Mi Homecare
Action Planned
MiHomecare is updating its training on choking/aspiration risks, to be released by the end of July, including a "Talking Head" discussion and updated prompt card via their new CCH Connect app. They are also reviewing care planning tools to specifically reference aspiration risks. (AI summary)
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Dear Assistant Coroner Lee Report for the Prevention of Future Deaths following the Inquest into the death of Angela Carpos
1. I am the Chief Executive Officer of City & County Healthcare Group (“CCH Group”), the parent company of MiHomecare Limited (“MiHomecare”). I am writing to you on behalf of MiHomecare further to the Inquest into the death of Angela Carpos and the Report for the Prevention of Future Deaths dated 22 April 2024.
2. The training, supervision and guidance provided to care workers
2.1. CCH Group has a dedicated Learning and Development team that is overseen by our Chief of Quality, (Registered Nurse). The role of the Learning and Development team is to design and draw up the training delivered to staff members, and to then organise, facilitate and deliver this.
2.2. The Learning and Development team consists of the following roles to ensure that learning materials are up to date, follow best practice and are delivered to our teams through blended e-learning and face to face workshops.
2.2.1. 3 Learning Content specialists – who are responsible for the design and implementation of learning materials. They are managed by an experienced Head of Quality, who is also a Registered Nurse, , and supported by experts in digital learning program design. Since January 2024, this team now sits as a part of the CCH Group Quality Team. This structural change means that there is close collaboration with our learning content that is not only operationally but clinically led.
Additionally, we have restructured our Best Practice Forum, and since March 2024, this is now led by an experienced Head of Quality, Craig McCall. This Forum undertakes best practice reviews from all areas of our organisation to ensure that we review serious incidents and trends and take action to learn from these incidents or trends. This includes reviews of policy, ways of working, improvements to documentation or systems and training initiatives. Nicola Brown sits as a standing participant in these reviews to ensure that any learning from the Forum / reviews is reflected in / used to enhance training for our teams.
2.2.2. 3 Regional Training Managers – who manage the timetables and ensure that training is delivered.
2.2.3. 26 Trainers – who work regionally to deliver practical and face to face training locally to our teams. This team is overseen by , Chief of Staff.
2.3. All of our trainers are experienced in social care and as a minimum hold a train the trainer qualification and an approved first aid and manual handling training qualification. Many of them hold much higher-level qualifications in training, including Level 3, 4 or 5 training or social care specific training qualifications. Some have relevant post graduate qualifications also.
2.4. When new care workers join MiHomecare or other companies that are part of CCH Group they receive induction training. This training is delivered through a blended approach with e-learning modules and practical workshops. This induction training covers all aspects of the Care Certificate1 and includes the core capabilities training for people with learning disability and Autistic people (Oliver McGowan Mandatory Training Level 1). There are practical workshops covering first aid, moving and handling and medication.
2.5. In terms of refresher training, our revised Care Professional Development training (CPD training) has just been launched. This annual update training has been redesigned and now includes relevant updates alongside scenarios to enhance understanding around the impact and consequences of decisions made by our care staff. It looks to expand knowledge as our care workers progress and to bring our training to life, linking these to outcomes for people under our care. This is an online modular course covering the following topics: Health and Safety; First Aid Awareness (which covers choking and aspiration); Moving and Assisting; Infection Prevention and control; Food Safety; Medication administration; Handling Information (GDPR); Record Keeping and internal communications; and Dementia Awareness.
1 Developed by Skills for Care, Health Education England and Skills for Health, the Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. The Care Certificate is made up of the 15 minimum standards that should be covered if you are 'new to care'. The Care Certificate Standards include: Understand your role; Your Personal Development; Duty of Care; Equality and Diversity; Work in a person centred way; Communication; Dignity and privacy; Fluids and nutrition; Awareness of mental health, dementia and learning disability; Safeguarding Adults; Safeguarding Children; Basic Life Support; Health and Safety; Handling information; and Infection prevention and control.
2.6. Care workers receive supervisions at their relevant Branch Office every 3 months. We have a specific type of supervision called a themed supervision – one of the available themed supervisions covers choking (and is in the process of being updated to cover aspiration / aspiration pneumonia – see paragraph 4.4.1). In a themed supervision, there will be scenarios that care workers need to answer and then Branch Office staff will discuss the answers with them. Staff can raise their concerns regarding a client in the supervision as well. They will be provided with clear and accurate guidance.
