Multi Care Community Services Suffolk
Action Taken
Multi-Care Community Services Suffolk has transitioned from paper-based to a digital care recording system (Access) and implemented a new multi-tiered escalation framework for clinical deterioration, including staff training. The organisation has also strengthened governance with weekly meetings and ongoing Board-level quality assurance oversight. (AI summary)
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Dear Mr Stewart, Re: Regulation 28 Report to Prevent Future Deaths Multi-Care Community Services Suffolk Ltd Thank you for your Regulation 28 Report to Prevent Future Deaths issued following the inquest concerning the care provided by Multi-Care Community Services Suffolk Ltd. Multi-Care Community Services Suffolk Ltd fully acknowledges the concerns identified by the Court and takes these matters extremely seriously. Following the incident, immediate actions were undertaken to review practice, strengthen governance arrangements, and improve the safety and quality of care delivery across the organisation. Please find below a summary of the actions taken and proposed in response to the concerns raised.
1. Inadequate Record Keeping Following the incident, Multi-Care undertook a full audit of all care records and care plan activities across the service. Any concerns or areas of non-compliance identified during the audit process were addressed immediately. To strengthen record-keeping standards and improve oversight, Multi-Care transitioned from a paper-based record-keeping system to a digital care recording system (Access). This was implemented immediately following the incident and remains fully operational. The digital system provides:
• Improved accuracy and legibility of records
• Real-time monitoring by management teams
• Automated alerts and notifications for missed or incomplete care notes
• Monitoring of care plan activities, including medication administration and catheter care
• Immediate audit capability across all service user records In addition, Multi-Care has introduced standardised documentation processes to ensure:
• Contemporaneous and accurate recording
• Consistent fluid balance monitoring documentation
[Page 2]
• Clear escalation pathways
• Consistent standards across all records Timescale:
• Digital care recording system implemented immediately following the incident and remains ongoing
• Standardised documentation procedures implemented within 3 months of the incident
• Continuous monitoring and auditing ongoing weekly and monthly
2. Medication Management Multi-Care reviewed and updated all medication management policies and procedures following the incident. These revised policies were communicated to all staff, with clear expectations regarding compliance and escalation procedures. All care staff have completed mandatory refresher training and competency assessments relating to medication administration. The training includes:
• Safe administration of medication
• Accurate recording requirements
• Management of omitted medication
• Escalation procedures for medication errors
• Audit and monitoring expectations To ensure continued compliance, Multi-Care now conducts:
• Weekly spot checks
• Monthly medication audits
• Direct observation of practice
• Formal supervision sessions
• Competency reassessment where required Timescale:
• Policy review completed immediately following the incident and reviewed annually or as needed to reflect any legislative changes.
• Mandatory refresher training and competency assessments completed within 3 months.
• Ongoing annual mandatory refresher training in place
• Weekly and monthly monitoring arrangements are ongoing
3. Catheter Management Regulation Multi-Care also reviewed and updated its catheter care policies and procedures to ensure safe and consistent practice across the organisation. Mandatory catheter care training has been provided to all relevant staff and includes:
• Catheter care procedures
• Recognition of urinary tract infection symptoms
• Monitoring urinary output
• Escalation procedures for concerns or deterioration
• Documentation requirements and fluid balance recording Competency assessments are conducted following training and reviewed regularly through supervision and observational practice checks.
[Page 3] Timescale:
• Policy review completed immediately following the incident and reviewed annually
• Staff training and competency assessments completed within 3 months
• Ongoing annual refresher training established
• Weekly spot checks and monthly supervision are ongoing
4. Strengthened Management Oversight and Governance Multi-Care has significantly strengthened management oversight and governance arrangements to ensure sustained improvement and organisational learning. The organisation now holds weekly governance meetings to review:
• Audit findings
• Compliance monitoring
• Care quality concerns
• Required actions and outcomes Additional governance measures include:
• Formal supervision processes for staff
• Performance management procedures where persistent non-compliance is identified
• Regular audits and competency reviews
• Increased senior management oversight
• Feedback processes involving service users, families, and relevant healthcare professionals To further strengthen independent scrutiny, Multi-Care Community Services Suffolk Ltd. commissioned external audits and service reviews. These reviews include ongoing involvement and oversight from Daniel Joy (Suffolk County Council Commissioning and Contracts Officer, Strategic Commissioning & Contract Management Adult & Community Services). Additionally, they conducted a PAMMS inspection on the 9th of April 2025, which resulted in a "Good" standard rating. This followed up on a document review from the 30th of March 2026, which resulted in good feedback. Quality assurance reporting is now reviewed directly by the Board of Directors to ensure accountability and sustained oversight of care quality and compliance. Timescale:
• Weekly governance meetings implemented immediately following the incident
• Quarterly external audit programme commenced within 6 months and remains ongoing
• Board-level quality assurance oversight ongoing Multi-Care Community Services Suffolk Ltd remains committed to continuous improvement and to ensuring that lessons learned from this tragic incident are embedded throughout the organisation to minimise the risk of future harm. We trust this response provides reassurance regarding the actions taken in response to the concerns identified in the Regulation 28 report.
