Prevention of Future Deaths reports · 2024

Maureen Woollen

Regulation 28 report to prevent future deaths, reference 2024-0335, written 19 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jun 2024
Reference2024-0335
DeceasedMaureen Woollen
CoronerTanyka Rawden
Coroner areaSouth Yorkshire (West)
CategoryCare Home Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Death of Maureen Alison Woollen (D.O.B. 24 September 1931, D.O.D. 31 October 2023) 

Response to Regulation 28 Report to Prevent Future Deaths 

Bundle of Additional Documentation 

Document 
No. 
1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

13. 

Document 

Page No. 

Prevention and Management of Falls Policy 

Admissions Policy 

Quality Assurance Audit 

Quality Dashboard Metric 

Service Report 

1 – 4 

5 – 6 

7 

8 

9 

Team Leader Monthly Monitoring Draft, July 2024 

10 – 13 

Weekly ‘Huddle’ Team Meetings, December 2023 – July 2024 

14 – 49 

Staff Training Completion Sheet 

Deputy Good Practice Group Minutes, 2 July 2024 

Lessons Learned, 21 June 2024 

YAS Flow Chart 

50 – 128 

129 – 132 

133 

134 

Falls Prevention Group Meeting Notes, 23 January 2024 

135 – 139 

Standard Operating  Procedure  –  Actions  Following  Accident  or 

140 – 144 

Fall 

14. 

Team Leader Monthly Monitoring Reports, October 2023 – March 

145 – 160 

2024 

 
 
 
 
 
 Prevention and Management of Falls Policy 

This policy sets out a consistent approach to risk assessment and risk 

management, the protocol to follow when a fall occurs, measures and 

prevention and the means by which compliance with this policy will be 

measured.  

It is important that staff know how to manage the risk of falling in Sheffcare 

services, how to deal with a fall when it happens and the methods by which 

falls can be prevented.    

SheffCare works in line with the CQC Care Framework, legalisation, and NICE 

guidelines to enhance the quality of care provided for service users'.  

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: 

Regulation 12. The intention of this regulation is to prevent people from 

receiving unsafe care and treatment and prevent avoidable harm or risk of 

harm. Providers must assess the risks to people's health and safety during any 

care or treatment and make sure that staff have the qualifications, 

competence, skills and experience to keep people safe.  

There are general duties placed upon employers to safeguard the health 

and safety of employees and others (including residents, the public and 

contractors) by Sections 2 and 3 of the Health and Safety at Work etc. Act 

1974.   

The Management of Health and Safety at Work Regulations 1999, 

Regulations 3 and 5 and the associated Approved Code of Practice, require 

employers to assess risks to the health and safety of both employees and 

residents and to put into effect appropriate arrangements for health and 

safety planning, organisation, control and review.   

The Workplace (Health, Safety and Welfare) Regulations 1992, Regulation 12, 

and the associated Approved Code of Practice establish an absolute duty 

for floors to be suitable for their purpose (this includes adequate slip 

resistance, evenness and slope). Floors must be kept free of obstructions and 

any article or substance that may cause any person to slip, trip or fall. 

Reviewed September 2023 – Director of Care & Operations 

1 
 
 
 
 
 Regulation 13 requires measures to be taken to prevent any person falling a 

distance likely to cause personal injury.   

National standards and guidance relating to falls prevention and patient 

care is recommended within the NICE CG161 Falls (June 2013) and Pathway. 

The guidance published in June 2013 enhances the 2004 guidelines to 

include recommendations about patients within inpatient settings.  

https://www.nice.org.uk/guidance/cg161 

NICE161 Clinical Guideline Falls: The Assessment and Prevention of Falls in 

Older People.   

•  Older people in contact with health care professionals should be asked 
routinely whether they have fallen in the past year and asked about 

the frequency, context and characteristics of the fall.   

•  Older people reporting a fall or considered at risk of falling should be 
observed for balance and gait deficits and considered for their ability 

to benefit from interventions to improve strength and balance.   

•  Older people who present for medical attention because of a fall, or 
report recurrent falls in the past year, or demonstrate abnormalities of 

gait and/balance should be offered a multifactorial falls risk 

assessment.   

SheffCare aims to reduce the number of service users' falls which could result 

in a serious injury and cause impairment to that person's general abilities, 

needing effective pro-longed stressful treatment and rehabilitation for those 

who have fallen. The risk of falling can never be completely removed but by 

carrying out a falls risk assessment risk factors can be identified, and action 

taken to remove or alter risk where possible.   

On admission, all staff must follow any pre assessment advice/guidance.  

All assessed aids must be in place and checked that they are in safe working order. 

All aids are to be well maintained and kept in good working order, bed rails are to 

Reviewed September 2023 – Director of Care & Operations 

2 
 
 
 
 
 
 
 be checked in line with Central Alerting Systems guidance. Sensor mats and crash 

mats are to be kept clean and stored safely when not in use.  

A Falls Risk Assessment Form must be completed on admission and used in 

conjunction with the Service Users Care Plan. This must be updated monthly or more 

frequently as is required through the review process or as a result of a fall. 

All falls must be recorded in the Accident Book and a Service Users' Falls Monitoring 

Form must be completed and kept with the Service users Care Plan. 

Person Centred Softwear data is to be analysed on a monthly basis by the 

Registered Manager this will provide information which can be used to consider 

measures to reduce further falls.  

Registered Managers are to review falls data on a daily/weekly/monthly basis and 

report on their findings within the PCS care notes, if there are any trends or patterns 

or areas of concern these are to be referred to the GP for further review.  

Registered Managers should also conduct a monthly quality assurance accident 

monitoring form highlighting any issues or trends and any further action required. 

Compliance with the policy is monitored through the monthly quality assurance 

report submitted by the Registered Manager to the Head of Quality and 

Improvement who reports monthly to the Board of Trustees.  

If any individual staff highlight to have concerns over the number, frequency, type of 

falls, they have sustained must be referred to their own GP for advice and guidance 

& records updated accordingly. Referrals to the fall’s prevention team should be 

actioned who can provide advice and guidance on fall’s management.  

If any resident sustains an injury due to a fall immediate medial attention is to be 

taken, a trained first aider is to review the resident, and if required seek medical 

attention. Care notes are to be fully maintained on the action taken, advise 

provided by whom and when is to be fully documented. If an ambulance is required 

and goes over the allotted timeframe specified, or if the resident’s condition 

Reviewed September 2023 – Director of Care & Operations 

3 
 
 
 
 
 changes a 999 call is to be made to update on the resident’s condition or to inform 

the ambulance service of the timeframe allocated on the initial call.  

If a resident falls and there are no apparent injuries at the time, but staff then notice 

injuries these are to be reported and medical attention sought. All care notes are to  

reflect if a resident is injured and action taken to monitor and review the injury or 

injuries.   

Medications are to be reviewed by the GP and/or District Nurse due to the 

increased risks of residents who are prescribed medication which can contribute to 

the risk of falls. Residents who are prescribed Anticoagulation therapy as although 

this treatment does not increase the resident’s risk of falling the outcome of the fall 

could be more serious.   

Training is provided for use of hoists and/or equipment this is overseen by the 

Registered Manager. 

Reducing the likelihood of fall’s by ensuring the environment is well maintained is 

managed under Health and Safety audits.  

“I STUMBLE” is recognised by Sheffield City Council, Yorkshire Ambulance Service 

and Fall’s Prevention Team to be implemented within Sheffield care homes. 

Appendix A.  

“I STUMBLE” post fall audit can also be used to review actions and outcomes of a 

fall. Appendix B.  

. Appendices:  

Reviewed September 2023 – Director of Care & Operations 

i_stumble_audit_form.pdfiSTUMBLE.pdf4 
 
 
 
 
 
 
 
 
 Admissions Policy 

Full information must be received in the Home prior to each person's admission e.g. full time 
placement and respite placements. In the case of an emergency situation, the duty manager 
must ensure that all basic relevant information is obtained and made available to the care 
team and all such information should be received before or on admission.  

Such information should include the following; the service user's full name, their date of birth, 
address, NOK or carer, GP's details, medication details, name of the referring worker or their 
Assessors details, with an outlined statement re the persons emergency.   

The Registered Managers are responsible for ensuring that all prospective service users on 
planned admissions have a completed Care Needs Assessment prior to or on their 
admission. 

It is the Duty/Shift Manager/Care Coordinator (if in post)/Registered Managers responsibility 
to ensure that the home is able to meet the assessed emotional, social, nutritional (including 
weight on admission), cultural and health care needs of the service user as required by Care 
Quality Commission. 

Such details must be completed and supplied by the Social Services representatives, 
however for self funding service users; the Registered Manager must undertake a single 
assessment, using the company's Self Funders Assessment Form. Where the individual is 
self funding, a SheffCare Individual Placement Contract must also be completed. Section 
3.1.2.3 Financial Procedure on Admission gives full details.  

Prospective service users' should be presented with and asked to complete the Service 
Users Guide/Contract of Care/Contract of Finance on before or at the time of their 
admission,  the Manager supporting that persons admission must ensure that Section Two 
and Section Three are sent  to the appropriate Service Users' finance Adviser. 

It is the responsibility of the Registered Manager to ensure that all Service Users' nutritional 
needs are assessed, documented on admission and there after monitored on a 
daily/weekly/monthly basis. Fortified drinks are to be documented at all times. Training in this 
regard must be provided to all appropriate staff. 

All such information should be recorded on the individual's 'Service User Nutrition Screening' 
form which can be found stored as part of the Service Users' Care Plan documents, 

Team Leaders must take responsibility to ensure such information is documented and 
reviewed Monthly, using the review form to evidence such action whilst ensuring up-dates is 
passed on to the Senior Cook/Cooks and Care team. 

Falls Assessments must be completed on admission, at this point we need to use the 
information provided in the assessment document, if a resident presents with a falls history 
this information needs to be transferred onto the electronic care records system, and there 
after monitored on a daily/weekly/monthly basis. 

Reviewed June 24  – Care & Operations Director  

5 
 
 
 
 
 All history such as mobility needs, falls, health, medication, risk of wandering, overnight care 
needs, level of support required with eating and drinking, choking risk are to be assessed 
and considered at the point of admission for all types of admissions to the home.  

