Rose Hollingworth

Dear Sir,

Following the recently issued Regulation 28 Report to Prevent Future Deaths Rose Mary Hollingworth (Died 04/01/2022) on the 8th of March 2024, I write to the Coroner with actions taken to reduce the risk of a similar incident occurring.

For ease of reference, I have outlined the matters highlighted in the prevention of future death report and our responses:

A. The carer should have conducted a proper welfare check on her first care visit

The carer IE did call the office in the morning to report she had met the client asleep in bed. At that time, she believed the client was having a lie-in as she was snoring. The carer has stated that if she had not heard her snoring, it may have prompted her to check further and elicited a response from the client. The sound of snoring understandably re-assured the carer IE that the client was sleeping. Carer IE did not at that point think there was anything wrong as she was aware that the client had complained before of poor sleep during the nights and not getting enough sleep. She followed protocol by calling the office to report this as she met the client asleep at her first visit. Her intention was that when she

returned for the lunch visit, she would support the client with any tasks required that the client had been unable to do, knowing that the client was fairly independent with her care.

• We now have a sleeping protocol in place which is discussed at the induction and the 2-day additional orientation training and initial face to face supervision, the latter, which normally happens within 2 weeks of care staff starting work. Regular supervisions follow which takes place every 3 months. The sleeping protocol is a protocol to be followed by all staff when they meet a client asleep. It covers a set of instructions to follow to ascertain that the client is gently woken up to establish that they are well and responsive.

• We have also created a Good Guidance brochure highlighting the Sleeping protocol and what to do in an emergency. This brochure has been circulated to all staff and is signed and dated to evidence their understanding of care practices highlighted.

• These matters are also discussed at their performance reviews and checked against their care note audits or if we are notified of a no reply.

• Care workers are constantly reminded by way of communication on platforms, memos, newsletters, supervisions and spot checks to always call emergency services first and not leave the client alone.

• Carers are also knowledge checked of their understanding of the sleeping protocol when spot checks and supervisions take place.

• Field care supervisors take the time to explain the sleeping protocol to new clients at initial assessments and at ongoing client reviews. If a client refuses for HomeDot Care to carry out the sleeping protocol, we will then in turn inform the local authority and seek further guidance.

Timeline: Implemented January 2022

B. The carer should have been concerned that RH was not up and waiting for the arrival of her carer as she normally would have been.

Carer in her defence had said that because Rose Hollingworth had complained of not sleeping well at nights, she did not think it alarming to find her still asleep as she had assumed she was still sleeping and as the client was making a snoring noise, she thought she was in a deep sleep.

• However, since that incident we have implemented the sleeping protocol and insisted that they gently wake the client if they find them asleep on arrival and ascertain that they are alive and responsive.

• This is frequently discussed during training, supervisions and spot checks.

• Carers are trained to spot changes in client’s usual routines and follow the above process.

• As management we are re-assured that this is actually being carried out by our staff as we had a similar incident for another client named RH who sadly passed away. Care worker found him ‘asleep’ and carried out the sleeping protocol and the emergency contact procedure.

Timeline: Implemented January 2022

C. The carer should have checked Rose Hollingworth’s catheter bag which was later found to have 1-2 days of urine

Rose Hollingworth was independent managing her catheter care and catheter care management was not a task on the support plan meaning that it wasn’t a responsibility for the carers to do. That said, one can see reading the care notes that when carers visited and sometimes observed that the bag needed to be emptied, they assisted her with this. This belies the care assessment that Rose was able to manage her day-to- day catheter care (emptying the bag) independently. The care notes available indicate that the catheter bag was checked the day before the serious incident.

That said, we have taken learning from this incident and the following has been put in place:

• If the client is managing their own catheter care (and not part of the support plan) care workers are still trained and instructed to observe and report any concerns such as client not managing properly and we in turn can then escalate this to Social Services or make a GP referral if this could turn medical

• Carers now receive specialist training on catheter management to indicate smell, colour, volume output and any other concerns that may be picked up. They are also trained to empty and change bags. This is a practical one to one in-house training which sits alongside their Care skills theoretical catheter training.