2.7. Care workers are also subject to competency assessments every 6 months. These are completed in a client’s home and we will observe care tasks to ensure these are completed as expected and check care workers’ knowledge by asking questions.
2.8. We also have a suite of flash cards, posters and guidance available for staff. This ensures all the relevant guidance is available for staff if they are in any doubt or just want to know further details. The documents / information are available on employees’ work issued mobile phones. Posters are very useful as they are in the Branch Offices and staff when visiting can review these. We encourage staff to read all the guidance available on their phones and at the Branch Offices. These additional guidance notes and mechanisms are in place to support best practice and organisational learning, highlighting current trends in service delivery where there are concerns, or indeed any learning from a single event.
2.9. All of our operational teams (including Branch Managers and Regional Managers), as part of orientation and onboarding, are taken through key policies and operational guides, located on the CCH Group intranet. They are also made aware of the Intranet and how to navigate and search for information. They are supported through their orientation with a blended approach with eLearning modules, face to face mentoring and support and additional coaching by our central support teams. Mentoring and support also includes one to one support on where to find and how to use the systems we operate.
2.10. We have recently launched a new CCH Group app – called CCH Connect. Operational and care staff have instant access to key policies through this app. We believe this innovation will give our teams better visibility and in particular, it gives another platform in which to reach out to the teams and keep them informed of organisational learning, policies, procedures, and resources.
2.11. All Branches that are part of CCH Group will be subject to the governance review program conducted by our Quality team. Whilst this covers a broad spectrum of areas, relevant to this Inquest it will ensure and check CCH Group’s expectations surrounding training, supervision and guidance are met and maintained. Where
issues are identified, improvement support plans are put in place for the relevant branch and action take to track and monitor the completion of those plans.
3. The role of care workers – choking and aspiration
3.1. We considered that it would be helpful to set out the care and support MiHomecare provides and the expectations of care workers in respect of medical concerns / responding to medical incidents (including those related to choking and aspiration).
3.2. MiHomecare is a homecare provider that provides care and support to people within their own homes in the community. The care and support MiHomecare provides to individuals is varied and will depend on the package of care commissioned, usually, by the local authority. Care and support tasks completed by MiHomecare care workers can include assistance with personal care (for example, assistance with washing, dressing and toileting), assistance with administering medication, assistance with meal preparation, and support with shopping and domestic activities (such as hoovering). MiHomecare does not provide nursing care and whilst care workers receive basic first aid training, they are not trained medical professionals.
3.3. The first aid induction training currently received by care workers covers the following topics (please see paragraph 4.3 that discusses the updates that have been made to this training).
3.3.1. The principles and purpose of first aid and basic life support;
3.3.2. Understand and demonstrate the primary survey (DRABC);
3.3.3. Managing an unconscious casualty (how and when to seek help);
3.3.4. Demonstrate the recovery position (including knowledge on recovery position for potential spinal injury);
3.3.5. Understand and demonstrate CPR and the use of an AED (including knowledge around a DNACPR);
3.3.6. Understand what is choking and what is aspiration, the similarities and differences between the two conditions;
3.3.7. How to recognise when a person is choking;
3.3.8. How to recognise when a person is aspirating or at risk of aspiration (including the risk of developing aspiration pneumonia);
3.3.9. Understand and demonstrate emergency actions for a choking casualty (adult and child);
3.3.10. Understand what actions to take when a person is aspirating; and
3.3.11. How to recognise and deal with sudden illness and serious injury.
3.4. The fundamental message care workers receive from their training is that if they have any concerns about an individual’s health and wellbeing these should be escalated as appropriate – e.g., to the Branch Office, the GP, the District Nurses,
111 and / or 999 depending on the concern and the urgency. Where care workers are escalating to a medical professional (e.g., a GP or a 111 / 999 call handler), they are instructed that they should follow any guidance and instructions provided by the professionals.
3.5. Choking occurs when there is an obstruction in the windpipe causing difficulty breathing. This obstruction could be something solid such as food or a foreign object. Often, when an individual is choking, they will show outward signs such as coughing, gasping, and touching their throat. If care workers consider that an individual is choking, they are trained to follow a set emergency procedure that can be seen on the prompt card at Appendix 1.
