Maureen Colclough

Dear HM Coroner Ref: Maureen Colclough Re: Regulation 28 Report Inquest into the death of Maureen Ann Colclough Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 28 Report issued following the inquest touching on the death of Maureen Ann Colclough: We are writing to you with our response to the matters of concern raised in relation to Unique Care Services_ We note the legal requirement upon CQC to respond to your report within 56 days and thank you for granting CQC a four week extension to provide a response_ Following the receipt of the Regulation 28 Report we held three internal management review meetings to discuss the findings of the report and determine what action CQC should take. We reviewed our records and found that the Registered Provider had not notified us of the death of Maureen Ann Colclough as legally required: This failure to report has been raised with the Registered Provider and we will consider whether criminal enforcement action is appropriate. Ann

We also agreed to conduct an inspection of the service, reviewing staff training in the event of an emergency and also the oversight that is provided by Two inspectors visited the service on 11 September 2017 and 21 September. detailed some of our findings under your specific questions below_ Background The Registered Provider, was registered on December 2014. In May 2017 , the Registered Provider moved location from Unique Care Services, 19 Caldy Drive, Great Sutton, Ellesmere Port; Cheshire, CH86 4RN to Stanlaw Business Centre, Unit C11 Stanlaw Abbey Business Centre, Dover Drive, Ellesmere Port; Merseyside , CH85 9BF . Unique Care Services was inspected on 17 and 24 October 2016. The service was rated 'inadequate' in the Well Led domain, 'requires improvement' in the Safe domain and 'good' in the Responsive, Effective and Caring domains_ The service was rated 'requires improvement' overall. We issued a requirement notice for a breach of regulation 17 (good governance): We inspected the service again in May 2017. The service was rated 'good' overall with 'good' ratings in four domains (Safe , Effective, Caring and Responsive) and 'requires improvement' in the Well Led domain: Coroner's concerns In relation to the specific matters of concern raised in your report: Inadequate training of staff to recognise emergency situations_ During our recent inspection we found that all members of staff had received basic life support training This took place August and early September 2017 . The Registered Provider confirmed that additional classroom based training has been provided to staff on 26 September and 3 October 2017. We also noted that the two members of staff involved in the incident had received training to the incident and one of them has subsequently received updated training on emergency procedures_ CQC is of the view that although the Registered Provider has provided adequate training for staff in dealing with emergency situations in response to the death of MC, the lack of training for some staff to December 2016 and the delay in provision of that training put service users at risk at that time. Although the risk has been mitigated whereby all staff have now had training, CQC considers that there had been system failure to oversee the management of the service have during prior prior the

Relying on presumptions when finding an unresponsive patient in serious situation:. CQC is of the view that carers relying on presumptions when finding an unresponsive patient in a serious condition place that individual at high risk: Whilst some of this risk has been mitigated as emergency training has been provided for staff, more robust action by the Registered Provider is required with regard to oversight of the service Due to the concerns found during our inspection CQC is now taking substantive enforcement action; In addition, the Registered Provider is required to provide CQC with an action plan detailing how intend to improve the care provided to service users. Inspectors will continue to monitor the service to ensure that service users receive safe and effective care_ A copy of the report detailing our findings will be available when published on our website_ Should you require any further information please do not hesitate to contact me on my telephone number

Dear Mrs. Harkin: am in response to your request for Unique Care Services to provide details of actions and proposed actions taken regarding your concerns after the passing away of Maureen Ann Colclough: will always be open to new suggestions or information of how to continuously improve the training that we provide for all employees at Unique Care Services In response to your concerns have provided details of actions we have already taken since the inquest took place as well as further steps that we have taken in an effort to prevent future deaths. AlI employees have been notified and almost ALL have undertaken a revised performance appraisal (regardless of any recent or up to date training) containing specific information and questions relating to recognizing an emergency situation as well as steps to take when finding an unresponsive service user All new starters will be given the relevant information and must answer series of questions and show satisfactory level of competence and understanding in recognizing an emergency situation and responding accordingly. (Employees have always been given this information in the past in the form of a handbook and have been required to sign to confirm receipt) AII employees of Unique Care Services have been made aware of that MUST attend an extra Emergency First Aid training course on either of the dates provided and confirmed (Tuesday 26th September & Tuesday 3d October) writing We they

sincerely that the actions and extra measures that we have taken prove to be satisfactory for you report but please do not hesitate to get in further contact if there is anything else you require from myself or any other employees. Please allow me to state that we as a company have ALWAYS provided the relevant training as well as promoting the options of many other training courses and qualifications even for developing skills unrelated to Domiciliary Care: state this in relation to the unchallenged evidence provided by Iduring the recent inquest: stated that she had not been given the relevant first aid training: This is statement that must declare false but was unfortunately made out of our hands: We have since provided the Care Quality Commission with training_records as well as qualification certificates as evidence: When asked why had made such statement; she stated that she had not understood the question answered while under oath Unfortunately the matter remains unresolved as has been on sickness leave for a number of months since suffering a stroke and has not returned to work Sincerely Registered Manager hope yet