• We have a dedicated monitoring team who have the list of all clients with catheter care and who check the care notes and flag to the internal office team if the above parameters are not being met / reported.

• This is further discussed at supervisions and knowledge checked at spot-checks by field care supervisors who provide further guidance if needed.

• If concerns are picked, the care worker is referred to the in-house trainer to re-train them on the field.

Timeline: Implemented April 2022

D. The care worker should have made sure that RH took her medication

The medication task on the support plan for Rose Hollingworth was prompt and albeit the carer IE was not using recording involvement correctly, there is no evidence of medication backing up or not being taken. None of the other care workers attending to this client noticed medication being left or not given. The field care supervisor visited on at least 2 occasions and did not see any evidence of medication being backed up.

This said, the following practices have been further re-iterated and are being monitored:

• We ensure that carers undertake full medication training and this is done in a variety of ways through their Care Certificate, Induction training, Orientation training and medication competency in the field. This is then followed at a later stage with their attendance at a refresher medication clinic to ensure that they are following good medication care practices

• The carer is also trained to know the difference between medication prompt and medication administration and act accordingly

• Our ECM Team monitor the care notes to ensure that carers use the appropriate medication terms so that it isn’t conflicting with the original medication task

• There is prompt monitoring by a dedicated field care supervisor of all medication alerts and checking for changes, discrepancies or missed medication.

• We also undertake medication audits every 6 months.

• Carers are trained and instructed to always record their medication prompt and administration activities on their app which will provide evidence that they have undertaken this task

• Any concerns picked up on a daily basis are shared with the DN, GP, pharmacist

Timeline: Implemented February 2022

E. The care worker should not have been told by HomeDot Care when she called to leave Rose Hollingworth and return at lunch time

The out of hours officer had advised the carer to leave as it was known that Rose Hollingworth did not like early morning care visits and had trouble sleeping at nights and sometimes liked to have a lie-in. Carer had communicated she was asleep and snoring, so the assumption was made that she was asleep. There have been clients who would like to have a lie-in as they have had a bad night of sleep and may not want on that occasion to have an early morning visit. If they had a follow-up visit in the day, we would ensure that tasks unable to be carried out for the morning visit would be undertaken later that day. This would apply to clients independent with their care. As an organisation we have taken lessons from this and the following is now in place:

• At the back of this incident, we have introduced the sleeping protocol which would mean that no assumptions are made based on someone’s routine or observations.

• The sleeping protocol allows an effective process to be followed to ensure that when a client is met asleep in bed, that they are gently woken up to ascertain that they are well and responsive.

• We have re-trained our internal and out of hours team to adhere to that process when advising care workers who may call in regarding something similar

• We further re-iterate the importance of due diligence and safe practices by way of memos and newsletters

Timeline: Implemented January 2022

F. The carer should have provided basic first aid at the scene

At that time our care staff were not trained to give practical first aid and it would have been the expectation for them to call the emergency services which she did.

At the back of our CQC visit in November 2022 we did discuss this with our visiting CQC inspector and as part of her recommendation we have trained all staff in Life Support with anaphylaxis and AED.

This is a training that every member of staff has undertaken and is certified and is part of on-going recruitment training. We have a 100% compliance with care workers now trained up and certified and this training is done before they start work.

We also check in to see if they are confident and if need be, we re-enrol them for them additional training.

Timeline: Implemented November 2022

G. The carer assigned on the 3rd of January 2022 was a Somalian speaking care worker who required a Somalian translator in order for her to give evidence raising concerns that the carer lacked the ability to properly and safely communicate with Rose Hollingworth in English when attending to her care needs

During the recruitment process and during the time she worked at HomeDot Care, the carer IE was able to communicate and understand information in English shared between the care agency and herself. All staff communicated with her in English and her standard was a reasonable to good level and therefore there were no concerns about her ability to communicate in English to clients.

