Edith Pye

care UK ©

Mr David Donald William Reid

HM Senior Coroner for Worcestershire Connaught House
850 The Crescent
Worcestershire Coroner’s Court Colchester Business Park
Colchester
The Civic, Martins Way Essex
C04 90B

Stourport-on-Severn
Tel 0300 130 3030
Worcestershire careuk.com

DY13 8UN

13 February 2025

Dear Mr Reid,
Edith Theresa PYE- Prevention of Future Deaths report

Background

We write further to your Prevention of Future Deaths report (PFD) issued on 20 December 2024
following Mrs Pye’s Inquest. Your letter was addressed co 60S the Chief Executive
Officer of Care UK, who asked me to carry out a thorough investigation before formally responding.

| am a Solicitor having qualified in 1996. | joined Care UK in October 2007 to set-up the legal function
and have run it since then. One of my responsibilities is the oversight of any Coroners’ Inquests that
Care UK is involved with.

At Care UK we take a Prevention of Deaths report very seriously. The investigation has involved Lilly
Dahms the Home Manager of Chandler Court care fore the Regional Director who

manages | the Head of Nursing, Care and Dementia; the
Head of Health & Safety; Head of Regulatory Governance and arvey, the
Director of Care, Quality and Governance who also crane: nan

We will address your concerns separately:

Concern 1

1.“At the inquest, the care home manager gave evidence that the care home recognized that Mrs. Pye
was a high risk of falling or rolling from her bed, and also had a history of making unsubstantiated
accusations against staff. The care home therefore required:

(a) that Mrs. Pye’s personal care should always be provided by no less than

two carers; and

(b) that personal care should be provided, where possible, by two female carers, and if not possible,
one female carer should always be present.

These requirements should have been reflected in Mrs. Pye’s care plan, but the care plan was
ambiguous — for example, it stated:

Care UK Community Partnerships Limited. Registered in England. Registration Number 02644862
Registered office: Connaught House, 850 The Crescent, Colchester Business Park Colchester, Essex CO4 9QB

“Edith may require the support of 2 carers with personal hygiene needs” and “Edith prefers to receive
care from female carers — if this is not possible with the allocated staff for the shift, assistance should
be sought from another suite”

Our response:

All care plans at Chandler Court care home are being audited to ensure that there are no ambiguous
instructions in relation to residents’ care needs. This review includes moving and handling, and
personal care needs. Currently 20 care plans have been audited and we expect to complete the
remainder by close of business tomorrow; 14 February 2025.

The Home Manager and/or Deputy Manager speak to the care team ona daily basis in order to make
sure that all care plans are accurate and their team clearly understand the needs of every resident in
the care home. This takes place during (i) morning meetings where all heads of department, nurses
and team leaders are involved; (ii) each handover meeting and (iii) via the care home’s internal online
communication system.

Additionally, it is Care UK policy that care plans are audited ona monthly basis within the home. The
Home Manager is responsible for reviewing and signing-off the audit. As a consequence of this Inquest
we have updated the audit checklist to emphasise that the language used must be accurate. The
checklist now provides this incident as a specific example, such that in the future if a care plan states
that a resident may be assisted by two carers instead of must be assisted by two carers it can more
easily be identified and corrected.

Concern 2

“The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on
29.3.24 knew that he should have done so with a colleague but would regularly do so on his own. He
had never himself read Mrs. Pye’s care plan, and it became clear that two other members of staff who
provided evidence to the inquest were also unaware of some key aspects of the care plan.”

Our response:

Since the Inquest hearing, the entire care team at Chandler Court has received supervisory training
highlighting the importance of reading and understanding care plans and reiterating the relevant
components of the Care UK e-learning programme.

In line with Care UK policy, we will continue to review and update care plans on a monthly basis as
well as when there is a change in the care needs of the residents.

Additionally, Chandler Court now involves key workers who, along with the shift leads, are responsible

for having a sound knowledge of the residents’ care needs and disseminating key information to their
teams.

For new residents, the Home Manager or Deputy Manager notifies the entire care home of the arrival
of the new resident and their key care data.

