Ronald Nelson

Miss Sarah Wood 
Assistant Coroner 
Nottingham City and Nottinghamshire Coroners Service 
Transformation & Change 
Nottingham City Council 
Council House 
Old Market Square 
Nottingham 
NG1 2DT 

5 March 2026 

Dear HM Assistant Coroner Sarah Wood, 

Regulation 28 Report following the inquest into the death of Mr Ronald Colin 
Nelson 

Thank you for bringing the Regulation 28 Report to our attention following the 
inquest into the death of Mr Ronald Colin Nelson who died on 26th of January 2025 
at the Queens Medical Centre, Nottingham. We acknowledge the concerns you have 
raised and appreciate the opportunity to respond. 

We would like to express our sincere condolences to Mr Nelson’s family and loved 
ones following his death. 

We have noted the matters of concerns listed below, in respect of Mulberry Court 
Care Home, 61 Darnhall Crescent, Bilborough, Nottingham, NG8 4QA: 

i) 
ii) 

That there remain potential issues of poor record keeping. 
There are concerns over the level of compliance of care plans. 

We wrote to the Nominated Individual of Mulberry Court Care Home on 22 January 
2026, requiring them to set out in writing, within 7 days, the action taken to date and 
any further planned action to meet the serious concerns identified during the inquest 
and the two points listed above.  We received a response by return, 22 January 
2026 which informed us of the following: 

•  The Nominated Individual had been in post since 19 July 2025; 

Page 1 of 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  The Nominated Individual had instigated on 19 January 2026, a second 

independent investigation to determine the short comings in connection to the 
care of Mr Ronald Colin Nelson. This was due to conclude by the end of 
February 2026 and that a copy would be shared with the Care Quality 
Commission (CQC) will receive a copy of this. 

•  The Nominated Individual submitted to CQC on 28 January 2026, a service 

improvement plan. 

•  The Nominated Individual informed CQC that they had made a formal request 

to the Integrated Care Board for an unannounced quality audit to be 
undertaken ‘in the very near future’. 

The CQC held a Decision-Making Meeting (DMM) on 27 January 2026 on receipt of 
the Prevention of Future Deaths report, to agree next steps to respond to the 
concerns raised.   

Mulberry Court Care Home was previously inspected in January 2019, with the 
report published in March 2019.  The service was rated good overall with the key 
questions of Safe, Effective, Caring and Well Led rated good.  The key question of 
responsive was rated outstanding.  In line with The CQC’s current Adult Social Care 
(ASC) assessment priorities, Mulberry Court Care Home met the priority of a service 
not assessed within 6 years.  

An unannounced assessment was conducted at Mulberry Court Care Home on 17 
and 18 February 2026.  Further off-site assessment work continued such as 
reviewing documents and speaking with people. This assessment looked at all key 
questions to determine if Mulberry Court Care Home is safe, effective, caring, 
responsive and well-led. Details of the assessment framework used to undertake this 
assessment can be found here: Assessment - Care Quality Commission.   

The assessment reviewed a range of documents, systems and processes used by 
Mulberry Court Care Home, interviewed staff, observed clinical practice and 
interactions by staff and spoke with those who used the service.  This has allowed 
CQC to determine if the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014 (“The Regulations”) are complied with.  We have made a 
judgement on the standard of care including but not limited to the concerns raised 
within the Prevention of Future Deaths report. 

The Regulations under which care planning and record keeping are reviewed are: 

Regulation 9: Person-centred care - Care Quality Commission  

To meet the Regulations, providers must make sure that people using a service 
have care or treatment that is personalised specifically for them. This regulation 
describes the action that providers must take to make sure that each person 
receives appropriate person-centred care and treatment that is based on an  
assessment of their needs and preferences. 

Regulation 12: Safe care and treatment - Care Quality Commission 

Page 2 of 6 

 
 
 
 
 
 
 
 
 
 Providers must prevent people from receiving unsafe care and treatment and 
prevent avoidable harm or risk of harm. Providers must assess the risks to people's 
health and safety during any care or treatment and make sure that staff have the 
qualifications, competence, skills and experience to keep people safe. 
Regulation 17: Good governance - Care Quality Commission 

Providers must securely maintain accurate, complete and detailed records in respect 
of each person using the service. 

