Ramona Harbott

6 February 2026 

Ms Susan Ridge 
H.M. Assistant Coroner for Surrey 
H.M. Coroner’s Court 
Station Approach 
Woking 
Surrey 
GU22 7AP 

Dear Madam Coroner  

Regulation 28: Report to prevent future deaths in relation to Ramona Doreen Harbott 

I am responding to the Regulation 28 Report issued on 19 December 2025 following the 
inquest into the death of Mrs. Ramona Doreen Harbott. The inquest concluded on 8 
December 2025.  

Barchester Healthcare (‘Barchester’) deeply regrets the death of Mrs Ramona Harbott and the 
distress this has caused her family.   

Following this very sad incident we have made widespread changes to the provision of care 
and services at Windmill Manor Care Home. For the purpose of this response, we have 
considered the concerns raised by you and where possible we have grouped together details 
of assurance measures where these appear to deal with more than one area of concern.  

Coroner’s Concerns 

The matters of concern are:  

a.  The evidence heard by the court indicated that though the care home had 

policies and guidance for the prevention and management of bed sores that was 
not followed by on-site care or nursing staff.  Although at high risk of pressure 
sores Mrs Harbott was not regularly repositioned until she had developed a 
sacral sore. Her skin condition was not monitored and recorded to the extent 
that though the sore was apparently being treated, it had become an 
unstageable necrotic wound by the time she was taken to hospital.  The serious 
pressure sore on the right heel was not documented until it was seen on 23 
January 2025 although it was likely well established for at least a week. 

b.  The coroner acknowledges that Barchester Health Care have since this death 
and the inquest hearing in November 2025 commenced an action plan of 
improvements including greater regional management oversight however the 
coroner remains concerned that the matters identified at the inquest regarding 
issues surrounding early and appropriate assessment of risk, use of 
preventative measures, skin monitoring, pressure sore treatment and record 
keeping are the subject of ongoing improvement which has yet to be completed 
and audited.   

I have addressed the concerns below: 

Completion of action plan of improvements   

As you are aware an Action Plan of improvements was implemented following this incident 
and a copy of that was submitted to court on 12 November 2025. Further actions following 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 the hearing on 13 November were confirmed in the signed statement of the Regional 
Manager submitted to the court on 5 December 2025.  

Whilst some of the actions are completed such as replacement of the General Manager, 
appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are 
necessarily part of day-to-day documentation and process which will remain embedded and 
ongoing to ensure a robust approach to the planning and management of the needs of our 
residents.  

Otherwise, I can confirm completion of actions referred to as follows: 

•  Replacement of General Manager. 
•  Dismissal of Deputy Manager due to gross misconduct and referral to the NMC.   
•  Appointment of Regional Manager. 
•  Block of Bank Nurse involved in incident . 
• 

Introduction and embedding of electronic records and case management system 
‘Enable’.   

•  Review of investigation carried out post incident and subsequent disciplinary actions 

and outcomes. 

•  Post inquest reflective sessions with staff carried out by Regional Manager with focus 
on the matters of concern raised by you during the inquest and in your findings and 
conclusion delivered on 8 December 2025. 

•  Training and Supervision sessions took place with all staff at the Home on 22nd 

October 2025, and 18th December 2025 led by the Regional Operational Trainer and 
Clinical Development Nurse. As previously advised, the training focussed on pressure 
area care and management of pressure ulcer/wounds.  During the training there 
were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and 
specific focus on early and appropriate management of risk, use of preventative 
measures, skin monitoring, pressure ulcer treatment and record keeping. The 
Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework 
approach to promote comprehensive risk assessment, monitoring and care as a tool 
in pressure ulcer prevention. Early identification of skin compromise through regular 
checks is reinforced as part of daily care. Training sessions included knowledge 
testing and question and answer sessions prior to completion.  Particular note of the 
evidence at inquest of the Tissue Viability Nurse Consultant from the NHS Trust 
hospital was taken by the Regional Manager who as you are aware attended the 
inquest throughout. She has disseminated the evidence of the hospital nurse to the 
Home staff as part of a best practice approach to management of risk to skin 
integrity.  

