a meds error where action was taken. 
iii. Every audit for mat testing is recorded, but the mat that did not work on the day of inspection had 
not had the fault recorded as the Care Manager had not carried out their walk through because of 
the CQC Inspectors arrival and therefore it was done later than usual.  

iv. The Maintenance task list did pick up a faulty thermostatic valve, which had not yet been replaced 
when the inspection took place. The Registered Care Manager did apologise for this. It has been 
replaced and all water outlets have thermostatic valves. The Maintenance task list records water 
outlet testing, but it was reviewed again to include more detail about every water outlet. 
9.  The Registered Manager did not accept many of the concerns raised by the CQC during their attendance 

and this is a missed opportunity to learn lessons, improve care and prevent future deaths. 

I.  The Registered manager has accepted the concerns raised and did apologise on the day of inspection 

for any actions of concern missed. 

II.  There was a lesson learnt as the Care Manager was not aware that ‘near misses’ should be raised as 
Safeguarding. The Care Manager will report these going forward. It is not something they were 
aware that had to be done in all their years of care experience and training completed. This is the 
lesson learnt. 

III.  There were concerns over the staff member that was dismissed not signing some meeting notes. The 
Care Manager apologised and explained that the staff member was suspended and dismissed before 
there was opportunity to get the notes signed. The lesson learnt is that the Care Manager will ensure 
there are notes to sign on the day of any meeting if a signature is required. 

IV.  All concerns that were raised were addressed in the CQC Action Plan and all actions have been met. 
The Care Manager submitted representations to the CQC following inspection, about concerns 
raised, giving a full explanation with evidence for the concerns raised. The CQC ask for these to 
consider any changes for the inspection report, however they chose not to make any changes. 
V.  Broadland View has a long-standing relationship with an external compliance company that visit 4 
times a year to inspect the service. We have recently engaged them to do a more thorough 3-day 
inspection and are arranging monthly visits from them going forward to assist the Care Manager in 
identifying areas of continuous improvement and putting in new systems and processes in place, as 
required, and are appropriate to the service. The DTO from Careskills Academy is a source of remote 
advice and support and uses their knowledge of the health and social care sector to build systems, 
processes and reporting tools should they be needed to improve the service further. They meet with 
the Care Manager on a weekly basis to determine what actions are needed and discuss the 
completion of compliance records. This is a source of support for the Care Manager in keeping all 
parts of the service on track. 

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