We found that record keeping and care planning at Mulberry Court Care Home is in 
line with the regulations.  The provider ensured that daily records, care plans, risk 
assessments and contemporaneous records in relation to care delivery were 
detailed, individualised updated and reviewed regularly.  This meant staff knew how 
to care for people in the service.  

Staff were knowledgeable about how to care for people in the service, because they 
had read and understood health records, including care plans and risk assessments, 
and carried out care in line with guidance and instructions in the records.   

Staff had received training in tissue viability: pressure injuries training, wound 
healing (which included assessment, treatment and dressing).  Care staff were all 
either trained to National Vocational Qualifications (NVQ) Level 2 or 3 or had 
completed a Care Certificate which included positional care, nutrition and hydration 
care as well as safe food handling.  

We are assured that the service improvement plan to address concerns raised by 
you in the Prevention of Future Deaths report has been shared with staff across the 
service and actioned. There was a strong focus on the actions and how the service 
will meet them. There was a clear focus on safety.  There was evidence of how 
lessons were learned from the death of Mr Nelson.  Team meetings, reflective 
practice, daily huddles, handover meetings and clinical meetings were embedded.   

Our assessment has concluded, however, the report is in draft and will require the 
standard quality assurance and factual accuracy review by the provider. Therefore, 
the report will not be published until after the deadline for this response.  We will not 
advise on a provisional rating at this time, but we are assured that all matters of 
concern within the Prevention of Future Deaths report have been fully assessed as 
described above.  

Consideration of Criminal Investigation 

On 1 April 2015 the CQC assumed enforcement responsibility for health and safety 
related serious incidents concerning people using services in health and social care 
settings in England. 

In order to determine whether to commence a criminal investigation CQC apply the 
“Specific Incident Guidelines”.  

Under this guidance, Inspectors, supported by Operations Managers, undertake an 
initial assessment of specific incidents to ascertain whether there is reasonable 

Page 3 of 6 

 
 
 
 
 
 
 
 
 
 
 
 suspicion that people using a regulated service have sustained avoidable harm or 
been exposed to a significant risk of avoidable harm.  

Two questions are answered as part of the initial assessment. 

1.  Does the information about the specific incident raise concerns about ongoing 

risk of harm to users of the service which CQC should inspect?  

2.  Does the information about the specific incident suggest the harm sustained 
was avoidable and may have resulted from a registered person (Provider or 
Registered Manager) breach of a prosecutable fundamental standard? For 
example, a breach of Regulation 12(1) failure to provide safe care and 
treatment? If so, CQC should gather further evidence about the incident as 
part of a formal criminal investigation once that decision has been validated 
by CQC National Criminal Case Assessment and Progression Panel 
(CCAPP). 

Our National Customer Service Centre team received a statutory notification of 
death from Mulberry Court Care Home on 30 January 2025. This notification did not 
proceed for further review as the details within the notification stated the death was 
expected and was part of an end-of-life care pathway.   

In September 2025, CQC was notified of an inquest due into Mr Nelson’s death and 
requested information from the provider. This was to understand the actions taken in 
response to the incident and to assess whether there were any breaches of 
fundamental standards or regulatory requirements in line with our specific incident 
guidance. 

CQC have taken steps to strengthen support for inspection teams to ensure the 
Specific Incident process is consistently followed in future cases in line with CQC’s 
Specific Incident guidelines. To enhance our oversight of Specific Incidents, we have 
established a Specific Incident Progression Team (SIPT). This team supports 
inspection staff in meeting our responsibilities for incident follow-up and ensures 
alignment with our enforcement powers.  

The incident of Mr Nelson’s death was referred to SIPT on 28 November 2025. The 
team will consider the case to determine if it meets our regulatory threshold for 
enforcement action.  

CQC are bound by a statutory limitation period. The statutory limitation period is set 
out in section 90(2) of the Health and Social Care Act 2008. It means we need to 
bring any prosecution both:    

•  within 12 months of when we have enough evidence that the case passes the 

test in the Code for Crown Prosecutors    
in any event within 3 years of when the offence was committed    

• 

The latest date for limitation in this matter will be 26 January 2028. 

I trust that the considered response provided, alongside the actions undertaken by 
the Care Quality Commission, offers the necessary assurance in accordance with 

Page 4 of 6 

 
 
 
 
 
 
 
 
 
 
 our regulatory responsibilities. We will continue to monitor the provider’s compliance 
with regulatory standards and ensure that learning from this case is embedded into 
practice. We remain committed to supporting improvements in patient safety and 
care quality across all services. 

