Sonia Sore

North Court Care Home – Regulation 28 Response

Reference: North Court Care Home, 108 Northgate Street, Bury St Edmunds, Suffolk, IP33 1H5
Author and Designation: 
Date Report Compiled: 5th August 2025

 – Quality Assurance Consultant

Introduction
A Regulation 28 Report dated 17th June 2025 was received by Maven Healthcare in relation to North
Court Care Home following the inquest of the late Mrs. Sonia Grace Sore.

It is sincerely acknowledged how difficult the inquest process has been for family members and loved
ones of the late Mrs. Sonia Grace Sore therefore, on behalf of Maven Healthcare, we would like to
take this opportunity to extend our heartfelt sympathy and condolences for their loss of their loved
one.

As a company, we have taken steps to review the events leading up to the passing of Mrs Sonia
Grace Sore to ensure our systems and processes across the whole of our company have been
reviewed to support safe and compassionate care. We take the concerns raised within the Regulation
28 Report with the utmost seriousness and are fully committed to implementing measures that will
mitigate the risk of similar incidents occurring in the future.

Mrs. Sonia Grace Sore was a resident who had lived within North Court Care Home towards the later
stages of her life until her passing on the 8th November 2023. During Mrs. Sonia Grace Sore
residence North Court Care Home had been owned by Four Seasons Healthcare however, North
Court Care Home was acquired by Maven Healthcare in January 2024 and as such Maven
Healthcare take full responsibility to action and address the concerns raised within the Regulation 28
Report.

Within Maven Healthcare several systems and processes are utilized to ensure the care provided to
our residents is in alignment with the Care Quality Commissions legal framework and regulations. Our
company ethos supports a collaborative and transparent, team approach and we pride ourselves on
delivering safe, effective, and responsive care to the people we provide a service to.

In June 2022, North Court Care Home was inspected by the Care Quality Commission and was rated
as Requires Improvement. At this time, it was identified by the care Quality Commission that North
Court Care Home were required to implement improvements in relation to safe, responsive and well-
led care. In June 2025, North Court Care Home was reinspected by the Care Quality Commission
and whilst the full rating has not yet been shared with Maven Healthcare, the Care Quality
Commission provided feedback regarding the noted improvements within the service in relation to the
provision of safe, responsive and well-lead care. Maven Healthcare remains committed to providing
good quality care to everyone who resides within the Maven Healthcare communities and will
continue to work with supporting professionals to ensure our residents remain at the heart of all we
do.

 North Court Care Home – Regulation 28 Response

This response outlines the actions that have been taken, as well as those planned, to address the
systemic and cultural issues identified during the inquest process.

Summary of Concerns Identified

  A lack of diligent focus on risk assessment and mitigation.
  Repeated failures by multiple staff to implement agreed risk-reduction strategies.
  A wider cultural issue where risk assessments and care plans were not reliably translated into

practice.

Immediate Actions Already Taken to Date
Following the unfortunate and sad passing of Mrs. Sonia Grace Sore a number of actions have been
taken to address the concerns raised as stipulated below:

Internal Review and Disciplinary Investigation - Following Mrs. Sore’s second fall and prior to the
conclusion of the inquest, we believe a full internal investigation was initiated by Four Seasons
Healthcare. This included a review of the individual accountability of the staff involved team
leadership and handover processes and staff members’ adherence to clinical risk management
protocols.

Following the investigation process it was recognized that disciplinary action was deemed as an
appropriate response to take in relation to the conduct and performance of several key staff
members.

Management and Oversight - Maven Healthcare as a company, adopt an ethos whereupon lessons
learned and professional self-reflection forms part of the incident management process. It is believed
personal and professional reflective practice supports self-awareness; identification of professional
development needs and encourages a collaborative and transparent environment in which staff work
to ensure we continually learn from our experiences and drive forward improvements to support
effective quality care.

