Marjorie Evelyne Keogh

Dear Sir/ madam, Re: Regulation 28 report - Mrs Marjorie Keogh

1. We complete a needs assessment for potential residents prior to admission to our homes which identifies how much help and support a resident requires. A Registered Nurse would carry out the needs assessment for a resident who required nursing care. A copy of Homes policy "Residents plans of care" (appendix 1) and our pre-admission assessment pack (appendix 2) is enclosed. If we are able to meet the needs of the potential resident and decide to accept them for admission, risk assessments are completed We complete risk assessments to provide a means for taking the more difficult decisions arising from what the person is able or unable to do safely for themselves. Some of what is planned to improve the residents quality of life may involve their taking some risks, for example, improving and maintaining mobility may require the resident to walk rather than use a wheelchair, which carries the risk of a fall. For these risks we assess and put reasonable precautions put in place to minimise the risks. We try not to err on the side of risk avoidance or totally risk-averse on behalf of our residents as it can impose a loss to quality of life. We would complete a risk assessment using a Premises Internal area risk assessment form, if there are any risks in relation to specific areas in the home, e.g. is there a risk involved for the residents occupying a bedroom in the home that may be upstairs. Premises internal area risk assessment form (appendix 3) enclosed. MyMil Ltd Page 1

CQC inspection in November 2013 shows that the care home is fully compliant with regulations under the Health and Social Care Act 2008. CQC report (appendix 4) enclosed.
2. There is no legislative prescriptive staffing level for care homes. Our staffing levels are based on needs of residents; we care for residents with residential care needs and nursing needs. This is the shift pattern for nursing and care staff that we have in place for occupancy of 10 residential residents and 20 nursing residents (2 of these have one to one staffing periods) in February 2014: Registered Manager/ Nurse - 40 hours per week daytime Registered Nurse X 1 from 7am - 7pm Registered Nurse X 1 from 7pm - 7am Residential Manager/trainer - 32 hours per week Senior/Care staff x 6 from 7am -2.30pm Care staff x 1 from 7am - 2.30pm for resident requiring one to one supervision Care staff x 1 from 11am -2.30pm x 1 for resident requiring one to one supervision Senior/Care Staff x 6 from 2.30pm-10pm Care staff x 2 from 2.30pm-10pm for 2 residents requiring one to one supervision Care staff x 2 from 10pm-7am Care staff x 2 from 10pm-7am for 2 residents requiring one to one supervision. We use the staffing guidelines that the Regulation and Quality Improvement Authority (NI) have produced as guidance us in our staffing calculations. This example is taken from the guidance, however we only have 20 nursing residents and the remaining 10 are residential residents that require lower staffing ratios, so we are overstaffed at present. Example 1 - 30 bedded nursing home No of beds Time periods Staff/ Patient ratio Total no. of staff No. of Nurses No. of C/A's Total care hours 30 8am-2om 1:5 6 2 4 36
-
- -
-
- 2Q_m-8~m 8om-8am _1:6 _ 1:10 5 - 3 _2 1 _] 2 30 36 M"Mil I trl

This provides a total of 102 available care hours with an average of 3.4 care hours per patient over 24 hour period with 35% registered nurses and 65% care assistants over the 24 hour period. CQC Inspection in November 2013 shows that the care home is fully compliant with the regulation under the Health and Social Care Act 2008
3. Our Residents Plans of Care policy (appendix 1) outlines our objectives and strategies, in relation to risks, implementation and reviewing care plans. It outlines outlining staff's roles in care plan process. Care plans reflect the differences between, what the person can and cannot do for themselves, what they seek to do for themselves and the daily living tasks over which they seek or need help. Each person has an individualised plan of care, which takes into account significant nsks. Our Falls Prevention and Risk Assessment Policy (appendix 5) which outlines how we aim to balance the protection of residents from risks with the promotion of independence, in accordance with Dept. of Health guidance, Independence, Choice, and Risk: A Guide to Best Practice in Supported Decision Making. We use a fall risk assessment tool/care plan which is widely used in Leicester hospitals and other care homes. A copy of which is enclosed. (Appendix 6) The tool/care plan considers the "Place" a resident is cared for, which would include consideration about which bedroom a resident occupied and where it was located. This does not only apply on admission but it is reviewed each month or the period specified on the care plan or when there is a change of care need. Our in house moving and handling trainer has been trained by Leicestershire County Council and the documentation she uses has been supplied by them for use. To ensure safety and to maximise residents independence and dignity we operate a minimal handling of residents whereby physical handling is or lifting of residents is minimised or avoided wherever possible. MyMil Ltd Page3