Reviewed June 24  – Care & Operations Director  

6 
 
 
 
 
 Quality Assurance Audits Sheffcare 

Audit 
Daily monitoring 
Area report 
Whole home report 
Walk round 
Accident monitoring 
Care plan  
Health and Safety 
IPC  
Kitchen  
Medication  

Frequency 
Daily 
Monthly 
Monthly 
Daily  
Monthly 
Monthly  
Monthly 
Monthly  
Monthly 
Monthly  

Responsible person 
Team Leader 
Team Leader 
Deputy Manager 
Manager  
Manager 
Manager 
Manager 
Manager  
Manager  
Manager  

7 
 
 Quality Dashboard
Medication errors - harm
Medication errors - no harm
Falls
Choking 
Pressure Care Gradient 
Accidents* - residents 
Accidents - staff
Safeguarding referrals
New S42 enquires in month
Ongoing open S42 enquires in the month
Closed S42 cases in the month 
CQC notifications
Regulatory breaches
Duty of Candour reports
Hospital admission unplanned 
Any placement at risk 
Death of resident 
Environment 
External Inspections
Resident concerns
Complaints
All monthly QA audits complete
Compliments
IPC outbreak number of residents
DoLS 

0
0
0
0
>0-1
0-3
0
0-3
0
1

0
0
>1
1
0

0
0
0
0
0
1+
0
All in place

Nurtition & Hydration-weight gain
Nutrition & Hydration-weight loss

>0-1kg
>0-1kg

Safeguarding

r
e
m
o
t
s
u
C

Compliments 
and 
complaints

1-2
>1

>2
4-10
1-2
3-5
1
2

1

1-2
1

1-5

1
1

>1
>3
>2
1 or more
>3
>11
>2
>5
>2
>3

>2
>1

>3
>2
>1
>5
>1
>2
>2
>1 

Metric 

* 3 or more falls is the reporting threshold for referrals 

*Accidents refers to just accidents e.g. slips, trips, falls, not other incidents

* Needing to move resident out of the home 

*Number of items required i.e. maintenance, repairs, tasks 
* EHA, Fire Service, CQC, SCC

* 0 all complete 

1-5
Waiting for outcome 
of review 
>1-2kg
>1-2kg

>6
Lack of follow up 
from authority
>over 3kg
>over 3kg

* Denotes any type of outbreak 

*Narrative on any red reporting 
* Narrative for over 3kg weight gain 
*Narrative for over 3kg weight loss

8 Jan-24

Feb-24 Mar-24

Apr-24 May-24

Jun-24

Jul-24

Aug-24

Sep-24

Oct-24

Nov-24

Dec-24

Outcomes
Medication errors - harm
Medication errors - no harm
Falls
Choking 
Pressure Care Gradient 
Accidents* - residents 
Accidents - staff
Safeguarding referrals
New S42 enquires in month
Ongoing open S42 enquires in the month
Closed S42 cases in the month 
CQC notifications
Regulatory breaches
Duty of Candour reports
Hospital admission unplanned 
Any placement at risk 
Death of resident 
Environment 
External Inspections
Resident concerns
Complaints
All monthly QA audits complete
Compliments
IPC outbreak number of residents
DoLS 
Nurtition & Hydration-weight gain
Nutrition & Hydration-weight loss
PCS
Dining Experience

1

1

1

1

0
0
22
0
0
0
0
0
0
0
0
0
0
0
2
1
0
0
0
0
0
0
1
0
3
0
1

13

13

2
2
2
0
2

9
1
0

1

1

3

0
0
7
0
0
7
0
1
0
0
0
0
0
0
8
0
0
0
0
0
0
1
1
0
0
0
1

0
0
19
0
0
19
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
1
0
0
1
0
1

0
0
16
0
0
19
0
0
3
0
0
1
0
0
2
0
0
0
0
0
1
1
1
0
12
0
1

0
0
17
0
0
20
0
1
0
0
0
3
0
0
0
0
1
4
0
0
1
1
1
0
2
0
0

9 Team Leader Monthly Monitoring Draft July 2024  

Month: 

Corridor: 

Resident Clinical Needs: 
Falls: Please record all falls within the month individually and answer all the questions in detail. 
Resident 
Initials and 
date of fall 

Injury/mark 
photographed 
onto PCS? 

Any 
injuries/marks? 

Witnessed or 
unwitnessed 

Medical 
support 
sought? 

Body map 
completed? 

Family 
Informed? 

Comments 

MUST: Please record any changes in MUST and/or +/- 2kgs of weight, include any high risk residents in detail. 
Resident 
Initials 

Possible 
cause known 

MUST Score  Amount of 

GP Informed 
and advice 

Comments 

Referral to 
SALTs/Dietician 
made 

weight 
lost/gained 

Tissue & Skin Viability: Please record any pressure sores/skin tears/redness individually with detail. 
Resident 
Initials 

Medical support 
sought 

Photographed 
onto PCS 

Description 
of area/issue 

Body map 
completed 

Family 
informed 

Treatment plan 
recorded on 
PCS 

Comments 

Infections/Illness: Please record any infections/illness individually with detail. 
Treatment plan 
Resident 
on PCS 
Initials 

GP informed 
and advice 

Description of issue 

Family 
informed 

Comments 

10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Team Leader Monthly Monitoring Draft July 2024  

Hospital Admissions: Please record any admissions in detail. 
Resident 

Reason for hospital visit 

Date went to 
hospital 

Family informed  Returned to 

home 

Comments 

Resident Care and Wellbeing 
Are residents actively participating in scheduled activities: Please record any issues with individuals being able to 
participate and suggestions for improving this. 
Resident 

Suggestions to improve engagement 

Activity and reason unable to attend 

Are residents enjoying the dining experience and meals: Please complete a review of the meals each week and record your 
thoughts and any resident feedback. 
Week start 
date 

TL Feedback (Quality, flavour, presentation) 

Resident Feedback 

Resident daily checks: Please check that these checks are being completed and report on any missed checks or issues. 
Area 

Checked by 

Any Issues 

Area 

Number in 
use 

Checked 
by 

Any 
Issues 

Number 
in use 
X 
X 

Hair Care 
Nail Care 

Clothing/Laundry 
Toiletries 
Commodes 
Walking Frames 

X 
X 

Oral Hygiene 
Meals and 
Hydration 
Footwear/Footcare 
Wheelchairs 
Walking Sticks 
Hospital Beds 

X 
X 

X 

11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Team Leader Monthly Monitoring Draft July 2024  

Yes/No 

Bed Rails 
Records, Audits and co-production 
Area 
Have all incidents and accidents been 
reported and documented on PCS 
Have risk assessments been reviewed and 
updated where necessary 
Have daily care notes on PCS been checked 
Has a resident meeting/consultation taken 
place 
Has any feedback from the resident or their 
family been received this month 
Health and Safety and Environmental Checks 
Please record when all checks are being done and by who. 
Any issues 
Area 

Number in 
use 

Checked 
by/date 

First Aid 
Boxes 
Bedding 
Trolleys 
Fire Alarm 
Tests 
H&S Audit 

Wardrobes 
and Drawers 
tidy 
Dining 
rooms (inc 
kitchen 
areas) tidy 
All repairs 
identified 
and reported 

Pillows/Mattresses 

Checked by 

Comments/Actions identified 

Number in use  Checked 

by/date 

Any 
issues 

Area 

Sluices 

Nurse Call 

Emergency 
Lights test 
Bedrooms Clean 
and tidy 
Lounges tidy 

Bathrooms and 
toilets clean and 
tidy 

12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Team Leader Monthly Monitoring Draft July 2024  

Comments/Issues 

Dates checked  Checked by 

Medications 
Please record when checked and by who. 
Area 
MAR sheets checked 
Any gaps in MAR sheets 
Topical creams chart checked 
Any gaps in topical cream charts 
Medication room/trolleys cleaned weekly 
Staffing 
Please record detailed commentary including dates and who led the activity. 
Area 
Comments/concerns/actions 
Number of huddles and topics covered 
Any 1:1’s conducted 
Training completed 
How would you rate the team’s morale this 
month (High, Medium, Low) 
Summary 
Please record any improvement actions, concerns or good practice to report to deputy/manager. 

Signed 
Dated 

13 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 HUDDLE 

Huddle Topic  Falls 

Date  5-10-  223 

Discussion  Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing prior to 
falling, do we think there  could  be an infection,  has medication changed. We 
need to be  looking at what could  be causing fall or is it un-preventable. 
Ensure we are assisting those with  poor mobility, checking their foot ware  is 
suitable and seeking advice where we  need it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to help prevent falls. 

Any Action Required 

14 HUDDLE 

Huddle Topic  Falls 

Date  4 

12  23 

Discussion Held With 

Content 
Monitoring falls and any patterns,  is there something they are doing prior to 
falling, do we think there could be an  infection, has medication  changed. We 
need to be  looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has  been do to  help prevent falls. 

Any Action  Required 
Tao leode«vs  o volor  tool  he  above  vs 
+okq 0lace 

15 HUDDLE 

Huddle Topic  Falls 

Date  H  1. 224- 

Discussion  Held With 

Content 
Monitoring falls and any patterns,  is there something they are doing  prior to 
falling,  do we think there could be an  infection, has medication changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we  are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to  Physio 
and fall team. 
Also documenting any changes and what has been do to help prevent falls. 

Any Action  Required 

S(£  lo  nolor 

16 HUDDLE 

Huddle Topic  Falls 

Date  8- 2-244 

Discussion  Held With 

Content 
Monitoring falls and any patterns,  is there something they are doing prior to 
falling,  do we think there  could be an infection, has medication changed. We 
need to  be  looking at what could be causing fall or is it un-preventable. 
Ensure we  are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to  help prevent falls. 

Any Action  Required 

17 Lesson Learned: 012 

Sheffcare 

Dear all, 

Background: Resident experienced an unwitnessed fall and sustained  injuries. 

Extract of the findings: 

During a  period of respite  care a  resident experienced an  unwitnessed fall resulting in hospital 
admission via ambulance. 
This  matter was  referred to the Social Care  Ombudsman  by the family and they have reached a 
conclusion, their findings  are for Sheffcare: 

a)  it does  not overlook the  need to  prompt people to take fortified drinks  and 

documents this  properly; 

b)  its staff have  access to people's care  plans and follow them when  delivering 

care; 

c)  care records are not misplaced after someone has left the care home. 

What you as a  Leader need to do next: Please ensure the following is  implemented,  as appropriate, 
at your site: 

1.  Share lessons  learnt of the incident in all Sheffcare  homes  to raise the awareness of this 

incident 

2.  Review residents who are prescribed/taking fortified drinks and ensure that they are 

prompted to take them and that this is documented correctly 

3.  Review that all staff have access to care  plans (days  and nights} and that these are followed 

by undertaking reviews  and observations of care  practice 

4.  Review archiving processes within the home to ensure that records are  kept safe and secure 
5.  Admissions policy reviewed to specify respite admission procedures 

Assurance:  Discussion in huddles,  1:1 meetings  and staff meetings.  Feedback to Head of Quality and 
Improvement by 30" April  24 that the above actions are  completed. 