The care coordinator has in her statement testified that on the two occasions she spoke to RH, the latter was complimentary about her carer IE and the service provided and raised no concerns about a language barrier.

The carer has always stated that due to it being a coroner’s court hearing and legal proceedings, she felt more comfortable having an interpreter to fully understand the nuances of proceedings as English is not her first language.

As an equal opportunities and non-discriminatory employer, we as an organisation recruit staff from various backgrounds and ethnicities who also represent our clientele base as long as they speak reasonable to good English and can make themselves understood.

Coroners Concerns:

There was a failure to provide suitably trained, experienced and competent carers for a vulnerable person depending on the package of care

Carer IE was the care worker primarily involved with RH. We have indicated our view that training was given in accordance with our policies

at the time and were given to understand that IE had previous care experience.

As a standard ongoing practice, we now ensure that our recruitment and training process covers the following:

• Care Certificate training that needs to be completed before the induction training

• 2 full days of Orientation training which covers in-depth care operational practices, care systems, practical medication demonstration, future safety catheter care, emergency procedures, pressure sores, etc.

• 2 full days induction training

• 1 full day manual handling and First aid training with anaphylaxis and AEB

• 3 to 5 days shadowing based on experience with a senor care worker

• 1 day with a field care supervisor with feedback given to management and completion of shadowing certificate checklist, medication competency and an eventual sign-off to evidence community care competency

• This is followed by a face-to-face supervision within 2 to 3 weeks of start of work to discuss how confident they feel working in the community and above training and support received to date

• They attend a refresher medication clinic to ensure that good practices are being followed

• We provide specialist training for our staff such as Stoma Care and Tracheostomy, Epilepsy with Buccal administration, Peg Feeding, Mental Health, Mental Health First Aider, Learning Disabilities and Autism, Oral Suctioning and Dysphagia, etc.

Timeline: Implemented April 2022

H. There was a failure to properly supervise and manage the carers

At the time of the incident, we were in the middle of the second Corona virus wave which resulted in quite a number of staff being off sick after testing positive including RH’s care worker

This meant carer IE worked for 2 weeks with the client and then went off sick to start with her again on the 3rd of January 2022 when this serious incident took place.

The following is now in place:

• 1st initial supervision 2 weeks within commencing the role

Monitoring of the carers now comprises of the following checks:

• Daily monitoring by a dedicated ECM Team to check accurate log- ins using NFC for geo-fencing

• Checking quality of care notes by using a care worker compliance audit form covering task completion tasks such:

(visit duration, personal care, catheter management, medication, pressure sore, food preparation, leaving arrangements, etc)

• Carers have approximately 2 weeks plus of training and are signed off before they are signed off to work in the community

• Ongoing and on demand in-house training such as 121 medication training, catheter care training

• When concerns are up by the ECM Team / Care Coordinators / clients feedback / Nok / Field Care supervisors, we carry out a response to Concern meeting and agree improvement actions to discuss / advise and check if re-training is required

Timeline: Implemented April 2022

I. The care and support plan was not properly completed and contained significant errors

We have not been made aware that there were significant errors with the care assessment completed by HomeDot Care and are not sure if the above is in reference to HomeDot Care’s care assessment. However, we have continued to improve upon the care assessment planning process and we have done this by:

• Re-training of our field care supervisors to undertake more in- depth person-centred care assessments to capture any gaps that may not have been covered within the original support plan received by the local authority

• Specialist risk assessments once complex needs are identified such as clients with choking risks, breathing issues, Parkinsons, diabetes, epilepsy, etc.

• If and when we identify any additional needs or support required, we feed then back to the local authority requesting an updated support plan

Timeline: Implemented February 2022

J. There was a failure to properly monitor, review and manage and check the performance of the care agency

Whilst this is directed towards the CQC and Islington, it is to be noted that there was a challenge presented with on-site visits due to the pandemic and being in the second wave when this serious incident happened.

At the back of this incident, we have since had Islington Social Services carry out 2 comprehensive inspections, one in May 2022 and again in June 2023 with the next due later this summer of 2024.