•  The Clinical Development Nurse now visits the Home on a weekly basis to review the 
approach to the management of risk to skin integrity and care and treatment plans 
in place where skin damage has been identified for any resident. She checks that 
wound assessment and categorisation is being completed correctly with review of 
wounds by staff in person supported by photographs. She attends the daily stand-up 
meeting during her visit to follow up on assessments and referrals and any clinical 
concerns. She is also available for advice and assistance to all staff outside these 
visits and can review concerns on an ‘as needed’ basis. She has reported an 
improvement overall in the approach of staff and their recognition of the importance 
of early interventions and comprehensive treatment plans.  

•  The Regional Operational Trainer and Clinical Development Nurse have attended the 
Home on several occasions to carry out observations and monitoring and to identify 
any further areas for improvement for the clinical team. Visits took place on 7,10, 15 
and 22 October.  On 15 October 2025 the Clinical Development Nurse attended the 
Home to review equipment used by staff to support resident care needs. A group 
session with staff was held to discuss availability of equipment, appropriate use and 
processes and procedures to assess need and request equipment including pressure 
relieving mattresses. During an observation visit on 22 October 2025 there was a 
focus on Moving and Handling techniques used by staff at the Home. No concerns 

 
 
 
 
 
 were identified with staff using appropriate procedures. During the visits, there were 
sessions arranged with the Home team to discuss the importance of regular 
repositioning of residents. Group supervisions of all staff were completed during the 
visits.   

•  Advice has been provided by the Regional Operational Trainer and Clinical 

Development Nurse in respect of the use of beds and mattresses as vital equipment 
for the management of skin integrity and as an aid to prevention of damage to skin. 
Full staff training has been carried out with the Head of Maintenance at the Home in 
respect of the use of dynamic air mattress settings and how to use these 
appropriately and the importance of regular checks. Refresher training has also been 
provided to the Home team in respect of how to access mattress replacements in the 
event of a mattress failure occurring out of hours.  

Audit 

i. 

ii. 

iii. 

iv. 

v. 

There is a robust admissions process in place which the General Manager controls 
and monitors throughout the stages from pre-admission to admission. This ensures 
that all prospective resident needs are identified prior to admission and appropriate 
training for staff and equipment for the individual is in place prior to and on 
admission. A robust pre-admission assessment is completed, both written and 
electronically. If there are any specific risks/complex care identified they would need 
the approval of the Regional Director before a place in the home would be offered. 
This ensures that an appropriate level of care is in place from the outset with a 
dedicated care plan to accommodate risks. The General Manager monitors changing 
needs and provides direction through the senior care team.  

All residents are part of the Resident of the Day process. As part of Resident of the 
Day process, all assessments, risk assessments and care plans are reviewed monthly 
and updated as required if needs change. This is completed by the Nurse leading the 
shift.  

The General Manager daily walk around of the Home includes ad hoc sampling of 
resident care records and supporting documentation.  This audit tool also directs the 
General Manager to approach and question both residents, families and staff to 
identify any concerns. Any actions identified are discussed at the daily stand-up 
meeting and then carried forward to the next meeting, to ensure review of 
completion. 

A monthly documentation audit is also completed by the General Manager, which 
enables them to monitor care planning for all residents., Generally, there has been 
an improvement in the quality and frequency of recording of care interventions and 
evidence of robust triangulation of decision making and monitoring and response to 
changing care needs.  

A monthly skin integrity audit is completed by the General Manager which reviews all 
residents deemed as ‘high’ or ‘very high’ risk of pressure damage. This looks at care 
interventions and equipment in place, including mattresses and chair cushions. The 
audit also reviews the care plans and the completion of Waterlow scores in line with 
the Resident of the Day process. The Regional Manager completes this audit bi-
monthly to add increased oversight and safety netting and to identify any further 
interventions required for residents.  

vi. 

In accordance with Barchester procedures the Home holds a monthly clinical 
governance meeting. Following the appointment of a new General Manager at the 

 
 
 
 
 
 
 
 
 Home, this has been completed bi-weekly to provide increased oversight. This will 
review any high risk residents and all tissue viability issues and care in the Home. 

vii. 