Yours sincerely,  

Deputy Director of Adult Social Care 
Central Region 

Page 5 of 6 

 
 
 
 
 
 
 
 Page 6 of 6 

Miss Sarah Wood Assistant Coroner Nottingham City and Nottinghamshire Coroners Service Transformation & Change Nottingham City Council Council House Old Market Square Nottingham NG1 2DT   5 March 2026  Dear HM Assistant Coroner Sarah Wood, Regulation 28 Report following the inquest into the death of Mr Ronald Colin Nelson Thank you for bringing the Regulation 28 Report to our attention following the inquest into the death of Mr Ronald Colin Nelson who died on 26th of January 2025 at the Queens Medical Centre, Nottingham. We acknowledge the concerns you have raised and appreciate the opportunity to respond.  We would like to express our sincere condolences to Mr Nelson’s family and loved ones following his death. We have noted the matters of concerns listed below, in respect of Mulberry Court Care Home, 61 Darnhall Crescent, Bilborough, Nottingham, NG8 4QA: i) That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans. We wrote to the Nominated Individual of Mulberry Court Care Home on 22 January 2026, requiring them to set out in writing, within 7 days, the action taken to date and any further planned action to meet the serious concerns identified during the inquest and the two points listed above.  We received a response by return, 22 January 2026 which informed us of the following: • The Nominated Individual had been in post since 19 July 2025; • The Nominated Individual had instigated on 19 January 2026, a second independent investigation to determine the short comings in connection to the care of Mr Ronald Colin Nelson. This was due to conclude by the end of February 2026 and that a copy would be shared with the Care Quality Commission (CQC) will receive a copy of this.

MULBE1 

)URT

C A R E   H O M E

13 th March 2025

Miss. Sarah Wood,
Assistant Coroner,
Coroner’s Court,
The Council House,
Old Market Square,
Nottingham,
NG1  2DT.

Dear Miss. Wood,

REF: Response to Regulation 28 Report to Prevent Future Deaths
Mr Ronald Colin Nelson (Deceased)

On  behalf  of  Mulberry Healthcare Ltd, I am writing in connection with the Regulation 28
report  which  was  issued  in  connection  with  the  death  of  Mr  Ronald  Nelson, who  was
resident  of  Mulberry  Court  Care  Home  (‘Mulberry Court/the Home’).  I  would  like  to
express my deepest condolences to Mr Nelson’s family and friends.

Introduction
The  Company and its staff  strive to deliver the highest level of  care to all residents.  Prior
to  and  during  the  course  of  the  Inquest,  the  Registered  Manager  provided  evidence  to
assist the Coroner’s enquiry and to explain the care and treatment provided to Mr Nelson,
specifically with regard to protecting his skin integrity and  providing appropriate pressure
management.  The  Registered  Manager  provided  and  open  and  candid  account  and
explained  the  changes  that  were  implemented  following  Mr  Nelsons’  death  to  further
strengthen  care  recording and  compliance with  care  plans.  A  Regulation  28  report  was
however issued on 15 January 2026, which raised concerns about poor record keeping and
compliance with care plans.

The  Company  has  fully  taken  on  board  the  concerns  raised  by  the  Coroner  and  is
committed to taking any necessary steps to improve resident safety. The actions that were
implemented following Mr Nelson’s death, and actions taken post inquest to address these
issues are set out below.

TEL:  0115  929  4483 

(cid:127)  EMAIL:  INFO@MULBRRY  COURTCAREHOME.COM 

’  WWW.MULBERRYCOURTCAREHOME.COM

61  DARNHALL CRESCENT  ■ B1LBOROUGH  (cid:127)  NOTTINGHAM ■ N G 8   4 Q A

MULBERRY COURT  CARE  HOME  IS  A TRADING NAME  OF  MULBERRY  COURT  HEALTHCARE L I M I T E D   COMPANY REGISTERED  IN  ENGLAND NO.  09612462

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Notwithstanding  the  Company’s  acceptance  of  the  Coroner’s  findings  that  there  were
omissions  in  care  records  and  compliance  with  the  care  records, we  have  reviewed  the
Coroner’s  judgement and make the following observations;

(cid:127)  Following Mr  Nelsons’ first admission  to  NUH,  Mr  Nelson’s sacral area was not
photographed  by staff  at  NUHuntil 19.17  hours on  22  October 202 4,  nearly an
hour and  half  after he left Mulhrny Court.  Attliis point  therccords s  tate that Mr
Nelson  had  a Grade  2 pressure wound to  theright  butt  ockand SDT  I  to  the left
buttock.  A  Grade  2  pressure  wound  and  STDI  can  develop  in  under  1  hour  in
high-riskindividuals  (which Mr Nelson was), particularly if  no  pressure area relief
is given,tor example  if  he remained on a stretcher or trolley.

