Jake Baker

Dear HM Assistant Coroner Topping,

Prevention of future death report following inquest into the death of Jake Brian Baker Thank you for naming the Care Quality Commission as a respondent in the prevention of future deaths report issued following the death of Mr. Jake Baker.

CQC has a clear internal process to follow whenever a Regulation 28 report is received, including where CQC are named within report.

In line with the CQC’s enforcement and internal specific incident guidance, policies and procedures, a decision review meeting (DRM) takes place. This DRM considers the matters of concern raised, reviews the facts, and gathers additional information where required to inform regulatory decision-making. CQC considers if any potential breaches of regulation may have taken place, and undertakes an initial assessment using our specific incident guidance. In summary terms, this initial assessment enables the CQC to consider and/or determine any appropriate regulatory response in line with CQC’s published enforcement policy. More specifically, it enables CQC to consider and determine whether any formal and/or informal regulatory actions are required. This may include monitoring, inspection and/or civil enforcement action to further assess compliance of the provider or protect service users from ongoing risks; and to assess and determine whether there may be reasonable grounds to suspect that a service user(/s) may have sustained avoidable harm or been exposed to a significant risk of avoidable harm, as a result of registered person failure to provide safe care and treatment.

The concerns set out in your report centre on the extent to which Surrey County Council have rigorously reviewed the circumstances of Mr. Baker’s death and taken

action to avert the risk of future deaths. Specifically, you identify the following matters of concern:

a) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years. Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation.
b.) The process by which diagnoses of learning disabilities can be obtained remains opaque. There is no protocol in relation to this. The current situation leaves those making decisions in relation to young people struggling to obtain this vital information.
c.) The issue of how the numerous adult social care teams are accessed to obtain adult social care assessments for care leavers leads to confusion and delays. Vulnerable care leavers are at risk of being denied necessary support.
d.) How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions.
e.) Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs.

Actions taken by CQC following receipt of the information of concern concerning Jake Baker’s death

At the time of Mr. Baker’s death, CQC did not have any statutory powers in relation to the assessment of Surrey County Council or any other local authority.

On 1 April 2023, the Health and Care Act 2022 gave CQC new powers to assess how local authorities are meeting their duties under part 1 of the Care Act 2014. CQC’s role is carried out by way of undertaking an assessment in relation to how local authorities are meeting these duties, then rate and report on the findings. Where CQC find that a local authority is failing to perform its functions under the Care Act to an acceptable standard, CQC must inform the Secretary of State for Health and Social Care.

Between May and November 2023, CQC completed 5 pilot local authority assessments, to test the associated assessment framework, methods and processes. In December 2023, CQC commenced a rollout of its formal local authority assessment programme.

CQC have recently started an assessment process for Surrey County Council. CQC have shared details of the concerns in your PFD report regarding Surrey County Council with CQC’s local authority assessment team, to inform their assessment of Surrey County Council.

Your report highlights the failure of Ruskin Mill Trust to ensure Mr Baker’s safety when he went home for family contact in 2019. This included a failure to assess and put plans in place to manage the risks posed to Mr. Baker by his diabetic condition during such visits.

On 1 April 2015 the CQC assumed enforcement responsibility for health and safety related serious incidents concerning people using services in health and social care settings in England. This includes where people using services have sustained avoidable harm including death or have been exposed to a significant risk of avoidable harm as a result of a failure by the Registered Person. The ‘Registered Person’ (RP) is the Registered Provider and/or Registered Manager. Where Registered Providers are corporate bodies (such as limited companies) or unincorporated associations (such as partnerships), individual office holders or members may in certain circumstances be criminally liable under sections 91 and 92 Health and Social Care Act 2008.

The initial assessment and specific incidents guidance processes identified above were initiated following receipt of information of concern following the death of Mr. Baker. Following a thorough criminal investigation, this culminated in CQC bringing a successful prosecution against Transform Residential Limited, which operated Glasshouse College at the time of Mr. Baker’s death. This was due to their mismanagement of his diabetes care. On 31 May 2023, the provider pleaded guilty to causing Mr. Baker avoidable harm and was ordered to pay a total of £22,721.04 at Staines Magistrates’ Court.

As part of CQC’s considered response to any ongoing risk of harm to people living at Glasshouse College, CQC conducted a comprehensive inspection of the service in June 2021. During this inspection, CQC identified significant concerns and 2 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to the safety of people’s care and the provider’s governance arrangements. This inspection resulted in an overall rating of inadequate. Upon CQC’s re-inspection of Glasshouse College in March 2022, CQC found the provider had made significant improvements in the quality and safety of people’s care. Ruskin Mill Trust Limited were now meeting their legal requirements and CQC gave the service an overall rating of good.

It may also be helpful to the coroner to know that, as part of CQC’s broader work around reducing mortality and acting to understand and improve health inequalities for people with a learning disability and autistic people, CQC are working to establish better links with local Learning Disability Mortality Review (LeDeR) teams. This is with a view to establishing relationships which can combine the intelligence held by these teams with CQC’s regulatory function.

CQC are also working to improve access to the data that LeDeR hold about the deaths of people with a learning disability and autistic people and have already been given access to a LeDeR data tool which enables CQC to scrutinise themes and trends in a place. Through this work, CQC aim to improve the knowledge and understanding of CQC’s workforce by providing advice, learning and tools to enable them to better understand the contributory factors to avoidable deaths and take the right regulatory actions as a result.

Please do not hesitate to contact me if you require any further information.