1. Inadequate Record Keeping Following the incident, Multi-Care undertook a full audit of all care records and care plan activities across the service. Any concerns or areas of non-compliance identified during the audit process were addressed immediately. To strengthen record-keeping standards and improve oversight, Multi-Care transitioned from a paper-based record-keeping system to a digital care recording system (Access). This was implemented immediately following the incident and remains fully operational. The digital system provides:
• Improved accuracy and legibility of records
• Real-time monitoring by management teams
• Automated alerts and notifications for missed or incomplete care notes
• Monitoring of care plan activities, including medication administration and catheter care
• Immediate audit capability across all service user records In addition, Multi-Care has introduced standardised documentation processes to ensure:
• Contemporaneous and accurate recording
• Consistent fluid balance monitoring documentation
[Page 2]
• Clear escalation pathways
• Consistent standards across all records Timescale:
• Digital care recording system implemented immediately following the incident and remains ongoing
• Standardised documentation procedures implemented within 3 months of the incident
• Continuous monitoring and auditing ongoing weekly and monthly
2. Medication Management Multi-Care reviewed and updated all medication management policies and procedures following the incident. These revised policies were communicated to all staff, with clear expectations regarding compliance and escalation procedures. All care staff have completed mandatory refresher training and competency assessments relating to medication administration. The training includes:
• Safe administration of medication
• Accurate recording requirements
• Management of omitted medication
• Escalation procedures for medication errors
• Audit and monitoring expectations To ensure continued compliance, Multi-Care now conducts:
• Weekly spot checks
• Monthly medication audits
• Direct observation of practice
• Formal supervision sessions
• Competency reassessment where required Timescale:
• Policy review completed immediately following the incident and reviewed annually or as needed to reflect any legislative changes.
• Mandatory refresher training and competency assessments completed within 3 months.
• Ongoing annual mandatory refresher training in place
• Weekly and monthly monitoring arrangements are ongoing
3. Catheter Management Regulation Multi-Care also reviewed and updated its catheter care policies and procedures to ensure safe and consistent practice across the organisation. Mandatory catheter care training has been provided to all relevant staff and includes:
• Catheter care procedures
• Recognition of urinary tract infection symptoms
• Monitoring urinary output
• Escalation procedures for concerns or deterioration
• Documentation requirements and fluid balance recording Competency assessments are conducted following training and reviewed regularly through supervision and observational practice checks.
[Page 3] Timescale:
• Policy review completed immediately following the incident and reviewed annually
• Staff training and competency assessments completed within 3 months
• Ongoing annual refresher training established
• Weekly spot checks and monthly supervision are ongoing
4. Strengthened Management Oversight and Governance Multi-Care has significantly strengthened management oversight and governance arrangements to ensure sustained improvement and organisational learning. The organisation now holds weekly governance meetings to review:
• Audit findings
• Compliance monitoring
• Care quality concerns
• Required actions and outcomes Additional governance measures include:
• Formal supervision processes for staff
• Performance management procedures where persistent non-compliance is identified
• Regular audits and competency reviews
• Increased senior management oversight
• Feedback processes involving service users, families, and relevant healthcare professionals To further strengthen independent scrutiny, Multi-Care Community Services Suffolk Ltd. commissioned external audits and service reviews. These reviews include ongoing involvement and oversight from Daniel Joy (Suffolk County Council Commissioning and Contracts Officer, Strategic Commissioning & Contract Management Adult & Community Services). Additionally, they conducted a PAMMS inspection on the 9th of April 2025, which resulted in a "Good" standard rating. This followed up on a document review from the 30th of March 2026, which resulted in good feedback. Quality assurance reporting is now reviewed directly by the Board of Directors to ensure accountability and sustained oversight of care quality and compliance. Timescale:
• Weekly governance meetings implemented immediately following the incident
• Quarterly external audit programme commenced within 6 months and remains ongoing
• Board-level quality assurance oversight ongoing Multi-Care Community Services Suffolk Ltd remains committed to continuous improvement and to ensuring that lessons learned from this tragic incident are embedded throughout the organisation to minimise the risk of future harm. We trust this response provides reassurance regarding the actions taken in response to the concerns identified in the Regulation 28 report.