If anyone  identifies additional learnings  based on feedback of this matter,  this  is to be reported to 
Head of Quality and  Improvement. 

Any questions,  please  do let me  know. 

Thank you for your continuing efforts to keep the people we support safe and happy. 

Kind regards, 

Lo

18 HUDDLE 

Huddle Topic  Falls 

Date 

)- 3- 2l  

Discussion Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing  prior to 
falling, do we think there could be an .infection, has medication changed.  We 
need to be looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been do to help prevent falls. 

Any Action  Required 

19 Dlaculon Held Wih 

Con%en 

elauel Wat  ooobeof sle[p  ad 
eon nodal  al  p  or otoll.iv 
<bat not [dlg un  m[ate» Deoo 
6old 

Any Action Required 

20 HUDDLE 

Huddle Topic  Falls 

Date  2% 3 --2L 

Discussion Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing  prior to 
falling, do we think there could be an infection, has medication changed.  We 
need to be looking at what could  be causing fall or is it un-preventable. 
Ensure we are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to help prevent falls. 

Any Action Required 

21 HUDDLE 

Huddle Topic  Falls 

Date  7-L-2Lu 

Di

i

H ld With

Content 
Monitoring falls and any patterns,  is there something they are  doing prior to 
falling,  do we think there could be an infection, has medication changed. We 
need to be looking at what could be causing fall or Is it un-preventable. 
Ensure we are assisting those with poor mobility,  checking their foot ware is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to  help prevent falls. 

Any Action Required 

22 HUDDLE 

Huddle Topic  Falls 

Date 

l% --L -2A- 

Discussion Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing prior to 
falling,  do we think there could  be an infection, has medication changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we  are  assisting those with poor mobility,  checking their foot ware  is 
suitable and seeking advice where we need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to  help prevent falls. 

Any Action  Required 

23 HUDDLE 

Huddle Topic  Falls 
Date  6o  -L,-2l4 
Discussion  Held With 

Content 
Monitoring falls and any patterns,  is there something they are doing  prior to 
falling, do we think there could be an  infection,  has medication changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we need it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been do to help prevent falls. 

Any Action  Required 

24 HUDDLE 

Huddle Topic:  Quality Strategy 2023-2025 

Date 

1-S- l 

Discussion  held with 

Content: 
Sheffcare's Quality Strategy is the vision  for quality from  2023-2025.  This outlines how we 
will  be working towards achieving  good quality outcomes for the residents and 
organisation. 

The quality metrics will  be measured through audits and meetings. 

A governance calendar of audits provides the organisation with  qualitive and quantitative 
data so we can  inform and  develop our homes. 

Louise Beaumont will  oversee the progress of the Quality Strategy and  provide 
feedback and updates 

Any Action  required: 

For you to  read the Quality Strategy and  up to date Quality Assurance policy 
For you to display The Quality Strategy-page 1  is the overview strategy on a  page 
For you to engage with the Quality Strategy through the quality assurance 
processes and audits 

25 HUDDLE 

Huddle Topic  Falls 

Date  7-5-2L 

Discussion Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing prior to 
falling, do we think there could be an infection, has medication  changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been do to  help prevent falls. 

Any Action  Required 

26 Voad  cw  csa&s 
u  Hacflo 

lesson Learned: 012 
Sheffcare 

Dear all, 

Background: Resident experienced an unwitnessed fall and sustained  injuries. 

Extract of the findings: 

During a  period of respite care a  resident experienced an  unwitnessed fall resulting in hospital 
admission via ambulance. 
This  matter was referred to the Social  Care  Ombudsman by the family and they have  reached a 
conclusion, their findings are for Sheffcare: 

a)  it does  not overlook the  need to prompt people to take fortified drinks  and 

documents this  properly; 

b)  its  staff have access to people's care  plans and follow them when delivering 

care; 

c)  care  records are  not misplaced after someone  has  left the care  home. 

What you  as a  Leader need to do next:  Please ensure the following is  implemented,  as  appropriate, 
at your site: 

1. 

Share lessons  learnt of the incident in all Sheffcare  homes to  raise the awareness  of this 

incident 

2.  Review residents  who are  prescribed/taking fortified drinks and ensure that they are 

prompted to take them and that this is documented correctly 

3.  Review that all staff have  access to care  plans {days and nights) and that these are followed 

by undertaking reviews and observations of care  practice 

4.  Review archiving processes within the home to ensure that records are  kept safe  and secure 
5.  Admissions policy reviewed to specify respite admission procedures 

Assurance:  Discussion in  huddles,  1:1  meetings  and staff meetings.  Feedback to Head of Quality and 
Improvement by 30" April  24 that the above actions are  completed. 

If anyone identifies  additional learnings  based on feedback of this  matter,  this  is to be reported to 
Head of Quality and  Improvement. 

Any questions,  please do  let me know. 

Thank you for your continuing efforts to keep the people we support safe and happy. 

Kind regards, 

27 HUDDLE 

Huddle Topic  Falls 

Date  17.6.2u 

Discussion  Held With 

Content 
Monitoring falls and any patterns,  is there something they are  doing  prior to 
falling, do we think there could be an .infection,  has medication  changed. We 
need to  be looking at what could be causing fall  or is it un-preventable. 
Ensure we are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to  Physio 
and fall team. 
Also documenting any changes  and what has  been do to  help prevent falls. 

Any Action  Required 
Sf¢  Io  eooxe +hey  c«re  ox(kin  uxth  5eco 
(S0Ys  tkal  ave  a  xk_ af Clls.  (cdce  core 
lo@ea cuds  ave  mo  <eck  rd  ore  been 
used  . 
Docexek  ou  {lls  correc'\  cf ((  deoils 

28 HUDDLE 

Huddle Topic  Falls 

Date  323-5- 24 

Discussion  Held With 

Content 
Monitoring falls and any  patterns,  is there something they are doing prior to 
falling,  do we think there could be an infection,  has  medication changed. We 
need to  be looking at what could  be causing fall or is  it un-preventable. 
Ensure we are assisting those with  poor mobility, checking their foot ware is 
suitable and seeking advice where we  need  it via GP for referrals to  Physio 
and fall team. 
Also documenting any changes and what has  been  do to  help  prevent falls. 

Any Action  Required 

±da long  all about  [rares  end Us 
<cl foot eor e kelp  olevent (auks 
loolc o to  tog  5oo  bevice ase  7y 
rot use  +tor  (ham  Docuro @  el7 
seog  ha. ran. 

29 HUDDLE 

Huddle Topic  Falls 

0ate 27-5-2l 

Content 
Monitoring falls and any patterns,  is there something they are doing prior to 
falling, do we think there  could be an infection,  has medication changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with  poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been  do to help prevent falls. 

Any Action Required 

Tclzed bl His  saloect  de 
@klkcdg  ua(tg  skateg.2o2so=¢ 
about  turd o  documota0 

30 HUDDLE 

Huddle Topic  Falls 
bas  I-%-2+ 

Di

i

H l Wi h

Content 
Monitoring falls and any patterns,  is there something they are doing prior to 
falling,  do we think there could be an Infection,  has medication changed. We 
need to be  looking at what could be causing fall or is it un-preventable. 
Ensure we are assisting those with poor mobility,  checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been do to  help prevent falls. 

Any Action  Required 

31 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  zz/6z 

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on  ambulance call outs  when given  a  timeframe for response times 

Actions  required 

• 

• 

If any residents have an injury from a witnessed or unwitnessed  accident,  we seek 
urgent medical attention  at the time 

If any residents have an  injury which  appears  and  is  unknown, we seek urgent 
medical attention  when this  is noticed 

• 

If we seek medical attention and are  provided with  a  timeframe for an  ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above is to be documented  in the PCS  notes 

32 
 HUDDLE 

Huddle Topic:  Accessing  medical tre

Date:  au- ¢=  .  au 

Content: 

• 

Seeking medical  attention for residents 

•  Chasing up on ambulance call outs when given  a  timeframe for response times 

Actions  required 

• 

• 

If any residents have an  injury from a witnessed or unwitnessed accident,  we seek 
urgent medical attention at the time 

If any residents have an injury which appears and is unknown, we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention  and are provided  with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to  be documented  in the PCS  notes 

33 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  25.G Du 

Discussion  held with 

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions required 

• 

• 

If any residents  have an injury from a  witnessed or unwitnessed  accident,  we seek 
urgent medical attention at the time 

If any residents have an  injury which appears  and  is unknown,  we seek urgent 
medical attention  when this is noticed 

• 

If we seek medical attention and are provided  with  a timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to  be documented  in the PCS  notes 

lt  ordersstxxl 
c»ol  egnect    

34 HUDDLE 

Huddle Topic:  Accessing  medical treatment -residents 

Date:  34%- 2Lr 

Discussion  held with 

Content: 

•  Seeking medical attention  for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions  required 

• 

• 

If any residents have an  injury from a  witnessed or unwitnessed accident, we seek 
urgent medical attention at the time 

If any residents have an  injury which appears  and is unknown,  we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention and are  provided with  a  timeframe for an  ambulance 
to attend, we  ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to  be documented  in the PCS  notes 

35 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 
Date:  21-  %  -24 
Discussion  held with 

Content: 

•  Seeking medical attention  for residents 

•  Chasing up on  ambulance call outs when given  a  timeframe for response times 

Actions required 

• 

• 

If any residents have an  injury from a  witnessed or unwitnessed accident, we seek 
urgent medical attention  at the time 

If any residents  have an injury which appears  and is  unknown,  we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention  and are  provided with  a  timeframe for an ambulance 
to attend, we  ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to be documented  in the PCS  notes 

36 tkac\  cud dsces 

m  lido 

lesson Learned: 012 

Sheffcare 

Dear all, 

Background: Resident experienced an  unwitnessed fall and sustained injuries. 

Extract of the findings: 

During a  period of respite care a  resident experienced an unwitnessed fall resulting in  hospital 
admission via  ambulance. 
This  matter was referred to the Social  Care  Ombudsman by the family and they have  reached a 
conclusion,  their findings  are for Sheffcare: 

a)  it does  not overlook the need to prompt people to take fortified drinks and 

documents this  properly; 

b)  its staff have  access to people's care plans and follow them when delivering 

care; 

c)  care  records are not misplaced after someone has  left the care home. 

