Jake Baker

Date of report	8 Feb 2024
Reference	2024-0068
Deceased	Jake Baker
Coroner	Caroline Topping
Coroner area	Surrey
Category	Other related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT 
IN THE MATTER OF: 

__________________________________________________________ 

The Inquest Touching the Death of Jake Brian BAKER 
A Regulation 28 Report – Action to Prevent Future Deaths 
__________________________________________________________ 

1  THIS REPORT IS BEING SENT TO: 

1. 
2. 

 Chief Executive - Surrey County Council 
, Chief Executive – Care and Quality Commission 

2  CORONER 

Miss Caroline Topping, H.M. Assistant Coroner for Surrey 

3  CORONER’S LEGAL POWERS 

I make this report under paragraph 7(1) of Schedule 5 to The Coroners 
and Justice Act 2009. 

4 

INQUEST 

An inquest into the death of Jake Baker was opened on the 13th August 
2020 and resumed on the 23rd January 2021. The resumed inquest was 
adjourned on 2 occasions for further evidence to be provided and 
suspended to await the result of a prosecution under regulation 22 of the 
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 

The inquest was concluded on the 14th December 2023. Evidence in 
respect of matters pertaining to this report was heard on the 1st February 
2024.   

Jake Baker died on the 31st December 2019 at home at Queen Elizabeth 
Way, Woking and the medical cause of his  death was: 

1a Diabetic Ketoacidosis  

The narrative conclusion found that:  

 
 
 
 
 
 
 
 
 
 
 
 
 Jake Baker had twin diagnoses of learning disability and type 1 diabetes. 
He was not capable of, and had not been trained to, manage diabetes 
independently if he developed hyperglycemia and became unwell. His 
family had not been given any training to recognise a deterioration in 
Jake’s condition and when to seek emergency medical assistance. 

Those involved in making decisions for Jake from the Surrey Care Leavers 
team and Childrens Services failed to ensure Jake’s safety when he went 
home for overnight contact from March 2019 by :  
a.) Failing to obtain information about the risks posed by type 1 diabetes 
from specialist diabetic services.  
b.) Failing to obtain information about Jake’s cognitive ability and how it 
impacted on his ability to manage his diabetes independently.  
c.) Failing to undertake a risk assessment in relation to his ability to 
manage diabetes independently. 
d.) Failing to create an adequate pathway plan which included a proper 
evaluation of what support Jake needed to have contact with his family  
e.) Failing to co-ordinate the agencies providing support for Jake to 
inform the pathway plan.  
f.) Failing properly to plan for Jake’s care leaving by failing to hold 
properly minuted and informed meetings prior to making a decision that 
Jake could have unsupported contact with his family.  
g.) Failing to ensure that Ruskin Mill Trust were aware that the local 
authority had not risk assessed Jake having unsupported contact with his 
family. 
h.) Failing to inform Jake of the risks of going home unsupported and to 
suggest ways to mitigate the risks  
i.) Failing to correctly identify that, had Jake been made aware of the risks 
and despite that insisted on going home unsupported without any 
mitigation in place, a capacity assessment would be required. Had such a 
capacity assessment been undertaken he would have lacked capacity to 
make that decision and safeguarding measures would have had to be 
taken.  

There was a systemic failing on the part of Surrey County Council 
adequately to train and oversee personal advisers in relation to their legal 
obligations in preparing pathway plans.  

Ruskin Mill Trust failed to ensure Jake’s safety when he went home for 
contact by: 

 
 
 
 a.) Failing to ensure that any employees involved with pathway planning 
meetings for Jake were fully informed about the extent of the risks posed 
by type 1 diabetes. 
b.) Failing to risk assess the risk posed to Jake by his diabetic condition 
when he went home for contact.  
c.) Failing to put in place a care plan informed by his diabetic specialist 
team, Jake, his family and staff.  
d.) Failing to ensure that they were aware on a daily basis when he was 
away from the college what his blood sugar readings were. Had they 
done so they could have ensured admission to hospital at the latest by the 
morning of December 29th 2019.  
e.) Failing to establish the nature of his condition when notified that he 
was unwell on the 30th December 2019 and to give appropriate advice 
that he needed immediate hospital admission.  

The death was contributed to by neglect. 

