Christopher Ajayi

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: fF Managing Director Sunrise

Senior Living Ltd.

1 | CORONER

| am John Pollard, senior coroner, for the coroner area of South Manchester.

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 7" March 2014 | commenced an investigation into the death of RHYS TUDOR
WILLIAMS dob 29™ APRIL 1927. The investigation concluded on the 3°° DECEMBER
2014 and the conclusion was one of ACCIDENTAL DEATH AGGRAVATED BY
NEGLECT. The medical cause of death was (1a) ISCHAEMIC HEART DISEASE AND
ATRIAL FIBRILLATION. (11.) ALZHEIMER’S DISEASE.

4 | CIRCUMSTANCES OF THE DEATH

On the 3 March 2014 at Sunrise Senior Living, 1 Dairy Ground Road, Bramhall,
Stockport, Dr Williams was put to bed by Carers at approximately 8.00pm. At 1.40
am he was found, deceased, between his bed and the wall. The brakes to his bed
had not been applied and there was a crash mat and a sensor mat on one side of
his bed only. _

5 | CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

1. There appeared to be a lack of training (in a number of areas) of the carers
having immediate care of Dr Williams. | was told that they should all
undertake e-learning but it was far from clear as to how (or whether) this
was monitored and checked.

2. Despite the assurances of the Managing Director, who was very frank and
helpful in her evidence, | remained far from satisfied that all the staff
members were aware of the rules relating to the positioning of the ‘profile
beds’ which are on caster wheels. Because of this lack of certainty
amongst the staff members, Dr Williams’ bed was placed, allegedly,
against the wall when apparently this should not have been the case. Are
all the staff members now clear as to the Rules relating to the positioning
of the profile beds? Is there a rule about the need for crash mats and
sensor mats on both sides of the bed?

3. | was told about the way in which Care Establishments must now assess
their clientele and based on that assessment, they should determine how
many staff members are required at any time. | remain unconvinced that a
proper assessment had taken place but in any event | was told that the
night staff members had to perform additional tasks of cleaning and
laundry. Has this assessment of the number of staff and the additional
duties to be undertaken by them, been addressed?

4. During the course of the evidence it became apparent that public money
was being sent to Sunrise Senior Living for the provision of nursing care
for Dr Williams. Whilst | accept that a nurse was present on site albeit in
the other part of the Home, this was accepted by the Managing Director as
not amounting to the provision of nursing care. The payment was
apparently ‘credited’ against the account of Dr Williams, but | am
concerned that as a result of this apparently flawed system, he was not in
fact allocated to the correct type of care. Has this system now been
reviewed and any change brought about?

5. The requirement for bed brakes to be properly applied when the staff
members are not in the room should be an absolute requirement and this
should be reinforced in writing to all staff.

6. There was an apparent failure by the staff (notably the managers who
changed on a number of occasions) to pass relevant information to their
successors, and the daughter of Dr Williams had to reiterate the same
information several times. This led to a lack of confidence by the family of
the deceased that his care needs were properly being made known to
those having care of him.

7. Following on from 6 above, the system for providing relevant information
to the relatives was flawed as the necessary files were archived and
inaccessible. Has this been changed or is it intended that it should so be?
This is relevant to future deaths, because it may hamper the ability to
ensure that the patient is receiving optimum care in the most appropriate
establishment.

8. Care notes were completed for the full period of the night shift of the 3 to
the 4" March 2014, at the beginning of that shift, i.e. before the visits had
actually taken place. This was clearly unacceptable. Has anything been
put in place to prevent this happening in the future?

9. Some members of staff were clearly under the impression that they should
not call an ambulance but should contact the nurse on site who would
then do so. This could lead to unacceptable delays in the attendance of
potentially life-saving emergency services. Has this misapprehension
been addressed?

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 9th February 2015. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons rane an (son-in-law and daughter of Dr Williams) and
Stockport MBC Environmental Health Officers. | have also sent it to The Care Quality
Commission who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You wfa} make representations to me, the coroner, at the time of your
response, aboutfhe rélease or the publication of your response by the Chief Coroner.

15.12.14 John Pollard, HM Senior Coroner

South London and Maudsley NHS

NHS Foundation Trust

Inquest touching on the death of Christopher Ajayi:
Ms Ormond-Walshe, HM Coroner

Southwark Coroner’s Court, 1 Tennis Street, London SW1 1YD

South London and Maudsley NHS FT response to Preventing Future Death (PFD) report

December 22™ 2014

Page 1 of 8

1, Introduction

The following statement has been written in response to the Coroner's regulation 28 report
to prevent future deaths (dated 30.10.14), which detailed failures identified in CA’s care,
together with a number of related concerns.

These failures related primarily around discharge planning and discharge follow up (9 in
total, 6 ‘gross’). The Coroner judged that on the balance of probabilities one or more of the
identified gross failures were linked with CA’s death by uncontrolled diabetes.

The Trust accepts the Coroner’s duty to report (under Section 5, paragraph 7) and this
statement seeks to respond to the failures identified, together with addressing the concerns
raised.

The Trust had invited the Coroner to write her PFD report specifically to our Trust in order
that we may further clarify matters of concern as lead provider for CA’s integrated health
and social care.