What you as a  leader  need to do next: Please ensure the following is  implemented,  as  appropriate, 
at your site: 

1.  Share  lessons  learnt of the incident in all Sheffcare  homes to raise the awareness of this 

incident 

2.  Review residents who are prescribed/taking fortified drinks and ensure that they are 

prompted to take them and that this is documented correctly 

3.  Review that all staff have access to care plans {days  and nights) and that these are followed 

by undertaking reviews and observations of care  practice 

4.  Review archiving processes within the home to ensure that records are  kept safe and secure 
5.  Admissions policy reviewed to specify respite admission procedures 

Assurance:  Discussion  in  huddles,  1:1  meetings  and staff meetings.  Feedback to Head of Quality and 
Improvement by 30" April  24 that the above actions are completed. 

If anyone identifies additional learnings  based on feedback of this  matter,  this  is to  be reported to 
Head of Quality and  Improvement. 

Any questions,  please do let me  know. 

Thank you for your continuing efforts  to keep the people we support safe and happy. 

Kind regards, 

Louise 

37 Huddle Topic:  Accessing  medical treatment -residents 

Date:1-- 2+1 

Discussion  held wit

Content: 

•  Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a  timeframe for response times 

Actions  required 

• 

• 

If any residents have an  injury from a  witnessed or unwitnessed accident,  we seek 
urgent medical attention at the time 

If any residents have an  injury which  appears and is  unknown,  we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention and are  provided  with  a timeframe for an  ambulance 
to attend, we ensure that we chase the call to ensure that this does  not lapse 

•  All of the above is to be documented in the PCS  notes 

38 HUDDLE 

Huddle Topic:  Accessing  medical treatment -residents 

Date: 

az/7/Z+ 

Discussion  held with 

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on  ambulance call outs when  given  a  timeframe for response times 

Actions  required 

• 

• 

If any residents  have an  injury from a  witnessed or unwitnessed accident, we seek 
urgent medical attention at the time 

If any residents have an  injury which  appears  and is unknown,  we seek urgent 
medical attention  when this is noticed 

• 

If we seek medical attention  and are  provided with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to  be documented  in the PCS  notes 

39 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  3 7 22u 

Discussion  held with 

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a  timeframe for response times 

Actions  required 

• 

• 

If any residents  have an injury from a  witnessed  or unwitnessed  accident,  we seek 
urgent medical attention  at the time 

If any residents have  an injury which  appears and is  unknown, we seek urgent 
medical attention  when this is noticed 

• 

If we seek medical attention  and are provided with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above is to be documented  in the PCS  notes 

40 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  -7- 2lt 

Content: 

•  Seeking medical attention  for residents 

•  Chasing up on ambulance call outs when given a  timeframe for response times 

Actions  required 

• 

• 

If any residents have an  injury from a  witnessed or unwitnessed accident,  we seek 
urgent medical attention at the time 

If any residents have an injury which appears and is unknown, we seek urgent 
medical attention  when this is noticed 

• 

If we seek medical attention and are provided with  a  timeframe for an ambulance 
to attend, we ensure that we  chase the call to ensure that this does not lapse 

•  All of the above  is to  be documented  in the PCS  notes 

41 MUDDLE 

Hu«tee Tppie  polo,Clocamont,  (epork  <n 
+Haq ford re (dmckcs, boYunes 

Dr

la
a
c
Vi
l .

Con@sn% 

ha fclg  any  bras r arts 
lo  #lc  oholo fo ors»'s  oht 
on olocmont, and  fepoft to a 
lean  loaclor lo +le c  look- lWon 
cloclo  ukak achon  noecls halo 

Any Action  Required 

42 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  «.1.2+ 

Content: 

•  Seeking medical attention  for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions  required 

• 

• 

If any residents  have  an injury from a  witnessed or unwitnessed  accident,  we seek 
urgent medical attention at the time 

If any residents have an  injury which  appears  and  is  unknown, we seek urgent 
medical attention when this is  noticed 

• 

If we seek medical attention and are provided  with  a timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to be documented in the PCS  notes 

43 HUDDLE 

Huddle Topic:  Accessing  medical treatment -residents 

Date: 

to/z/z9 

Di

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions required 

• 

• 

If any residents  have  an injury from a  witnessed or unwitnessed  accident,  we seek 
urgent medical attention at the time 

If any residents have an  injury which appears  and  is unknown,  we seek urgent 
medical attention when this is  noticed 

• 

If we seek medical attention  and are provided with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above is to be documented  in the PCS  notes 

44 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  13--2\ 

Disc

Content: 

•  Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a  timeframe for response times 

Actions required 

• 

• 

If any residents have an  injury from a witnessed or unwitnessed accident, we seek 
urgent medical attention  at the time 

If any residents have an injury which  appears  and is  unknown, we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention  and are  provided with a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to be documented  in the PCS  notes 

45 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:+--21 

Content: 

• 

Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions  required 

• 

• 

If any residents  have an injury from a  witnessed or unwitnessed accident, we seek 
urgent medical attention at the time 

If any residents have an injury which  appears and is  unknown,  we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention and are provided with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above  is to be documented  in  the PCS  notes 

46 HUDDLE 

Huddle Topic  Falls 
Date  7%  7 -2u 

Content 
Monitoring falls and any patterns,  is there something they are doing prior to 
falling,  do we think there could be an infection, has medication changed. We 
need to  be looking at what could be causing fall or is it un-preventable. 
Ensure we are  assisting those with poor mobility, checking their foot ware  is 
suitable and seeking advice where we  need  it via GP for referrals to Physio 
and fall team. 
Also documenting any changes and what has been do to help prevent falls. 

Any Action  Required 

47 HUDDLE 

Huddle Topic:  Accessing  medical  treatment -residents 

Date:  7- 1-2l. 

Discussion  held with 

Content: 

•  Seeking medical attention for residents 

•  Chasing up on ambulance call outs when given a  timeframe for response times 

Actions  required 

• 

• 

If any residents have an  injury from a  witnessed or unwitnessed accident, we seek 
urgent medical attention at the time 

If any residents have an injury which appears and is unknown, we seek urgent 
medical  attention  when this is noticed 

• 

If we seek medical attention  and are provided  with a timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above is to be documented  in the PCS  notes 

48 HUDDLE 

Huddle Topic:  Accessing medical treatment -residents 

Date:  e  a2u- 

D

Content: 

•  Seeking medical attention  for residents 

•  Chasing up on ambulance call outs when given a timeframe for response times 

Actions required 

• 

• 

If any residents have an injury from a  witnessed or unwitnessed accident,  we seek 
urgent medical attention  at the time 

If any residents have an  injury which  appears and is unknown, we seek urgent 
medical attention when this is noticed 

• 

If we seek medical attention  and are provided  with  a  timeframe for an ambulance 
to attend, we ensure that we chase the call to ensure that this does not lapse 

•  All of the above is to be documented  in the PCS  notes 

49 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

FLEXEBEE

Palliative and End of Life 
Care

13/6/2022

3/11/2022

20/3/2023

00:41:35

100

PASSED

Yes

HACCP Awareness

15/6/2022

11/3/2023

11/3/2023

00:06:46

12/7/2022

9/3/2023

16/6/2023

00:04:52

80

90

PASSED

Yes

PASSED

Yes

Autistic Spectrum 
Disorder (ASD) 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

Learning Disability 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

12/7/2022

9/3/2023

16/6/2023

00:03:42

100

PASSED

Yes

12/7/2022

9/3/2023

19/6/2023

00:04:34

100

PASSED

Yes

12/7/2022

27/9/2022

11/3/2023

00:05:01

100

PASSED

Yes

12/7/2022

11/3/2023

11/3/2023

00:04:27

90

PASSED

Yes

12/7/2022

11/3/2023

11/3/2023

00:02:54

90

PASSED

Yes

12/7/2022

12/3/2023

16/6/2023

00:03:12

100

PASSED

Yes

12/7/2022

12/3/2023

16/6/2023

00:01:12

100

PASSED

Yes

12/7/2022

9/3/2023

16/6/2023

00:01:12

90

PASSED

Yes

12/7/2022

16/6/2023

16/6/2023

00:03:04

100

PASSED

Yes

12/7/2022

16/6/2023

16/6/2023

00:03:00

90

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

50 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

Learning Disability 
Awareness

Autistic Spectrum 
Disorder (ASD) 
Awareness

Learning Disability 
Awareness

Palliative and End of Life 
Care

Palliative and End of Life 
Care

Palliative and End of Life 
Care

12/7/2022

16/6/2023

16/6/2023

00:02:07

100

PASSED

Yes

12/7/2022

16/6/2023

16/6/2023

00:18:34

100

PASSED

Yes

12/7/2022

9/3/2023

19/6/2023

00:02:05

90

PASSED

Yes

12/7/2022

19/6/2023

19/6/2023

00:02:35

100

PASSED

Yes

12/7/2022

19/6/2023

19/6/2023

00:04:29

90

PASSED

Yes

13/7/2022

4/8/2021

11/3/2023

00:08:34

100

PASSED

Yes

13/7/2022

3/11/2022

11/3/2023

00:04:11

90.9

PASSED

Yes

13/7/2022

16/6/2023

16/6/2023

00:03:18

81.81

PASSED

Yes

Allergen Awareness

13/7/2022

9/3/2023

19/6/2023

00:04:45

81.81

PASSED

Yes

Allergen Awareness

26/1/2023

19/2/2023

19/2/2023

00:10:14

81.81

PASSED

Yes

Autistic Spectrum 
Disorder (ASD) 
Awareness

26/1/2023

19/2/2023

19/2/2023

00:59:54

100

PASSED

Yes

Disability Awareness

26/1/2023

20/2/2023

20/2/2023

00:13:32

85.71

PASSED

Yes

Falls Prevention

26/1/2023

20/2/2023

20/2/2023

00:10:41

100

PASSED

Yes

Allergen Awareness

26/1/2023

17/10/2023

17/10/2023

00:23:00

90.9

PASSED

Yes

Autistic Spectrum 
Disorder (ASD) 
Awareness

26/1/2023

18/10/2023

18/10/2023

00:28:52

90

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

51 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Coronavirus Awareness 
and Infection Control