3.6. Aspiration is when a person inhales something into their airway that enters their lungs. In a fit and healthy person, the foreign substance irritates the airways and triggers coughing and the foreign substance will likely be ejected. In someone who is frail or elderly they may not notice the particles (or liquid etc.) going in and not feel the irritation and so they may not cough it out or be able to do this. As the substance inhaled by aspiration is not sterile, when it stays in the lungs it can cause infection – this can cause aspiration pneumonia.
3.7. When a person has a known risk of aspiration (e.g., sometimes individuals living with dementia have increased risks), there are precautions that can be taken to make it less likely (e.g., ensuring the individual is sat up straight to eat, prompting them to eat slowly). Notwithstanding this, it will not always be obvious that an individual has aspirated something into their airway. Whilst we would expect care workers to be able to identify the potential signs of aspiration, the key action we would expect them to take if they had any concerns about an individual’s presentation or condition, would be to escalate for medical support, which in an emergency situation, would involve calling 999 for assistance, giving the call handler all relevant information and following any instructions given.
4. Actions taken in respect of choking and aspiration
4.1. Prior to the Inquest into the death of Angela Carpos in December 2023, the Finchley Camden Branch of MiHomecare (the Branch from which Ms Carpos received care) had taken a number of actions relevant to the issues surrounding Ms Carpos’ death. The two care workers on shift with Ms Carpos on the evening of 25 December 2022 completed themed choking supervisions, and the Branch Manager also included reference to the expectations surrounding choking within the branch newsletter and sent a specific email to care workers with relevant information and a flashcard on choking.
4.2. More widely across CCH Group, the expectations in respect of choking, aspiration and swallowing difficulties were and are regularly included in bulletins that are sent to / shared with both operational teams and care staff. We currently use a number of different mechanisms to deliver bulletins – for example, emails to care and operational staff, team meetings and through our new CCH Connect app (discussed above at paragraph 2.10 and at paragraph 4.4.3).
4.3. CCH Group had also updated its induction and refresher training from October 2022 (starting with the induction training and then moving to the refresher training) to include more detail on choking and aspiration. This version of the training was completed by the two care workers on shift on the evening on 25 December 2022, in June and August 2023. Our training on choking and aspiration has since been further updated and launched to include additional clarity around aspiration (again, starting with the induction training and then moving to the refresher training, the updated version of which is due to go live this week). I have appended a printout of the materials from the most recently updated [induction / refresher] training at Appendix 2 to demonstrate the topics covered.
4.4. In addition, following the Inquest in December 2023 and after reflecting on the Report for the Prevention of Future Deaths, MiHomecare and CCH Group has made, and will make the following changes:
4.4.1. CCH Group’s Best Practice Forum has considered the circumstances surrounding Ms Carpos’ death as part of a serious incident review. A number of actions have been prompted by this review. For example, the themed supervision relating to choking (see paragraph 2.6) is being updated to include more detail on aspiration / aspiration pneumonia and the updated version is due to be released by the end of July. In addition, there is also a campaign initiative that has been created to highlight both choking risks and management alongside aspiration and the differences in presentation. This initiative is expected to be launched prior to the end of June 2024 and will be included on our new CCH Connect app as a ‘’Talking Head’ discussion, along with an updated prompt card for all staff. Please see the latest version of this updated prompt card at Appendix 1. Staff will be encouraged to review the initiative / prompt card via notifications in the app, and Branch Offices will be informed to tell staff about the initiative / card in team meetings.
4.4.2. Our care planning tools are also being reviewed and as a part of this extensive project, the risk management around difficulties with eating and drinking (and hence the risks surrounding aspiration) will be considered. This project is still ongoing (expected to be concluded before the end of summer), but it is expected that one of the amendments made will be to ensure the tools include particular reference to aspiration rather than just swallowing difficulties more generally.
4.4.3. As stated earlier we have our new CCH Connect app. This has just launched and gives us the opportunity to connect with our teams instantly and to highlight policy changes, learning initiatives and other group news. We have talked about some of the specific benefits / uses of this app above in this letter.