5  CIRCUMSTANCES OF THE DEATH 

Jake Baker was made subject to a care order in 2009 and remained in the 
care of Surrey County Council until he turned 18 on the 29th March 2019. 
He was diagnosed with type 1 diabetes in 2014. He was diagnosed as 
learning disabled and in 2015 was assessed to have an overall IQ of 42 
with working memory and processing scale of 50 placing him below the 
0.1 centile in these domains.  

Once subject to a care order he retained contact with his family in Woking 
during thrice yearly supervised contact visits. Following being diagnosed 
with type 1 diabetes he was cared for both at school and in his residential 
care home by staff who were given training by St Peter’s Hospital in 
relation to diabetes management. In September 2018 he was placed in a 
full-time residential placement at Ruskin Mill College. Whilst at the 
college the management of his diabetic condition was overseen by 
members of staff who supervised Jake whilst he took blood readings and 
calculated the insulin dose required. Secondary diabetic care transferred 
to Gloucester Royal Hospital.  

Jake continued to have a social worker until he reached 18 years old when 
he became a care leaver and came under the auspices of the Surrey Care 
Leavers team. He was entitled to a personal adviser once he left care. 
There was a statutory duty on the personal adviser to write a pathway 
plan for Jake which would include consideration of what support he 

 
 
 
 
 required to sustain appropriate family relationships and how his health 
needs were to be met. The personal adviser was required to coordinate 
support and ensure that agencies providing services that contributed to 
the pathway plan were engaged in information sharing and pathway 
planning. No advice was sought from specialist diabetes services to 
inform the pathway plan and no risk assessment was undertaken in 
relation to the risks of Jake having unsupported contact with his family in 
so far as management of diabetes was concerned.  

 A referral was made to the Surrey County Council Transitions Team for 
an assessment of Jake’s care needs. The entry requirement for that team 
required an evidenced diagnosis of learning disability. The report 
containing the original diagnosis had been lost. Childrens Services were 
unable to obtain an up to date diagnosis of learning disabilities. Jake was 
assessed not to meet the threshold for the transitions team. He did not 
have the support of an adult social work team. This outcome was being 
challenged when he died.  

Two professional meetings took place, attended only by local authority 
employees, prior to Jake’s 18th birthday and agreed that Jake should have 
unsupported staying contact with his family on the 29th March 2019. The 
meetings were unminuted and the emails which refer to the decisions 
made at the meetings make no reference to any consideration of the 
dangers inherent in Jake’s diabetic condition nor his ability to manage it 
unsupported. The local authority employees held the mistaken belief that 
if Jake wanted to go home unsupervised once he turned 18 there was 
nothing they could do to stop him.  

Jake lacked the ability to be wholly independent in managing his diabetes. 
He was not given any information about the dangers inherent in him 
having unsupported contact if his blood sugars became deranged and he 
became acidotic. No capacity assessment was undertaken in relation to 
Jake’s ability to make a decision to go home unsupported.  

His final looked after child and pathway planning meeting took place on 
the 27th March 2019 at Ruskin Mill College attended by his social worker, 
independent reviewing officer and 2 members of staff from the college. 
There are no minutes of the meeting. The pathway plan was deficient in 
that the domain relating to contact with family was not filled in. The only 
reference to what would take place in relation to contact was that he 
would be supported with travel warrants by the local authority and 

 
 
 
 
 would stay in touch with college staff so they know he was safe and when 
he was returning. 

Jake had two overnights stays with his family in March and November 
2019 of one and two nights respectively. He then asked his personal 
adviser for travel warrants to travel for contact from the 24th December to 
the 30th December 2019. No risk assessment was undertaken in relation to 
him having unsupported contact for this length of time by either his 
personal adviser or the college. In November 2019 he transferred to 
Glasshouse College in Stourbridge which was an internal transfer within 
the Ruskin Mill Trust Group.  

On the 24th December 2019 Jake was dropped at his family home at 
Queen Elizabeth Way, Woking. He was provided with sufficient insulin 
for the stay. The family were not given any advice at any stage on how to 
keep Jake safe if he became unwell nor any emergency contact numbers. 
They were not given any training in diabetes management nor the 
symptoms which might suggest he needed immediate medical attention. 
Overnight from the 28th to the 29th December 2019 he developed diabetic 
ketoacidosis as a result of being hyperglycaemic in the preceding days. He 
began to vomit. He required immediate hospitalisation. On the 30th 
December 2019 the college was notified by his family that he was too ill to 
travel. The staff who were travelling to collect him were told to return to 
the college. His family was not told to take him to hospital. He was last 
seen alive at 11pm and found dead at 3am on the 31st December 2019. If 
Jake had been admitted to hospital at any time prior to 5 pm on the 30th 
December 2019 he would have been successfully treated.  