Following the implementation of the bi-weekly clinical governance meetings, there 
has been a noticeable improvement in the understanding of the importance of 
consistent and effective management of our residents’ risks and care needs 
including skin integrity. This is measured through monthly skin integrity audits 
completed by the Regional Director, General Manager and Clinical Development 
Nurse. The audits comprise of a review of ‘Waterlow’ scores which indicate risk of 
pressure injury. It correlates this risk in line with interventions to mitigate, such as 
repositioning regimes. The monthly documentation audit that is undertaken by 
management in the care home is reviewed by the Regional Director to ensure that 
actions identified have sufficient timeline and follow up for completion. In addition, 
there is enhanced and dedicated training undertaken by staff and improved 
documentation and oversight by the General Manager resulting from the 
implementation of the electronic records system, ‘Enable’.   

viii. 

During the clinical governance meeting, any external referrals are discussed and 
these are documented electronically on the system enabling all levels of 
management to maintain oversight. The clinical governance meeting minutes are 
shared within the service and uploaded onto the service’s clinical governance system 
which enables the senior management team to review these remotely and to raise 
any concerns with the Home as appropriate. 

Windmill Manor Care Home   

(i) 

(ii) 

As part of the lessons learned for Windmill Manor Care Home it was highlighted that 
staff required further training from the organisation’s Clinical Development Nurse in 
the approach to management of skin integrity.  Following completion of the inquest 
and receipt of the Regulation 28 Report, the Managing and Regional Directors made 
arrangements for further refresher training to be delivered at Windmill Manor Care 
Home with follow up by the Regional Manager and Quality Assurance Team. This has 
already taken place and will be repeated at intervals as necessary. As part of the 
training delivered, the specific concerns arising out of this case were used as a case 
study to demonstrate how early recognition and management of risk to skin integrity 
and damage and robust documentation should lead to measures to mitigate 
increased risk. There has been an additional emphasis on the requirement to 
maintain robust handover documentation on a daily and weekly basis.  

It has also been recognised that staff at Windmill Manor Care Home required further 
training on the Barchester Tissue Viability and Skin Tear Policy. If staff had followed 
the policy in this case, they would have followed the prompts to ensure that every 
aspect of the risk review was undertaken along with the immediate action following 
identification of risk of skin damage. This includes early recognition and 
management of risk and consideration of the equipment and monitoring and 
repositioning regimes which should be revisited daily. This training has taken place 
and will be repeated as necessary. This has proven effective as those at higher risk of 
deterioration to skin integrity have had effective mitigation measures put in place, as 
evidenced on the online documentation system, ‘Enable’.  

(iii)  The General Manager at Windmill Manor Care Home has been provided with 

dedicated support from the Managing and Regional Directors and the Clinical 
Development Nurse during the recent period of change at the home. When changes 
to a resident’s clinical status are identified, including deterioration to skin integrity, 
these are added to the online systems which immediately notifies the Clinical 

 
 
 
 
 
 
 
 
 
 Development Nurse and Regional Director. This allows increased oversight and 
assessment of triangulation, including categorisation of wounds and associated care 
planning and treatment regimes. This increased oversight has demonstrated 
improvement in the detection of issues and prompt investigation of incidents. The 
General Manager has developed a strong relationship with the care team through 
regular staff meetings, daily ’Pulse’ meetings and daily stand-up meetings to discuss 
events occurring within the service and any resident clinical concerns. The bi-weekly 
clinical governance meetings, address recent changes to resident’s skin integrity, 
safeguarding issues, weight loss or general clinical deterioration. This is attended 
monthly by the supporting Clinical Development Nurse who offers, advice, clinical 
guidance and any further clinical training required for the care team. Staff have been 
supported to complete regular knowledge checks which enables the wider team and 
General Manager to identify any knowledge gaps to be able to tailor their support 
delivery. This has improved staff confidence and enhanced their ability to implement 
preventative measures to support individuals within our care.  