5. I would like to take this opportunity to express my sincere condolences to Ms Carpos’ family and friends. I understand she was very well regarded by those who cared for her and will be missed.
6. Please do not hesitate to contact me should you have any questions.
1. I am the Chief Executive Officer of City & County Healthcare Group (“CCH Group”), the parent company of MiHomecare Limited (“MiHomecare”). I am writing to you on behalf of MiHomecare further to the Inquest into the death of Angela Carpos and the Report for the Prevention of Future Deaths dated 22 April 2024.
2. The training, supervision and guidance provided to care workers
2.1. CCH Group has a dedicated Learning and Development team that is overseen by our Chief of Quality, (Registered Nurse). The role of the Learning and Development team is to design and draw up the training delivered to staff members, and to then organise, facilitate and deliver this.
2.2. The Learning and Development team consists of the following roles to ensure that learning materials are up to date, follow best practice and are delivered to our teams through blended e-learning and face to face workshops.
2.2.1. 3 Learning Content specialists – who are responsible for the design and implementation of learning materials. They are managed by an experienced Head of Quality, who is also a Registered Nurse, , and supported by experts in digital learning program design. Since January 2024, this team now sits as a part of the CCH Group Quality Team. This structural change means that there is close collaboration with our learning content that is not only operationally but clinically led.
Additionally, we have restructured our Best Practice Forum, and since March 2024, this is now led by an experienced Head of Quality, Craig McCall. This Forum undertakes best practice reviews from all areas of our organisation to ensure that we review serious incidents and trends and take action to learn from these incidents or trends. This includes reviews of policy, ways of working, improvements to documentation or systems and training initiatives. Nicola Brown sits as a standing participant in these reviews to ensure that any learning from the Forum / reviews is reflected in / used to enhance training for our teams.
2.2.2. 3 Regional Training Managers – who manage the timetables and ensure that training is delivered.
2.2.3. 26 Trainers – who work regionally to deliver practical and face to face training locally to our teams. This team is overseen by , Chief of Staff.
2.3. All of our trainers are experienced in social care and as a minimum hold a train the trainer qualification and an approved first aid and manual handling training qualification. Many of them hold much higher-level qualifications in training, including Level 3, 4 or 5 training or social care specific training qualifications. Some have relevant post graduate qualifications also.
2.4. When new care workers join MiHomecare or other companies that are part of CCH Group they receive induction training. This training is delivered through a blended approach with e-learning modules and practical workshops. This induction training covers all aspects of the Care Certificate1 and includes the core capabilities training for people with learning disability and Autistic people (Oliver McGowan Mandatory Training Level 1). There are practical workshops covering first aid, moving and handling and medication.
2.5. In terms of refresher training, our revised Care Professional Development training (CPD training) has just been launched. This annual update training has been redesigned and now includes relevant updates alongside scenarios to enhance understanding around the impact and consequences of decisions made by our care staff. It looks to expand knowledge as our care workers progress and to bring our training to life, linking these to outcomes for people under our care. This is an online modular course covering the following topics: Health and Safety; First Aid Awareness (which covers choking and aspiration); Moving and Assisting; Infection Prevention and control; Food Safety; Medication administration; Handling Information (GDPR); Record Keeping and internal communications; and Dementia Awareness.
1 Developed by Skills for Care, Health Education England and Skills for Health, the Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. The Care Certificate is made up of the 15 minimum standards that should be covered if you are 'new to care'. The Care Certificate Standards include: Understand your role; Your Personal Development; Duty of Care; Equality and Diversity; Work in a person centred way; Communication; Dignity and privacy; Fluids and nutrition; Awareness of mental health, dementia and learning disability; Safeguarding Adults; Safeguarding Children; Basic Life Support; Health and Safety; Handling information; and Infection prevention and control.
2.6. Care workers receive supervisions at their relevant Branch Office every 3 months. We have a specific type of supervision called a themed supervision – one of the available themed supervisions covers choking (and is in the process of being updated to cover aspiration / aspiration pneumonia – see paragraph 4.4.1). In a themed supervision, there will be scenarios that care workers need to answer and then Branch Office staff will discuss the answers with them. Staff can raise their concerns regarding a client in the supervision as well. They will be provided with clear and accurate guidance.
