Margaret Medlicott

Head Office
Juniper House. Sitka Drive
Shrewsbury Business Park
Shrewsbury
SY2 6LG

Capital Care

Mr  D Reid
H M  Senior Coroner
Coroner's Court
Martin Way
Stourport-on-Severn
DY13 8UN

25th September 2025

Response of Capital Care Group to Regulation 28 Report

Dear Sir,

I  write  in  respect  of  the  Regulation  28  Report  ("Report"),  issued  on  1  August  2025,  following the

conclusion of  the  inquest touching on  the  death  of  Mrs  Margaret  Medlicott. The  Report  raised  the

following concerns:

1.  The  resident  whose  actions  caused  Mrs  Medlicott's fatal  head  injury  had  clear  and  recent

history  of  unpredictable  physical  aggression  towards  his  wife.  The  decision  to  admit  that

resident to the care home was made by a member of  senior management without the clinical

qualifications  to  assess whether  the  care  home could  meet  his care  needs and  was  in  clear

breach of  a  restriction agreed  by  the care home  with  Worcestershire County Council  that  no

person  was  to  be  admitted who  presented  with  "physically  challenging  behaviour".  Despite

having  concerns  about  the  decision  to  admit  him,  no  member  of  staff  at  the  care  home felt

able to raise or  question that  decision with senior management. There is therefore a concern

that  staff  at  the care home  may  not  understand that  it  is their  professional duty  to  question

such  decisions,  and  that  the  care  home  is  not  providing  a  working  environment  which

encourages them to do so.

2.  Despite  being  aware  of  concerns  about  the  behaviour  of  both  Mrs  Medlicott  and  the  other

resident both before and shortly after their respective admissions to the care home, staff failed

to complete proper risk assessment and care plans addressing the risks posed by each of  them

to  themselves  and  to  others.  Those  failures  were  accepted,  but  the  inquest  heard  no

satisfactory explanation as to why they might have occurred. There is therefore a concern that

the  staff  concerned,  and  perhaps  other  staff  at  the  care  home,  have  not  received  proper

training in how  to carry out these important tasks.

The  response  to  this  Report  has been  prepared  in  conjunction with  senior  management. To ensure

each  element  of  the  concerns  identified  are  addressed,  I  seek  to  respond  under  the  following

subheadings:

1.  The Admission Decision.

t. 0345 075 0380  I  f. 01743 341 578  I  e.admin@capitalcoregroup.co.uk I  www.capitalcaregroup.co.uk
Registered Office: Juniper House. Sitka Drive. Shrewsbury Business Park. Shrewsbury. SY2 6LG  I  Company  No. 05061 769

 2.  Staff Empowerment.

3.  Risk Assessments and Care Plans.

The Admission Decision:

As raised and acknowledged during the inquest the admission of both residents occurred in the early

days  of  the  COVID-19  pandemic.  During  this  time,  the  Home  did  not  have  the  standard  home

management structure in situ -  namely, a deputy manager and home manager - o w i n g  to unexpected

absence and long-term sick. In response to this, the Home established an interim structure to manage

admissions.  This  change  occurred  amongst  the  ever-changing  landscape  of  COVID-19 guidance  for

Health and Social Care Providers.

This interim structure is no longer in place and has not been for a significant period of time.

All Home's within the organisation work to the following management structure:

Regional Manager

Home Manager

Deputy Manager

Administration

Kitchen Chef

Senior Carers

Receptionist

Assistant

Care Assistants

Domestic Team

Hostess

Activities Co-

Ordinator

Activities Assistant

The Regional Manager sits within Head Office and is the direct contact for any of the Home's to escalate

concerns to senior management.

All admissions are overseen by the Home Manager and /  or Deputy Manager. This means that no new

resident is admitted without the knowledge and /  or assessment of the Home Management Team.

In terms of the admission process:

1.  First contact with the Home is received from either Brokerage, Social Worker, Family or Friend.

With this initial contact a brief description of the  individual needs is gathered and input on a

bed enquiry form.