For new employees, team leaders and nurses allocate specific time during their induction programme
to review residents’ care plans.

Concern 3

“other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had
reported this to senior staff or taken any action to try to stop it happening...”

Page 2 of 4

Our response:

All Care UK employees receive Safeguarding and Protection of Vulnerable Adults eLearning training
during their induction programme. This training covers the Care UK Whistleblowing policy and
ensures that colleagues understand their right and duty to raise concerns. This training must be
completed within 2 weeks of their start date and refresher training is carried out every 15 months
after that.

The key Whistleblowing information is summarised on posters that are displayed throughout Chandler
Court, such as the nurse offices and colleagues’ rooms. These posters highlight the relevant contact
details both inside and outside of Care UK.

The Care UK induction booklet for new employees also covers our Whistleblowing policy and provides
contact details for raising concerns.

We appreciate that colleagues did not raise concerns regarding the staff member who was providing
care to Mrs. Pye in contravention of her care plan. This was not in line with our policies and the
training that colleagues had received at Chandler Court.

Since this incident, there have been changes in personnel at Chandler Court, and current colleagues
have been reminded of their duty to report concerns and the mechanisms available to progress any
such concerns.

Additionally, individual supervision has been completed for moving and handling whereby senior
members of the care team observe junior colleagues to ensure correct compliance with Care Plans and
policies. Refresher training on moving and positioning has also been carried out. This training is
currently at 90% compliant and is expected to be 100% compliant by close of business tomorrow; 14
February 2025. This refresher training will further assist colleagues with understanding the importance
of following individual care plans and reporting bad practices, or any other concerns that may pose a
risk to a resident or colleague as per Care UK policy.

Concern 4

“At the inquest, | was shown a handover document which had been drafted by the home’s Deputy
Manager and was told that a nurse in charge would have gone through this document with all carers
at the beginning of the relevant shift. The document was meant to highlight each resident’s care
needs, based on their respective care plans. It did not make clear that Mrs. Pye required two carers for
the provision of personal care, or that at least one of those carers should be female. There was no
system in place at the time for auditing these handover documents.”

Our response:

Care UK has reviewed our handover templates to ensure that they highlight the key aspects of each
resident’s care needs.

At Chandler Court, handover sheets are now reviewed by the Deputy Manager at the weekly clinical
review meetings to ensure accuracy. In addition, any changes to a resident’s care needs are reported
during the daily morning meetings and the person in charge of the suite, which would either be the
Team Leader and/or Registered Nurse, is directed to complete the relevant update under the
supervision of either the Deputy Manager or the Home Manager.

This process ensures that the Home Manager is monitoring care plans and handover sheets are
updated accordingly to reflect residents’ preferences and safety needs.

Page 3 of 4

Concern 5

“The Deputy Manager who had drafted this handover document, was also responsible for the care
home’s own internal investigation into Mrs. Pye’s fall. That internal investigation failed to highlight the
deficiencies in the handover document, and the handover document itself was not disclosed to the
Coroner’s Office until the final inquest hearing was underway.”

Our response:

In September 2024 Care UK introduced a revised Safety Incident Response Framework (SIRF) policy
based on the NHS Patient Safety Incident Response Framework that was also issued last year by the
NHS. This policy places the responsibility to investigate serious incidents on Home Managers, so that
incidents are investigated by an independent individual.

The incident involving Mrs. Pye occurred prior to the roll-out of the new policy and the training
provided to support the implementation of the policy. The Deputy Manager who investigated this
incident no longer works for Care UK and any future investigation will be completed by an
independent Home Manager as per the SIRF policy.

The handover document was forwarded to the legal team by the Home Manager prior to the Inquest
hearing. We overlooked to share it with the Court for which we apologise.

Our new investigation process (SIRF) would allow us to identify any learnings and prevent this
happening again in the future.

We are confident that we have implemented a robust series of improvements which address the
concerns that were raised during the Coroner’s Inquest and set-out in the PFD. However, please do
not hesitate to contact me should you have any queries.

Y

General Counsel and Company Secretary

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