(cid:127)  We note that the Coroner found the Home’s notes contradictory and suggests that
they were misleading.  However, to clarify, thedescriptio  ns of  ‘redness’, ‘sore’ and
‘skin intact’ are all consistent statena  nts  to desribe skin  that is not broken down.
These  descriptions  are  consistent  with  a  Grade  1  pressure  wound.  A  Grade  2
pressure wound is where the  outer surface of  the skin is damaged and  the skin is
broken down.

(cid:127)  Whilst in  the  care  of  NUH,  it  is  recorded  that  on  25  October 2024,  Mr  Nelson
developed a Grade  2 pressure wound  of  the left  buttock and  a Grade  2 pressure
wound  of  the  sacrum.  These  were  new  wounds  that  not  recorded  in  NUH’s
records  when  Mr  Nelson  was  admitted  to  the  Ward  on  22  October  2024.  The
SDTI was described by staff  at NUH  as ‘evolving’.

(cid:127)  Mr Nelson was reviewed by his GP on 16 December 2024, who reported that the
pressure area was improving, with some areas of  healing on  the edges, suggesting
that the plan of  care was appropriate.

(cid:127)  When  Mr Nelson was admitted to NUH  on 16 December 2024. , NUH’s records
record  that  a  skin  assessment  carried  out  on  17  December  at  05.33am  and
recorded that the pressure wound was reviewed on admission and was Grade 3. A
further review carried out on 17 December 2024 at 07.19am  again confirmed the
pressure wound  to  be  Grade 3. When  Mr  Nelson  was  transferred to  the ward at
and  reassessed at 22.41pm, the pressure wound was assessed and at this stage was
Category 4.

(cid:127)  As  acknowledged  by  the  Coroner,  Mr  Nelson  had  a  number  of  comorbidities
which  impacted  on  his  skin  integrity  and  the  healing  process,  including  poor
nutritional intake, weight loss, urinary and  faecal incontinence  (which resulted in
more  frequent  dressing  changes,  lessening  their  efficacy),  and  prescribed
medication.

TEL: 0115  929  4433 

'  EMAIL: INFO  MULflERRYCOURTCAREHOME.COM 

(cid:127)  WWW.MULRERRYCOURrCARfHOME.COM

61 DARNHALL CRESCENT  '  BILBOROUGH  (cid:127) NOTTINGHAM (cid:127) NG8 -QA

MULBERRY  COURT  CARE  HOME  IS  A TRADING  NAME  OF  MULBERRY  COURT  HEALTHCARE  LIMITED  COMPANY REGISTERED  IN  ENGLAND  NO.  09612462

 MULBERR

COURT

C  A R E   H  O  M  E

Action taken in response to the Regulation 28 Report:

We have undertaken a review of  the care delivery at Mulberry Court Care Home.  This was
independently  led  by  a  Manager  from  one  of  other  services.  Following  this  review, we
prepared a service  improvement plan  (SIP).  A copy  of  the SIP  is attached at Annex  A.
The SIP was shared with both  the CQC and ICB.

All actions listed on  the SIP have been completed.

Dealing with the Coroner’s specific concerns we have taken the following action:

1.  All staff  were  briefed regarding the  Inquest and  the Coroner’s  findings and  made
aware  of  the  concerns  identified  and  informed  of  the  action  the  Company  was
taking to address the Coroner’s concerns.

2.  Every  service  user’s  relative  was  contacted  and  provided  with  details  of  the
Coroner’s findings and informed of  the action the Company was taking to address
the Coroner’s concerns. Families were offered the opportunity to for face-to-face
meetings.

3.  Clinical and  medication  competencies  were  carried  out  to  ensure  that  staff  were

competent to run  the shift.