2.  The  bed  enquiry form  is  reviewed  by  either  the  Home  Manager or  Deputy  Manager,  and  a

preliminary decision to undertake further assessments is made. Essentially, we are asking i f -

whether on initial information provided -  we feel that  we can meet the individual's needs. In

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 some instances, it  may be evident from the outset that  we are not  the appropriate home for

the individual. For example, if they are more suited to a nursing care placement.

3. 

If -  following a review of  the  bed enquiry form  -  we  feel  that  we  can meet  the  individual's

needs, then a more fulsome assessment is undertaken. This is the  preadmission assessment.

This assessment compiles information from  several sources, including social worker, hospital

staff, GP, family, friend and any other  professional body  currently involved in the  individual's

care and treatment. This assessment will be completed either face to face, over the  phone or

via MS Teams, and seeks insight on:

a.  Personal  Information:  name,  preferred  name,  DOB,  NHS number,  current  medical

issues, current address, next of  kin details.

b.  Communication Needs: can the individual communicate verbally? Is it coherent or, due

to  their  dementia, is it  muddled? Do they  have ways of  expressing  emotions or  pain

visually or verbally?

c.  Behaviour Issues: what behaviours has the person displayed to date? What impact has

this had on previous carers and the individual? Is the mental health team  or memory

clinic involved? Are they  prescribed medications to  help with  these behaviours? Any

triggers for  challenging behaviour?

d.  Continence: are  they fully  continent? Incontinent  of  just  urine  and  able  to  indicate

when they need to open their bowels? Doubly incontinent? Are they using continence

aids?

e.  Nutrition Needs: can  the  individual feed  themselves  independently  or  do  they  need

support  or  full  assistance?  What  are  their  likes  and  dislikes?  What  is  their  food

preparation as per the IDDSI guidelines? Are they underweight, overweight, or within

normal limits? Are they under the care of  a dietician or speech and language team ?

f.  Mobility: are they  independently mobile with  or without aids? Are they  a high risk of

falls?  Have  they  had falls  recently  (within  the  last 12  months)?  Do  they  walk  with

purpose or do they have a history of  absconding?

g.  Sensory Perception: any vision or hearing needs? Are they aware of  their surroundings

or have knowledge of  where they are?

h.  Skin Integrity: is their skin fragile? Do they have any pressure care concerns? Do they

have any pressure areas that have broken down and need treatment? If  they do, what

grade  is  the  wound  and  what  is  the  current  treatment  regime?  Are  they  able  to

reposition themselves or do they need staff  to reposition at specified intervals?

i.  Pain Management: what pain relief  are they prescribed? Are they able to indicate that

they are in pain either verbally or visually?

j.  Oral Hygiene: do they have their own teeth ? Do they have full  dentures or part? What

is  their  dental  care  regime?  Have  they  seen  a  dentist?  Can  they  brush  their  teeth

themselves, or do they need full or part assistance? Are they compliant?

k.  Footcare: are they diabetic with  a regular appointment to see a Chiropodist? Do they

have  a regular Chiropodist? Do they  have issues with  their feet?  Fungal  nails? Long

toenails etc?

l.  Personal  Hygiene  Needs:  do  they  need  full  assistance  or  are  they  able  to  wash

themselves with  guidance, support or  independently? Do they  have a history of  self-

s'

 neglect? Do they prefer baths or showers? Do they use prescribed toiletries or off  the

shelf?

m.  Sleep: what is their sleep pattern? Do they sleep or do they need medication to assist

with  their sleep? Do they require a bed set at a low level with  crash mats  and alarm

mats? Do they need regular repositioning?

n.  Social Care Information: what  was their employment history, hobbies, interests, skills

and abilities? Who is important them?

o.  Further Information: any other  information that  the family, current carer  or hospital

can provide.

4. 

If  -  following completion  of  the  preadmission  assessment -  the  Home  Manager  and  /  or

Deputy Manager (or in the absence of these parties, the Regional Manager) deem the Home

to  be  a  suitable placement for  the  individual then  the  requesting party  (EG: Social Worker,

Brokerage,  Family,  Friend)  is  informed  of  the  decision  and  action  is  taken  to  arrange  an

admission date.