26/1/2023

18/10/2023

18/10/2023

00:26:44

83.33

PASSED

Yes

COSHH Awareness

26/1/2023

19/10/2023

19/10/2023

00:24:32

Disability Awareness

26/1/2023

19/10/2023

19/10/2023

00:30:52

80

80

PASSED

Yes

PASSED

Yes

Palliative and End of Life 
Care

26/1/2023

17/10/2023

21/10/2023

00:43:00

81.81

PASSED

Yes

Oral Health

26/1/2023

21/10/2023

21/10/2023

00:15:21

100

PASSED

Yes

Falls Prevention

26/1/2023

22/10/2023

22/10/2023

00:04:38

100

PASSED

Yes

Fire Safety CSTF Aligned 26/1/2023

22/10/2023

22/10/2023

00:28:49

90

PASSED

Yes

GDPR Awareness

26/1/2023

22/10/2023

22/10/2023

00:23:30

100

PASSED

Yes

HACCP Awareness

26/1/2023

22/10/2023

22/10/2023

00:31:03

26/1/2023

22/10/2023

22/10/2023

00:32:54

90

80

PASSED

Yes

PASSED

Yes

Learning Disability 
Awareness

Manual Handling of 
Inanimate Objects 
Awareness

Moving and Handling of 
People Awareness

Communication and 
Record Keeping

Standard 1 – 
Understand Your Role

Standard 2 – Your 
Personal Development

Standard 3 – Duty of 
Care

26/1/2023

22/10/2023

22/10/2023

00:28:18

100

PASSED

Yes

26/1/2023

22/10/2023

22/10/2023

00:22:03

26/1/2023

22/10/2023

22/10/2023

80

0

PASSED

Yes

PASSED

Yes

26/1/2023

22/10/2023

23/10/2023

00:02:09

83.33

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:17:37

83.33

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:20:44

83.33

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

52 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Standard 4 – Equality 
and Diversity

Standard 5 – Work in a 
Person Centred Way

Standard 6 – 
Communication

Standard 7 – Privacy 
and Dignity

Standard 8 – Fluid and 
Nutrition

Standard 9 – Awareness 
of Mental Health, 
Dementia and Learning 
Disability

Standard 12 – Basic Life 
Support

Standard 13 – Health 
and Safety

Standard 14 – Handling 
Information

Standard 15 – Infection 
Prevention Control

Standard 10&11 – 
Safeguarding Adults and 
Children

26/1/2023

23/10/2023

23/10/2023

00:29:38

83.33

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:20:35

83.33

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:08:36

100

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:06:37

100

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:19:49

100

PASSED

Yes

26/1/2023

23/10/2023

24/10/2023

00:02:13

83.33

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:15:09

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:12:21

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:05:36

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:08:46

83.33

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:45:32

83.33

PASSED

Yes

Care Certificate

26/1/2023

24/10/2023

24/10/2023

04:28:00

91.11

PASSED

Yes

Managing Challenging 
Behaviour Positive 
Behaviour Support

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

26/1/2023

24/10/2023

24/10/2023

00:13:18

100

PASSED

Yes

26/1/2023

22/10/2023

25/10/2023

00:16:10

90

PASSED

Yes

Food Safety Level 2

26/1/2023

22/10/2023

26/10/2023

00:05:00

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

53 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Food Safety Level 3

26/1/2023

22/10/2023

26/10/2023

00:12:49

90

PASSED

Yes

Standard 10&11 – 
Safeguarding Adults and 
Children

26/1/2023

1/2/2023

7/2/2024

00:39:09

83.33

PASSED

Yes

Care Certificate

26/1/2023

7/2/2024

7/2/2024

01:39:00

91.67

PASSED

Yes

Food Safety Level 2

26/1/2023

7/2/2024

7/2/2024

00:30:04

Fire Safety CSTF Aligned 26/1/2023

7/2/2024

7/2/2024

00:06:21

GDPR Awareness

26/1/2023

7/2/2024

7/2/2024

00:08:01

90

90

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

Learning Disability 
Awareness

Managing Challenging 
Behaviour Positive 
Behaviour Support

Manual Handling of 
Inanimate Objects 
Awareness

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

Moving and Handling of 
People Awareness

26/1/2023

7/2/2024

7/2/2024

00:04:39

100

PASSED

Yes

26/1/2023

7/2/2024

7/2/2024

00:04:28

100

PASSED

Yes

26/1/2023

7/2/2024

7/2/2024

00:02:16

100

PASSED

Yes

26/1/2023

7/2/2024

7/2/2024

00:03:54

100

PASSED

Yes

26/1/2023

7/2/2024

7/2/2024

00:08:42

80

PASSED

Yes

Oral Health

26/1/2023

7/2/2024

7/2/2024

00:02:31

100

PASSED

Yes

Palliative and End of Life 
Care

Safeguarding of 
Vulnerable Adults 
Awareness

26/1/2023

7/2/2024

7/2/2024

00:04:42

90.9

PASSED

Yes

26/1/2023

7/2/2024

7/2/2024

00:54:44

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

54 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Dementia Care

26/1/2023

24/10/2023

24/10/2023

00:54:44

100

PASSED

Yes

Diet and Nutrition

26/1/2023

23/10/2023

23/10/2023

00:54:44

100

PASSED

Yes

Dignity, Privacy and 
Respect

Emergency First Aid 
Awareness

Equality, Diversity and 
Human Rights

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

26/1/2023

23/10/2023

23/10/2023

00:54:44

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:54:44

100

PASSED

Yes

26/1/2023

23/10/2023

23/10/2023

00:54:44

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:54:44

100

PASSED

Yes

26/1/2023

24/10/2023

24/10/2023

00:54:44

100

PASSED

Yes

Person Centred Care

26/1/2023

23/10/2023

23/10/2023

00:54:44

100

PASSED

Yes

Safeguarding of 
Vulnerable Adults 
Awareness

26/1/2023

24/10/2023

24/10/2023

00:54:44

100

PASSED

Yes

Food Safety Level 2

11/3/2023

11/3/2023

11/3/2023

00:05:25

100

PASSED

Yes

Food Safety Level 2

11/3/2023

17/3/2023

17/3/2023

00:03:34

100

PASSED

Yes

Health and Safety 
Awareness

11/3/2023

17/3/2023

16/6/2023

00:02:11

100

PASSED

Yes

Food Safety Level 2

11/3/2023

12/3/2023

15/6/2023

00:02:20

100

PASSED

Yes

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

11/3/2023

12/3/2023

15/6/2023

00:01:47

100

PASSED

Yes

11/3/2023

12/3/2023

15/6/2023

00:02:17

100

PASSED

Yes

Dementia Care

11/3/2023

12/3/2023

16/6/2023

00:02:29

80

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

55 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Equality, Diversity and 
Human Rights