4.  We  reviewed  the Transfer to  Hospital and  provided  further guidance to  the staff
about completion of  the pack to ensure itcontains all relevant information for the
resident..  The Transfer to Hospital pack ensures that the Hospital is provided with
accurate  information  about  a  residents  condition  at  the  point  of  admission  to
hospital  (including  skin  integrity  and  any  concerns  about  skin  breakdown).
Compliance with the Transfer to Hospital pack is being reviewed on a weekly basis
for a period of  6 months to ensure compliance.

5.  We reviewed the Transfer Back Hospital pack to ensure it remains fit for purpose
and  Nurses  have  been  trained  on  its  use.  Compliance  with  the  Transfer  back
Hospital  pack  is  being  reviewed  on  a  weekly  basis  for  a  period  of  6  months  to
ensure compliance.  Use of  the Transfer Back from  Hospital back is compulsory.
The Pack requires;

a.  Review  of  key  documentation  on  return  from  hospital,  including;  body
map,  skin integrity  check  and  documenting any  areas  of  concern  or  skin
breakdown, weight check, physical observations.

b.  Review and upload of  the discharge summary onto Nourish and copy sent
to the Registered Manager (RM ) and Clinical Services Manager (CSM) for
review.

TEL:  0115  929  4483 

'  EMAIL: 1NFO@MULBERRYCOURTCAREHOME.COM 

’  WWW.MULBERRYCOURTCAREHOME.COM

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MULBERRY COURT  CARE  HOME  IS A TRADING NAME  OF  MULBERRr  COURT  HEALTHCARE  L I M I T E D   COMPANY REGISTERED  IN  ENGLAND NO  09612462

 6.  We  reviewed  the  Wound  Care  Plans  to  ensure  that  they  were  fit  for  purpose,
including  the  escalation  process  and  that  they  were  being  used  correctly  and
consistently by staff  Staff  have been instructed to ensure;

a.  Each wound has an individual care plan and wound assessment in Nourish

Care Planning system and wounds are not consolidated.

b.  All  wound  photos  have  the  measurements,  date,  name,  body  part,  etc

visible in  the photo.

c.  All wounds are documented on the wound tracker which is sent to the RM

and CSM weekly for review and to ensure oversight.

d.  All  letters  from  the  Tissue  Viability  Nurse  (TVN)  and  dietician  are
uploaded into  the correct care plan on  the  Nourish system. The care plan
also  details  any  instructions  given  by  the  TVN,  including  dressings  &
regime and any external health professionals to be contacted e.g., dieticians.

e  The TVN service has been informed that all instructions must be in writing

and will not  be accepted if  given verbally.

f.  A  body  map  is  completed  for  each  individual wound  or  skin  change  on
Nourish. Body maps are produced daily for all high-risk residents and are
reviewed  by Clinical Lead and  Home  Manager. Body  maps  are  produced
weekly  for  all  residents  and  are  reviewed  by  Clinical  Lead  and  Home
Manager.

7.  We have reviewed communication process to ensure that staff  are up to date with
residents  care  requirements  and  changes  in  care  need.  We  have  reviewed  our
current processes to ensure that they are followed by staff.  This includes;

a.  A detailed handover is held at the start of  each shift. This will be for all the
care  team  allocated  to  that  shift. The  Nurse  in  Charge  (NIC)  will give  a
summary of  the last 24 hours.

b.  All residents are discussed at the  handover. The  NIC  checks with all staff
on  shift  before  writing  up  the  handover  to  ensure  the  information  is
reflective and  up  to  date. This  is in  addition  to  the information recorded
on  the Nourish care planning system.

61  DARNHALL CRESCENT  (cid:127)  B1LBOROUGH  ■ NOTTINGHAM (cid:127)  NG8  €>A
TEL: 0115  929  4483  ■  EMAIL: 1NFO@MULBERRYCOURTCAREHOME.COM  ■  WWW.MULBERRYCOURTCAREHOME.COM

MULBERRY COURT  CARE  HOME  IS  A TRADING NAME  OF  MULBERRY COURT  HEALTHCARE L I M I T E D   COMPANY REGISTERED  IN  ENGLAND NO  09612462

