June Peel

I am the Managing Director of Sequoia CH Group Ltd (‘SCG’), the registered provider of Belle 

Green  Court  Care  Home.  I  am  submitting  this  Regulation  28  Report  at  the  request  of  HM 

Coroner following the death of Mrs June Peel, who at the time of her death was a resident of 

Belle Green Court Care Home.  

This report address the Matters of Concern identified by HM Coroner, namely; 

1.  There was a failure to record the injury from the body map in the daily communication 

records  both  on  3rd  June  and  6th  June,  and  a  failure  to  pass  that  information  on  at 

handover (or to document that the information had been passed on). This led to a 

period  in  which  June  was  being  turned  on  a  2-hourly  basis  with  a  displaced  femur 

fracture.  

2.  There was a failure to recognise that medical attention was required for June from at 

least  3rd  June  2022,  notwithstanding  all  personal  care  being  conducted  by  the 

healthcare assistants.   

3.  There was a failure to follow the care plan by the healthcare assistants. There has been 

no  investigation  done  to  identify  whether  this  is  a  condoned  or  common  practice 

within the home.  

In this report I will explain, how Sequoia CH Group Ltd operates and provides care services, 

how we manage and oversee our care, how we have reflected on the incident that led to Mrs 

Peel’s deaths and improvements made since the time of the incident in June 2022. I would 

like to take this opportunity to again express on behalf of all the Directors how sorry we are 

that Mrs Peel sustained an injury whilst being cared for at Belle Green Court Care Home.  I 

wish to offer my sincerest apologises to Mrs Peel’s family for the care failures that occurred. 

For the reasons I set out in this report, I strongly believe that Sequoia CH Group Ltd has learnt 

from this event and I am able to assure the Coroner and Mrs Peel’s family that changes have 

been implemented to ensure that our systems are more robust so that any failures identified 

are not repeated. 

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 The Coroner’s concerns relate to 4 areas of our practice in the care home: 

1.  Documentation and Recording 

2.  Communication between staff 

3.  Assessment of Injury and referral to external health care professionals 

4.  Staff performance and investigation of substandard performance. 

Below I set out the review that we have undertaken and the action taken to ensure that our 

systems are robust to minimise the risk of future events. 

BACKGROUND AND SUMMARY OF CARE DELIVERED 

1.  Mrs  Peel  (DOB  28.06.33.  DOD  22.06.22)  was  admitted  to  the  Home  following  her 

discharge from Barnsley District General Hospital (BDGH) on 24.03.22.  Mrs Peel had been 

an  inpatient  at  BDGH  since  20.02.22,  when  she  was  admitted  with  wrist  and  leg  pain 

following a suspected fall resulting from a stroke.  Her admission to the Home was planned 

on a discharge to assess basis, whilst her family decided the plan for her long-term care 

needs as she was unable to continue to live independently at home due to a significant 

deterioration in her mobility and cognition. 

2.  Mrs Peel was dependant on carers for personal care and support.  Whilst at BDGH, she 

had developed a number of pressure ulcers, and due to frailty and pain on movement she 

was cared for in bed.  Any required transfers from bed required the use of a hoist. Mrs 

Peel  was  repositioned  every  two  hours  to  support  the  healing  of  her  existing  pressure 

ulcers and to prevent further pressure areas from developing. 

3.  On 03.06.22, a senior carer noticed a hard lump on Mrs Peel’s left knee. At this stage there 

was no bruising.  No assessment of pain was recorded. 

4.  On 06.06.22 an attending community district nurse was asked to review the lump. It is 

recorded that the nurse had no concerns. 

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 5.  On 07.06.22, staff identified that there was bruising and swelling around the knee and a 

referral was made to the GP and 111.  A GP visit took place on 08.06.22 and arrangements 

were made for Mrs Peel to be admitted to BDGH, where she was diagnosed with a fracture 

of  the  distal  femur.  Initially  the  fracture  was  treated  with  traction  and  surgery  was 

undertaken on 10.06.22.  

6.  Mrs Peel was initially very poorly postoperatively requiring resuscitation.  She made some 

improvements  and  plans  were  being  made  for  her  discharge  back  to  the  care  home. 