We also have had a CQC inspection in November 2023 for which we were rated overall Good and all above concerns were looked into and addressed with lessons learnt shared.

As an organisation, we are committed to continuous improvement in providing safe and effective services and have committed to having annual Mock Inspections with a care consultancy company.

As part of our on-going governance review, we have introduced further improvement actions within the organisation which include and are not limited to:

• Internal and community staff being made clear on job roles and areas of responsibilities to effectively and safely carry out their roles

• Fully transitioning to electronic care recording systems and subsequent day to day monitoring of this

• Regular reviewing of policies and processes

• Expanding on our training offer

• Dedicated team of officers for monitoring purposes

• Ongoing sharing of lessons learnt and reviewing CQC serious incidents (for further learning and improvement actions)

• Widening our auditing scope

• Investing in annual mock inspections

We hope above actions demonstrate how serious we have taken the recommendations and have acted promptly and decisively to prevent a similar incident from happening again.

Sincere regards,

Registered Manager

Dear HM Coroner Stevens,

Prevention of future death report following inquest into the death of Rose Hollingworth.

Thank you for addressing your Regulation 28 prevention of future deaths report (PFD) to the Care Quality Commission (‘the Commission’) following the inquest into the death of Rose Hollingworth.

This letter represents the Commission’s formal response to your PFD report.

In response to the death of Rosie Hollingworth, the Commission carried out a comprehensive inspection of HomeDotCare Limited in November 2022 with the attached report published in February 2023. The service was rated ‘Good’ overall.

During this inspection we found action had already been taken to mitigate risk, specifically:

• There was evidence of learning from incidents and improving practice as a result. Examples of this included: o Individual fire risk assessments o A policy to wake up a sleeping person to check on their health ('sleep protocol') o A policy to inform next of kin of when a person had to go to hospital even if person was not admitted and a new orientation training for staff (p8 of the attached inspection report of HomeDotCare Limited:

Assessing risk, safety monitoring and management; Learning lessons when things go wrong). o Staff training also covered how to respond in an emergency. We asked some new staff if they knew who to call in an emergency and what to do if they found a person unwell. They knew what action to take and said the training had been helpful. o Staff did not have first aid training and the registered manager arranged this immediately after the inspection for all staff (p10 of the inspection report, Staff support: induction, training, skills and experience). o There was evidence of a culture of continuous learning and improvement. The registered manager was able to demonstrate learning from incidents which led to improvements in safety and quality of care provided. These improvements included improved training before staff started working with people and the introduction of a ‘sleep protocol’. This was a procedure for staff to follow if they found their client asleep on arrival and required them to gently wake the person and ensure they were well. Staff were aware of this protocol and able to explain clearly to us the action they were expected to take o (p16, Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving care). o As with all services regulated by the Commission, HomeDotCare Limited continues to be monitored and should concerns arise, this could prompt a responsive assessment if necessary. No immediate action is proposed.

Given the action already taken by the Commission, we are reassured that HomeDotCare Limited have responded appropriately in response to the death of Rose Hollingworth. We have not seen evidence to suggest the concerns mentioned in section 5 of the regulation 28 report remain.

For completeness, the CQC National Investigations team have also been looking into the death of Rose Hollingworth specifically, this investigation is ongoing, and the outcome will be shared with the coroner separately, once complete.

Dear Coroner Stevens,

London Borough of Islington response to the Regulation 28 Prevention of future death report into the death of Rose Hollingworth

In response to the matter of concerns of the PFD that there was a failure to properly review, manage and check the performance of the care agency, Islington’s response is the following:

The Council’s Adult Social Care vision is for Islington to be a place made up of strong, inclusive, and connected communities, where regardless of background, people have fair and equal access to adult social care support that enables residents to live healthy, fulfilling and independent lives. This vision underpins all our activity, and we expect our providers that we commission to embrace this approach. Adult Social Care commission providers to support residents on a range of services, this includes placements in care homes and supported living, advocacy services and home care services.