(iv)  All staff within the service have completed their training on the electronic records 
system which has supported them to ensure they understand the process of 
recording ‘at point of care’. The introduction of e-care documentation has given 
greater oversight to the General Manager and central supporting functions of the 
organisation and facilitates remote access on a 24/7 basis.  The Clinical 
Development Nurse reviews the records on ‘Enable’, alongside the clinical 
governance system. The clinical governance system is a system that allows 
systematic review of care practices such as documentation of skin integrity, weight 
monitoring, infections and accidents and incidents. The Clinical Development Nurse 
focuses her monthly visits to the findings to enable her to tailor her support to the 
needs as identified.  The implementation of the electronic records system has given 
the General and Regional Managers improved oversight of staff action or inaction 
and enables them to identify shortfalls in staffing skills and abilities. The electronic 
records system has a dashboard which can be used to view all care domains for all 
the residents in the home in discrete sections.  The General Manager can therefore 
swiftly and easily review all residents’ wounds within the home and ensure that these 
are categorised correctly, and all relevant risk assessments and care plans are in 
place. All wound assessments are now completed electronically.  

Thank you for raising your concerns. I hope that the content of this letter provides sufficient 
assurance that Barchester Healthcare take the concerns raised seriously, has taken action 
following the death of Mrs Ramona Harbott, is committed to ongoing and continuous 
improvement and is auditing and monitoring compliance regularly and robustly. We accept  
your concerns and continue to work to improve the service we provide. Should you have any 
questions or concerns or comments, please do not hesitate to contact me directly. 

Yours sincerely 

Chief Executive Officer  
Barchester Healthcare

6 February 2026 

Ms Susan Ridge 
H.M. Assistant Coroner for Surrey 
H.M. Coroner’s Court 
Station Approach 
Woking 
Surrey 
GU22 7AP 

Dear Madam Coroner  

Regulation 28: Report to prevent future deaths in relation to Ramona Doreen Harbott 

I am responding to the Regulation 28 Report issued on 19 December 2025 following the 
inquest into the death of Mrs. Ramona Doreen Harbott. The inquest concluded on 8 
December 2025.  

Barchester Healthcare (‘Barchester’) deeply regrets the death of Mrs Ramona Harbott and the 
distress this has caused her family.   

Following this very sad incident we have made widespread changes to the provision of care 
and services at Windmill Manor Care Home. For the purpose of this response, we have 
considered the concerns raised by you and where possible we have grouped together details 
of assurance measures where these appear to deal with more than one area of concern.  

Coroner’s Concerns 

The matters of concern are:  

a.  The evidence heard by the court indicated that though the care home had 

policies and guidance for the prevention and management of bed sores that was 
not followed by on-site care or nursing staff.  Although at high risk of pressure 
sores Mrs Harbott was not regularly repositioned until she had developed a 
sacral sore. Her skin condition was not monitored and recorded to the extent 
that though the sore was apparently being treated, it had become an 
unstageable necrotic wound by the time she was taken to hospital.  The serious 
pressure sore on the right heel was not documented until it was seen on 23 
January 2025 although it was likely well established for at least a week. 

b.  The coroner acknowledges that Barchester Health Care have since this death 
and the inquest hearing in November 2025 commenced an action plan of 
improvements including greater regional management oversight however the 
coroner remains concerned that the matters identified at the inquest regarding 
issues surrounding early and appropriate assessment of risk, use of 
preventative measures, skin monitoring, pressure sore treatment and record 
keeping are the subject of ongoing improvement which has yet to be completed 
and audited.   

I have addressed the concerns below: 

Completion of action plan of improvements   

As you are aware an Action Plan of improvements was implemented following this incident 
and a copy of that was submitted to court on 12 November 2025. Further actions following 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 the hearing on 13 November were confirmed in the signed statement of the Regional 
Manager submitted to the court on 5 December 2025.  

Whilst some of the actions are completed such as replacement of the General Manager, 
appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are 
necessarily part of day-to-day documentation and process which will remain embedded and 
ongoing to ensure a robust approach to the planning and management of the needs of our 
residents.  