The death was avoidable. 

 
 
 
 
 6  CORONER’S CONCERNS 

The MATTER OF CONCERN is: 

During the course of the inquest the evidence revealed matters giving rise 
to concern. In   my opinion there is a risk that future deaths could occur 
unless action is taken. In the circumstances it is my statutory duty to 
report to you. 

Jake died more than 4 years ago. Evidence was provided as to what steps 
have been taken by both Ruskin Mill Trust and Surrey County Council to 
address the concerns enumerated in the narrative conclusion. I am 
satisfied that Ruskin Mill Trust have undertaken an extensive review of 
their practices since the death to address the concerns.  

I am not satisfied that Surrey County Council have undertaken a rigorous 
review of the circumstances of the death, nor that the risk of future deaths 
has been averted.  

The MATTERS OF CONCERN are as follows: 

a.)  The issues surrounding the inadequacy of Jake’s pathway plan have 
not been addressed comprehensively in the last 4 years. Training for 
personal advisers is not mandatory and is only now being rolled out. 
The court was not provided with copies of the training or any 
protocol in relation to it so as to be assured of the adequacy of the 
training and its implementation.  

b.) The process by which diagnoses of learning disabilities can be 

obtained remains opaque. There is no protocol in relation to this. The 
current situation leaves those making decisions in relation to young 
people struggling to obtain this vital information.  

c.)  The issue of how the numerous adult social care teams are accessed to 

obtain adult social care assessments for care leavers leads to 
confusion and delays. Vulnerable care leavers are at risk of being 
denied necessary support.  

d.) How internal meetings and formal review meetings with other 
interested parties are informed and recorded is not subject to a 
protocol and the risk remains that decisions will be taken without 
adequate information and inquiry as to the risks inherent in those 
decisions.  

e.)  Practice standards have not been put in place in relation to risk 

assessments of care leavers to inform their needs.  

 
 
  
 
 
 f.)  Mental Capacity Act training is not mandatory in children’s services 

and the adult services have no audit of the effectiveness of the 
mandatory training provided and how it is being used in practice. 
There is therefore a risk that erroneous assumptions as to capacity 
will continue to be made. 

7  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe that the people listed in paragraph one above have the power to 
take such action.  

8  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of its date; I 
may extend that period on request. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for such action. Otherwise, you must 
explain why no action is proposed. 

9  COPIES 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons: 

Ruskin Mill Trust  
Gloucester Royal Hospital  
The Care Quality Commission  

I am also under a duty to send a copy of your response to the Chief 
Coroner and all interested persons who in my opinion should receive it. 

 
 
 
  
  
 
 
 I may also send a copy of your response to any other person who I believe 
may find it useful or of interest. 

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he believes may find it useful or of interest. 

You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response.  

10  Signed: 

Caroline Topping 

H.M Assistant Coroner for Surrey 
Dated this 8th day of February 2024

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Care Quality Commission (PDF)

HSCA Further Information Citygate  
Gallowgate  
Newcastle upon Tyne  
NE1 4PA 

HM Assistant Coroner Miss Caroline Topping, for Surrey 

3 April 2024 

Care Quality Commission  

Dear HM Assistant Coroner Topping,  

Prevention of future death report following inquest into the death of Jake Brian 
Baker 

Thank you for naming the Care Quality Commission as a respondent in the 
prevention of future deaths report issued following the death of Mr. Jake Baker. 

CQC has a clear internal process to follow whenever a Regulation 28 report is 
received, including where CQC are named within report.  

In line with the CQC’s enforcement and internal specific incident guidance, policies 
and procedures, a decision review meeting (DRM) takes place. This DRM considers 
the matters of concern raised, reviews the facts, and gathers additional information 
where required to inform regulatory decision-making. CQC considers if any potential 
breaches of regulation may have taken place, and undertakes an initial assessment 
using our specific incident guidance. In summary terms, this initial assessment 
enables the CQC to consider and/or determine any appropriate regulatory response 
in line with CQC’s published enforcement policy. More specifically, it enables CQC to 
consider and determine whether any formal and/or informal regulatory actions are 
required. This may include monitoring, inspection and/or civil enforcement action to 
further assess compliance of the provider or protect service users from ongoing 
risks; and to assess and determine whether there may be reasonable grounds to 
suspect that a service user(/s) may have sustained avoidable harm or been exposed 
to a significant risk of avoidable harm, as a result of registered person failure to 
provide safe care and treatment. 