Adult Social Care have a dedicated team of 8 people who are employed to manage their contracts, this includes checking the quality of our providers who we commission with, ensuring they are delivering on their agreed key performance indicators. The team work alongside other teams to develop a holistic understanding of a provider. This includes social workers, occupational therapists, health colleagues and contract managers from other local authorities. Islington Council has a robust process in place to monitor the quality of care of our providers. We work closely with CQC and across the system to ensure a system wide approach. This is overseen by the Islington Provider Quality Oversight Board (IPQOB), which reports to the Senior Leadership Team within Adult Social Care and the Independent Adults Safeguarding Board. The Islington Provider Quality Oversight Board is a monthly multi-agency meeting with colleagues from across health and social care and CQC in attendance. The role of the board is to work in partnership with health and CQC to triangulate information about providers where

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there are concerns from across agencies. The Board shares intelligence and agrees key actions to support provider improvement and ensure residents are safe. Providers are risk rated based on agreed criteria. Providers on the IPQOB agenda, receive enhanced monitoring, oversight and support from an allocated contract officer employed by London Borough of Islington.

Where providers are found not to be performing well, the Council can enact its Provider Concerns Process. This process is supported by CQC who attend meetings. The process supports the provider to identify areas of improvement.

Further, it seeks assurances that these changes are embedded to ensure that Islington residents are receiving safe care. Where a provider is not assessed to be making the necessary changes to ensure a safe service, the Council may then seek to move individuals to another provider. This board reports to the Islington Safeguarding Adults Partnership Board so that the whole system can review and consider concerns, this has also helped refine the process to ensure we are effectively capturing and addressing concerns.

The council undertakes an annual audit of home care providers. The audit is based on CQC Key Lines of Enquiry, which provides robust assurance around the suitability of providers who work with Islington residents. This includes reviewing the care plans, staff files and reviewing key policies to ensure that people are receiving a safe service in line with the standards.

The council leads quarterly provider forums with the aims of fostering a supportive learning environment to share, reflect and shape best practice across the sector. It’s also an opportunity to hear from commissioning colleagues any key trends and important information to share including presentations from other areas to share learning and commissioners share important information and key trends. The forum is supplemented by a regular provider bulletin, which provides updates and news stories that may be of interest to providers, as well as reminders of changes in regulation.

Contracts and commissioning colleagues work closely with safeguarding and operational social work teams to share intelligence about providers, to ensure a coordinated approach to decision making and agreeing the proportionate approach to address concerns. Operations colleagues submit “service issues” to providers where they have identified issues with an individual’s package of care. The provider is expected to investigate and report back to the Council within 10 days. Service issues are a useful source of intelligence to identify if there are wider quality concerns about a provider. This process also enables general trends to be identified, which feed into provider forums to share learning that may be useful for all home care providers.

During 2023, the Council undertook a robust procurement exercise for a new home care service through a framework, to replace the previous contracts which expired in March 2024. The procurement aimed to reduce the number of providers London Borough of Islington uses,

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enabling the council to work more closely with a smaller number of providers and further enhance the focus on quality and safety of residents. The procurement exercise was extensive and included site visits and interviews with prospective providers. Residents were also part of the procurement evaluation panel. The new framework went live on 1 April 2024 with 9 locality providers and 14 secondary providers.

Learning and strengthening practice All providers commissioned by Islington Council are expected to be on a journey of continuous improvement, and the contracts and commissioning functions in the Adults Social Care Strategic Commissioning and Investment Department also take this approach within their own practice.  

ASC continues to review their process for contracting and quality monitoring. The Council have updated their provider audit approach to include resident and staff voice in the process. This forms part of the Quality Assurance Framework, which has recently been reviewed. London Borough Islington continues to work closely with other London councils and responds to concerns from host boroughs, regarding providers supporting Islington residents, where we have placed individuals or where we are the lead authority. Contracts and commissioning functions are always included in any learning, strengthening of practice and service improvements being made across the department.  This includes membership on the Prevention and Learning subgroup of the Safeguarding Adults Board.