Otherwise, I can confirm completion of actions referred to as follows: 

•  Replacement of General Manager. 
•  Dismissal of Deputy Manager due to gross misconduct and referral to the NMC.   
•  Appointment of Regional Manager. 
•  Block of Bank Nurse involved in incident . 
• 

Introduction and embedding of electronic records and case management system 
‘Enable’.   

•  Review of investigation carried out post incident and subsequent disciplinary actions 

and outcomes. 

•  Post inquest reflective sessions with staff carried out by Regional Manager with focus 
on the matters of concern raised by you during the inquest and in your findings and 
conclusion delivered on 8 December 2025. 

•  Training and Supervision sessions took place with all staff at the Home on 22nd 

October 2025, and 18th December 2025 led by the Regional Operational Trainer and 
Clinical Development Nurse. As previously advised, the training focussed on pressure 
area care and management of pressure ulcer/wounds.  During the training there 
were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and 
specific focus on early and appropriate management of risk, use of preventative 
measures, skin monitoring, pressure ulcer treatment and record keeping. The 
Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework 
approach to promote comprehensive risk assessment, monitoring and care as a tool 
in pressure ulcer prevention. Early identification of skin compromise through regular 
checks is reinforced as part of daily care. Training sessions included knowledge 
testing and question and answer sessions prior to completion.  Particular note of the 
evidence at inquest of the Tissue Viability Nurse Consultant from the NHS Trust 
hospital was taken by the Regional Manager who as you are aware attended the 
inquest throughout. She has disseminated the evidence of the hospital nurse to the 
Home staff as part of a best practice approach to management of risk to skin 
integrity.  

•  The Clinical Development Nurse now visits the Home on a weekly basis to review the 
approach to the management of risk to skin integrity and care and treatment plans 
in place where skin damage has been identified for any resident. She checks that 
wound assessment and categorisation is being completed correctly with review of 
wounds by staff in person supported by photographs. She attends the daily stand-up 
meeting during her visit to follow up on assessments and referrals and any clinical 
concerns. She is also available for advice and assistance to all staff outside these 
visits and can review concerns on an ‘as needed’ basis. She has reported an 
improvement overall in the approach of staff and their recognition of the importance 
of early interventions and comprehensive treatment plans.  

•  The Regional Operational Trainer and Clinical Development Nurse have attended the 
Home on several occasions to carry out observations and monitoring and to identify 
any further areas for improvement for the clinical team. Visits took place on 7,10, 15 
and 22 October.  On 15 October 2025 the Clinical Development Nurse attended the 
Home to review equipment used by staff to support resident care needs. A group 
session with staff was held to discuss availability of equipment, appropriate use and 
processes and procedures to assess need and request equipment including pressure 
relieving mattresses. During an observation visit on 22 October 2025 there was a 
focus on Moving and Handling techniques used by staff at the Home. No concerns 

 
 
 
 
 
 were identified with staff using appropriate procedures. During the visits, there were 
sessions arranged with the Home team to discuss the importance of regular 
repositioning of residents. Group supervisions of all staff were completed during the 
visits.   

•  Advice has been provided by the Regional Operational Trainer and Clinical 

Development Nurse in respect of the use of beds and mattresses as vital equipment 
for the management of skin integrity and as an aid to prevention of damage to skin. 
Full staff training has been carried out with the Head of Maintenance at the Home in 
respect of the use of dynamic air mattress settings and how to use these 
appropriately and the importance of regular checks. Refresher training has also been 
provided to the Home team in respect of how to access mattress replacements in the 
event of a mattress failure occurring out of hours.  

Audit 

i. 

ii. 

iii. 

iv. 

v. 

There is a robust admissions process in place which the General Manager controls 
and monitors throughout the stages from pre-admission to admission. This ensures 
that all prospective resident needs are identified prior to admission and appropriate 
training for staff and equipment for the individual is in place prior to and on 
admission. A robust pre-admission assessment is completed, both written and 
electronically. If there are any specific risks/complex care identified they would need 
the approval of the Regional Director before a place in the home would be offered. 
This ensures that an appropriate level of care is in place from the outset with a 
dedicated care plan to accommodate risks. The General Manager monitors changing 
needs and provides direction through the senior care team.  