The Management oversight within North Court Care Home has been strengthened with the
introduction of a new Home Manager, 
Quality Commission. 
recognized for her positive contributions within the social care sector and who has a history of leading
services with a focus on kind and compassionate care.

 is an experienced Care Home Manager who is

 who is registered with the Care

Risk Assessment Compliance Audits – A full review of each resident’s individual risk assessments
was completed which included the review of the associated care plan and supporting supplementary
records. The review not only focused on the identification of key risks but also on the actions taken to
minimize risk and how key information was communicated to the staff team and each residents

 North Court Care Home – Regulation 28 Response

nominated representative. It is imperative to recognize that one of the lessons we learned as part of
this review was the involvement of key professionals, for example, falls team and social worker who
could have been involved in the decision-making process in relation to the use of bed rails and
supporting records. We recognize that effective communication and collaborative working with both
professionals and family members is the crux of supporting safe and individualized care within our
homes. It is the Maven Healthcare expectation that collaboration with external professionals will
become part of the care planning, risk assessment and general management plan for the residents
we care for and staff have now been fully coached to ensure this expectation is understood and
adhered to.

Enhanced Staff Training - Mandatory refresher training in relation to falls prevention, regulatory
responsibilities, and care plan adherence has been delivered. Reflective practice has been completed
with the staff members who are registered with the Nursing and Midwifery Council to reinforce their
understanding of their professional competence and responsibilities in alignment with the
Professional Code of Conduct

Communication – The communication systems used within the service have been reviewed and
robust systems such as daily huddles, Clinical Risk meetings, general staff meetings have been
introduced to ensure information is safely communicated to all staff members. In addition, a weekly
Clinical Risk Register is in place which includes the use of bed rails and prevalence of falls. The
Clinical Risk Register is reviewed weekly at a minimum and shared with the Regional Manager who
completes a visit to the service to validate the data. As a company additional support is provided by
the Operational Team who also visit the service at a minimum of monthly to validate and monitor the
adherence to internal governance systems and external regulations.

Regular relative meetings and care reviews have been instigated to ensure our residents allocated
representatives are fully involved in their loved ones’ care and are aware of any health and well-being
risks.

Strategic and Systemic Actions

  New 'Sign-Off' System for High-Risk Plans has been implemented in relation to identified
critical fall risk measures. This system is called PCS which is an electronic care planning
platform.

  Supervision and Escalation Protocol which supports staff members understanding of the
protocol to follow and the steps they are required to take in relation to the refusal of care
interventions. This system also includes the requirement to escalate to the MDT

Cultural Change and Governance

  Leadership Development – The Home Manager and Deputy Managers have previously

completed relevant courses and training in relation to Enhanced Leadership training course.

 North Court Care Home – Regulation 28 Response

 

Incident Review Panels – A mandatory process has been implemented to ensure post-incident
debriefing is completed for all adverse events.

  An organizational lesson learned has been formulated to ensure all learning is shared across

the service and the company as a whole.

  Company Policies and Procedures in relation to the Safe Use of Bed Rails and Falls Risk
Management have been reviewed to ensure all company Policies and Procedures are
reflective of all new systems, processes and initiatives. Changes to the Policies and
Procedures will be cascaded across the company.

  Lessons learned have been shared across the home and companywide lessons learned is in

progress.

Monitoring and Timetable

 Staff refresher falls prevention training completed 13th  and 15th of January 2025.
 Record keeping workshop was held - on 6th of January 2025.


Incident reporting and record keeping training completed on 31st of March 2025 another
session booked for 26th of August 2025.

 Electronic care planning system PCS implemented in January 2025, fully embedded by the

end of March 2025.

 Monthly audit program in place.
 Revised escalation protocols implemented July 2025
 Policies and Procedure around safe use of bedrails and falls risk assessment and

management review completed.

 Lessons learned completed at home level and in progress at companywide level.

Conclusion
Maven Healthcare continues to remain committed to learning from the unfortunate passing of Mrs.
Sonia Grace Sore incident, ensuring that the safety and dignity of our residents remain our key
priority. The death of Mrs. Sonia Grace Sore has been a solemn reminder of the responsibility we
have to provide outstanding care to all our residents which has already led to significant and lasting
changes within our daily practice, implementation of systems, and team culture within North Court
Care Home.

Signed

Quality Assurance Consultant
North Court Care Home
Maven Healthcare