5.  The information from the pre-admission assessment is transferred to PCS by either the Home

or Deputy Manager and is utilised by the Care Team Leader's to complete the individual's first

care plan and risk assessments.

It  is  the  expectation that  care  documentation  will  be  available  within  72  hours  of  the  individual's

admission to the  Home, with any urgent care needs being captured within 12 hours of arrival. I note

that, on most occasions, these urgent care needs are already within the PCS system by the time of the

individual's arrival because of the  pre-admission assessment. For example, If an individual had a nut

allergy, this would be identified at the pre-admission assessment and immediately available on PCS as

an alert to all Home Staff. These urgent needs would also be shared via the Home's WhatsApp Group

and at the first stand-up meeting.

Further, to ensure that those best placed to advise on a new resident's care needs are able to feed into

the  72-hour  care  plan,  a  new  standard  operating  procedure  has  been  circulated  to  all  Home's,

requesting that  the key care actions outlined in the 72-hour care plan  are raised with the individual's

representative for feedback. All attempted contact is to be documented.

A person-centred plan should be completed within one week of the individual residing with the Home.

This will develop as the Home's staff get to know the individual on a more personal level.

Accordingly, when making the final admission decision, the Home Manager will be informed by:

1.  Subject  to  the  individual's  funding status, a  support  plan  from  social  services  providing a

breakdown of individual care needs from brokerage.

2.  A completed internal pre-admission assessment form  which includes the  involvement of  all

interested parties, plus (where required) a face-to-face assessment.

While  the  admission  process  is  reliant  on  accurate information sharing,  the  Home's  internal  pre-

admission  process  seeks to  'fact  check'  information and  obtain  its  own  insight into  an  individual's

needs. It  is only  once all this information has been meaningfully considered that  a final decision on

whether the Home can safely provide care will be made.

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 For  completeness,  Haresbrook  Park  Care  Home,  has  successfully  completed  the  recruitment  of  a

Deputy Manager. Following the completion of a six-month probationary period, this individual will be

able to support in the admission, and general management, processes.

Staff Empowerment:

QCS, an external provider, produces all of the Home's policies. The contract includes the routine review,

update  and  distribution  of  the  documents  to  ensure  they  remain  in  line  with  regulations,  care

standards and internal expectations. The Policies include Raising Concerns, Freedom to Speak Up and

Whistleblowing Policies. These  are  all  fit  for  purpose and  are  available  to  all  staff  on  the  electronic

policies and procedures platform. The platform also produces a reading list for all managers to outline

which staff  have  engaged with  the  Policy. Any staff  failing to  review the  policies will  be  reminded of

their  importance and  their  professional  obligations to  consider, and  adhere, to  the  documentation.

Any continued shortfalls will be escalated.

The importance of speaking up -  either formally or informally -continues to be promoted throughout

the organisation:

1.  New starters are provided with the Whistleblowing Policy in their handbooks.

2.  The  relevant  contact  numbers  for  Whistleblowing  are  displayed  throughout  the  Homes,

including  in  staff  rooms.  The  flyers  include  contact  numbers  for  1)  internal  escalation,  2)

external escalation -  CQC and Whistleblowing Helpline.

3. 

It is a standing headline topic in all Home's daily stand-up meetings.

4.  Home Manager's operate with an open-door policy.

To further empower staff to  speak up, at the  beginning of each shift, the team leader and /  or senior

will ask whether any member on shift wishes to raise any concerns. This may include a care concern,

personal concern or practice concern. Any concerns raised will be noted on the  staff allocation sheet

with the intention of either addressing and /  or escalating them by the end of the shift. If no concerns

are noted, this is also documented.

At the conclusion of the shift, it is the expectation that the team leader and /  or senior will personally

ask each member of  staff whether there  were  any  concerns noted on  shift  which they  would like  to

raise.  The  concerns  are  documented  and  managed  according  to  the  nature  of  the  concern.  For

example: if an individual's care needs amending, this will be raised at handover with the next shift and

the care documentation updated. If no concerns are noted, this is also documented.

As an organisation, I feel that we have provided all levels of staff with the appropriate tools to express

-  and if necessary, escalate -  concerns.

Risk Assessments and Care Plans:

The  Home  is  now  benefitting from  a  fully  integrated  electronic  care  system,  namely  PCS (Person-

Centred Software). The maintaining of  care documentation, including risk assessments, in one  place

allows for one point of reference for all members of staff.

Alongside complete care plans and risk assessments, all staff can see:

1.  Summary Sheet: this highlights all key areas of care and risk for an individual resident.

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 2.  Plan Care Day Sheet: this instructs care  staff in  relation to  tasks (for  example: repositioning,

welfare, medications, weight, fluid) that need to be completed for an individual. If staff do not

complete these tasks, the system generates a 'red flag' which can be seen by all staff on duty,

including management.

Further, the  Home's Manager and Deputy Manager has access to  the PCS desktop which provides an

overview of all its residents care delivery, including any red flags. This quickly identifies to a manager

any areas which urgently need to be addressed at hand over and / or the daily stand-up meeting.

When generating care documentation, the Care Team Leaders and / or Seniors will start by completing

risk  assessments. These are a tick box  exercise which result in the generating of  a generic care plan.

For example: if an individual is deemed to be at high risk of falls, a generic care plan will be generated

suggesting ways to mitigate this risk. It is the role of the Care Team Leader and / or Senior to personalise

the  care plan by using information obtained at pre-admission stage and  then  in getting to  know the

individual.

All staff are trained on PCS at their induction. This training is conducted by review of videos and use of

the system in 'TUTOR' mode.

As a business, all staff are required to complete mandatory training through an online training portal.

This training supports staff in  knowing how to  capture the  care needs to  be documented. Subject to

the nature of the training, these need to be renewed on either an annual or bi-annual basis. If a staff

member is deemed to be falling short of expected standards, then they will be directed to recomplete

the  training. The  mandatory training modules include living with  dementia, MCA  and  DoLS, person

centred  care,  health  and  safety,  and  safeguarding  adults  at  risk.  The  required  training  includes

communication, documentation and  reporting, positive behaviour and  support, and  leadership and

management.

Alongside  the  training modules,  the  organisation's  compliance  manager  is  working  to  generate  a

routine PCS training schedule. The nature of the electronic system means that it is constantly updating

and  creating new  processes to  support the  safe  delivery of  care. The intention is  to  conduct a six-

monthly interactive seminar at each Home in which every member of staff will be taken through the

updates and the organisations expectations on how they will be utilised. Haresbrook Park Care Home

will be the first Home to receive this training on 25 September 2025.

Each  Home  conducts  its  own  internal  audits  on  care  documentation.  Each  Home  Manager  is

responsible for managing how  its Home completes its oversight. At Haresbrook Park Care Home, the

Care Team Leaders are responsible for overseeing the care plans on their unit. Every month, they will

be required to  conduct an audit on a sample of care plans on the  alternate unit. The results of these

audits will be shared with the Home Manager who will compose an action plan to be addressed by the

next month's audit. The Care Team Leaders are also responsible for conducting random spot checks on

both documentation and on the floor care.

To ensure organisation oversight, the organisation's compliance manager is completing a full audit of

all  Homes  care  documentation. This  was  completed for  Haresbrook  Park Care Home  on  22  August

2025.  The  results  have  been  shared  with  the  Home  Manager  and  all  staff  will  be  addressed  at  a

mandatory Home-wide meeting on 24 September 2025. Beyond organisation oversight, the audit has

allowed  the  compliance  manager  to  obtain  each  Home's  baseline  and  then  work  to  generate  an

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 the appropriate training, tools and governance to routinely complete robust documentation . However,

where there are lessons, these are being utilised to generate an audit schedule which burrows down

to understand the core of the issue and provide a foundational fix.

Thank you for allowing us this opportunity to reflect.

Chief Executive Officer

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