Dear Ms Topping,

Regulation 28 Report – Jake Baker

I write on behalf of Surrey County Council ("SCC") in response to the Coroner's Regulation 28 Report dated 8 February 2024. I address each of the Matters of Concern set out in that Report in turn: a) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years. Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation. SCC Response: Pathway Plan training has always formed part of personal advisers' induction when they join SCC. A formal training programme has been in place since at least September 2021. Whilst there is no written document confirming this is mandatory, since the training commenced in 2021 managers have been clear in supervision and performance conversations with staff about the mandatory nature of this training. In addition, SCC’s Practice Standards are being reviewed and updated this year as part of our review cycle and will confirm the mandatory nature of pathway plan training for clarity. The current training content for personal advisers was updated in 2024 with a rolling programme of training throughout the year. In addition, pathway plan surgeries are in place across the Looked After Teams which also extend to social workers in the Safeguarding Adolescents Teams to ensure timely completion of pathway plans whilst providing advice and guidance on the content of the pathway plan. SCC has a well-developed audit process and pathway plans are audited as part of that activity within the Looked After Children and Care Leavers service with any learning arising disseminated across the service to further improve practice.

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b.) The process by which diagnoses of learning disabilities can be obtained remains opaque. There is no protocol in relation to this. The current situation leaves those making decisions in relation to young people struggling to obtain this vital information. SCC Response: Diagnosis is a health led process and it starts with a healthcare professional identifying a learning disability, through assessment, based on the person’s needs. Diagnosis can be undertaken at different times such as birth, in childhood or in adulthood. The Local Authority accepts that timely diagnosis can in some cases lead to improved outcomes for children and young people. SCC staff have, and will continue to, liaise with the young person's GP in the first instance to confirm diagnosis. Where necessary, SCC staff will also liaise with specialist health services if they are known to be working with the young person. SCC are in the process of developing a Multi-Agency Transition Protocol which is due to be launched in the coming weeks having now been signed off by all key parties. This Protocol will include direction to frontline staff on steps to take where a person's diagnosis is unclear. SCC also have integrated meetings with health colleagues such as the Preparation for Adulthood Board, Post 16 SEND panel and the Joint Commissioning panel to name but a few. These forums provide additional opportunities for people’s health needs to be explored and joint solutions to be found around how best to meet needs.
c.) The issue of how the numerous adult social care teams are accessed to obtain adult social care assessments for care leavers leads to confusion and delays. Vulnerable care leavers are at risk of being denied necessary support. SCC Response: Our Adults, Wellbeing and Health Partnerships Directorate (AWHP) is made up of both locality and specialist teams. There is a locality team covering each specific geographic area across Surrey. The specialist teams are the Transition Team, Learning Disability and Autism Team and the Mental Health Teams. Both the locality teams and specialist teams offer a clear pathway into adult social care for those individuals meeting the eligibility criteria under the Care Act 2014. These teams offer information and advice as to the available pathways for people seeking adult social care and support. In addition to that advice and information, SCC has a contact centre that is able to signpost people to the most relevant team to meet their needs. Our Care Leavers Services have access to this information and advice service and are also able to contact any of the teams directly if they require additional information or support.

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d.) How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions. SCC Response: The Looked After Children’s Review process provides a dedicated framework for monitoring the care planning, including Pathway Plans, up until the point a young person becomes 18. This involves two formal Reviews per year that bring together all those involved in a young person’s care and any involved family members as well as the young person. In addition, there are two informal midway reviews at which the Independent Reviewing Officer ("IRO") tracks progress against the agreed Care/Pathway Plan. SCC recognises that there is not currently a formal review mechanism for ongoing support post 18. A pilot is therefore under development with a view to formalising a post 18 review process to be attended by IROs. SCC has an expectation that any meetings that involve other professionals, and which have the remit to make decisions that may affect the care arrangements for children and young people, should be properly minuted and that those records be accessible. In light of the Coroner’s findings these expectations are being reinforced across key service areas in supervision meetings and team meetings. Completion of minutes of meetings is checked as part of the Performance Dashboard, a system through which managers are able to review compliance. Managers will continue to use this system to ensure that meetings are being minuted and to address any gaps with staff.
e.) Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs. SCC Response: Surrey has a generic risk assessment tool used to understand the risks presented to children and care leavers. The assessment tool does enable consideration of care leaver’s needs however on review could be strengthened to consider more specifically issues related to learning disability, mental capacity and health. A review of the current assessment tool is underway and will be completed by end April 2024.
f.) Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice. There is therefore a risk that erroneous assumptions as to capacity will continue to be made. SCC Response: Within the SCC Adults Service, Mental Capacity Act ("MCA") training is now mandatory to all front line staff. Team Managers and Senior Managers are responsible and have access to lists of staff attendance and are required to follow up with any staff who have not undertaken the compulsory training.

The position with MCA training within SCC's Childrens Service is currently under review. The intention is to mandate e-learning around the MCA as part of induction and refresher training to all staff to heighten awareness of the MCA.

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We adopt a stratified approach to training staff across both adults and children’s directorates due to the diverse range of qualification and expertise involved across our teams, taking into account the requirements for individual roles. Staff in roles that require mental capacity act awareness and knowledge will continue to receive the necessary training specific to their role, however, staff across both directorates will be supported to understand circumstances where the MCA framework may need to be implemented.

In addition to MCA training, we use various other forums such as professional supervision, peer reflection and team meetings. AWHP also have both a Practice Assurance Board and a Practice Improvement Group which oversee practice development and guidance and ensure that any lessons learnt from complaints, Ombudsman outcomes, Coroner’s Findings and Safeguarding Adults Reviews, amongst others, are shared with the workforce and that there is evidence of improved and enhanced practice in our service delivery as a result.