2.7. Care workers are also subject to competency assessments every 6 months. These are completed in a client’s home and we will observe care tasks to ensure these are completed as expected and check care workers’ knowledge by asking questions.
2.8. We also have a suite of flash cards, posters and guidance available for staff. This ensures all the relevant guidance is available for staff if they are in any doubt or just want to know further details. The documents / information are available on employees’ work issued mobile phones. Posters are very useful as they are in the Branch Offices and staff when visiting can review these. We encourage staff to read all the guidance available on their phones and at the Branch Offices. These additional guidance notes and mechanisms are in place to support best practice and organisational learning, highlighting current trends in service delivery where there are concerns, or indeed any learning from a single event.
2.9. All of our operational teams (including Branch Managers and Regional Managers), as part of orientation and onboarding, are taken through key policies and operational guides, located on the CCH Group intranet. They are also made aware of the Intranet and how to navigate and search for information. They are supported through their orientation with a blended approach with eLearning modules, face to face mentoring and support and additional coaching by our central support teams. Mentoring and support also includes one to one support on where to find and how to use the systems we operate.
2.10. We have recently launched a new CCH Group app – called CCH Connect. Operational and care staff have instant access to key policies through this app. We believe this innovation will give our teams better visibility and in particular, it gives another platform in which to reach out to the teams and keep them informed of organisational learning, policies, procedures, and resources.
2.11. All Branches that are part of CCH Group will be subject to the governance review program conducted by our Quality team. Whilst this covers a broad spectrum of areas, relevant to this Inquest it will ensure and check CCH Group’s expectations surrounding training, supervision and guidance are met and maintained. Where
issues are identified, improvement support plans are put in place for the relevant branch and action take to track and monitor the completion of those plans.
3. The role of care workers – choking and aspiration
3.1. We considered that it would be helpful to set out the care and support MiHomecare provides and the expectations of care workers in respect of medical concerns / responding to medical incidents (including those related to choking and aspiration).
3.2. MiHomecare is a homecare provider that provides care and support to people within their own homes in the community. The care and support MiHomecare provides to individuals is varied and will depend on the package of care commissioned, usually, by the local authority. Care and support tasks completed by MiHomecare care workers can include assistance with personal care (for example, assistance with washing, dressing and toileting), assistance with administering medication, assistance with meal preparation, and support with shopping and domestic activities (such as hoovering). MiHomecare does not provide nursing care and whilst care workers receive basic first aid training, they are not trained medical professionals.
3.3. The first aid induction training currently received by care workers covers the following topics (please see paragraph 4.3 that discusses the updates that have been made to this training).
3.3.1. The principles and purpose of first aid and basic life support;
3.3.2. Understand and demonstrate the primary survey (DRABC);
3.3.3. Managing an unconscious casualty (how and when to seek help);
3.3.4. Demonstrate the recovery position (including knowledge on recovery position for potential spinal injury);
3.3.5. Understand and demonstrate CPR and the use of an AED (including knowledge around a DNACPR);
3.3.6. Understand what is choking and what is aspiration, the similarities and differences between the two conditions;
3.3.7. How to recognise when a person is choking;
3.3.8. How to recognise when a person is aspirating or at risk of aspiration (including the risk of developing aspiration pneumonia);
3.3.9. Understand and demonstrate emergency actions for a choking casualty (adult and child);
3.3.10. Understand what actions to take when a person is aspirating; and
3.3.11. How to recognise and deal with sudden illness and serious injury.
3.4. The fundamental message care workers receive from their training is that if they have any concerns about an individual’s health and wellbeing these should be escalated as appropriate – e.g., to the Branch Office, the GP, the District Nurses,
111 and / or 999 depending on the concern and the urgency. Where care workers are escalating to a medical professional (e.g., a GP or a 111 / 999 call handler), they are instructed that they should follow any guidance and instructions provided by the professionals.
3.5. Choking occurs when there is an obstruction in the windpipe causing difficulty breathing. This obstruction could be something solid such as food or a foreign object. Often, when an individual is choking, they will show outward signs such as coughing, gasping, and touching their throat. If care workers consider that an individual is choking, they are trained to follow a set emergency procedure that can be seen on the prompt card at Appendix 1.