 MULBERRY! C P U   RT
C A R E   H  O  M  E

c.  The  handover template has been reviewed and redrafted. It includes;

i.  High risk information
ii.  AM  /  PM handover
iii.  Supplementary Reviews

d.  A  daily huddle is  undertaken  in  addition  to  the  handover  meeting at  the
start  of  the  shift. All staff  on  shift  are asked  for  an  update  on  what  they
have  noticed  during  their  shift.  Specific  information  includes;  any  skin
changes, urine colour  I  odours, skin changes, residents not their usual self-
etc.  This  is  documented  by  the  NIC  or  SCA  every  day  at  10:30am  &
15:30pm. Any concerns noted are to be checked by the NIC.

e.  A daily meeting is carried out every day at 1 lam with the NIC of  each floor,

maintenance, catering, CSM, HR and  the Home Manager.

f.  All staff  on shift are required to sign a “Read & Understood” document to
state  they  are  aware  of  what  is  currently  being  discussed  in  the  daily
meetings.

8.  We have reviewed whether the current care planning systems is effective and have
implemented a new auditing system to ensure that care plans are up to date, reflect
residents’ needs, are understood by staff  and are followed. This includes;

a.  An effective care plan audit was devised for the home and staff  trained on

its use.

b.  All care plans are evaluated effectively to reflect the information in the care
plan  has  been  reviewed.  This  is  completed  following  any  changes  in
presentation/need, or monthly as part of  Resident of  the Day

c.  All residents care plans will be subject to  full audit  following readmission

and then periodically.

d.  All residents have a Resident of  the Day completed every month. This is a

full evaluation of  the care plan and all risk assessments

e  The  nursing  team  have  regular  clinical  supervisions  carried  out  and

independently verified

TEL:  0 1 1 5   929  4483 

’  EMAIL:  1NFO@MULBERRYCOURTCAREHOME.COM  ■  WWW.MULBERRYCOtRTCAREHOME.COM

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MULBERRY COURT  CARE  H O M E   IS A TRADING NAME  OF  MULBERRY COURT  HEALTHCARE L I M I T E D   COMPANY REGISTERED  IN  ENGLAND NO.  1)9612462

 MULBERR COURT
C  A  F< E  H  O  M  E

9.  We  have  reviewed  how  repositioning  of  residents  is  planned  and  recorded  to
ensure  that it  is person  centred  for  the individual and  addresses  potential  risk of
harm.  We  have  implemented  further  processes  to  make  this  more  robust  and
ensure that there is appropriate oversight. This includes;

a.  All repositioning times are set  as an interaction on  the individual timeline
for  the  resident  on  the  Nourish  Care  Planning  system,  setting  out  the
intervals required between turns and  the position.

b.  All repositioning must  be  documented within  the individuals  care plan in

the relevant sections, Skin Integrity, Wounds.

c.  All  care  plans  are  evaluated  to  ensure  that  they  effectively  reflect  the
information  in  the  care  plan  has  been  reviewed.  This  is  completed
following  any  changes  or  monthly  as  part  of  Resident  of  the  Day
evaluation.

d.  The  recording of  repositioning  and  oversight  has  been  strengthened  has
been addressed by staff  utilising the full functionality of  the  Nourish Care
Planning system. This is set out in more detail below.

10.  We  have  a  robust  electronic  care  planning  system  that  when  staff  use  its  full
functionality it can effectively support staff  to provide prompts to staff  when care
interventions are due, ensure that time critical care interventions are' met, and alerts
are triggered to senior managers if  any care intervention is missed.  The system also
provides the NIC and RM with effective oversight of  care delivery staff  utilise the
full functionality of  Nourish and that the system is used consistently in accordance
with the Company procedures.  This includes;

a.  Each resident’s personalised interactions have been reviewed and set up on

Nourish to ensure they are reflective of  all their care needs.

b.  Personalised prompts are set on  the Nourish system to ensure that critical

interventions are met.

c.  For time critical interventions (for example repositioning) alarms are set to

alert the NIC  or RM if  the intervention has not  taken place.

d.  The  RM  and  CIM  have  oversight  of  the  Nourish  system  to  ensure  that
this  is  monitored

repositioning  has  been  completed  correctly  and 
throughout the day.

TEL: 0 1 1 5   929  4483 

(cid:127)  EMAIL:  INFO(*MULBERRYCOURTCAREHOME.COM 

'  WWW.MULBERRYCOURTCAREHOME.COM

61  DARNHALL CRESCENT  ■ BILBOROUGH  (cid:127)  N O T T I N G H A M   ’  N G 8   4 Q A

MULBERRY  COURT  CARE  H O M E   IS  A TRADING NAME  OF  MULBERRY' COURT  HEALTHCARE  L I M I T E D   COMPANY REGISTERED  IN  ENGLAND NO  09612462

 MULBER  RyfC  OURT
C  A R E   H O   M  E

e.  Any paper documents  that  are  required are evaluated and  uploaded on  to

Nourish into the relevant section of  the care plan.

f.  A  professionals  /  relatives  log  to  be  implemented  on  the  electronic  care

plan

g.  All information must  be documented on  Nourish. Any  paper  documents

that are required are evaluated and uploaded on  to Nourish.

All  staff  have  received  training  to  support  of  the  systems  and  process,  including  the
Nourish care planning system to ensure that have the skills and competence to follow the
Company’s  procedures.  Oversight is  maintained  through  the  Company’s  oversight  and
governance policies.

As stated above all actions have been completed.

The Coroner raised concerns that issues may recur in the future.  We wish to reassure the
Coroner that  the systems that  have been  put in  place since Mr  Nelson’s death are robust
and  the  Company is  fully committed  to  ensure  that  compliance  is  maintained. This  has
been verified by our external regulators.

External Assurance
We should also highlight that  the  CQC  carried out an  inspection on 17 and  18  February
2026.  Whilst  the  final  report  is  awaited  we  have  received  written  feedback, and  this  is
attached at Annex B.

The  CQC  reported that  they found  no serious issues or concern within  the service. With
regard  the  specific areas of  highlighted  by the  Coroner in  her  judgement,  (assessment of
risk continuity of  care, assessing need and managing risk including pressure areas, and care
recording) the CQC reported;

lnvo/i>ingpeop/e to manage risks
Risks were assessed and managed in line withpeople k needs, supported by training and monitoring systems.
Alerts and reviews helped ensure interventions were delivered as  planned, including  positional changes.

Safe systems,  pathways and transitions
Systems supported continuity of care and safe transitions, including timely referrals and information sharing
with  partners. Care  plans were reviewed  following hospital discharge and  processes were in place to share
information in the event of an emergency hospital admission.

Assessing needs
People k needs were assessed and reviewed using recognised tools, with
detailed and  personalised care  plans. Additional guidance supported staff  to
manage key risks including nutrition and hydration and skin damage.

TEL: 0115  929  4483  (cid:127) 

61  DARNHALL CRESCENT  (cid:127)  B1LBOROUGH  - N O T T I N G H A M  (cid:127)  N G 8   4QA
EMAIL: INFOtjiMULBERRYCOURTCAREHOME.COM  ■  WWW.MULBERRYCOURTCAREHOME.COM

MULBERRY COURT  CARE  HOME  IS  A TRADING NAME  OF  MULBERRY  COURT  HEALTHCARE  LIMITED  COMPANY REGISTERED  IN  ENGLAND NO  09612462

 MULBER RAI C O U R T
C A R E   H O M E

Delivering  evidence-based care duel  treatment
Care  was delivered in  line  with  best  practice, including  pressure  care and  nutrition. Monitoring supported
timely responses to changes in  health including weight loss.

Monitoring and improriw outcomes
Outcomes were monitored to identify risks and drive improvement. Staff responded positively to  professional
guidance.

Shared direction and  culture
Leaders  promoted a  clear vision and expectations. Staff  understood their roles and  responsibilities.

I  trust  that  this  report  demonstrates  the  Company  and  its  staff  have  undertaken  a  detailed
and  robust review of  systems and  process to  ensure that  the  issues the  Coroner  raised have
been  addressed  and  effective  measures  have  been  implemented  to  ensure  that  improved

ways  of  working are  sustained.

the  meantime,  should  you  require  any  further  information,  assistance  or  require

In 
discussing this  matter  further,  then  please don’t  hesitate to  contact  me  on 

YourssinceivTy?

Director

TEL: 0115  929  4483 

’  EMAIL: INFO@MULBERRYCOURTCAREHOME.COM 

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61  DARN HALL CRESCENT  (cid:127)  B1LBOROUGH  (cid:127)  NOTTINGHAM (cid:127)  N G 8   4)A

MULBERRY COURT  CARE  HOME  IS A TRADING  NAME  OF  MULBERRY COURT  HEALTHCARE  LIMITED  COMPANY REGISTERED  IN  ENGLAND NO.  09612462