We undertake a moving and handling assessment using the tool enclosed, (appendix 7). A risk assessment form is completed for any of the tasks identified on the moving and handling assessment form . I am enclosing copies some of the risk assessments templates (appendix 8 & 9) as examples. We have reviewed and changed all our care home documentation over the past 3 years and we have received a lot of positive feedback from professionals. We use a handover sheet each day to ensure that all information is passed between shifts and it highlights changes to care plans and/or medication. Staff sign to say that they have attended the handover. (appendix 10) CQC Inspection in November 2013 demonstrates that the care home is fully compliant with regulations under of the Health and Social Care Act 2008.
4. We have not been able to confirm with Building Control at Charnwood Borough Council that the balustrade is compliant to the required standard. They did ask us to undertake work on the balustrade after the incident at Scraptoft Court, which we did. However, they have now come back to me and state that we must obtain a report from an independent surveyor to give us the information that you require relating to its compliance. We have therefore now commissioned an independent surveyor to address this and will forward this report to you within the next 28 days. We would therefore ask that the period for this reply to be extended by a further 28 days. Yours faithfully.

Director MyMil Ltd Page 4

I MyMil Limited, T/a Scraptoft Court Care Home 273a Scraptoft Lane, Leicester. LES 2HT Tel/ fax: 0116 2431115 'iM Coroner The Town Hall Town Hall Square Leicester LEl 9BG 3 Apr LEICESTER CITY & 60UTH LEICESTERSHIRE CORu,.ERS DISTRICT
- 7 APR 2014 I 2014 RECEIVED Dear Sir/ madam, Re: Regulation 28 report -Mrs Marjorie Keogh

Further to your letter dated 1 April 2014. Your letter states that I requested a further 28 day extension, can I clarify that I asked for a 21 day extension. The information that you require to make the decision is as follows:
1. In the matter of concerns (section 5, Reg. 28 report) 4, it asks "Is the staircase at Syston Lodge compliant with the requirements referred to". I have not been able to get this information from Chamwood Borough Council Building Control Dept., who signed the building off when the care home was completed in 1998 as I have been told they no longer have records available. On the advice of our Solicitor we have commissioned a structural engineer to help us address this. I returned to work on the 26th March 2014, the structural engineer came out last week and I am awaiting correspondence from him after this visit. 5th
2. has been off sick since 16 February 2014. I had surgery on March 2014 so was off from this date.
3. sick certificate is for 2 months, it is not known if he will be able to resume work after this.
4. The outstanding matter needed to be addressed by a director; we were involved with the building and registration of the care home in 1998 and need to ensure that the question asked is answered. Yours faithfully.

Director My Mil Ltd

MyMil Limited, T/a Scraptoft Court Care Home 273a Scraptoft Lane, Leicester. LES 2HT Tel/ f~0ll6 2431115 HM Coroner The Town Hall Town Hall Square Leicester LEl 9BG 10 April 2014 Dear Sir/ madam, Re: Regulation 28 report -Mrs Marjorie Keogh

In relation to the remaining question (4) relating to the stairs at Syston Lodge Residential Home. knows that the same company who supplied the balustrading at Scraptoft Court supplied Syston Lodge Residential Home. The balustrading at Scraptoft Court has been found not to comply therefore we feel that the balustrading at Syston Lodge is not compliant. We have instructed a Structural Engineer to look into this and make recommendations to ensure they comply. We will undertake these recommendations once we receive his report. Please do not hesitate to contact me should you require any further clarification. Yours faithfully ~ .,., r ,, ··•cf/ C(A. ..£ _~SiG_Ify & It:.._-_;;, D,{}SH1f?f Flier 14 4PR lON

Keg. Off c.e We'>twood ouse, 78 LOughboroi.g!l Road, Quorn, Le1ce~tcr~h1re, LE!L BDX Cor1pany Reg11,t•at1on lllo 7180927 D1·ecto1,;: Di:ie;h Gokarn, Heleri Appleton

MyMil Limited, T/a Scraptoft Court Care Home 273a Scraptoft Lane, Leicester. LES 2HT Tel/ fax: 0116 2431115 HM Coroner The Town Hall Town Hall Square Leicester LEl 9BG 19 September 2014 Dear Sir/ madam, Re: Regulation 28 report -Mrs Marjorie Keogh

Further to my letter dated 3 July 2014. Please find enclosed a copy of the summary of the report that was undertaken by our commissioned Structural engineer in relation to the balustrading at Syston Lodge Residential Home.