3.6. Aspiration is when a person inhales something into their airway that enters their lungs. In a fit and healthy person, the foreign substance irritates the airways and triggers coughing and the foreign substance will likely be ejected. In someone who is frail or elderly they may not notice the particles (or liquid etc.) going in and not feel the irritation and so they may not cough it out or be able to do this. As the substance inhaled by aspiration is not sterile, when it stays in the lungs it can cause infection – this can cause aspiration pneumonia.
3.7. When a person has a known risk of aspiration (e.g., sometimes individuals living with dementia have increased risks), there are precautions that can be taken to make it less likely (e.g., ensuring the individual is sat up straight to eat, prompting them to eat slowly). Notwithstanding this, it will not always be obvious that an individual has aspirated something into their airway. Whilst we would expect care workers to be able to identify the potential signs of aspiration, the key action we would expect them to take if they had any concerns about an individual’s presentation or condition, would be to escalate for medical support, which in an emergency situation, would involve calling 999 for assistance, giving the call handler all relevant information and following any instructions given.
4. Actions taken in respect of choking and aspiration
4.1. Prior to the Inquest into the death of Angela Carpos in December 2023, the Finchley Camden Branch of MiHomecare (the Branch from which Ms Carpos received care) had taken a number of actions relevant to the issues surrounding Ms Carpos’ death. The two care workers on shift with Ms Carpos on the evening of 25 December 2022 completed themed choking supervisions, and the Branch Manager also included reference to the expectations surrounding choking within the branch newsletter and sent a specific email to care workers with relevant information and a flashcard on choking.
4.2. More widely across CCH Group, the expectations in respect of choking, aspiration and swallowing difficulties were and are regularly included in bulletins that are sent to / shared with both operational teams and care staff. We currently use a number of different mechanisms to deliver bulletins – for example, emails to care and operational staff, team meetings and through our new CCH Connect app (discussed above at paragraph 2.10 and at paragraph 4.4.3).
4.3. CCH Group had also updated its induction and refresher training from October 2022 (starting with the induction training and then moving to the refresher training) to include more detail on choking and aspiration. This version of the training was completed by the two care workers on shift on the evening on 25 December 2022, in June and August 2023. Our training on choking and aspiration has since been further updated and launched to include additional clarity around aspiration (again, starting with the induction training and then moving to the refresher training, the updated version of which is due to go live this week). I have appended a printout of the materials from the most recently updated [induction / refresher] training at Appendix 2 to demonstrate the topics covered.
4.4. In addition, following the Inquest in December 2023 and after reflecting on the Report for the Prevention of Future Deaths, MiHomecare and CCH Group has made, and will make the following changes:
4.4.1. CCH Group’s Best Practice Forum has considered the circumstances surrounding Ms Carpos’ death as part of a serious incident review. A number of actions have been prompted by this review. For example, the themed supervision relating to choking (see paragraph 2.6) is being updated to include more detail on aspiration / aspiration pneumonia and the updated version is due to be released by the end of July. In addition, there is also a campaign initiative that has been created to highlight both choking risks and management alongside aspiration and the differences in presentation. This initiative is expected to be launched prior to the end of June 2024 and will be included on our new CCH Connect app as a ‘’Talking Head’ discussion, along with an updated prompt card for all staff. Please see the latest version of this updated prompt card at Appendix 1. Staff will be encouraged to review the initiative / prompt card via notifications in the app, and Branch Offices will be informed to tell staff about the initiative / card in team meetings.
4.4.2. Our care planning tools are also being reviewed and as a part of this extensive project, the risk management around difficulties with eating and drinking (and hence the risks surrounding aspiration) will be considered. This project is still ongoing (expected to be concluded before the end of summer), but it is expected that one of the amendments made will be to ensure the tools include particular reference to aspiration rather than just swallowing difficulties more generally.
4.4.3. As stated earlier we have our new CCH Connect app. This has just launched and gives us the opportunity to connect with our teams instantly and to highlight policy changes, learning initiatives and other group news. We have talked about some of the specific benefits / uses of this app above in this letter.
5. I would like to take this opportunity to express my sincere condolences to Ms Carpos’ family and friends. I understand she was very well regarded by those who cared for her and will be missed.
6. Please do not hesitate to contact me should you have any questions.