Unfortunately, she deteriorated and sadly passed away on 22.06.22. 

7.  Concerns were raised in the Home and by staff at BDGH as to the cause of the fractured 

femur.  A  safeguarding  investigation  was  undertaken  by 

  (who  was  the 

registered manager of the Home at the time of the incident). 

 found that on 

29.05.22, two members of staff had moved Mrs Peel from her bed to a weighing chair. 

The  staff  had  failed  to  move  Mrs  Peel  in  accordance  with  the  moving  and  handling 

directions set out in her care plan, that directed she should be moved from bed with the 

use of a hoist. All staff denied that Mrs Peel fell during the transfer. Whilst Ms Durham 

did not find evidence that the fracture was caused during the transfer, 2 members of staff 

were dismissed for gross misconduct for using an unsafe procedure. 

The above summary is documented in the following records: 

03.06.22 – Wound care plan ‘Hard Lump near knee cap. No bruising’. (Senior Carer) 

06.06.22 (12.55pm)– DN Communication Record ‘June’s Left Knee, the DN was asked to look 

at it but wasn’t concerned by the lump’. (Senior Carer) 

08.06.22 (03.00 am overnight shift 07.06.22/08.06.22)- Daily Communication Record. June 

was  settled  in  bed  at  start  of  shift.  Staff  noticed  June  has  an  injury  on  her  left  knee.  Staff 

contacted 111/999 and they have said that they are referring it to her GP which should be out 

today 08.06.22. 

07.06.22 ?[Incorrect date should be 08.06.22] – GP Communication Record ‘Contacted Clara 

from GP surgery regarding my call to 111 over a hard lump on June’s left knee.  

 said they 

had sent a referral through from 111. 

 said that she could put June on tomorrows list if 

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 it was urgent to contact I-heart. I spoke to 

 (Manager) who said it was ok for GP to visit 

tomorrow. (Senior Carer). 

08.06.22  –  Daily  Communications  Record  –  2  hourly  turns  were  maintained  but  June  was 

crying out in pain so she refused on some occasions. Good fluid intake. 

08.06.22 – Daily Communication Record – June has had poor diet and fluids this afternoon 

however is talkative when staff came to see her. She has had a visit from the doctor about 

her query dislocated knee (see care plan) she has also had her pad changed. 

07.06.22  [?  Incorrect  date  should  be  08.06.22]–  Wound  care  Plan  –  ‘Bruising  on  left  knee 

(query dislocation). 

09.06.22 [? incorrect date should be 08.06.22]– GP Communication Record- ‘GP practitioner 

from 111 came to see June about her left knee. GP did June’s obs and rang for a[n] ambulance 

as she believes that June may have dislocated her left knee due to her left side weakness’  

Other professionals made the following corresponding entries: 

06.06.22  DN  Record  (14.20pm)  –  Wound  care  left  calf  wound  care  haematoma  right  shin, 

wound care lacerations left foot. 

08.06.22 – (17.45pm) GP Record: History ….a senior carer has noticed a bony lump on Friday 

[03.06.22] during the night when she was on night shift, was handed over to day staff……… 

Obvious deformity of the left knee, bony tenderness +++ on the outer aspect, bruising over 

the area (care staff report only started with bruising yesterday) movement restricted due to 

previous CVA, normal colour of the lower limb no signs of infection. 

Summary of Findings 

The records demonstrate that staff identified the change in Mrs Peel’s condition on 3 June 

2022 when a hard lump was identified by a senior carer. At this stage there was no bruising. 

There is no documentation as to whether Mrs Peel was in pain. On 6 June 2022, Mrs Peel was 

seen by the District Nurse. Staff record the District Nurse reviewed the lump when dressing 

wounds on her leg and the District Nurse had no concerns. The District Nurse made her record 

of the visit over and an hour after the visit and did not reference the review of Mrs Peel’s 

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 knee. On the night of 7 June 2022, the swelling worsened with bruising and a referral was 

made to 111 and Mrs Peel was assessed by the GP on 8 June 2022.  