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

11/3/2023

12/3/2023

16/6/2023

00:02:23

11/3/2023

12/3/2023

16/6/2023

00:02:44

80

90

PASSED

Yes

PASSED

Yes

11/3/2023

12/3/2023

16/6/2023

00:02:38

100

PASSED

Yes

Food Safety Level 2

11/3/2023

12/3/2023

16/6/2023

00:02:25

100

PASSED

Yes

Food Safety Level 2

11/3/2023

12/3/2023

16/6/2023

00:02:36

100

PASSED

Yes

Infection Prevention and 
Control Level 2 CSTF 
aligned

11/3/2023

14/3/2023

16/6/2023

00:02:34

100

PASSED

Yes

Food Safety Level 2

11/3/2023

14/3/2023

16/6/2023

00:02:21

100

PASSED

Yes

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

Health and Safety 
Awareness

11/3/2023

14/3/2023

16/6/2023

00:02:56

100

PASSED

Yes

11/3/2023

14/3/2023

16/6/2023

00:02:17

100

PASSED

Yes

11/3/2023

16/3/2023

16/6/2023

00:02:43

100

PASSED

Yes

Person Centred Care

11/3/2023

16/3/2023

16/6/2023

00:02:09

100

PASSED

Yes

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

11/3/2023

17/3/2023

16/6/2023

00:02:36

100

PASSED

Yes

11/3/2023

17/3/2023

16/6/2023

00:02:26

100

PASSED

Yes

Food Safety Level 2

11/3/2023

17/3/2023

16/6/2023

00:02:12

100

PASSED

Yes

Food Safety Level 2

11/3/2023

17/3/2023

16/6/2023

00:02:19

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

56 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

11/3/2023

17/3/2023

16/6/2023

00:02:56

100

PASSED

Yes

11/3/2023

19/6/2023

19/6/2023

00:20:46

100

PASSED

Yes

Food Safety Level 2

11/3/2023

19/6/2023

19/6/2023

00:02:03

100

PASSED

Yes

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

Managing Challenging 
Behaviour Positive 
Behaviour Support

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

Moving and Handling of 
People Awareness

Moving and Handling of 
People Awareness

Managing Challenging 
Behaviour Positive 
Behaviour Support

11/3/2023

19/6/2023

19/6/2023

00:05:01

80

PASSED

Yes

11/3/2023

19/6/2023

19/6/2023

00:05:10

100

PASSED

Yes

11/3/2023

19/6/2023

19/6/2023

00:03:00

100

PASSED

Yes

11/3/2023

19/6/2023

19/6/2023

00:04:04

100

PASSED

Yes

11/3/2023

16/8/2023

16/8/2023

00:06:33

80

PASSED

Yes

11/3/2023

16/8/2023

16/8/2023

00:05:53

100

PASSED

Yes

11/3/2023

16/8/2023

16/8/2023

00:05:31

11/3/2023

19/9/2023

19/9/2023

00:03:42

11/3/2023

19/6/2023

23/9/2023

00:02:49

80

80

80

PASSED

Yes

PASSED

Yes

PASSED

Yes

Emergency First Aid 

11/3/2023

16/6/2023

24/9/2023

00:01:23

90

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

57 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Awareness

Fire Safety CSTF Aligned 11/3/2023

27/9/2023

27/9/2023

00:02:12

90

PASSED

Yes

Food Safety Level 2

11/3/2023

27/9/2023

27/9/2023

00:01:33

100

PASSED

Yes

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

Manual Handling of 
Inanimate Objects 
Awareness

Safeguarding of 
Vulnerable Adults 
Awareness

Communication and 
Record Keeping

Communication and 
Record Keeping

11/3/2023

27/9/2023

27/9/2023

00:27:32

100

PASSED

Yes

11/3/2023

27/9/2023

27/9/2023

00:01:40

100

PASSED

Yes

11/3/2023

27/9/2023

27/9/2023

00:04:02

100

PASSED

Yes

11/3/2023

27/9/2023

27/9/2023

00:02:16

90

PASSED

Yes

22/5/2023

9/11/2023

9/11/2023

00:31:07

100

PASSED

Yes

22/5/2023

7/2/2024

7/2/2024

00:03:22

Fire Safety CSTF Aligned 22/5/2023

13/2/2024

13/2/2024

00:15:12

COSHH Awareness

22/5/2023

13/2/2024

13/2/2024

00:01:29

90

80

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

Food Safety Level 2

22/5/2023

13/2/2024

13/2/2024

00:02:20

100

PASSED

Yes

Falls Prevention

22/5/2023

13/2/2024

13/2/2024

00:02:44

100

PASSED

Yes

GDPR Awareness

22/5/2023

13/2/2024

13/2/2024

00:02:54

80

PASSED

Yes

Moving and Handling of 
People Awareness

Manual Handling of 
Inanimate Objects 

22/5/2023

13/2/2024

13/2/2024

00:01:34

100

PASSED

Yes

22/5/2023

13/2/2024

13/2/2024

00:06:08

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

58 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Awareness

Mental Capacity Act and 
Deprivation of Liberties 
Awareness

22/5/2023

13/2/2024

13/2/2024

00:02:01

80

PASSED

Yes

Allergen Awareness

22/5/2023

13/2/2024

13/2/2024

00:02:22

90.9

PASSED

Yes

22/5/2023

13/2/2024

13/2/2024

00:03:34

100

PASSED

Yes

22/5/2023

13/2/2024

13/2/2024

00:01:44

90

PASSED

Yes

22/5/2023

13/2/2024

13/2/2024

00:48:12

83.33

PASSED

Yes

22/5/2023

13/2/2024

13/2/2024

00:03:57

83.33

PASSED

Yes

22/5/2023

13/2/2024

22/2/2024

00:01:24

100

PASSED

Yes

22/5/2023

13/2/2024

22/2/2024

00:06:35

83.33

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:06:25

83.33

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:03:24

100

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:02:09

100

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:02:33

83.33

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:34:37

100

PASSED

Yes

Managing Challenging 
Behaviour Positive 
Behaviour Support

Autistic Spectrum 
Disorder (ASD) 
Awareness

Standard 2 – Your 
Personal Development

Standard 3 – Duty of 
Care

Standard 1 – 
Understand Your Role

Standard 4 – Equality 
and Diversity

Standard 5 – Work in a 
Person Centred Way

Standard 6 – 
Communication

Standard 7 – Privacy 
and Dignity

Standard 8 – Fluid and 
Nutrition

Standard 9 – Awareness 
of Mental Health, 
Dementia and Learning 
Disability

Standard 10&11 – 
Safeguarding Adults and 

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

22/5/2023

22/2/2024

22/2/2024

00:01:37

83.33

PASSED

Yes

Yes

Deerlands

59 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Children

Standard 12 – Basic Life 
Support

Standard 13 – Health 
and Safety

Standard 14 – Handling 
Information

Standard 15 – Infection 
Prevention Control

22/5/2023

22/2/2024

22/2/2024

00:02:02

100

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:02:51

100

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:03:04

83.33

PASSED

Yes

22/5/2023

22/2/2024

22/2/2024

00:02:14

100

PASSED

Yes

Care Certificate

22/5/2023

22/2/2024

22/2/2024

02:55:00

92.22

PASSED

Yes

Disability Awareness

22/5/2023

13/2/2024

27/3/2024

00:10:44

90

PASSED

Yes

Palliative and End of Life 
Care

Communication and 
Record Keeping

Learning Disability 
Awareness

22/5/2023

27/3/2024

28/7/2024

00:01:16

81.81

PASSED

Yes

22/5/2023

28/7/2024

28/7/2024

00:01:20

22/5/2023

28/7/2024

28/7/2024

00:01:57

90

90

PASSED

Yes

PASSED

Yes

Oral Health

22/5/2023

28/7/2024

28/7/2024

00:01:07

100

PASSED

Yes

Communication and 
Record Keeping

5/6/2023

23/10/2023

25/10/2023

00:21:10

100

PASSED

Yes

Fire Safety CSTF Aligned 15/6/2023

25/8/2023

25/8/2023

00:03:35

Fire Safety CSTF Aligned 15/6/2023

24/9/2023

24/9/2023

00:03:55

90

90

PASSED

Yes

PASSED

Yes

Dysphagia Care

11/7/2023

22/10/2023

22/10/2023

00:44:20

100

PASSED

Yes

Diet and Nutrition

12/7/2023

16/8/2023

16/8/2023

00:06:44

Oral Health

12/7/2023

16/8/2023

16/8/2023

00:04:50

90

90

PASSED

Yes

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

60 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Oral Health

12/7/2023

16/8/2023

16/8/2023

00:09:56

90

PASSED

Yes

Oral Health

12/7/2023

16/8/2023

16/8/2023

00:03:36

100

PASSED

Yes

Diet and Nutrition

12/7/2023

16/8/2023

16/8/2023

00:02:53

100

PASSED

Yes

Diet and Nutrition

12/7/2023

23/8/2023

23/8/2023

00:13:36

100

PASSED

Yes

Oral Health

12/7/2023

23/8/2023

23/8/2023

00:18:48

90

PASSED

Yes

Diet and Nutrition

12/7/2023

25/8/2023

25/8/2023

00:15:46

100

PASSED

Yes

Diet and Nutrition

12/7/2023

25/8/2023

25/8/2023

00:03:26

90

PASSED

Yes

Oral Health

12/7/2023

25/8/2023

25/8/2023

00:10:12

100

PASSED

Yes

Oral Health

12/7/2023

25/8/2023

25/8/2023

00:02:53

Diet and Nutrition

12/7/2023

25/8/2023

25/8/2023

00:01:44

Oral Health

12/7/2023

25/8/2023

25/8/2023

00:05:10

90

90

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

Diet and Nutrition

12/7/2023

30/8/2023

30/8/2023

00:13:03

100

PASSED

Yes

Oral Health

12/7/2023

30/8/2023

30/8/2023

00:07:56

90

PASSED

Yes

Diet and Nutrition

12/7/2023

8/9/2023

8/9/2023

00:05:41

100

PASSED

Yes

Oral Health

12/7/2023

8/9/2023

8/9/2023

00:04:58

100

PASSED

Yes

Diet and Nutrition

12/7/2023

9/9/2023

9/9/2023

00:02:53

90

PASSED

Yes

Oral Health

12/7/2023

9/9/2023

9/9/2023

00:04:53

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

61 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Diet and Nutrition

12/7/2023

9/9/2023

9/9/2023

00:14:23

90

PASSED

Yes

Oral Health

12/7/2023

9/9/2023

9/9/2023

00:05:34

100

PASSED

Yes

Diet and Nutrition

12/7/2023

13/9/2023

13/9/2023

00:06:52

90

PASSED

Yes

Oral Health

12/7/2023

13/9/2023

13/9/2023

00:02:29

100

PASSED

Yes

Diet and Nutrition

12/7/2023

14/9/2023

14/9/2023

00:04:01

90

PASSED

Yes

Oral Health

12/7/2023

14/9/2023

14/9/2023

00:04:11

100

PASSED

Yes

Diet and Nutrition

12/7/2023

14/9/2023

14/9/2023

00:01:52

Diet and Nutrition

12/7/2023

14/9/2023

14/9/2023

00:02:41

90

90

PASSED

Yes

PASSED

Yes

Oral Health

12/7/2023

14/9/2023

14/9/2023

00:04:33

100

PASSED

Yes

Diet and Nutrition

12/7/2023

14/9/2023

14/9/2023

00:02:59

90

PASSED

Yes

Oral Health

12/7/2023

14/9/2023

14/9/2023

00:02:13

100

PASSED

Yes

Oral Health

12/7/2023

15/9/2023

15/9/2023

00:09:03

100

PASSED

Yes

Diet and Nutrition

12/7/2023

15/9/2023

15/9/2023

00:16:39

Diet and Nutrition

12/7/2023

18/9/2023

18/9/2023

00:02:13

90

90

PASSED

Yes

PASSED

Yes

Oral Health

12/7/2023

18/9/2023

18/9/2023

00:04:12

100

PASSED

Yes

Diet and Nutrition

12/7/2023

23/9/2023

23/9/2023

00:01:43

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

62 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Oral Health

12/7/2023

23/9/2023

23/9/2023

00:01:26

100

PASSED

Yes

Diet and Nutrition

12/7/2023

23/9/2023

23/9/2023

00:03:14

100

PASSED

Yes

Oral Health

12/7/2023

23/9/2023

23/9/2023

00:04:31

100

PASSED

Yes

Diet and Nutrition

12/7/2023

23/9/2023

23/9/2023

00:01:49

100

PASSED

Yes

Oral Health

12/7/2023

23/9/2023

23/9/2023

00:01:40

100

PASSED

Yes

Diet and Nutrition

12/7/2023

23/9/2023

23/9/2023

00:01:16

100

PASSED

Yes

Oral Health

12/7/2023

23/9/2023

23/9/2023

00:28:01

100

PASSED

Yes

Fire Safety CSTF Aligned 12/7/2023

24/9/2023

24/9/2023

00:39:29

90

PASSED

Yes

Manual Handling of 
Inanimate Objects 
Awareness

12/7/2023

24/9/2023

24/9/2023

00:01:17

100

PASSED

Yes

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:01:56

100

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:01:19

100

PASSED

Yes

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:02:02

100

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:15:15

100

PASSED

Yes

Oral Health

12/7/2023

14/9/2023

24/9/2023

00:01:46

100

PASSED

Yes

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:01:34

100

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:01:17

100

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

63 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:02:33

100

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:07:52

100

PASSED

Yes

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:02:52

100

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:01:59

100

PASSED

Yes

Diet and Nutrition

12/7/2023

24/9/2023

24/9/2023

00:01:58

90

PASSED

Yes

Oral Health

12/7/2023

24/9/2023

