Maureen Powell

Red Oaks Care Home 

Dear Coroner,  

We  write  in  connection  with  the  Regulation 28  report  which  was  issued  in  connection  with  the 

Inquest  into  the  death  of  Maureen  Powell,  who  was  a  resident  of  Red  Oaks  Care  Community 

(“the Home”).  

The  Inquest  into  the  death  of  Maureen  Powell  was  held  at  Nottingham  Coroner’s  Court on  12 

May  and  10  June  2025.  Prior  to  and  during  the  course  of  the  Inquest  the  Home  provided 

evidence to assist your inquiry into the care arrangements in place for Maureen Powell whilst a 

resident  at  the  Home,  and  the  reflection  which  has  taken  place  following  Maureen’s  death  to 

further strengthen the Home’s existing procedures moving forward.  

A  Regulation  28  Report  was  however  issued  on  11  June  2025  which  raised  concerns  with 

regard the implementation of the Home’s systems and procedures for the delivery of pressure 

management  care  to  residents,  communications made to  Maureen’s  family and  the  CQC,  and 

the investigation processes followed.  

It  is  relevant  to  explain  at  the  outset  that  we  have  reflected  seriously  on  the  contents  of  your 

Report, and remain saddened that you considered this a necessary step despite the evidence 

given.  

Pressure Management 

The Report acknowledges that it was the Home’s policy to provide a high standard of care for 

residents at risk of pressure damage as well as those who had suffered pressure damage. It is 

also acknowledged that the Home had in place suitable equipment and caring regimes to 

reduce the risks of pressure damage worsening to heal damage which had occurred. It is 

however noted, and accepted, that these systems and procedure were not sufficiently 

implemented in practice on this occasion.  

The Home reflected significantly prior to the Inquest and had taken steps to strengthen the 

processes in place to ensure compliance against the systems and procedures in place. We do 

not seek to repeat the entirety of the evidence given below, but would draw attention to the 

following specific factors in respect of the measures in place for oversight of pressure 

management care:  

 
 
 
 
 
   Care staff are required to complete SSKIN Inspections Records every 24 hours, with any 

concerns reported to the Registered Nurse on duty. The SSKIN Inspection Records are 

now in turn audited by management upon the generation of daily reports.  

  Weekly  and  monthly  audits  are  conducted  by  management  in  relation  to  care  records 

relating to residents’ pressure care and skin integrity, for the purpose of ensuring that all 

actions have been completed in a timely manner, any external professional input required 

has  been  sought  accordingly,  and  that  care  plans  and  risk  assessments  have  been 

reviewed and updated as appropriate.  

  An  audit  schedule  is  in  place  which  captures  all  audits  on  a  daily,  weekly  and  monthly 

basis.  Audits  are  completed  across  the  different  areas  of  the  Home,  to  ensure  that  a 

‘fresh eyes’ review of care delivery is completed. The Home Manager then completes a 

check  of  the  audits  which  have  taken  place  from  a  compliance  perspective,  before 

signing off against these.  

  All  records,  including  for  wound  management,  are  now  held  electronically  on  the  care 

system enabling increased oversight by the management team.  

  The mattress type to be supplied to a resident is determined following the consideration 

of  a  number  of  factors  including  an  assessment  of  the  resident’s  weight,  diet  and  fluid 

intake,  mobility,  skin  integrity  and  capacity.  Airflow  mattresses  are  checked  on  a  daily 

basis  by  the  housekeeper  to  monitor  that  the  correct  mattress  is  in  place,  that  it  is 

functional  and  that  it  is  set  to  the  correct  resident  weight.  These  checks  are  again 

recorded on the care system to enable oversight of compliance against the procedure.  

  Following further reflection at the Inquest, a documented Skin Integrity Protocol has now 

been  introduced,  formalising  the  instructions  which  the  nursing  team  and  carers  have 

received  through  their  respective  training  and  providing  a  single  point  of  reference  for 

them  when  escalating  pressure  concerns.  The  Protocol  encompasses  guidance  on  the 

importance  of  ensuring  that  next  of  kin  are  kept  informed  of  developments,  the 

requirements of the duty of candour and guidance on the delivery of this, amongst other 

relevant matters.  

More broadly, it was explained that a new Registered Manager was appointed to the home on 7 

October 2024, with a new Deputy Manager having since also been introduced. The Registered 

 
                                                          
 
 Manager now conducts daily walk arounds of the Home for the purpose of reviewing resident 

care and ensuring that the correct measures are in place. 

A Clinical Lead role has also separately been introduced to provide additional support with care 

planning, evaluations, audits and the provision of care to residents, amongst other matters.  

In addition, the Operations Manager conducts weekly unannounced visits to the Home to 

provide an additional level of oversight of compliance against the procedures in place. These 

are supplemented by additional focused visits for the purpose of assessing any areas of lessons 

learned across other services, with any learnings and remedial actions identified reported to the 

Registered Managers for dissemination to the staff employed at each home. Full compliance 

visits are separately undertaken on a quarterly basis, capturing all areas of the service. A 

Regional Manager has also now been employed to provide additional compliance support and 

oversight.  

Senior Management meetings are now held on a quarterly basis, and manager supervisions 

completed on a bi-monthly basis again providing an additional layer of oversight and 

management to the service and its management team.  

Additional Observations 

With regard the additional observations made at points 8 to 10 of the Report, we can advised as 

follows:  

  Point  8  –  The  Home  has  in  place  a  documented  policy  concerning  the  requirement  to 

undertake  an  internal  investigation  in  relevant  circumstances.  All  staff  have  received  a 

copy  of  the  policy  and  are  familiar  with  the  requirements  of  this  to  ensure  that  an 

investigation is undertaken in all circumstances that trigger this.   

  Point 9 - The Home utilises an electronic care record system where resident records are 

held.  Electronic  care  records  are  now  checked  by  the  Registered  Manager,  Deputy 

Manager  and  Clinical  Lead  during  each  shift,  for  the  purposes  of  ensuring  that  all 

relevant  documentation  and  entries are  in place for each  resident.  This is  in  addition  to 

the daily walk around checks referred to above.  

Separately, such matters will be considered during the checks and audits undertaken by 

the Operations Manager, providing a secondary layer of oversight to monitor that the 

processes are being followed correctly.  

 
                                                          
 
   Point 10 – Previously it was the responsibility of the Home Manager, as the responsible 

person,  to  complete  any  necessary  safeguarding  or  CQC  notifications.  Following  the 

Inquest,  this  process  has  been  amended  to  require  that  all  serious  injury  notification 

reports must be sent to the Operations Manager for review prior to submission.  

Accordingly, significant steps have been taken by the Home to strengthen the systems and 

procedures in place to monitor the correct implementation of care arrangements for 

residents, which are considered to be appropriate in all the circumstances.