My review of the documentation demonstrates that although staff asked the DN to review 

Mrs Peel on 6 June 2022, she was not referred to the GP/Paramedics until the early hours of 

8 June 2022.  

Mrs Peel’s records did not contain sufficient detail and there were some records where the 

dates had not been or had not been correctly recorded. Accordingly, it is difficult to clearly 

track the care provided to Mrs Peel. The records were not robust enough to evidence the care 

pathway and decisions that were made by staff.   

I  have  reviewed  the  Matters  of  Concern  and  considered  our  policies  and  procedures, 

documentation,  communication  processes,  training,  auditing  and  governance  in  order  to 

identify any organisational improvements that can be made. 

REVIEW UNDERTAKEN AND ACTIONS IMPLEMENTED 

A: POLICIES AND PROCEDURES 

As a regulated provider we are required to have written policies and procedures that cover 

all aspects of  service delivery. The Company subscribes to Croner – I. This is a well-regarded 

service providing policies and procedures for use in care homes. Croner - I provides detailed 

policy templates which are designed to be compliant with the regulatory requirements. We 

review and amend the draft policies to ensure that they are relevant for the Home. Some, or 

all of the policies are reviewed during Care Quality Commission (CQC) Inspections. No issues 

or concerns have been raised by the CQC regarding the quality of the policies in use. A copy 

of the CQC’s last inspection report can be reviewed at this link. 

https://api.cqc.org.uk/public/v1/reports/0e25d37c-0312-4d64-8395-

04565de9996b?20220622120000 

We currently have circa 130 policies in use. 

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 I have reviewed the policies relevant to the Matters of Concern. The Home already has in 

place policies on; 

•  Moving and Handling 

•  Falls Prevention and Risk Assessment 

•  Use of Hoists 

•  Record Keeping 

•  Care and Support Plan 

•  Training 

•  Accident and Injury 

•  Supervisions and Competencies 

•  Auditing and Auditing Processes 

•  Whistleblowing 

•  Escalation Policy 

These policies are robust and provide clear guidance to staff regarding our expectations for 

record keeping, communication, using safe moving and handling techniques, delivering care 

in  accordance  with  resident  care  plans  and  seeking  medical  assistance.  The  policies  also 

provide clear guidance to the management team on auditing the quality of the records and 

assessing staff performance to ensure that the expected standards are met. We review the 

policies annually to ensure they remain in date. 

Action Taken 

Whilst the policies are robust, we cannot be assured that staff delivered care to Mrs Peel in 

accordance with the policies.  Accordingly, we have taken the following action,  

1.  We have added further information to some of the policies to provide more detailed and 

specific guidance to staff, please see below.  

2.  We  have  also  introduced  specific  guidelines  for  staff  regarding  action  that  they  are 

required to take in the event of a resident presenting with symptoms suggestive of an 

injury. (Referral for Medical Attention policy – see below). 

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 3.  We have formalised the process for staff reviewing our policies. Staff are required to read 

the policies relevant to their area of practice before being signed off as competent to work 

without supervision and staff are required to review these annually. We now maintain a 

record of staff undertaking the required policy reviews. 

4.  We have introduced a learning exercise of ‘Policy of the week’ where staff are required to 

review a specified policy in depth and the policy is discussed at staff meetings. 

5.  The  Manager  now  undertakes  supervisions  with  staff  around  their  knowledge  of  the 

policies. 

6.  If staff fail to follow the guidelines set out in the policy, they will be required to undergo 

further training or supervision as appropriate and may be subject to disciplinary action. 

B: DOCUMENTATION AND RECORDING 

All  staff  are  required  to  make  a  comprehensive  record  of  any  care  intervention  and  any 

communication  with  external  professionals.  Staff  are  trained  to  look  for  changes  in 

presentation, signs of illness and injury, and report and record this.   

I identified that the documentation around Mrs Peel’s injury was not as robust as it should 

have been, specifically, 

•  There appear to be dates recorded incorrectly. 

•  The names of the external professionals providing advice was not recorded. 

•  When  the  small  lump  was  identified  on  03/06/22,  it  was  not  recorded  in  the  daily 

communication record, it was not photographed, no pain assessment was carried out 

and there was no instruction for follow up review. 

•  Staff did not document  a follow up plan. 

•  Staff did not reference the small lump in the handover document. 

•  There  was  no  record  of  ongoing  review  and  assessment  of  improvement  or 

deterioration. 

