“Stars Social Support Limited (1) Stars Social Support Limited have a culture which does…”

The coroner’s concerns

– Stars Social Support Limited (1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour. This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime. (2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff. (3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address. (4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones; this is especially the case 3 where there are not adequate policies in place around the use of personal phones by staff members. (5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion. (6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users. (7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited. (8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication (9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual. (10) The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date. (11) I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet. (12) I would like to see evidence of how Stars Social Support Limited will positively engage with Regulators and other bodies to enhance the quality of their services. Care Quality Commission (13) CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event. (14) CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC. (15) CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator. (16) The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no 4 evidence of harm however there is a woeful lack of detail about the context of this within the report. CQC should review this particular report for this provider and also reconsider the way in which reports are written to ensure that they are not misleading and therefore dangerous. This includes either omitting from the report any comment about harm where there is clearly a context and evidence of harm to service users previously, which is open and live, but which does not form part of the inspection or very clear confirmation in the report that there has been evidence of harm which does not form part of the specific inspection report. (17) Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0102

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0