All residents are part of the Resident of the Day process. As part of Resident of the 
Day process, all assessments, risk assessments and care plans are reviewed monthly 
and updated as required if needs change. This is completed by the Nurse leading the 
shift.  

The General Manager daily walk around of the Home includes ad hoc sampling of 
resident care records and supporting documentation.  This audit tool also directs the 
General Manager to approach and question both residents, families and staff to 
identify any concerns. Any actions identified are discussed at the daily stand-up 
meeting and then carried forward to the next meeting, to ensure review of 
completion. 

A monthly documentation audit is also completed by the General Manager, which 
enables them to monitor care planning for all residents., Generally, there has been 
an improvement in the quality and frequency of recording of care interventions and 
evidence of robust triangulation of decision making and monitoring and response to 
changing care needs.  

A monthly skin integrity audit is completed by the General Manager which reviews all 
residents deemed as ‘high’ or ‘very high’ risk of pressure damage. This looks at care 
interventions and equipment in place, including mattresses and chair cushions. The 
audit also reviews the care plans and the completion of Waterlow scores in line with 
the Resident of the Day process. The Regional Manager completes this audit bi-
monthly to add increased oversight and safety netting and to identify any further 
interventions required for residents.  

vi. 

In accordance with Barchester procedures the Home holds a monthly clinical 
governance meeting. Following the appointment of a new General Manager at the 

 
 
 
 
 
 
 
 
 Home, this has been completed bi-weekly to provide increased oversight. This will 
review any high risk residents and all tissue viability issues and care in the Home. 

vii. 

Following the implementation of the bi-weekly clinical governance meetings, there 
has been a noticeable improvement in the understanding of the importance of 
consistent and effective management of our residents’ risks and care needs 
including skin integrity. This is measured through monthly skin integrity audits 
completed by the Regional Director, General Manager and Clinical Development 
Nurse. The audits comprise of a review of ‘Waterlow’ scores which indicate risk of 
pressure injury. It correlates this risk in line with interventions to mitigate, such as 
repositioning regimes. The monthly documentation audit that is undertaken by 
management in the care home is reviewed by the Regional Director to ensure that 
actions identified have sufficient timeline and follow up for completion. In addition, 
there is enhanced and dedicated training undertaken by staff and improved 
documentation and oversight by the General Manager resulting from the 
implementation of the electronic records system, ‘Enable’.   

viii. 

During the clinical governance meeting, any external referrals are discussed and 
these are documented electronically on the system enabling all levels of 
management to maintain oversight. The clinical governance meeting minutes are 
shared within the service and uploaded onto the service’s clinical governance system 
which enables the senior management team to review these remotely and to raise 
any concerns with the Home as appropriate. 

Windmill Manor Care Home   

(i) 

(ii) 

As part of the lessons learned for Windmill Manor Care Home it was highlighted that 
staff required further training from the organisation’s Clinical Development Nurse in 
the approach to management of skin integrity.  Following completion of the inquest 
and receipt of the Regulation 28 Report, the Managing and Regional Directors made 
arrangements for further refresher training to be delivered at Windmill Manor Care 
Home with follow up by the Regional Manager and Quality Assurance Team. This has 
already taken place and will be repeated at intervals as necessary. As part of the 
training delivered, the specific concerns arising out of this case were used as a case 
study to demonstrate how early recognition and management of risk to skin integrity 
and damage and robust documentation should lead to measures to mitigate 
increased risk. There has been an additional emphasis on the requirement to 
maintain robust handover documentation on a daily and weekly basis.  

It has also been recognised that staff at Windmill Manor Care Home required further 
training on the Barchester Tissue Viability and Skin Tear Policy. If staff had followed 
the policy in this case, they would have followed the prompts to ensure that every 
aspect of the risk review was undertaken along with the immediate action following 
identification of risk of skin damage. This includes early recognition and 
management of risk and consideration of the equipment and monitoring and 
repositioning regimes which should be revisited daily. This training has taken place 
and will be repeated as necessary. This has proven effective as those at higher risk of 
deterioration to skin integrity have had effective mitigation measures put in place, as 
evidenced on the online documentation system, ‘Enable’.  