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 Action Taken 

Although staff received training and guidance on record keeping during their induction, we 

have policies in place that set out the action that is expected of staff and records are also 

audited regularly to ensure that staff are meeting the required standards, the documentation 

was not of the required standard.  Accordingly, we have implemented the following changes: 

1.  We have prepared a recording keeping guide which has been distributed to all staff which 

sets out the principles of record keeping and expected standards. (Please see attached). 

2.  All  staff  are  required  to  review  our  policy  relating  to  record  keeping  and  the  record 

keeping guidance. 

3.  The record keeping guidance is displayed throughout the home to as a reference guide 

and reminder for staff. 

4.  Staff receive training on record keeping on induction and supervisions will be carried out 

throughout the year. 

5.  The quality of record keeping is reviewed regularly by the management team as part of 

the  weekly  and  monthly  audits.  The  Manager  also  undertakes  spot  checks  on 

documentation. 

6.  If staff fail to meet the required levels of recording keeping, they will be provided with 

further training and supervisions.  

C: COMMUNICATION BETWEEN STAFF 

We  have  identified  that  the  communication  between  the  staff  teams  was  not  robust.  The 

Senior Carer who identified the lump on 3 June 2022 recorded the lump on a wound chart 

but failed to record this in the daily communication record. They also failed to record this in 

the written handover record and therefore we could not determine whether all staff were 

made aware of the lump.  

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 Effective communication between staff is central to the delivery of consistent and effective 

person-centred  care.  Our  policies  make  it  clear  about  the  information  that  must  be 

communicated between staff to ensure the effective delivery of care. 

Action Taken 

We have taken the following action to ensure information is effectively communicated across 

the team; 

1.  All staff are required to document key information in accordance with our record keeping 

guidelines set out above. 

2.  Care staff are required to report any changes/concerns to the senior carer on shift. Both 

the  carer  and  senior  carer  are  required  to  document  their  concerns  and  review  of  the 

resident. The senior carer is responsible for ensuring that the care plan is updated if any 

specific care needs/follow up are required. 

3.  All relevant information must be recorded in the daily records and the written handover 

record so that we can be assured that staff are handing over the relevant information to 

the next team. 

4.  The senior carer who receives the handover is responsible for communicating information 

to the carers about the residents who they will be responsible for that shift.   

5.  At the beginning of each shift, all carers are required to review the daily communication 

records and the wound plans for the residents who they will be responsible for during 

that shift and sign to say that they have read the daily communication records from the 

previous week, the wound chart and the GP communications record. 

6.  The Manager reviews the handover record every day to ensure that the records are robust 

and key information is included. The Manager signs of the report to evidence that it has 

been reviewed. 

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 D: ASSESSMENT OF INJURY AND REFERRAL TO EXTERNAL HEALTH CARE PROFESSIONALS 

Concerns were raised by the Coroner that there was a delay in referring Mrs Peel for medical 

attention from at least the 3 June 2022 when the lump was first identified and this resulted 

in Mrs Peel continuing to be repositioned when she may have had a displaced fracture. 

The records are not sufficiently robust to evidence the Senior Carers rationale for not seeking 

immediate medical attention when the lump was first identified on Friday 3 June 2022, and 

waiting for the DN to attend and review on Monday 6 June 2022. I can only deduce that this 

was  because  of  Mrs  Peel’s  presentation  the  Senior  Carer  exercised  her  judgement  that 

medical assessment could wait until after the weekend, however the records do not record 

any plan or reasons for the delay in asking for Mrs Peel to be assessed. 

Action Taken 

We have implemented a new policy ‘Referral for Medical Attention’. Staff must not exercise 

their judgement as to whether urgent referral/ treatment is required or whether assessment 

can be delayed. The policy requires that 

1.  Any resident who presents with 

1.1. a change in health condition,  

1.2. a deterioration in condition, or  

1.3. presents  with  any  physical  changes  (however  minor  and  whether  or  not  they  are 

indicative of an injury)  

will be referred to the GP/111/999 with a request for a clinical assessment as soon as 

reasonably practicable after the concern is identified. 