The concerns set out in your report centre on the extent to which Surrey County 
Council have rigorously reviewed the circumstances of Mr. Baker’s death and taken 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 action to avert the risk of future deaths. Specifically, you identify the following 
matters of concern: 

a) The issues surrounding the inadequacy of Jake’s pathway plan have not 
been addressed comprehensively in the last 4 years. Training for personal 
advisers is not mandatory and is only now being rolled out. The court was not 
provided with copies of the training or any protocol in relation to it so as to be 
assured of the adequacy of the training and its implementation. 
b.) The process by which diagnoses of learning disabilities can be obtained 
remains opaque. There is no protocol in relation to this. The current situation 
leaves those making decisions in relation to young people struggling to obtain 
this vital information. 
c.) The issue of how the numerous adult social care teams are accessed to 
obtain adult social care assessments for care leavers leads to confusion and 
delays. Vulnerable care leavers are at risk of being denied necessary support. 
d.) How internal meetings and formal review meetings with other interested 
parties are informed and recorded is not subject to a protocol and the risk 
remains that decisions will be taken without adequate information and inquiry 
as to the risks inherent in those decisions. 
e.) Practice standards have not been put in place in relation to risk 
assessments of care leavers to inform their needs. 

Actions taken by CQC following receipt of the information of concern concerning 
Jake Baker’s death 

At the time of Mr. Baker’s death, CQC did not have any statutory powers in relation 
to the assessment of Surrey County Council or any other local authority.  

On 1 April 2023, the Health and Care Act 2022 gave CQC new powers to assess 
how local authorities are meeting their duties under part 1 of the Care Act 2014. 
CQC’s role is carried out by way of undertaking an assessment in relation to how 
local authorities are meeting these duties, then rate and report on the findings. 
Where CQC find that a local authority is failing to perform its functions under the 
Care Act to an acceptable standard, CQC must inform the Secretary of State for 
Health and Social Care. 

Between May and November 2023, CQC completed 5 pilot local authority 
assessments, to test the associated assessment framework, methods and 
processes. In December 2023, CQC commenced a rollout of its formal local authority 
assessment programme. 

CQC have recently started an assessment process for Surrey County Council. CQC 
have shared details of the concerns in your PFD report regarding Surrey County 
Council with CQC’s local authority assessment team, to inform their assessment of 
Surrey County Council.  

Your report highlights the failure of Ruskin Mill Trust to ensure Mr Baker’s safety 
when he went home for family contact in 2019. This included a failure to assess and 
put plans in place to manage the risks posed to Mr. Baker by his diabetic condition 
during such visits. 

 
 
 
 
 
 
 
 On 1 April 2015 the CQC assumed enforcement responsibility for health and safety 
related serious incidents concerning people using services in health and social care 
settings in England. This includes where people using services have sustained 
avoidable harm including death or have been exposed to a significant risk of 
avoidable harm as a result of a failure by the Registered Person. The ‘Registered 
Person’ (RP) is the Registered Provider and/or Registered Manager. Where 
Registered Providers are corporate bodies (such as limited companies) or 
unincorporated associations (such as partnerships), individual office holders or 
members may in certain circumstances be criminally liable under sections 91 and 92 
Health and Social Care Act 2008. 

The initial assessment and specific incidents guidance processes identified above 
were initiated following receipt of information of concern following the death of Mr. 
Baker. Following a thorough criminal investigation, this culminated in CQC bringing a 
successful prosecution against Transform Residential Limited, which operated 
Glasshouse College at the time of Mr. Baker’s death. This was due to their 
mismanagement of his diabetes care. On 31 May 2023, the provider pleaded guilty 
to causing Mr. Baker avoidable harm and was ordered to pay a total of £22,721.04 at 
Staines Magistrates’ Court.  