(iii)  The General Manager at Windmill Manor Care Home has been provided with 

dedicated support from the Managing and Regional Directors and the Clinical 
Development Nurse during the recent period of change at the home. When changes 
to a resident’s clinical status are identified, including deterioration to skin integrity, 
these are added to the online systems which immediately notifies the Clinical 

 
 
 
 
 
 
 
 
 
 Development Nurse and Regional Director. This allows increased oversight and 
assessment of triangulation, including categorisation of wounds and associated care 
planning and treatment regimes. This increased oversight has demonstrated 
improvement in the detection of issues and prompt investigation of incidents. The 
General Manager has developed a strong relationship with the care team through 
regular staff meetings, daily ’Pulse’ meetings and daily stand-up meetings to discuss 
events occurring within the service and any resident clinical concerns. The bi-weekly 
clinical governance meetings, address recent changes to resident’s skin integrity, 
safeguarding issues, weight loss or general clinical deterioration. This is attended 
monthly by the supporting Clinical Development Nurse who offers, advice, clinical 
guidance and any further clinical training required for the care team. Staff have been 
supported to complete regular knowledge checks which enables the wider team and 
General Manager to identify any knowledge gaps to be able to tailor their support 
delivery. This has improved staff confidence and enhanced their ability to implement 
preventative measures to support individuals within our care.  

(iv)  All staff within the service have completed their training on the electronic records 
system which has supported them to ensure they understand the process of 
recording ‘at point of care’. The introduction of e-care documentation has given 
greater oversight to the General Manager and central supporting functions of the 
organisation and facilitates remote access on a 24/7 basis.  The Clinical 
Development Nurse reviews the records on ‘Enable’, alongside the clinical 
governance system. The clinical governance system is a system that allows 
systematic review of care practices such as documentation of skin integrity, weight 
monitoring, infections and accidents and incidents. The Clinical Development Nurse 
focuses her monthly visits to the findings to enable her to tailor her support to the 
needs as identified.  The implementation of the electronic records system has given 
the General and Regional Managers improved oversight of staff action or inaction 
and enables them to identify shortfalls in staffing skills and abilities. The electronic 
records system has a dashboard which can be used to view all care domains for all 
the residents in the home in discrete sections.  The General Manager can therefore 
swiftly and easily review all residents’ wounds within the home and ensure that these 
are categorised correctly, and all relevant risk assessments and care plans are in 
place. All wound assessments are now completed electronically.  

Thank you for raising your concerns. I hope that the content of this letter provides sufficient 
assurance that Barchester Healthcare take the concerns raised seriously, has taken action 
following the death of Mrs Ramona Harbott, is committed to ongoing and continuous 
improvement and is auditing and monitoring compliance regularly and robustly. We accept  
your concerns and continue to work to improve the service we provide. Should you have any 
questions or concerns or comments, please do not hesitate to contact me directly. 

Yours sincerely 

Chief Executive Officer  
Barchester Healthcare

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 

www.cqc.org.uk 

H.M. Assistant Coroner Susan Ridge 

Email: coronersoffice@surreycoroner.gov.uk sarah.church@surreycoroner.gov.uk (PA to 
HM Coroner) 

11 February 2026 

Care Quality Commission 
Our Reference: CAS-1208398-N4M4T2 

Dear HM Assistant Coroner, Susan Ridge 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Mrs 
Ramona Doreen Harbott 

Thank you for sending CQC a copy of the prevention of future death report issued 
following the sad death of Mrs. Harbott.  

We note the legal requirement upon CQC and Barchester Healthcare Homes Limited 
to respond to your report by 13 February 2026. 

The role of the CQC & Inspection methodology 

The role of the Care Quality Commission (CQC) as an independent regulator is to 
register health and adult social care service providers in England and to assess 
whether or not the fundamental standards set out in the Health and Social Care Act 
2008 (Regulated Activities) 2014 regulations are being met. 

