Inspire You Care Ltd
Other
Action Taken
Inspire You Care Ltd conducted an internal investigation, provided refresher training to staff on record keeping/communication and wound prevention, and will perform competency spot checks on staff. Staff have been informed that they must go through a refresher training programme around record keeping / communication training alongside also completing a training module in wound prevention. (AI summary)
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Investigation Report: Celia Marion Phillips
Date: 15th January 2026
Introduction
This document provides Inspire You Care Ltd.'s formal response to the Coroner’s report. Following receipt of the report, we undertook an immediate and thorough internal investigation to understand the concerns raised in the care provided to Celia Phillips. This report details our findings, and the comprehensive actions we are taking to prevent any recurrence of these concerns raised. We accept the coroner's findings and express our profound condolences and apologies to the family of Celia Phillips.
Below are the concerns that were raised and have been investigated. Thereafter actions will be set out by Inspire You Care Ltd.
1. Celia Phillips was bed bound. / On the 12th March 2025 the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day.
2. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
3. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
What measures have been taken to reduce risk in future and internal investigation
Inspire You Care Ltd - Management team opened an investigation upon receiving these concerns, this included meeting and speaking with the core staffing team that worked with CP in her last two weeks of receiving care. The below report outlines the summary findings of the investigation, staff responses, agreed actions, and learning outcomes.
1. Celia Phillips was bed bound. / On the 12th March 2025 the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day.
Concern Raised
The concern raised was that Celia was bed bound; this is a part of her care plan and the subsequent care that she would require.
Investigation – Fact Find:
− Carers informed the management team that they were aware Celia was bed bound as they read her care plan. Carers said they had the appropriate skills/training to support her whilst she was in bed. This includes the importance of repositioning her at an appropriate interval when they attended their care calls. They also understood that if there were any concerns around Celia skin then this should be immediately informed to the district nurses. − When staff were asked that it was not reported in the daily logs that Celia was repositioned, staff admitted that this was their failing part due to poor record keeping and not mentioning this important information in the daily notes.
Findings:
− There is some evidence of staff not understanding their role of caring for Celia whilst in bed as when asked to document how they cared for Celia they did not mention key information. − Staff do agree that they failed to include important information in their daily logs which could now be seen as they did not reposition Celia accordingly.
Agreed Actions:
− Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. − Staff will undergo refresher training on Record Keeping and Communication. − Staff will also undertake further training in Wound Prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. − Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.
2. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
Concern Raised:
In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
Staff Response:
− Staff stated that as mentioned before they did reposition Celia at all four daily visits as this would have to take place due to them having to complete personal care tasks for Celia at each visit.
− Staff were asked in the investigation if they understood the importance of repositioning and all the staff responded in the affirmative that yes, they understand with the primary concern being the development of pressure sores if repositioning does not take place. − Staff accepted that their record keeping had been poor and due to this it may appear that repositioning did not take place. Staff said in their written evidence also they detailed the care that Celia received but again they failed to be accurately detailed to also include information around repositioning Celia.
Findings: − Staff response clearly shows that they do understand the importance of repositioning service users who are bed bound as this will then reduce the likelihood of pressure sores developing. − Staff agree with their failing on not being detailed enough when making their daily records and when giving their written evidence for care provided to Celia.
Agreed Actions:
− Staff have been informed through the investigation that they must go through a refresher training programme around record keeping / communication training alongside also completing a training module in wound prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members.
3. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
Concern Raised:
Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
Staff Response:
− Staff stated that they mentioned the pressure sore to the family of Celia and also reported to the management team who subsequently reported this to the district nurse team. − Staff said they understand the importance of pressure sores and that they must be attended too and reported to the appropriate professionals.
Findings:
− Staff did understand the importance of pressure sores and that they must be reported to the appropriate professionals. − Staff through their written evidence did not mention repositioning Celia, which could make pressure sores worse.
Agreed Actions:
− Staff have been informed through the investigation that they must go through a refresher training programme around record keeping / communication training alongside also completing a training module in wound prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members
Conclusion
The concerns raised by the coroners report and, while concerning, have provided an opportunity to reflect on our practices and identify areas for learning and growth. By addressing these concerns with transparency, and a commitment to improvement, we can ensure that all our service users receive the highest standard of care. This investigation reaffirms our dedication to safeguarding the well-being of those we serve and upholding the values of trust, respect, and professionalism that define Inspire You Care Ltd.
