Maureen Powell

Dear Coroner, We write in connection with the Regulation 28 report which was issued in connection with the Inquest into the death of Maureen Powell, who was a resident of Red Oaks Care Community (“the Home”). The Inquest into the death of Maureen Powell was held at Nottingham Coroner’s Court on 12 May and 10 June 2025. Prior to and during the course of the Inquest the Home provided evidence to assist your inquiry into the care arrangements in place for Maureen Powell whilst a resident at the Home, and the reflection which has taken place following Maureen’s death to further strengthen the Home’s existing procedures moving forward. A Regulation 28 Report was however issued on 11 June 2025 which raised concerns with regard the implementation of the Home’s systems and procedures for the delivery of pressure management care to residents, communications made to Maureen’s family and the CQC, and the investigation processes followed. It is relevant to explain at the outset that we have reflected seriously on the contents of your Report, and remain saddened that you considered this a necessary step despite the evidence given. Pressure Management The Report acknowledges that it was the Home’s policy to provide a high standard of care for residents at risk of pressure damage as well as those who had suffered pressure damage. It is also acknowledged that the Home had in place suitable equipment and caring regimes to reduce the risks of pressure damage worsening to heal damage which had occurred. It is however noted, and accepted, that these systems and procedure were not sufficiently implemented in practice on this occasion. The Home reflected significantly prior to the Inquest and had taken steps to strengthen the processes in place to ensure compliance against the systems and procedures in place. We do not seek to repeat the entirety of the evidence given below, but would draw attention to the following specific factors in respect of the measures in place for oversight of pressure management care:

 Care staff are required to complete SSKIN Inspections Records every 24 hours, with any concerns reported to the Registered Nurse on duty. The SSKIN Inspection Records are now in turn audited by management upon the generation of daily reports.  Weekly and monthly audits are conducted by management in relation to care records relating to residents’ pressure care and skin integrity, for the purpose of ensuring that all actions have been completed in a timely manner, any external professional input required has been sought accordingly, and that care plans and risk assessments have been reviewed and updated as appropriate.  An audit schedule is in place which captures all audits on a daily, weekly and monthly basis. Audits are completed across the different areas of the Home, to ensure that a ‘fresh eyes’ review of care delivery is completed. The Home Manager then completes a check of the audits which have taken place from a compliance perspective, before signing off against these.  All records, including for wound management, are now held electronically on the care system enabling increased oversight by the management team.  The mattress type to be supplied to a resident is determined following the consideration of a number of factors including an assessment of the resident’s weight, diet and fluid intake, mobility, skin integrity and capacity. Airflow mattresses are checked on a daily basis by the housekeeper to monitor that the correct mattress is in place, that it is functional and that it is set to the correct resident weight. These checks are again recorded on the care system to enable oversight of compliance against the procedure.  Following further reflection at the Inquest, a documented Skin Integrity Protocol has now been introduced, formalising the instructions which the nursing team and carers have received through their respective training and providing a single point of reference for them when escalating pressure concerns. The Protocol encompasses guidance on the importance of ensuring that next of kin are kept informed of developments, the requirements of the duty of candour and guidance on the delivery of this, amongst other relevant matters. More broadly, it was explained that a new Registered Manager was appointed to the home on 7 October 2024, with a new Deputy Manager having since also been introduced. The Registered

Manager now conducts daily walk arounds of the Home for the purpose of reviewing resident care and ensuring that the correct measures are in place. A Clinical Lead role has also separately been introduced to provide additional support with care planning, evaluations, audits and the provision of care to residents, amongst other matters. In addition, the Operations Manager conducts weekly unannounced visits to the Home to provide an additional level of oversight of compliance against the procedures in place. These are supplemented by additional focused visits for the purpose of assessing any areas of lessons learned across other services, with any learnings and remedial actions identified reported to the Registered Managers for dissemination to the staff employed at each home. Full compliance visits are separately undertaken on a quarterly basis, capturing all areas of the service. A Regional Manager has also now been employed to provide additional compliance support and oversight. Senior Management meetings are now held on a quarterly basis, and manager supervisions completed on a bi-monthly basis again providing an additional layer of oversight and management to the service and its management team. Additional Observations With regard the additional observations made at points 8 to 10 of the Report, we can advised as follows:  Point 8 – The Home has in place a documented policy concerning the requirement to undertake an internal investigation in relevant circumstances. All staff have received a copy of the policy and are familiar with the requirements of this to ensure that an investigation is undertaken in all circumstances that trigger this.  Point 9 - The Home utilises an electronic care record system where resident records are held. Electronic care records are now checked by the Registered Manager, Deputy Manager and Clinical Lead during each shift, for the purposes of ensuring that all relevant documentation and entries are in place for each resident. This is in addition to the daily walk around checks referred to above. Separately, such matters will be considered during the checks and audits undertaken by the Operations Manager, providing a secondary layer of oversight to monitor that the processes are being followed correctly.

 Point 10 – Previously it was the responsibility of the Home Manager, as the responsible person, to complete any necessary safeguarding or CQC notifications. Following the Inquest, this process has been amended to require that all serious injury notification reports must be sent to the Operations Manager for review prior to submission. Accordingly, significant steps have been taken by the Home to strengthen the systems and procedures in place to monitor the correct implementation of care arrangements for residents, which are considered to be appropriate in all the circumstances.