Dear Mr Coutts-Wood Thank you for your letter of December in which you wrote to uS under the provisions of Regulation 28 of the Coroners (Investigations) Regulations 2013 in relation to the inquest into the death of Mrs Marjorie Evelyne Keogh: We were extremely saddened by the news of the death of Mrs Keogh and the circumstances surrounding it We are also grateful for your report and for requiring us to review what actions have and should be taken to prevent any reoccurrence of such circumstances_ Please treat this letter as the formal response of the Care Quality Commission 'the Commission') to your report: In your report and pursuant to the requirements of Regulation 29 you require the Commission to provide details of any action that we have taken or which we propose to be take in response to the concerns highlighted in your report, or an explanation as to why no action is proposed if appropriate. We deduce from your report that your primary concerns arising the Inquest into the death of Mrs Keogh relate to the following issues: 1_ The verification of compliance with building regulations, other relevant quality standards and architects' plans on the transfer of regulatory authority and registration of providers between the National Care Standards Commission (NCSC ); then the Commission for Social Care Inspection ('CSCI') , and finally then to the Care Quality Commission 'the Commission'); and 2 The Commission's current and future intended practice in relation to these issues with respect to new and pre-existing registrations with Us_ from

In relation to both questions we feel that it would be useful to outline first how the relevant regulatory frameworks have changed and developed since 1997. Historic Regulatory Framework: 1997 to 2009 When Scraptoft Court was originally registered in 1997 the prevailing legislation was the Registered Homes Act 1984 ('RHA' and the registration authority was Leicester City Council: The RHA provided for a fundamentally different regulatory framework from that currently in existence under the Health and Social Care Act 2008 ('HSCA 2009'). In particular, 'residential care homes' were required to be registered as distinct establishments, whereas under the HSCA 2008 residential care homes as distinct establishments are not registered. Instead, persons are registered to provide regulated care activity at specified locations. We assess that the RHA system was more directly concerned with the physical environment and indeed the accompanying Residential Care Homes Regulations 1984 were more specific about what was required in respect of the physical environment. The current HSCA 2008 is more focussed on the outcomes experienced by the people using services, while the regulations that underpin those outcomes are far less prescriptive about particular physical andlor environmental requirements providing that those outcomes are met The relevant regulations under the HSCA 2009 are the Health and Social Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009. It is our understanding that under the RHA regime there was no statutory duty on registration authorities to check that care homes were compliant with building regulations, architects' plans or relevant British Standards_ We understand that this was then considered primarily matter for planning departments of relevant local councils However we also understand that many registration authorities may upon RHA registration have routinely checked for compliance with those regulations, standards and plans_ As well as being RHA registration authorities most Councils were also planning authorities with responsibilities for planning and building control. Accordingly, appears that planning and building control checks were done 'internally' between council departments_ In having set out our understanding of the role undertaken by Local Councils in respect of checking; at the point of registration compliance, with relevant buildings regulations we are mindful that the Local Authorities themselves would have greater and more comprehensive insight into those practices. We interpret that the Care Standards Act 2000 ('CSA 2000') enacted similar regulatory to that under the RHA. In particular; CSA 2000 provided for the regulation of establishments. However, responsibility for regulating care homes was moved away from local authority control to the NCSC, then and subsequently in 2004 to the CSCI: We understand that the NCSC initially carried out building control andlor planning checks upon registration: However, by the time that CSCI came into existence physical andlor environmental checks were being phased out in favour of a focus on outcomes for people. Care

By the end of its existence CSCI had ceased to check routinely compliance with planning andlor building control requirements on registration. We understand that those were regarded as being responsibilities of local authorities and providers rather than the care regulator: In conclusion; it is our assessment that it is unlikely that either the NCSC or the CSCI checked that the original registration in 1997 included checks that Scraptoft Court met Building Regulations or complied with the original architect's plans or other relevant quality standards_ Current Regulatory Framework The Commission was established on April 2009 by the Health and Social Care Act 2008 ("the Act') The Act introduced single registration system which applies to both healthcare and adult social services_ Once registered with the Commission, providers such as Scraptoft Court are required to comply with conditions placed on their registration; as well as under the Health and Social Care Act 2008 (Registered Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009 (the Regulations') The regulations set out the essential standards of quality and safety that service users have a right to expect_ The Act also requires the Commission to publish guidance about compliance with the requirements of the Regulations_ The Commission has published "Guidance about compliance, Essential standards of Quality and Safety" ("the Guidance' which provides advice to providers about how and what need to do to comply with the Regulations in the form of outcomes and prompts The Regulations implemented under section 20 of the Act make particular provision with view to securing service that is of an appropriate quality and secures the health, safety and welfare of persons for whom any such service is provided Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which is assessed as Outcome 10 under the Guidance, has particular relevance to your concerns relating to staircase furniture and is set out below: "Regulation 15: Safety and suitability of premises The registered person must ensure that service users and others having access to premises where regulated activity is carried on are protected against the risks associated with unsafe or unsuitable premises, by means of a) suitable design and layout; appropriate measures in relation to the security of the premises; and (c) adequate maintenance and, where applicable, the proper operation of the premises which are owned or occupied by the service provider in connection with the carrying on of the regulated activity: Prompts for all providers to consider The following prompts relate to all registered providers except where care, treatment and support is delivered in a person's own home_ they