Prepared by
Position: Nominated Individual Date: 15th January 2026
Date: 15th January 2026
Introduction
This document provides Inspire You Care Ltd.'s formal response to the Coroner’s report. Following receipt of the report, we undertook an immediate and thorough internal investigation to understand the concerns raised in the care provided to Celia Phillips. This report details our findings, and the comprehensive actions we are taking to prevent any recurrence of these concerns raised. We accept the coroner's findings and express our profound condolences and apologies to the family of Celia Phillips.
Below are the concerns that were raised and have been investigated. Thereafter actions will be set out by Inspire You Care Ltd.
1. Celia Phillips was bed bound. / On the 12th March 2025 the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day.
2. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
3. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
What measures have been taken to reduce risk in future and internal investigation
Inspire You Care Ltd - Management team opened an investigation upon receiving these concerns, this included meeting and speaking with the core staffing team that worked with CP in her last two weeks of receiving care. The below report outlines the summary findings of the investigation, staff responses, agreed actions, and learning outcomes.
1. Celia Phillips was bed bound. / On the 12th March 2025 the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day.
Concern Raised
The concern raised was that Celia was bed bound; this is a part of her care plan and the subsequent care that she would require.
Investigation – Fact Find:
− Carers informed the management team that they were aware Celia was bed bound as they read her care plan. Carers said they had the appropriate skills/training to support her whilst she was in bed. This includes the importance of repositioning her at an appropriate interval when they attended their care calls. They also understood that if there were any concerns around Celia skin then this should be immediately informed to the district nurses. − When staff were asked that it was not reported in the daily logs that Celia was repositioned, staff admitted that this was their failing part due to poor record keeping and not mentioning this important information in the daily notes.
Findings:
− There is some evidence of staff not understanding their role of caring for Celia whilst in bed as when asked to document how they cared for Celia they did not mention key information. − Staff do agree that they failed to include important information in their daily logs which could now be seen as they did not reposition Celia accordingly.
Agreed Actions:
− Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. − Staff will undergo refresher training on Record Keeping and Communication. − Staff will also undertake further training in Wound Prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. − Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.
2. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
Concern Raised:
In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning.
Staff Response:
− Staff stated that as mentioned before they did reposition Celia at all four daily visits as this would have to take place due to them having to complete personal care tasks for Celia at each visit.
− Staff were asked in the investigation if they understood the importance of repositioning and all the staff responded in the affirmative that yes, they understand with the primary concern being the development of pressure sores if repositioning does not take place. − Staff accepted that their record keeping had been poor and due to this it may appear that repositioning did not take place. Staff said in their written evidence also they detailed the care that Celia received but again they failed to be accurately detailed to also include information around repositioning Celia.
Findings: − Staff response clearly shows that they do understand the importance of repositioning service users who are bed bound as this will then reduce the likelihood of pressure sores developing. − Staff agree with their failing on not being detailed enough when making their daily records and when giving their written evidence for care provided to Celia.
Agreed Actions:
− Staff have been informed through the investigation that they must go through a refresher training programme around record keeping / communication training alongside also completing a training module in wound prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members.
3. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
Concern Raised:
Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore.
Staff Response:
− Staff stated that they mentioned the pressure sore to the family of Celia and also reported to the management team who subsequently reported this to the district nurse team. − Staff said they understand the importance of pressure sores and that they must be attended too and reported to the appropriate professionals.
Findings:
− Staff did understand the importance of pressure sores and that they must be reported to the appropriate professionals. − Staff through their written evidence did not mention repositioning Celia, which could make pressure sores worse.
Agreed Actions:
− Staff have been informed through the investigation that they must go through a refresher training programme around record keeping / communication training alongside also completing a training module in wound prevention. − These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members
Conclusion
The concerns raised by the coroners report and, while concerning, have provided an opportunity to reflect on our practices and identify areas for learning and growth. By addressing these concerns with transparency, and a commitment to improvement, we can ensure that all our service users receive the highest standard of care. This investigation reaffirms our dedication to safeguarding the well-being of those we serve and upholding the values of trust, respect, and professionalism that define Inspire You Care Ltd.
Prepared by
Position: Nominated Individual Date: 15th January 2026