24/9/2023

00:01:29

100

PASSED

Yes

Diet and Nutrition

12/7/2023

27/9/2023

27/9/2023

00:02:30

100

PASSED

Yes

Oral Health

12/7/2023

27/9/2023

27/9/2023

00:03:16

100

PASSED

Yes

Diet and Nutrition

12/7/2023

27/9/2023

27/9/2023

00:03:17

100

PASSED

Yes

Coronavirus in Health 
and Social Care

Mental Health 
Awareness

12/7/2023

22/10/2023

22/10/2023

00:41:59

12/7/2023

22/10/2023

22/10/2023

00:15:13

Diet and Nutrition

12/7/2023

10/11/2023

10/11/2023

00:13:59

Diet and Nutrition

12/7/2023

7/2/2024

7/2/2024

00:05:43

Diet and Nutrition

12/7/2023

28/7/2024

28/7/2024

00:01:25

16/8/2023

2/8/2021

23/9/2023

00:02:14

90

90

90

80

80

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

PASSED

Yes

PASSED

Yes

PASSED

Yes

16/8/2023

4/8/2021

24/9/2023

00:01:55

100

PASSED

Yes

Equality, Diversity and 

16/8/2023

4/8/2021

23/9/2023

00:01:46

100

PASSED

Yes

Equality, Diversity and 
Human Rights

Equality, Diversity and 
Human Rights

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

64 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Human Rights

Equality, Diversity and 
Human Rights

Equality, Diversity and 
Human Rights

Equality, Diversity and 
Human Rights

16/8/2023

5/8/2021

24/9/2023

00:01:52

100

PASSED

Yes

16/8/2023

5/8/2021

23/9/2023

00:01:55

16/8/2023

29/7/2021

25/8/2023

00:02:15

90

80

80

PASSED

Yes

PASSED

Yes

PASSED

Yes

COSHH Awareness

16/8/2023

16/8/2023

16/8/2023

00:06:31

Communication and 
Record Keeping

Moving and Handling of 
People Awareness

Managing Challenging 
Behaviour Positive 
Behaviour Support

Equality, Diversity and 
Human Rights

Emergency First Aid 
Awareness

Health and Safety 
Awareness

Infection Prevention and 
Control Level 2 CSTF 
aligned

Manual Handling of 
Inanimate Objects 
Awareness

16/8/2023

16/8/2023

16/8/2023

00:06:21

100

PASSED

Yes

16/8/2023

16/8/2023

16/8/2023

00:06:16

16/8/2023

18/8/2023

18/8/2023

00:05:25

80

90

PASSED

Yes

PASSED

Yes

16/8/2023

30/7/2021

18/8/2023

00:04:53

80

PASSED

Yes

16/8/2023

18/8/2023

18/8/2023

00:06:37

100

PASSED

Yes

16/8/2023

18/8/2023

18/8/2023

00:07:17

90

PASSED

Yes

16/8/2023

18/8/2023

18/8/2023

00:04:35

100

PASSED

Yes

16/8/2023

18/8/2023

18/8/2023

00:11:24

100

PASSED

Yes

COSHH Awareness

16/8/2023

23/8/2023

23/8/2023

00:12:46

Communication and 
Record Keeping

16/8/2023

23/8/2023

23/8/2023

00:15:32

COSHH Awareness

16/8/2023

25/8/2023

25/8/2023

00:06:30

80

80

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

65 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 
PASSED 
(YES/NO)

HAS COURSE 
BEEN 
STARTED 
(YES/NO)

MANAGER 
NAME

SITE 
NAME

Communication and 
Record Keeping

Communication and 
Record Keeping

Manual Handling of 
Inanimate Objects 
Awareness

Emergency First Aid 
Awareness

Equality, Diversity and 
Human Rights

Communication and 
Record Keeping

Emergency First Aid 
Awareness

16/8/2023

25/8/2023

25/8/2023

00:32:40

16/8/2023

25/8/2023

25/8/2023

00:07:02

90

90

PASSED

Yes

PASSED

Yes

16/8/2023

25/8/2023

25/8/2023

00:19:41

100

PASSED

Yes

16/8/2023

25/8/2023

25/8/2023

00:03:08

100

PASSED

Yes

16/8/2023

25/8/2023

25/8/2023

00:02:31

16/8/2023

25/8/2023

25/8/2023

00:03:51

80

90

PASSED

Yes

PASSED

Yes

16/8/2023

25/8/2023

25/8/2023

00:05:58

100

PASSED

Yes

Dementia Care

16/8/2023

25/8/2023

25/8/2023

00:01:47

16/8/2023

30/8/2023

30/8/2023

00:08:30

16/8/2023

30/8/2023

30/8/2023

00:06:21

100

PASSED

Yes

Communication and 
Record Keeping

Emergency First Aid 
Awareness

Moving and Handling of 
People Awareness

Moving and Handling of 
People Awareness

16/8/2023

30/8/2023

30/8/2023

00:16:06

16/8/2023

25/8/2023

1/9/2023

00:21:39

Food Safety Level 2

16/8/2023

1/9/2023

1/9/2023

00:44:35

80

90

PASSED

Yes

PASSED

Yes

80

80

90

PASSED

Yes

PASSED

Yes

PASSED

Yes

COSHH Awareness

16/8/2023

4/9/2023

4/9/2023

00:14:30

100

PASSED

Yes

Infection Prevention and 
Control Level 2 CSTF 
aligned

16/8/2023

4/9/2023

4/9/2023

00:37:27

90

PASSED

Yes

COSHH Awareness

16/8/2023

8/9/2023

8/9/2023

00:03:26

80

PASSED

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

Deerlands

66 USER NAME

USER 
ID

COURSE NAME

COURSE 
ASSIGNED 
DATE

COURSE 
START 
DATE

COURSE 
COMPLETION 
DATE

COURSE 
ACCESS TIME 
(HH:MM:SS)

SCORE COURSE 
STATUS

HAS 
COURSE 
BEEN 

Text truncated at 80,000 characters — see the source PDF for the remainder.

Also filed under 2024-0335: Maureen-Woollen-Prevention-of-future-deaths-report-2024-0335_Published.pdf
1 

2 

3 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  

Deerlands Residential Home, 48 Margetson Road, Parson Cross, Sheffield S5 
9LS. 
CORONER 

I am Tanyka Rawden, HM Senior Coroner for the Coroner area of South 
Yorkshire (West). 

CORONER'S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice 
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 

http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 
INVESTIGATION and INQUEST 

On 6 November 2023 I commenced an investigation into the death of Maureen 
Alison Woollen. The investigation concluded at the end of the inquest on 18 
June 2024.   
CIRCUMSTANCES OF THE DEATH 

Maureen Alison Woollen (born 24 September 1931) was discharged from the 
Northern General Hospital in Sheffield to Deerlands Residential Home in 
Sheffield on 2 October 2023. 

The S2A assessment identified she was a high risk of falls due to her 
underlying dementia and psychosis, her frailty, her limited mobility, the side 
effects of her medication and her previous falls. 

On admission to Deerlands residential home a falls risk assessment was not 
conducted. 

4 

On 3 October 2023 Mrs Woollen was heard shouting and was found on the 
floor in her room. She could not say how she came to be on the floor. Staff did 
not identify any external injuries and did not seek medical assistance. 

On 6 October 2023 a carer noticed a 'fresh big bruise and a lump on her right 
forehead and temple'. A team leader was notified and decided to call an 
emergency care practitioner. This call was not made. 

Between 6 October 2023 and 13 October 2023 there are no references to Mrs 
Woollen's facial injury in the care notes. 

On 11 October 2023 staff noticed a decrease in Mrs Woollen's food and drink 
intake. This was not recorded in the care notes and medical assistance was 
not sought. 

  
  
  
  
  
  
  
 On 13 October 2023 a general practitioner was contacted due to concerns 
from Mrs Woollen's family and Deerlands Residential home that Mrs Woollen 
had experienced a recurrence of psychotic symptoms over the previous two 
days. 

A general practitioner attended on 13 October 2023 and found Mrs Woollen to 
be 'slumped in a chair'. He was told the facial bruising occurred on 9 or 10 
October 2023. There are no incidents recorded in the care notes on those 
dates. 

Mrs Woollen was admitted to Northern General Hospital in Sheffield on 13 
October 2023 and diagnosed with an intracerebral haemorrhage. 

She died in hospital on 31 October 2023 as a result of the intracerebral 
haemorrhage. 
CORONER'S CONCERNS 

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

The inquest found there were missed opportunities to conduct a falls risk 
assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek 
medical attention when she was found on the floor on 3 October 2023, to seek 
medical attention when a bruise on her face was noted on 6 October 2023 and 
to monitor the progression of her bruise. 

The MATTERS OF CONCERN are as follows.  - 

I am concerned there is no process in place to ensure medical attention is 
promptly sought for residents who require it, that care notes are not fully 
utilised, especially for the recording of injury and incidents, and that falls risk 
assessments are not being conducted on admission. 
ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe 
you have the power to take such action. 
YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 14 August 2024 I, the Coroner, may extend the period. 

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

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

The family of Mrs Woollen. 

I have also sent it to Sheffield City Council who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your response. 

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 

5 

6 

7 

8 

  
  
  
 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 by the Chief Coroner. 
19 June 2024 

9 

Signature 

Tanyka Rawden H.M Senior Coroner for South Yorkshire (West)

Responses

1 response 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 Sheffcare (PDF)
FAO Ms Tanyka Rawden
HM Senior Coroner for South Yorkshire
(West)

South Yorkshire (West) Coroner’s Service,
Medico-Legal Centre,
Watery Street,
Sheffield
S3 7ES

Sent by Email:

T:
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Office:

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Birmingham

Your ref:

TBC

13 August 2024

Death of Maureen Alison Woollen (D.O.B. 24 September 1931, D.O.D. 31 October 2023)
Response to Regulation 28 Report to Prevent Future Deaths

Dear Sirs

We have been asked to assist Sheffcare in relation to the matters of concern raised in the Coroner’s

Report  to  Prevent  Future  Deaths  (PFD)  dated  19  June  2024  raised  under  Paragraph  7  of Schedule  5

Coroners and Justice Act 2009.   The PFD was addressed to Deerlands Residential Home, 48 Margetson

Road, Parson Cross, Sheffield S5 9LS (“Deerlands”) which is the address at which Mrs Maureen Woollen
was  residing  when  she  had  an  unwitnessed  fall  on  3rd  October  2023.    We  attach  a  small  bundle  of
documents which is referred to in this response.   For the avoidance of doubt Sheffcare is the company

that own Deerlands.

Although we did not represent Sheffcare at the Inquest it is our understanding that the Learned Coroner

considered several areas of concern which were: a failure to escalate matters and seek medical advice
on 3rd October 2023 and subsequently a care worker noted on 6th October that Mrs Woollen had bruising
to her face but did not seek medical advice about this either.  There were also concerns about the lack

of detailed risk assessment from the outset and that care notes were not completed adequately.   Before

dealing with the specific concerns, we thought it would be helpful to set out an overview of the current

status regarding changes that have been made since the sad death of Mrs Woollen as well as the generic

systems that Sheffcare have in place that are relevant.

 is the new Director of Quality and Care for SheffCare.  

 was not in post at the

time  of  Mrs Woollen’s  fall, but  since  she  took  on  the role of Director  of Quality  and Care, has  been

implementing changes and improvements at the service.   She is a senior and very experienced member

of the management team at Sheffcare having over 30 years’ experience in the private care sector.   The

service through 

, has taken the opportunity to consider wider matters arising from the inquest

and although strictly not part of the PFD request, Sheffcare wish to document reassurance that it has

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reviewed its relevant policies and guidance including Falls and Risk Assessment and Admission Policy

[see documents 1 and 2].  There is also stringent auditing at “root” level within the service and detailed

reporting to the Board to track incidents and ensure compliance with various relevant regulations [see

documents 3-6].

