Marcus Hanlin Inquest, Keaton Pullen, Registered Manager Cheddar Grove

The final witness who gave evidence on Day One of Marcus’s inquest was the Registered Manager of Brandon Trust Cheddar Grove, Keaton Pullen.

The CQC (Care Quality Commission, the health and social care regulator) state the following is the role of a registered manager:

Registered managers make sure that people who use services have their needs met. Registered managers and providers share legal responsibility to meet the requirements of regulations. We will often use the registered manager as the key contact for a service.

You can read the relevant regulations about registered manager’s here.

Asked to the witness box by the coroner, he gave an affirmation and confirmed his name.

C: Keaton Pullen. What was your role at the time?

KP: I was the Registered Manager at Cheddar Grove

C: The Registered Manager?

KP: Yes, yes

C: That’s at Cheddar Grove

KP: Yes

C: OK, now how well did you know Marcus?

KP: I would have only known Marcus for a period of 5 to 6 months, a lot of what I knew was reading from his care plans, speaking to staff who’d worked with him before, speaking with his family, his mum, yeh

C: Were you involved at all with his day to day care?

KP: No, not in terms of providing 1-1 support in that way

C: So, you say not in terms of 1-1 support, did you do any care provision for Marcus?

KP: No, no

C: So was your role was more in relation to running the facility?

KP: Yes, yes

C: And then, so as the Registered Manager, what input did you have then into any of the residents?

KP: So, I was overseeing the Nurse Team Leaders, who in turn would oversee the Support Workers. We would obviously work together… documents, look at risk assessments, things like that

C: OK, thank you. So, Cheddar Grove is a care home, is that right?

KP: A nursing care home yeh

C: A nursing care home. Just explain to me then, what sort of facility it is, so I can understand.

KP: So it was, there was two stories, there are two stories, there were five people who lived on the bottom floor, two who lived on the second floor if my memory is correct. It was quite open, yeh, um, sorry what was?

C: No, that’s fine. There’s a, I believe, there’s a floorplan I’ve been provided with.

KP: Yes

C: Have you got that to hand?

KP: No

Coroner asks counsel for the bundle reference

SL [I think]: 509, volume 2

C: Alright then, this is the floor plan, did you draw this?

KP: No, this is not me

C: Do you recognise this though?

KP: I recognise the layout of the house, this is what I remember.

C: Alright then, if we look at the ground floor first, this is the, where was Marcus then, where did Marcus live? Where was his room?

KP: From my recollection, where it says bedroom number 5 BT, would in fact be Marcus’s bedroom

C: The dining room?

KP: To the left as you went in, to the left and follow it round, just before the kitchen

C: So the dining room and kitchen are linked are they?

KP: Linked by a door

C: Is that door open to residents, can residents come in and out of the kitchen?

KP: Essentially in the kitchen there was an extra, smaller door which separated the cooking area as it were from the rest of the kitchen. So everyone could enter the kitchen, but you couldn’t enter all of the kitchen. If that makes sense.

C: So residents couldn’t get around to the area where food was prepared?

KP: Exactly. There was a breakfast bar around

C: Alright, thank you. So the care plans then, and risk assessments, you say they were written by the Team Leaders is that right?

KP: Yeh they’d usually be written by the Team Leaders, in Marcus’s case a lot was rewritten by a lady who came to help out at Cheddar Grove for a little while, her name was Teresa, she’d been employed at Cranwell Grove, so she knew Marcus before.

C: What was Teresa, was she a nurse?

[It was very hard to hear this answer, the witness spoke very quietly and would turn to face the coroner away from the microphone. I believe he said that she was a team leader, and her background was as a support worker, not a nurse]

C: One area I wanted to ask you about was the SALT (Speech and Language Therapy) team and their impact, how would that work?

KP: The SALT Team had already done an assessment of Marcus before I arrived at Cheddar Grove. If there was anything that highlighted a need for review or change the SALT Team would be contacted, think his name was Josh, he was regularly around anyway. Just before Marcus died he was due to have, or did have a procedure looking at tongue reflex when swallowing, they were quite actively involved yeh.

C: OK. With SALT assessments, is that something you and your team get involved with, or the external team come in and do an assessment and your team follow guidance?

KP: Its sort of done in collaboration, they’ll ask questions of the team of their day to day experience of Marcus, or anyone, but they’d usually do a meal at the time and then it would be our job to follow the instructions.

C: OK, so the guidance was set, your team follow it. One of the other areas I wanted to ask you about was the dysphagia training. What does dysphagia mean anyway?

KP: My understanding was Josh from the SALT Team said was new training on dysphagia, to me is aspiration of things when eating. The whole team was going to that training. Was also training Brandon Trust had an e-learning site with all sorts of training on, that was done through that as well, yeh.

C: What about choking incidents, are your staff trained on choking?

KP: Yeh all staff undertook first aid courses, where obviously choking would form part of that, we need to ring 999 and things like that, was first aid provided.

C: Have you got your statement in front of you?

KP: I do yes

C: Paragraph 18 could you read that to me a minute.

KP: Of course. There was a specific risk assessment for Marcus on eating and supporting him around the home, made reference to follow SALT instructions at all times, as well as not leaving food that complied… [missed] understood this to mean any food not yet prepared or adapted to meet Marcus’s requirements… I was not aware of Marcus previously eating any non-food items or items that had not been prepared for him.

C: OK, I wanted to ask about the unadapted food. We know this sensory dish set up had rice in it?

KP: Yes

C: Uncooked rice. Do you feel as the Manager that is unadapted food?

KP: So, I didn’t know if I would, yeh, anything that’s not, obviously the rice if it had been adapted would become food if that makes sense, so yeh, I’d probably call that unadapted food.

C: SALT Guidelines in relation to unadapted food is not leaving food that doesn’t comply with his guidelines, or unadapted, where Marcus could access it.

KP: Yes

C: On the day of the incident, have you checked, and can you confirm staffing levels were appropriate?

KP: As far as I know, to my knowledge they were yeh

C: So, on the day then, you had no concerns around staffing levels?

KP: On that day, the day before I had essentially spoken to my manager at the time, spoke to them on the way, this had been an ongoing thing. I wasn’t in mentally the right place to continue working, we were due to have a meeting the day before, that got postponed because they were unavailable. On the day the incident happened I phoned the administrator and said I was going to be taking a period of leave from work. [Can’t hear, think he was checking what the coroner’s question had been]

C: That’s fine. It was about staffing levels on the day.

KP: Yeh I asked the administrator was everything ok, and it was, said yes.

C: So you weren’t in on the day?

KP: I wasn’t no

C: Were you contacted about the incident?

KP: I was phoned, if my memory is correct was quite late on in the day, between 1 and 3pm. I had a voicemail from the Nurse Team Leader Shabeena, saying something had happened with Marcus, it wasn’t anything to worry about, the GP had been called, was nothing to worry about.

I phoned back, I was on sick leave but couldn’t leave that situation as it was. I phoned back, and spoke to Laura who explained there had been an incident with rice or something like that. I think she told me it was a sensory activity, was rice around Marcus’s mouth potentially, so yeh, that was the contact I had.

I asked them to keep me updated, by that point they’d already contacted an ambulance and were waiting for an ambulance to come out. After I spoke to Laura again, Marcus had been taken to hospital. That’s the contact I had on that day.

C: Just to confirm, that’s Laura Bolus, your reference?

KP: Yes

C: At that time was there any reference made to conkers?

KP: Absolutely not, no, no

C: When did you become aware of the conkers?

KP: Literally well after this date, to the point I was given a statement, to that point I thought it was just rice.

C: OK, I’ll let others ask questions, might come back to you at the end.

Questioning then moved to Mr Lewis on behalf of Marcus’s family.

OL: Good afternoon, I’ll ask, volume 2, could you turn to page 376 please, 375, this is part of the support plan, on eating and drinking?

KP: This is the plan for particular pages on support plan for eating and drinking yeh

OL: This was written on 1 January 2022 and was to be reviewed in July 2022, right?

KP: Yes

OL: So it wasn’t the care plan, we’ll come to that, document that precedes it in a moment. Just on this, if you turn over the page, is two parts in red, the lower bold red wording, says ‘if I should choke, staff deliver backslaps to dislodge cause… then medical attention… ETAT also to be filled in’. What’s ETAT?

KP: Brandon’s incident form

OL: Backslaps for staff to deliver if Marcus chokes, is this a direction to staff to do backslaps?

KP: Um I would say so, yeh

OL: OK, if you turn back a few pages to 370, this is the same plan, but updated as far as I can understand on 17 June 2022. Previous one was 1 January 2022, this is the last one, the one that was applicable on 28 September 2022, is that correct?

KP: Yes

OL: The bullet points are not numbered, just see bottom box bullet points, will count down… 6th one says ‘I may try and pick up foods that do not comply with my guidelines if they are left around’

KP: Yes

OL: Do you know the reason why that was in here, in the risk assessment, why is that mentioned?

KP: Um, [he reads the pages], my from reading this now, I think it was a case of being extra vigilant, extra cautious. I don’t think there would have been anything that Teresa would have known about Marcus that would lead her to think that would happen but I can’t speak for Teresa.

OL: Next bullet says my support team should be vigilant and not leave non adapted food where I can access it, you’ve already answered to the coroner what non adapted food is. Is your understanding this applies not just in kitchen but in the whole service?

KP: This support plan?

OL: Yes

KP: Yeh, this covers eating and drinking, nothing to say couldn’t eat and drink out the house, so this is generic eating and drinking, yes

OL: I’ll ask you to turn to page 271, 7, says use a teaspoon to eat and colourful utensils from the Dementia Trust. Do you know why that is mentioned there?

KP: I honestly don’t know, sorry

OL: Who is best person to answer that question?

KP: I don’t know who you have coming, but if Teresa is coming I’d say Teresa.

OL: Thank you, two down, able to have corn based crisps e.g. Quavers, Skips or Wotsits when in good health, broken into 1.5cm pieces. Do you know why it specifies the need for breaking into 1.5cm pieces?

KP: My best guess is that was the advice of the SALT Team, but I would be speculating sorry.

OL: That’s ok. The first care and support plan we looked at mentions backslaps?

KP: Yeh

OL: This care and support plan doesn’t mention backslaps in case Marcus is choking. Do you know the reason for that direction being omitted from the most recent care plan?

KP: Would you be ok if I just read through this?

OL: Of course, take as much time as you need.

After Keaton had read the document, Oliver asked the question again and asked whether it was likely because staff had been given first aid training. I couldn’t hear his answer.

OL: 390, this is, and the next few pages are, photographs of a document. Could you explain what this document is?

KP: This document was in place before I joined Cheddar Grove. It was essentially an induction passport, aim of it was to ensure everyone had an induction that covered everything they could reasonably need to know. Or have a place to find out if they needed to know.

OL: So, each new staff starter was given one of these service induction passports were they?

KP: They were, I’m trying to remember, I think we tried to change it to make it more simple but Laura was obviously given this one.

OL: Did she start before the change?

KP: Yeh, she started on the 13 September 2021

OL: So when she started, Brandon Trust gave her this, it’s got her name on the front, couple of mentors/supervisors there, got her start date and the end date of her probation period?

KP: Yes

OL: The part about Marcus, relating to Marcus, is 397

KP: Yes

OL: And in the left hand column various documents that relate to, in this case Marcus, support plan, risk assessments, day notes, PFL files. What’s PFL?

KP: Plan for life

OL: The Brandon Trust name for care and support plans?

KP: Yeh

OL: Eating and drinking… [lists more documents, didn’t catch]. All apart from other identified needs, all the others have a date in them, apart from medications. The ones with a date, what does that indicate?

KP: So for me, that would be the date that person was first shown any of those things listed.

OL: They were shown those documents did you say?

KP: Yes

OL: Just that they were shown those documents, or any further requirement for them? In this case Laura, to read the documents or understand them?

KP: For me it would be to read it and understand it. And sign it. But the next one says date of competence and none of these are filled in.

OL: The date first shown, word you used, date of competence is the next column, assessor signs the next column. I’ll not ask you about other residents, whose names we see, but in none of these is the third and fourth column filled in. Do you know why that is?

KP: I don’t know why that is. What I’d expect to see, for some things in the left column, on the Support Plan would be an area where person would sign and date to say they understood it. For some of these, such as daily notes, it would be quite hard to sign to say you’re competent in that without doing it, if that makes sense.

OL: Umm, alright. Final bullet point says any other identified needs, it says careful with food and activities, is that correct?

KP: Yeh that’s what it says

OL: In the context of Laura, and this in relation to Marcus, what does that signify?

Long pause.

KP: Its quite hard for me to answer, I didn’t write this, I would presume that that is, whoever has written way of saying they understood the SALT Guidance and the needs to be careful with food, eating and drinking under SALT. It’s quite a vague thing.

C: Mr Lewis we do have Laura Bolus here, this witness is struggling to answer that.

OL: I understand that, but he was the Registered Manager at the time… is the purpose of signing it to flag something, Marcus specific, that other residents might not share?

KP: I would presume so, yeh

OL: Are you able to help with the box beneath that says ‘smoothies/food related activities, sensory colours, items red cup, yellow cup’ are you able to help with what that means?

KP: No, I’m sorry

OL: Right could you turn to page 477 please, this is another part of My Plan for Life?

KP: Yes

OL: In relation to support required in the kitchen, is that correct?

KP: Yes

OL: This is the latest one, reviewed January 2022, next review January 2023?

KP: Its definitely in date, so could well be, not sure. Teresa went through all of them, she may have seen this one was still in date and not updated.

OL: Bottom bullet it says, having said he enjoys spending time in kitchen, says 1-1 in kitchen should be pre-planned to ensure health and safety etc. At all other times fully supported and never left unattended in the kitchen. Do you know the reason he should never be left unattended in the kitchen?

KP: My guess he would potentially have access to things not in his SALT Guidelines

OL: Yes if you turn over the page, 4th paragraph down, is it also in relation to his cognitive impairment, ‘he is unable to properly assess risks [reads from plan] reduce hazards to acceptable and safe level’…

KP: Yes yeh

OL: So he’s not left unattended because of his cognitive impairment, he’s not able to weigh up risks?

KP: I would say so, yeh

OL: And then mid-way down it says ‘staff to encourage me to sit at the table’

KP: Rather than sit on the floor?

OL: Yes, I’ll read it out. ‘Once I realise an activity is taking place, I’ll be keen to sit up at the table and get stuck into the session’. I know you said you had limited interaction with Marcus, but you did know him, he was one of your residents. Was that your experience as well, he’d like to get stuck into things?

KP: Yeh, that was impression I got from Laura. If there was an activity, he was someone who needed to be approached for an activity to show to be engaged with it.

OL: I’ll turn my back, walk around. [He speaks with Marcus’s mother]. Thank you, those are all the questions I have.

There were no questions for Mr Pullen from Mr Hadden for UHBW, Mr Cousins for Laura Bolus, or from Mr Lindsay for SWAS. The final person to question him was Ian Brownhill, counsel for Brandon Trust.

C: Mr Brownhill

IB: Thank you, would you turn in Bundle 2 to page 405 for me please

KP: 405 did you say?

IB: Yes please. This is something called an Employee Dashboard

KP: Yeh

IB: We’ve seen one set of paper records, we’re now looking at electronic records. What are these electronic records of?

KP: The new way of doing things in HR really, this particular section looks to be supervision, or probation.

IB: You see Mr Lewis was asking you questions about forms and what was being written down, you’ve just said this is the new way of doing things in respect of HR?

KP: Yes

IB: What was the difference?

KP: The form before, the Cheddar Grove Service Induction, if that’s what you’re referring to?

IB: Yes

KP: That was a bespoke document created to be more individualised towards Cheddar Grove, and the people who live there.

IB: 405, box on wellbeing, ‘no issues, feel supported’, health and safety incidents, it says ‘you started Cheddar Grove induction, food training complete, you’ve read SALT instructions’

KP: It says that, yes

IB: Move down the page, 405 bottom of it, says, somebody says ‘Needs epilepsy training added to her list’. How has this month been ‘still slow process getting to know everyone… fitting in well [missed information]. So Laura was responsible for reading SALT plans and so on wasn’t she?

KP: Yes

IB: That was part of her supervision done by yourself and other members of management at Brandon Trust wasn’t it?

KP: Yes

IN: Thank you. On 406, Laura employed as a Support Worker, towards the bottom says ‘you have picked up extra shifts as a Support Worker when needed, this is great as it gives you an insight into the other side of the job’. Is that the support work side of things?

KP: Yeh, Laura’s day to day role was to create and facilitate sort of outgoing activities, activities essentially, but obviously she picked up shifts as a Support Worker, which would not be covering that as much.

IB: Thank you, I just want to take you finally to page 412, says SALT Marcus Hanlin?

KP: Yes

IB: Names of various staff, they sign it and then they date it?

KP: Yes

IB: What are they signing and dating here?

KP: To say they’ve read and understood whatever is at the top, in this circumstance the SALT Guidance

IB: Thank you. Those are my questions madam.

The final question for Keaton Pullen was one from the coroner.

C: Are you still employed by Brandon Trust?

KP: No

C: You’re not, ok.

The witness was released at 14:45.

The conversation then moved to timetabling.

[I’ve applied to attend court remotely this morning, that is at the coroner’s discretion. If I am unable to attend then I’ll report more next week as I am unavailable for the remainder of this week. With thanks to those supporting and funding my reporting, and reading, sharing and commenting. Comments can be left, but they are turned off until the end of the inquest].

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