As part of CQC’s considered response to any ongoing risk of harm to people living at 
Glasshouse College, CQC conducted a comprehensive inspection of the service in 
June 2021. During this inspection, CQC identified significant concerns and 2 
breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 
2014, relating to the safety of people’s care and the provider’s governance 
arrangements. This inspection resulted in an overall rating of inadequate. Upon 
CQC’s re-inspection of Glasshouse College in March 2022, CQC found the provider 
had made significant improvements in the quality and safety of people’s care. Ruskin 
Mill Trust Limited were now meeting their legal requirements and CQC gave the 
service an overall rating of good. 

It may also be helpful to the coroner to know that, as part of CQC’s broader work 
around reducing mortality and acting to understand and improve health inequalities 
for people with a learning disability and autistic people, CQC are working to establish 
better links with local Learning Disability Mortality Review (LeDeR) teams. This is 
with a view to establishing relationships which can combine the intelligence held by 
these teams with CQC’s regulatory function.  

CQC are also working to improve access to the data that LeDeR hold about the 
deaths of people with a learning disability and autistic people and have already been 
given access to a LeDeR data tool which enables CQC to scrutinise themes and 
trends in a place. Through this work, CQC aim to improve the knowledge and 
understanding of CQC’s workforce by providing advice, learning and tools to enable 
them to better understand the contributory factors to avoidable deaths and take the 
right regulatory actions as a result.  

Please do not hesitate to contact me if you require any further information. 

Yours sincerely 

 
 
 
 
 
 
 
 Deputy Director of Operations 
Midlands Network

Response from Surrey County Council (PDF)

Ms Caroline Topping
HM Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
WOKING
Surrey
GU22 7AP

5th April 2024

Dear Ms Topping,

Regulation 28 Report – Jake Baker

Interim Chief Executive
Surrey County Council
11 Cockshot Hill
REIGATE
Surrey
RH2 8EF

I write on behalf of Surrey County Council ("SCC") in response to the Coroner's Regulation
28 Report dated 8 February 2024.

I address each of the Matters of Concern set out in that Report in turn:

a) The issues surrounding the inadequacy of Jake’s pathway plan have not been

addressed comprehensively in the last 4 years. Training for personal advisers is not
mandatory and is only now being rolled out. The court was not provided with copies
of the training or any protocol in relation to it so as to be assured of the adequacy of
the training and its implementation.

SCC Response:

Pathway Plan training has always formed part of personal advisers' induction when
they join SCC. A formal training programme has been in place since at least
September 2021. Whilst there is no written document confirming this is mandatory,
since the training commenced in 2021 managers have been clear in supervision and
performance conversations with staff about the mandatory nature of this training. In
addition, SCC’s Practice Standards are being reviewed and updated this year as part
of our review cycle and will confirm the mandatory nature of pathway plan training for
clarity.

The current training content for personal advisers was updated in 2024 with a rolling
programme of training throughout the year. In addition, pathway plan surgeries are in
place across the Looked After Teams which also extend to social workers in the
Safeguarding Adolescents Teams to ensure timely completion of pathway plans
whilst providing advice and guidance on the content of the pathway plan.

SCC has a well-developed audit process and pathway plans are audited as part of that
activity within the Looked After Children and Care Leavers service with any learning
arising disseminated across the service to further improve practice.

b.) The process by which diagnoses of learning disabilities can be obtained remains
opaque. There is no protocol in relation to this. The current situation leaves those
making decisions in relation to young people struggling to obtain this vital
information.

SCC Response:

Diagnosis is a health led process and it starts with a healthcare professional
identifying a learning disability, through assessment, based on the person’s needs.
Diagnosis can be undertaken at different times such as birth, in childhood or in
adulthood. The Local Authority accepts that timely diagnosis can in some cases lead
to improved outcomes for children and young people.

SCC staff have, and will continue to, liaise with the young person's GP in the first
instance to confirm diagnosis. Where necessary, SCC staff will also liaise with
specialist health services if they are known to be working with the young person.

SCC are in the process of developing a Multi-Agency Transition Protocol which is due
to be launched in the coming weeks having now been signed off by all key parties.
This Protocol will include direction to frontline staff on steps to take where a person's
diagnosis is unclear. SCC also have integrated meetings with health colleagues such
as the Preparation for Adulthood Board, Post 16 SEND panel and the Joint
Commissioning panel to name but a few. These forums provide additional
opportunities for people’s health needs to be explored and joint solutions to be found
around how best to meet needs.

c.) The issue of how the numerous adult social care teams are accessed to obtain
adult social care assessments for care leavers leads to confusion and delays.
Vulnerable care leavers are at risk of being denied necessary support.

SCC Response:

Our Adults, Wellbeing and Health Partnerships Directorate (AWHP) is made up of both
locality and specialist teams. There is a locality team covering each specific
geographic area across Surrey. The specialist teams are the Transition Team,
Learning Disability and Autism Team and the Mental Health Teams. Both the locality
teams and specialist teams offer a clear pathway into adult social care for those
individuals meeting the eligibility criteria under the Care Act 2014.

These teams offer information and advice as to the available pathways for people
seeking adult social care and support. In addition to that advice and information, SCC
has a contact centre that is able to signpost people to the most relevant team to meet
their needs. Our Care Leavers Services have access to this information and advice
service and are also able to contact any of the teams directly if they require additional
information or support.

d.) How internal meetings and formal review meetings with other interested parties
are informed and recorded is not subject to a protocol and the risk remains that
decisions will be taken without adequate information and inquiry as to the risks
inherent in those decisions.

SCC Response:

The Looked After Children’s Review process provides a dedicated framework for
monitoring the care planning, including Pathway Plans, up until the point a young
person becomes 18. This involves two formal Reviews per year that bring together all
those involved in a young person’s care and any involved family members as well as
the young person. In addition, there are two informal midway reviews at which the
Independent Reviewing Officer ("IRO") tracks progress against the agreed
Care/Pathway Plan.

SCC recognises that there is not currently a formal review mechanism for ongoing
support post 18. A pilot is therefore under development with a view to formalising a
post 18 review process to be attended by IROs.

SCC has an expectation that any meetings that involve other professionals, and which
have the remit to make decisions that may affect the care arrangements for children
and young people, should be properly minuted and that those records be accessible.
In light of the Coroner’s findings these expectations are being reinforced across key
service areas in supervision meetings and team meetings.

Completion of minutes of meetings is checked as part of the Performance Dashboard,
a system through which managers are able to review compliance. Managers will
continue to use this system to ensure that meetings are being minuted and to address
any gaps with staff.

e.) Practice standards have not been put in place in relation to risk assessments of
care leavers to inform their needs.

SCC Response:

Surrey has a generic risk assessment tool used to understand the risks presented to
children and care leavers. The assessment tool does enable consideration of care
leaver’s needs however on review could be strengthened to consider more
specifically issues related to learning disability, mental capacity and health. A review
of the current assessment tool is underway and will be completed by end April 2024.

f.) Mental Capacity Act training is not mandatory in children’s services and the adult
services have no audit of the effectiveness of the mandatory training provided and
how it is being used in practice. There is therefore a risk that erroneous assumptions
as to capacity will continue to be made.

SCC Response:

Within the SCC Adults Service, Mental Capacity Act ("MCA") training is now
mandatory to all front line staff. Team Managers and Senior Managers are responsible
and have access to lists of staff attendance and are required to follow up with any
staff who have not undertaken the compulsory training.

The position with MCA training within SCC's Childrens Service is currently under
review. The intention is to mandate e-learning around the MCA as part of induction
and refresher training to all staff to heighten awareness of the MCA.

We adopt a stratified approach to training staff across both adults and children’s
directorates due to the diverse range of qualification and expertise involved across
our teams, taking into account the requirements for individual roles. Staff in roles that
require mental capacity act awareness and knowledge will continue to receive the
necessary training specific to their role, however, staff across both directorates will
be supported to understand circumstances where the MCA framework may need to be
implemented.

In addition to MCA training, we use various other forums such as professional
supervision, peer reflection and team meetings. AWHP also have both a Practice
Assurance Board and a Practice Improvement Group which oversee practice
development and guidance and ensure that any lessons learnt from complaints,
Ombudsman outcomes, Coroner’s Findings and Safeguarding Adults Reviews,
amongst others, are shared with the workforce and that there is evidence of improved
and enhanced practice in our service delivery as a result.

Yours sincerely,

On behalf of:

c.c.

Executive Director, Children, Families and Lifelong Learning

, Interim Chief Executive, Surrey County Council

, Executive Director, Children, Families and Lifelong Learning
Executive Director, Adults and Integrated Commissioning

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