The Learned Coroner is aware that Mrs Woollen was admitted to Deerlands when her previous placement

had stated that it could not address all of Maureen’s needs.  This was after a fall for which she had been

treated at hospital.  On discharge she was subject to the S2A Pathway.  This means that she needed to

leave hospital as she was medically fit for discharge but that her initial placement with Sheffcare was
for a period of assessment.   Assessment of risk is dynamic, and it can take some time for an individual

(especially with dementia) to settle in sufficiently for a baseline to be established so that person centred

care can be fully implemented.

The  relationship  between  the  service  provider  and  the  local  authority,  under  the  S2A  Pathway  is

important.    The  Local Authority  gleans  information  from  the discharging Trust, and  this  is what the

needs for admission into the private care provider’s service is based on.  There is therefore significant

reliance upon the Local Authority to provide the most up to date information although it is an essential

part of the admission that the service conducts its own risk assessment on admission too.

There must be liaison between the service and the local authority to ensure that the service can meet

the individual’s needs – a decision which needs to be made prior to discharge.  It is therefore paramount

that  all  the relevant  information  is given by  the discharge  team.   A further  full assessment must  be

undertaken  by  the  receiving  service  to  ensure  that  the  risks within  that  environment  are  noted  and

ameliorated.

At  a  recent  meeting  between  senior  members  of  the  management  team  of  Sheffcare  and  the  Local

Authority a frank discussion on Risk Management and Incidents was undertaken.  The service drew the

Local Authority’s attention to the following:

o Forms are often unreadable and filled with high-risk fall indications without detailed

explanations.

o There's a discrepancy between hospital and care home assessments,

o Lack of information about patients' routines and history from the community is

problematic.

A senior member of the team at the Local Authority (RA) confirmed that over the next six months (July
to December 2024) “efforts will focus on improving the S2A pathway, addressing identified issues, and

preparing for a new model to be implemented post-April.”

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RA also confirmed that comprehensive information from the discharging hospital would be sought to

enable better decision making around admission and to inform the risk assessment process.

Finally, RA confirmed that he would be immediately responsible through the “Referral Workstream” for

the implementation of a process for completing and transferring fall risk assessments from hospitals

to care homes seamlessly.

Whilst these matters are not a direct response to the concerns raised, Sheffcare is concerned to ensure

that the Learned Coroner has other pertinent background information to evidence the proactivity and

collaboration  between  the  service and  the  Local Authority  with  the intention  of reducing  risk  before

admission to the service.

It is anticipated that due to this enhanced reporting and more proactive relationship – service users’

risk will be assessed more accurately prior to joining the service.   This will provide the service with a

better  understanding  of  the  individual’s  needs  and  enable  staff  to  make  appropriate  provision  for

admission.

The Registered Manager of the service is then responsible for carrying out a full risk assessment on

admission.  Staff are subject to training to recognise changes in risk and have clear information of how

and when to escalate matters.

Directly after the incident with Mrs Woollen, the service met with staff at Deerland and what is known

as “huddles” were carried out [see document 7].  A huddle is an informal meeting at which matters to

celebrate  as  well  as  concerns  are  raised  directly  with  staff.    The  incident  with  Mrs  Woollen  was

discussed  and  staff  were  reminded  of  the  policies  in  relation  to  falls  risk,  documentation,  and

escalation  it  has  also  been  part  of  their  mandatory  training  and  discussed  in  supervisions.  [see

document 8].

The importance of maintaining care notes was discussed at the Deputy Managers’ meeting on 2 July

2024 [see document 9]. Sheffcare already have sophisticated Person-Centred Software, but this does

not appear to have been used effectively at the time of Mrs Woollen’s care.  Sheffcare has now improved

the training sessions which already focus on the importance of keeping timely and accurate care notes

by  incorporating  within  the  existing  training  real  and  anonymised  scenarios  to  reinforce  to  staff

understanding. The software includes training around ensuring a falls risk assessment is completed

on admission.  Falls (witnessed or otherwise) must be documented in the Person-Centred Care system

and there is a monitoring and tracking section in the notes.  This is audited.

Refresher training has been rolled out at all Sheffcare homes to include the completion of assessments

prior  to  admission  to  the  home  and  the  importance  of  making  detailed  Person-Centred  Software

entries and maintaining daily care notes. The roll out of this refresher training was completed on 31

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July  2024.    It  is  now  a  continuing  feature  of regular  updating  training.  The  training  programme  is

reviewed and reported upon every month.   The training matrix is attached [see document 8].

Subsequent to Mrs Woollen’s fall, there has also been a complete review spearheaded by Louise of the

Quality  Assurance  Systems  for  the  Person-Centred  Care  systems  which  links  care  plans  and  risk

assessments automatically this is audited [see document 3]. There is a three-tier approach to quality

auditing headed by the Team Leader, Deputy Manager and Registered Manager who undertake quality

audits which then inform the monthly quality dashboard report.

[see document 4]. There has been

further focus on the process at Team Leader level to capture whether falls and requirement for medical
attention is being escalated appropriately.  The auditing also includes analysis of whether care notes

are properly updated.  This review was completed on 8 July 2024. In addition, the Registered Manager

and Deputy Manager QA now incorporate management checks on the Person-Centred care system and

daily care notes are sampled to promote good record-keeping principles.  This gives further quality

assurance and the end of the roll out of this new part of the services oversight will be completed by

31 August 2024.

The governance of Quality Assurance processes is kept under review by the Executive team and Quality

Committee.  Reporting  at  Director  level  to  the  Board  is  in  place  and  includes  all  areas  of  risk

management. Director home Quality Assurance visits were introduced in May 2024.

A Lessons learned briefing was issued on 21 June 2024 to all homes to ensure that this matter was

discussed across all the teams [see document 10].

held a Deputy Managers’ meeting on 2 July 2024 and issued notes for all the homes to ensure

a generic approach and focus on, the process for completing body maps and taking photographs of

any injuries or marks. Updated guidance on ensuring correct and robust use of body maps. This was

completed on 12 July 2024 [see document 9].

 met with Care Plan Coordinators on 16 July 2024. The Care Plan Coordinator role and remit is

to  upload  the  PCS  notes  from  assessment  and  ensure  that  all  assessments  are  undertaken.  They

support the operational management team in building care plans on PCS and ensure care plans are

kept under close review. The meeting focussed on ensuring that falls risk assessments are in place

prior to admission or on admission day, along with care plan review processes.   
 is undertaking
an analysis of PCS falls assessment data, which will provide additional reassurances that all residents

have falls risk assessments in place and any additional information around the management of falls is

appropriately reviewed. The Initial findings will be presented at the 22 August 2024 Quality Committee

meeting, and this will be completed by 31 August 2024.

The  admissions  policy  was  reviewed  and  updated  on  1  July  2024  to  further  outline  that  falls  risk

assessment  are  to  be  completed  prior  to  or  on  admission  to  Sheffcare  homes.  This  will  include  a

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person’s falls history and associated risks which could increase the risk of falls along with any falls

which occur during the residency within a Sheffcare home.

The  falls  prevention  policy  was  reviewed  and  updated  1  July  2024  to  reiterate  the  procedure  for

completing first aid checks on a fallen resident and referring to medical attention, also to ensure that

any injury/injuries are monitored and reviewed within the care notes [see document 1].

The  updated  admissions  policy  and  falls  prevention  policy  were  sent  to  Registered  Managers  and

Deputy Managers on 1 and 3 July 2024 for them to read and to familiarise themselves with the changes,

and to update their staff teams [see document 9].

Unannounced visits have been undertaken by the Head of Quality and Improvement and the Director

of Quality and Care provide additional assurances and visibility to the team. Following these visits, a

review is being undertaken to include any observations and learning arising.

Increased due diligence of referrals was discussed with managers on 24 July 2024 at the managers’

meeting and a frank discussion regarding referrals which arise, with limited information, or areas of

assessment which identify possible areas of risk a new due diligence process has been implemented

(see comments regarding the Local Authority involvement above).

There  is  now  oversight  by  the  Executive  team  of  any  inquests  providing  further  opportunity  to

undertake thematic reviews that may require additional oversight or action, including any relating to

HR, health and safety or financial investment.

Mrs Woollen’s case (and the improvements and learning from it) will be discussed on 22 August 24 at

the Quality Committee meeting. This will include the outcome of inquest, the PFD, actions put in place

and  a  review  of  progress.  The  service  has  been  in  direct  contact  with  CQC  and  updated  on  all

improvements made.

In short there has been a significant overview by Sheffcare in relation to the quality of services, risk

assessment and training.

Specific matters of concern from PFD



No process in place to ensure medical attention is promptly sought for residents who require

it,

Please see the above regarding the Person-Centred care system.  Further, all staff at the service receive

basic training in relation to life support and falls management.  All staff are aware of how to contact

the local GP, when to escalate and when to call 111. Staff are aware that if in doubt then 111 should be

called for further advice [see document 11].

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That care notes are not fully utilised – especially for recording of injury and incidents.

The  Person-Centred  Care  system  as  stated  above  has  a  section  for  specific  recording  of  injury  and

incidents.  Staff have received refresher training and there is ongoing audit being undertaken.  Please

see response above



Falls risk assessments are not being conducted on admission.

A complete risk assessment including falls risk assessment is undertaken by the Registered Manager

on admission in accordance with the new policy [see documents 1 and 2]. As stated previously, the

care notes are subject to spot checks to ensure compliance.  In addition to the huddles and cascading

of information through managers, this is discussed at staff supervisions.

We do hope that this response will go some way to reassure the Learned Coroner that Sheffcare has

taken its responsibilities very seriously.  It has been gravely concerned at the issues that were identified

by  the  Learned  Coroner  and  has  used  this  opportunity  to  undertake  a  complete  review  under  the

supervision of the Director of Quality and Care.

If the Learned Coroner seeks clarification of any of the issues raised, then please contact Sarah Knight

(

).

Yours faithfully

Legal Director
Weightmans LLP

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