Hill Care Group
Action Taken
Hill Care Group has changed the electronic platform to record staff training, adding an alert function and automated compliance reports for the Home Manager. They have also added additional checks to governance systems, and revised agency worker check process including skills and training. (AI summary)
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Dear Sir, Re Regulation 28 Report to Prevent Future Deaths In response to your report to prevent future deaths dated 29 July 2025 following the inquest of Joan Whitworth; please find below the actions taken in relation to the Matters of Concern:
1. Basic Life Support and First Aid at Work Concerns related to a Registered General Nurse and a Senior care Assistant not being in date with their training in Basic Life Support and First Aid at Work There was a further concern listed that meant it could not be confirmed ifan agency care worker was up to date with their training in these areas: Actions Taken: la. We have changed the electronic platform on which we record staff training since the death of Joan Whitworth in March 2023. new platform offers an additional function in that it will alert the staff member when training is due to expire, meaning timely reminders and arrangements for refresher training can take place: Further to this, an automated report has been scheduled for the Home Manager to receive a compliance report at the same time each week in order that are fully aware of training that is nearing expiry and can therefore remind staff to complete promptly. Status In place 1b. We have added additional checks to our governance systems meaning that Regional Managers will also check for compliance with mandatory training (that includes refresher training) as part of their role_ Status In place 1c: With regard to the agency care worker, we have reviewed the system by which we check the skills and training credentials of agency workers. Profiles for workers are now received and checked for each care worker prior to their shift; this now includes the training they have completed and the dates of completion Since the inquest, we have reiterated with our agency staff supplier the mandatory training that is required of their workers that this must be kept up to date_ Hill Care Holdings Limited Registered Office: 91-97 Saltergate. Chesterfield Derbyshire, S40 ILA. Registered in England 08902865 The they and
Status In place 1d. We have reissued Basic Life Support and IDDSI/Dysphagia training to all staff on the electronic system and have allocated a specific timeframe in which this training is to be completed. All staff will have completed face to face emergency first aid training by 14th October 2025_ Status In progress with a completion date of 14.10.2025 1e. We have developed and issued a competency assessment to check staff knowledge of IDDSI diets_ Status- In place and to be completed by all staff by 30.9.25
2. Training Concerns related to a Senior Care Assistant not being able to recall having received formal training in the preparation of care plans, no training on MUST or calculating BMI; was completing care plans and documents. A further concern was listed regarding identification of high risk on the Nutritional Risk Assessment on three prior dates with no referral made to the GP, dietician or consideration of referral to SALT, and that in the absence of training; there was not an understanding of the assessment. Actions Taken: Za. We can confirm that the Senior Care Assistant had received training as she had previously undertaken a week Care Home Assistant Practitioner (CHAP) course: However, we acknowledge that measures were not in place to verify knowledge, nor was a schedule of refresher training in place to ensure she felt confident to carry out assessments and develop care plans. As a result of this, we have reviewed the content of the training that we deliver and have a plan for our internal quality improvement team to deliver training on assessments to nurses and senior care assistants as refresher to build this into our training programme to be repeated on a 3 year cycle: We will monitor this schedule using our electronic training platform. Status In progress. Deadline for completion 31.10.2025
3. Agency Staff Induction Concerns are raised that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord: The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. There is a further concern that it could not be confirmed if the agency staff had undergone an induction_ Actions taken: 3a. We have reviewed the induction forms for all agency roles that we use in our homes to ensure that they capture information that allows us to see that agency care assistants have up-to-date first aid training: For agency senior care assistants and nurses we have modified our form to ensure we check that mandatory training is in place and in date, and that residents modified diets are discussed and the worker is aware of IDDSI and nutritional report that is reviewed daily. Hill Care Holdings Limited Registered Oiice: 91-97 Saltergale. Cheslerfield , Derbyshire. 540 ILA Registered in England 08902865 yet 12 and the
Status In place. New forms implemented on 11.9.25 Normal Diet IDDSI L7 easy chew and to avoid difficult textures Concerns were noted that a chef in evidence at the inquest was not aware that breaded fish was not suitable food stuff in the diet identified for the deceased A further concern is identified in that other residents could be fed inappropriate food stuffs that are not in line with their identified diet plans: Actions taken: 4a. A specialist IDDSI training provider has been sourced and face to face training in preparation of modified foods is being delivered to all Hill Care Cooks and Chefs between the dates 13 September 2025 and 22 October 2025. This training will give chefs and cooks the opportunity to practically prepare meals of different consistencies and further their knowledge regarding appropriate and inappropriate foods for specific IDDSI level diets. The chef and cook at The Oaks attend on September and 24th September 2025_ 4b. We have developed and introduced a competency assessment to all members ofthe catering team: Status Completed 4c. We have introduced a reference sheet which highlights every residents' IDDSI level and additional nutritional needs which is available to all staff on each serving trolley: This form is reviewed at the daily 'flash' meeting to ensure that changes in need are documented without delay: Status Completed 4d. Following the death of Mrs Whitworth, we introduced a safety pause before meal times. This consists of the senior person on duty confirming that the team within the dining room are aware of any special diets and that the kitchen have provided the correct diet: The Regional Managers observe this to monitor practice when the visit the home__ Status Completed We trust that these measures are sufficient to satisfy your concerns_