Ensure the premises are adequate People who use services and others who work in or visit the premises can be confident that in relation to design and layout; the provider: Ensures the premises are suitable for the regulated activity: Takes account of identified risks Meets the requirements of the Health and Safety at Work Act 1974 and associated regulations and the Regulatory Reform (Fire Safety) Order 2005 and other relevant legislation. Takes account of the safety needs of people who enter or use the premises; including the safety of children and other vulnerable people where are permitted to enter: Ensures that all safety precautions are in place and tested with regard to all specialist equipment and engineering systems that are physically fixed to the premises: Ensures the premises reflect Department of Health published guidance. Lead effectively to manage risk about the premises People who work, visit or use services can be confident that; in relation to design and layout: Where premises are altered or their use is changed, the continued safety and suitability of the premises is assessed. In relation to maintenance of premises and grounds; renewal and service continuity: There are clear procedures; followed in practice, monitored and reviewed, which cover: how the premises are maintained the identification, assessment; management and review of risks Plans are developed and implemented for the adaptation of the premises in response to changes in: the needs of people who use services design, technical and operational guidance issued by appropriate expert bodies how the service intends to provide regulated activities relevant legislation: When the Health and Social Care Act 2008 came into force the move away from prescriptive environmental requirements was further enshrined in the legislation: Establishments were no longer required to be specifically registered and there is no specific requirement in the Regulations concerning planning permission or building regulations: Nor indeed are fire food safety or environmental health standards specifically and prescriptively incorporated into the Regulations. Under the current regulatory framework it remains the responsibility of providers to ensure that the premises in which on a regulated activity is fully compliant with any relevant Buildings Regulations or British Standards. It is our interpretation they they carry

that the responsibility for enforcement with these regulations lies with Building Control andlor Planning Departments in local authorities. The Commission would and does check such compliance when it has information that might indicate that people using or visiting a service may not be protected in the way the regulation specifies_ At the point of registration with the Commission in November 2010 the Commission did not specifically check whether Scraptroft Court was compliant with relevant Building Regulations. The provider declared that were compliant with the Regulations and the provider indicated that no consideration was being given to changes either in relation to the activities that were to provide, or to the location they were to be provided at, which would have resulted in more detailed assessment of their registration: The registration for Scraptoft Court was in effect a 'like for like' transition from the previous regime to the new one Scraptoft Court was adjudged compliant with the existing regulatory framework at the time of transition_ Additionally, there no information from either the provider or other sources to indicate a risk to the people using the service or other relevant concerns about service or the provider, which would otherwise have prompted more detailed analysis of Scraptoft Court's registration application at that point: The Commission has inspected Scraptoft Court on five occasions since it was registered under the Act in November 2010. We conducted three inspections in 2011_ one in 2012 and one in November 2013. We attach copy of each of those reports to this response_ During the course of three of those inspections we found that the service was non-compliant with one or more regulations: Non-compliance with Regulation 15 was assessed on one occasion, following the inspection on 18 December 2012, and as set out at pages 10 and 13 of the Report published on 6 February 2013. The Commission's concerns related to the carpeting in the entrance hall, some communal areas and both the downstairs and upstairs corridors of Scraptoft Court: Despite regular cleaning we assessed that this carpeting retained an odour of urine_ This carpeting was also heavily patterned and as such was not suitable for people using the service who had dementia: The provider replaced this carpeting and we found the service to be compliant with the regulations at our last inspection in November 2013. In terms of the Commission's registration policies and procedures, we are currently reviewing our approach to registration: The contents of your Regulation 28 report helps to inform that review. During the course of considering our response to your Report we have consulted with the Head of Registration within the Commission She has confirmed that particular and detailed consideration is being given to the extent to which the Commission should go beyond solely seeking a declaration at the point of registration from provider that are compliant with relevant Buildings Regulations andlor Planning regulations: That process of review is on-going_ However; at this stage the Commission's plan is to undertake checks and seek evidence to confirm provider's compliance with building regulations as part of registration application where the provider seeks to accommodate people and where the location is newly built or where building works have been undertaken Thank you for raising this issue with uS_ We intend to share it with inspectors and with other managers within the Commission as well the report informing our intelligence and policy processes they they the they

lfyou have any questions about this letter please do not hesitate to contact or via email at You can also make contact through our National Contact Centre using the details below: Telephone: 03000 616161 Email: Enquiries@CQC.org.uk Write to: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA