Susan Dale

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

Sally Robinson  
HM Assistant Coroner 
Coroner's Court 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

18 August 2026                           

Dear HM Assistant Coroner Sally Robinson,  

Prevention of future death report following inquest into the death of Susan 
Dale 

Thank you for sending the Care Quality Commission (CQC) a copy of the prevention 
of future deaths report issued following the sad death of Susan Dale.   

We note the legal requirement upon CQC to respond to your report within 56 days, 
by 21 August 2026.   

The registered provider of Westfield Residential Home is Westfield Residential Home 
Ltd. They have been registered with CQC since 7 January 2011. 

The provider’s location Westfield Residential Home is located at 16 Carr Lane, 
Willerby, Hull, HU19 6JW. The provider is registered for the following regulated 
activity: ‘Accommodation for persons who require nursing or personal care’. The 
provider is not permitted to provide nursing care at this location.   

 
 
 
 
 
 
 
 
 
 
    
 
 
  
  
  
 Background   

On 20 April 2026, 
 the registered manager of Westfield Residential 
Home, submitted a statutory notification to CQC informing us of the death of Susan 
Dale, who was using the service. The notification did not include any information 
about previous falls or any involvement from the coroner.  

Following receipt of the Regulation 28 Report, CQC have initiated a review of this 
incident in line with our specific incident guidance. CQC also conducted an 
unannounced inspection of Westfield Residential Home on 21 July 2026. The 
matters of concern highlighted in the Regulation 28 Report helped to inform our 
inspection activity and ensure there was a particular focus on record keeping, safe 
management of falls and handover processes.   

Matters of concern   

CQC assess Registered Persons against the regulatory framework relevant to the 
service provided, as well as accepted best practice and relevant national policies. It 
is not for CQC to instruct how a Registered Provider meets the standards required, 
but to assess whether the relevant standards are being met as expected and take 
appropriate action for any identified failures. Therefore, CQC cannot speak directly to 
the matters of concern raised outside of our role as a regulator and our assessment 
of the Registered Provider during our unannounced inspection.  

In respect of the matters of concern as they relate to the care provided to Susan 
Dale, further assessment is ongoing as part of our specific incident process in order 
to determine whether any relevant breaches have occurred and whether any criminal 
enforcement action should be considered as a result.  

During our unannounced inspection, in respect of any ongoing risk posed to service 
users, CQC did not identify any issues relating to the matters of concern raised that 
would require any regulatory action.    

1.  The record keeping in the home appears to be inaccurate and 

inconsistent. 

Susan Dale’s care records will be reviewed as part of our specific incident 
process to determine whether there are any regulatory breaches in respect of 
record keeping, and if so, what potential impact such breaches may have had 
in order to determine whether criminal enforcement action should be 
considered.  

During our recent inspection of the service last month, we reviewed record 
keeping in overarching general terms. Evidence available and gathered did 
not demonstrate poor record keeping overall, however, it is important to note 
that CQC’s inspection methodology follows a sampling approach, and 
therefore this does not mean there were not some shortfalls in some records.  

 
 
 
 
 
 
 
 
 
 
 
 CQC contacted the provider, as the registered provider of Westfield 
Residential Home, to seek assurances regarding the actions taken in 
response to receiving the Regulation 28 letter, including the steps they had 
taken regarding inaccurate and inconsistent record keeping. 

The provider advised that they have moved to a new electronic care planning 
system, which includes integrated accident and incident forms. They stated 
this system supports staff to record accidents and incidents more clearly and 
consistently. 

2.  The falls policy of the home states that there are number of scenarios to 

consider before lifting a resident for the floor and states that the 
resident should not be moved until clinical assistance arrive.  One such 
situation is if head, neck, back or hip injury is suspected. The incident 
log on advanced care cloud states there was a head injury, yet Mrs Dale 
was moved and no clinician saw her until she worsened and an 
ambulance was called. Inaccuracies in reporting can lead to missed 
opportunities to provide care and inaccurate time recording of incidents 
can lead to the accurate appraisal of the developing clinic picture being 
made more difficult which in turn would lead to a delay in medical 
assistance being sought. This could lead to resident safety being 
compromised and deaths occurring.  

The management of Susan Dale’s fall will be assessed in line with CQC’s 
specific incident guidance.  

In relation to our recent inspection of the service last month, we reviewed falls 
management as part of our assessment of whether the service was providing 
safe care and treatment to all who use the service. Evidence available and 
gathered in respect of this identified no concerns with the management of 
falls.  

CQC contacted the provider, as the registered provider of Westfield 
Residential Home, to seek assurances regarding the actions taken in 
response to receiving the Regulation 28 letter, including the measures 
implemented to prevent a similar incident from occurring in the future. 

The provider advised that a staff meeting had been held to discuss the 
lessons learned. They stated that during the meeting, staff were introduced to 
the Falls and Accident Guidance that had been developed to provide a clear 
procedure for responding to accidents or incidents. The provider also 
confirmed that the falls policy and associated procedures were discussed with 
staff. 

3.  The senior care worker who came on shift later that day said she did not 
receive any hand over from the staff going off shift. This is a concern as 
observations need to be carried out when someone has fallen and 
banged their head and a handover would detail such incidents and 
whether there are any concerns with residents. 

 
 
 
 
 
 
 
 
 The management of Susan Dale’s fall will be assessed in line with CQC’s 
specific incident guidance.  

In relation to our recent inspection of the service last month, we reviewed 
handover processes as part of our assessment of whether the service was 
providing safe care and treatment to all who use the service. Evidence 
available and gathered in relation to handover processes between staff did 
not identify any concerns. 

CQC contacted the provider, as the registered provider of Westfield 
Residential Home, to seek assurances regarding the actions taken in 
response to receiving the Regulation 28 letter, including the measures 
implemented to ensure effective communication and handover of information 
between shifts. 

The provider advised that the new electronic care planning system also has 
an inbuilt handover function, which staff are able to read and verbally discuss 
at the beginning of each shift. A file for senior carers has also been 
implemented and is being updated as an ongoing resource. They informed us 
this contains master copies of relevant documents and guidance tools to 
support senior carers in their role. 

The provider also advised that 24/7 on-call support is available to staff, who 
are aware that they can seek advice at any time, day or night. They advised a 
further senior carers’ meeting has been planned for September, to continue to 
embed knowledge and good practice. 

Thank you for drawing our attention to this matter and sharing this important 
information with us.  

Please do not hesitate to contact us via our customer contact centre on 03000 61 61 
61 if you have any further queries.  

If you do contact us, please quote CQC reference 

Yours sincerely,  

Deputy Director of Adult Social Care  
Care Quality Commission 
North East Area, 
North Region,

Response to Regulation 28 Report – Susan Dale
1. Documentation and Governance

As part of the Home’s ongoing commitment to continuous quality improvement, a new
electronic care management system has recently been introduced to replace the previous record-
keeping platform. Staff training is currently being delivered as part of the phased implementation
to ensure all staff are confident and competent in using the new system.

The platform incorporates integrated accident and incident reporting, body maps and observation
charts, providing a streamlined and consistent approach to recording and reviewing incidents.
This system ensures time stamped and consistent logs are made which are then reviewed by
management for further action before they can be signed off. Furthermore, all seniors have
been instructed to use the ‘witness’ portions of these forms to ensure two members of staff
are logging one accident at the same time to ensure consistency.

The incident reporting process now incorporates a structured three-stage workflow:

 The attending care staff member records the initial details of the incident.
 The senior member of staff reviews the information, completes any additional

documentation required and authorises the record.

 The incident is then electronically escalated to management for review, oversight and

confirmation that any appropriate follow-up actions have been considered.

In addition, monthly governance audits of all accident and incident records have been
incorporated within the new system. These audits provide ongoing oversight of documentation,
support continuous monitoring of practice and assist in identifying further opportunities for staff
development and service improvement.

2. Reinforcement of Training and Professional Development

The Home recognises the importance of continually strengthening staff knowledge and
maintaining a consistent approach to the assessment and management of incidents.

To support this commitment, additional training and educational sessions are being delivered to
reinforce existing policies and procedures relating to witnessed falls, unwitnessed falls and
situations where a resident has sustained an injury or is unable to explain what has occurred.

A dedicated staff meeting and practical learning workshop has been scheduled for 9 July 2026,
during which staff will revisit the home’s procedures for assessment, observation, escalation and
documentation. The session will further reinforce the circumstances in which advice should be
sought from NHS 111 or emergency services, ensuring staff remain confident in recognising
when urgent clinical assessment may be appropriate.

 As part of this programme, all staff will receive comprehensive guidance notes covering:

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the assessment of residents following falls or suspected injuries;
circumstances where residents should not be moved, including where head, neck, spinal,
pelvic or hip injuries are suspected;
indicators requiring immediate escalation to emergency services;
post-incident observations and ongoing monitoring;
documentation standards; and
internal reporting and management escalation procedures.

These sessions form part of the Home’s wider programme of continuous professional
development and are intended to further enhance staff knowledge, promote consistency of
practice and support the delivery of safe, person-centred care.

3. Reflective Supervision

Reflective supervision sessions have commenced for the staff members involved in the incident,
beginning on 29 June 2026.

These sessions are being undertaken as part of the Home’s routine commitment to professional
development and reflective practice. They provide an opportunity to reinforce existing policies
and procedures, discuss learning points, identify any additional training requirements and
support continued professional growth.

The Home remains committed to maintaining high standards of care through ongoing education,
regular competency assessments, robust governance processes and continual review of practice
to ensure learning and development remain embedded throughout the service.

4. Documentation Updates

Policies of the month at Westfield are now already in circulation in which an emphasized and
updated Falls policy will also be given to any existing and any new staff.  A system of Resident
of the Day has also already commenced which demonstrates:

care plans reviewed
risk assessments reviewed

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 mobility checked
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falls risk updated
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documentation audited

A new structured handover process is now replacing the old paperback diary format at Westfield
ensuring all members of staff can access the same information readily, to ensure all staff are well
educated on each residents health.

Westfield Residential Home recognizes the importance of continuous quality
improvement and will continue to monitor the effectiveness of these measures
through regular audits, competency assessments, governance meetings, and

 management oversight to ensure they remain effective and responsive to
residents' needs.