2.  At the time of referral to the GP/111/999, the Senior Carer will request instructions from 

the  external  health  professional  as  whether  any  specific  care  interventions  should 

continue  pending  the  clinical  assessment.  For  example,  whether  staff  should  cease 

repositioning the resident. 

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 3.  A record of the deterioration/injury will be made in accordance with the record keeping 

guidance. 

4.  A record of the referral will be recorded in the daily communication record and External 

Professionals  Communication  Record,  with  details  of  the  information  provided  to  the 

external health professional. 

5.  Any  guidance  given  by  the  external  health  professional  will  be  recorded  in  the  GP 

communication record.  

6.  The care plan will be reviewed an updated as necessary. 

7.   Any guidance and follow up instructions given will be recorded in the handover record. 

8.  The Manager will be made aware of any referrals to external professionals and any follow 

up required. 

E: STAFF PERFORMANCE AND INVESTIGATION OF SUBSTANDARD PERFORMANCE. 

Following  Mrs  Peel’s  injury  an  investigation  was  carried  out  by  the  Home  Manager.  She 

identified that two members of the care team failed to follow Mrs Peel’s care plan and used 

an  unsafe  moving  and  handling  technique.  The  staff  members  were  dismissed  for  gross 

misconduct. The staff members had received the appropriate training and had acted contrary 

to this training. On my review, I identified that the Manager did not document that she had 

undertaken a review of practice across the Home to determine whether the poor practice of 

these two staff members was systemic, whether there were any issues with training across 

the service that needed to be addressed, and whether staff had observed poor practice and 

if so, why this had not been raised as an issue. 

Poor individual performance can occur in any workplace setting, but I acknowledge in a care 

setting this can place people at risk of harm. We seek to provide the highest quality of care to 

all  our  residents  by  ensuring  that  the  staff  we  employ  have  the  appropriate  skills  and 

resources available.  We seek to achieve this through: 

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 •  Recruitment: We recruit staff who have the appropriate qualities to be a carer and 

who demonstrate honesty and integrity. 

•  Resources:  We  have  detailed  policies  and  procedures  that  staff  can  refer  to  for 

guidance  on  our  expectations  to  meet  our  standards  of  care  and  delivery  and  the 

processes that should be followed across all aspects of service delivery. 

•  Training and Development: We offer training to develop staff and training is ongoing. 

All  staff  are  required  to  undertake  mandatory  training  at  specific 

intervals 

(annually/biannually depending on the course). Following training, staff are assessed 

as being competent. If staff fail to undertake their training within a reasonable period 

set by the manager, they are removed from the rota until the training is complete. 

Staff receive 4 supervisions a year and an appraisal. The supervisions can be tailored 

around  areas  where  the  manager  has  identified  further  training  or  development  is 

required. 

Action Taken 

1.  Staff have received updating training on care planning and record keeping. (Please see 

details above) and manual handling. 

2.  Staff have reviewed all key policies and procedures relevant to their practice. This is an 

ongoing annual requirement for all key policies. 

3.  The Manager has commenced a tracker of all accidents and incidents which requires a 

high-level analysis to assist identifying any patterns or concerns. 

4.  Any incident/accident that identifies poor staff practice will lead to a review/assessment 

of  practice  across  the  staff  group.  The  outcome  of  this  assessment  will  determine  the 

further  action  that  is  required;  for  example  –  refresher  training,  review  of  policies, 

supervisions, competency assessments. 

5.  Issues of safe manual handling, delivery of care and care recording are addressed as a 

standing items at each team meeting to ensure that safe practice is engrained. 

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 6.  The Manager undertakes a daily walk around which includes observation of staff practice. 

7.  All  staff  have  reviewed  the  Whistleblowing  Policy  and  Safeguarding  Policy,  and  are 

required to familiarise themselves with their duties to report poor practice. 

F: AUDITING AND GOVERNANCE 

The Home operates a range of quality assurance systems to monitor and improve the service. 

These are used to identify areas for improvement. When issues are identified, action is taken 

to make improvements. We have incorporated the actions detailed in this report to ensure 

there is a continuous approach to improving care.  

ENCLOSURES: 

Enclosed is a copy of the updated Record Keeping Policy which includes the Record Keeping 

Principles at Appendix A.   

Copies of policies referred to are available on request. 

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