The regulatory approach considers five key questions. They ask if services are Safe; 
Effective; Caring; Responsive; and Well Led. The regulatory framework includes 
providers being required to meet fundamental standards of care; the standards 
below which care must never fall. We provide guidance to providers on how they can 
meet these standards (Regulations 4 to 20A of the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014). 

In December 2023 CQC’s Operations Network in the South region went live with our 
new Single Assessment Framework. This approach covers all sectors, service 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 types and levels and the five key questions remain central to this approach and are 
prompted by ‘quality statements’. The quality statements are described as ‘we 
statements’ as they have been written from a provider’s perspective to help them 
understand what we expect of them. They draw on previous work developed with 
Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative 
Care on Making it Real. They set clear expectations of providers, based on people’s 
experiences and the standards of care they expect. 

Regulatory History 

Windmill Manor was registered by CQC on 25 February 2011 to provide the 
regulated activity of ‘Accommodation for persons who require nursing or personal 
care’ and ‘Treatment of disease, disorder or injury’. This means Windmill Manor is 
registered as a nursing home. 

Windmill Manor was inspected from 22 January 2025 to 31 January 2025 with the 
report being published on 16 April 2025. A link to the report can be found here: 
https://www.cqc.org.uk/location/1-148193747/reports/AP8739/overall 
This was a responsive assessment based on concerns raised by the local authority. 
At that inspection we rated the service as good.  

CQC contacted the provider Barchester Healthcare Homes Limited (Windmill Manor) 
on 23 December 2025 to request written confirmation and evidence of the action 
they have taken to date following this death and any additional action they intend to 
take in response to the prevention of future death report. 

Barchester Healthcare Homes Limited responded to our request for information on 
14 January 2026.  

The Matters of Concern highlighted are: 

a. The evidence heard by the court indicated that though the care home had policies 
and guidance for the prevention and management of bed sores that was not followed 
by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott 
was not regularly repositioned until she had developed a sacral sore. Her skin 
condition was not monitored and recorded to the extent that though the sore was 
apparently being treated, it had become an unstageable necrotic wound by the time 
she was taken to hospital. The serious pressure sore on the right heel was not 
documented until it was seen on 23 January 2025 although it was likely well 
established for at least a week. 

b. The coroner acknowledges that Barchester Health Care have since this death and 
the inquest hearing in November 2025 commenced an action plan of improvements 
including greater regional management oversight however the coroner remains 
concerned that the matters identified at the inquest regarding issues surrounding 
early and appropriate assessment of risk, use of preventative measures, skin 
monitoring, pressure sore treatment and record keeping are the subject of ongoing 
improvement which has yet to be completed and audited. 

 
 
 
 
 
 
 
 
 
 In response Barchester Healthcare Home Limited have provided detail on a number 
of actions they have taken since the death of Mrs. Harbott, these included: 

•  Strengthening senior leadership oversight to ensure service users at risk of 

developing pressures sores are managed effectively, 

•  Recruitment of Clinical staff to increase the provision of training and 

• 

• 

supervision of staff delivering pressure care, 
Increased the systems in place to ensure appropriate monitoring and 
repositioning of service users at risk. They have also increased visits by their 
clinical teams, 
Introduced detailed reviews for any newly admits service users to monitor 
their skin integrity with additional management oversight and 

•  Provided refresher training for staff on their skin tear policy. 

Barchester Healthcare Homes Limited have advised us the above actions are now in 
place at Windmill Manor. As a CQC registered provider Barchester Healthcare 
Homes Limited is legally responsible for ensuring that all service users receive safe 
care and treatment.  

Whilst we have received assurances about the steps taken to address the concerns, 
we will continue to monitor the safety and quality of care at Windmill Manor and we 
are considering any criminal enforcement that may be appropriate in this case. If we 
identify safety concerns in relation to pressure wound care, we will consider whether 
an unannounced inspection and/or further regulatory action is required.   

If you require any more information please send to: 

By email: 

By post: 

CQCInquestsandCoroners1@cqc.org.uk 

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Please include the reference number CAS-1208398-N4M4T2 

Thank you in advance for your assistance. 

Yours sincerely 

Deputy Director 
Care Quality Commission