1. Basic Life Support and First Aid at Work Concerns related to a Registered General Nurse and a Senior care Assistant not being in date with their training in Basic Life Support and First Aid at Work There was a further concern listed that meant it could not be confirmed ifan agency care worker was up to date with their training in these areas: Actions Taken: la. We have changed the electronic platform on which we record staff training since the death of Joan Whitworth in March 2023. new platform offers an additional function in that it will alert the staff member when training is due to expire, meaning timely reminders and arrangements for refresher training can take place: Further to this, an automated report has been scheduled for the Home Manager to receive a compliance report at the same time each week in order that are fully aware of training that is nearing expiry and can therefore remind staff to complete promptly. Status In place 1b. We have added additional checks to our governance systems meaning that Regional Managers will also check for compliance with mandatory training (that includes refresher training) as part of their role_ Status In place 1c: With regard to the agency care worker, we have reviewed the system by which we check the skills and training credentials of agency workers. Profiles for workers are now received and checked for each care worker prior to their shift; this now includes the training they have completed and the dates of completion Since the inquest, we have reiterated with our agency staff supplier the mandatory training that is required of their workers that this must be kept up to date_ Hill Care Holdings Limited Registered Office: 91-97 Saltergate. Chesterfield Derbyshire, S40 ILA. Registered in England 08902865 The they and
Status In place 1d. We have reissued Basic Life Support and IDDSI/Dysphagia training to all staff on the electronic system and have allocated a specific timeframe in which this training is to be completed. All staff will have completed face to face emergency first aid training by 14th October 2025_ Status In progress with a completion date of 14.10.2025 1e. We have developed and issued a competency assessment to check staff knowledge of IDDSI diets_ Status- In place and to be completed by all staff by 30.9.25
2. Training Concerns related to a Senior Care Assistant not being able to recall having received formal training in the preparation of care plans, no training on MUST or calculating BMI; was completing care plans and documents. A further concern was listed regarding identification of high risk on the Nutritional Risk Assessment on three prior dates with no referral made to the GP, dietician or consideration of referral to SALT, and that in the absence of training; there was not an understanding of the assessment. Actions Taken: Za. We can confirm that the Senior Care Assistant had received training as she had previously undertaken a week Care Home Assistant Practitioner (CHAP) course: However, we acknowledge that measures were not in place to verify knowledge, nor was a schedule of refresher training in place to ensure she felt confident to carry out assessments and develop care plans. As a result of this, we have reviewed the content of the training that we deliver and have a plan for our internal quality improvement team to deliver training on assessments to nurses and senior care assistants as refresher to build this into our training programme to be repeated on a 3 year cycle: We will monitor this schedule using our electronic training platform. Status In progress. Deadline for completion 31.10.2025
3. Agency Staff Induction Concerns are raised that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord: The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. There is a further concern that it could not be confirmed if the agency staff had undergone an induction_ Actions taken: 3a. We have reviewed the induction forms for all agency roles that we use in our homes to ensure that they capture information that allows us to see that agency care assistants have up-to-date first aid training: For agency senior care assistants and nurses we have modified our form to ensure we check that mandatory training is in place and in date, and that residents modified diets are discussed and the worker is aware of IDDSI and nutritional report that is reviewed daily. Hill Care Holdings Limited Registered Oiice: 91-97 Saltergale. Cheslerfield , Derbyshire. 540 ILA Registered in England 08902865 yet 12 and the
Status In place. New forms implemented on 11.9.25 Normal Diet IDDSI L7 easy chew and to avoid difficult textures Concerns were noted that a chef in evidence at the inquest was not aware that breaded fish was not suitable food stuff in the diet identified for the deceased A further concern is identified in that other residents could be fed inappropriate food stuffs that are not in line with their identified diet plans: Actions taken: 4a. A specialist IDDSI training provider has been sourced and face to face training in preparation of modified foods is being delivered to all Hill Care Cooks and Chefs between the dates 13 September 2025 and 22 October 2025. This training will give chefs and cooks the opportunity to practically prepare meals of different consistencies and further their knowledge regarding appropriate and inappropriate foods for specific IDDSI level diets. The chef and cook at The Oaks attend on September and 24th September 2025_ 4b. We have developed and introduced a competency assessment to all members ofthe catering team: Status Completed 4c. We have introduced a reference sheet which highlights every residents' IDDSI level and additional nutritional needs which is available to all staff on each serving trolley: This form is reviewed at the daily 'flash' meeting to ensure that changes in need are documented without delay: Status Completed 4d. Following the death of Mrs Whitworth, we introduced a safety pause before meal times. This consists of the senior person on duty confirming that the team within the dining room are aware of any special diets and that the kitchen have provided the correct diet: The Regional Managers observe this to monitor practice when the visit the home__ Status Completed We trust that these measures are sufficient to satisfy your concerns_