This response elaborates on EE witness statement (17.07.14) and oral evidence to
the Inquest, given on behalf of the Trust. This evidence covered the Trust’s expected
standards of clinical communication about collaborative discharge care planning around
mental and physical health needs, together with all the changes that have taken place in the
Trust and'the learning that has arisen from this incident.

Although requested as a sole response from the Trust, this response has been discussed
with the London Borough of Southwark, as our Local Authority partners in delivering
integrated health and social care.

2. Inquest Evidence, Summing Up and Conclusions (determination)

In considering the failures and concerns raised, the Trust was reassured that the Coroner, in
her summing up, was comforted by the internal Trust Serious Incident (Sl) Investigation and
action plans, together with the senior level interest and attendance throughout the
evidence.

The Trust is grateful that the Coroner acknowledged that lessons have been learnt through
this incident, both internally within the Trust and across interface partnership working.

The lessons are being taken forward in very positive collaborations with our Southwark
Clinical Commissioners, together with Acute, Primary and Third sector providers, particularly
with regards to supporting patients, like CA, with severe and enduring mental illness and co-
morbid physical health problems.

3. Cause of Death

The Trust agrees with the Coroner’s verdict that on the balance of probabilities the cause of
CA’s death was found 1(a) Hyperosmolar Non-Ketotic Coma (HONK), 1(b) Diabetes Mellitis
type II (Insulin dependent), Schizoaffective disorder.

Page 2 of 8

4. Neglect (rider)

The Trust also accepts that the Coroner has reached a Part 4 (Conclusion) conclusion that
the death was due to natural causes to which Neglect contributed.

5. Concerns raised in the Regulation 28 report and Trust response
5.1 Discharge Planning and Discharge Follow Up

The Trust acknowledges and agrees with the Coroner that in this specific case discharge
planning and discharge follow up fell below expected standards.

Mental and Physical Health

CA was known to have complex mental and physical health needs, with a long history of not
complying with his treatment.

As a result, his mental health after care was appropriately discharged under a Community
Treatment Order with a condition of remaining adherent with depot antipsychotic
medication.

However it was also established, but not effectively communicated, that his physical health
status and treatment had changed significantly before discharge and that an appropriate
after care package should have been put in place to reflect this.

An appropriate physical health care plan that had been instigated on the in-patient unit was
not translated into an effective and robust community physical health care plan covering
appropriate support and supervision.

Social Care and Accommodation

CA was known by both The Trust and Local Authority providers to have complex social
housing needs.

An in-Patient ADL assessment identified that CA was able to live and function independently,
assuming his mental health was stable.

However, there was a lack of effective communication and clarification between the care co-
ordinator and in-patient unit and Local Authority Housing providers regarding the exact
nature of the support and supervision any post discharge accommodation would require,
and as such CA was discharged to unsupported accommodation with no assertive
community supervision.

Action taken:

¢ The breakdown in effective clinical communication and collaborative care planning
was noted in the Trust’s SI investigation report (together with action plans) and
further acknowledged and discussed in supporting evidence given at Inquest.

Page 3 of 8

All Trust and London Borough of Southwark (LBS) staff involved in this specific case
gave evidence, learnt lessons and have been de-briefed on the Coroner’s
conclusions.

All Trust and LBS staff involved have been given reminders about the Trust Policy
guidance on effective discharge planning, clinical documentation and physical health
which are all pertinent to this case.

Prior to the Inquest, the Trust SI Investigators had met with the In-Patient and
Community Teams (March 2014) to feedback findings of the investigation.

Progress has been made from the updated action plans following the Trust internal
Sl investigation, resulting in more robust systems and structures being in place
between the Southwark in-patient and community teams.

GP registration: this is a National MHMDS quality requirement, monitored for all
Trust patients; ordinarily administrative staff within the In-Patient ward concerned
are extremely vigilant in checking all patients have a registered GP; these GP checks,
including cross reference to the NHS Spine and ensuring GP email enablement are
under constant internal monitoring.

Pre-discharge meetings: community teams are sent dates for these meetings in
advance from the in-patient team (via email) and consider these in daily team
planning meetings.

Minimum standards of contact between community and in-patient teams: this
currently takes place on average once a week, with improvement noted in overall
communication between inpatient, community and other services.

Discharge proforma (discharge notification): this is now routinely completed and
copies sent to community team/team manager on the day of discharge (compliance
is monitored through ongoing audit).

Discharge summaries: the Trust has an expectation that all patients discharged have
a summary record to their in-patient mental and physical health care, treatments
and risks (compliance in monitored through ongoing audit).

Multidisciplinary team discussions: daily review meetings, ‘zoning’ systems and
more structured weekly clinical team review meetings have been developed
ensuring effective team-based case load reviews and to improve oversight and
monitoring or individual Care Co-ordinators work.

The community team involved have undertaken two specific audits; (a) Team 7 day
follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of
two patients with unstable diabetes (Dec 2014) demonstrated extensive
communication and forward planning prior to discharge, appropriately involving all
partners.

Page 4 of 8

e Audit processes, addressed in 1:1 supervision as well as monthly Performance
meeting with Director for Community services, and Borough Community Service
Leads, including (a) 7 day follow up, (b) discharge notifications, (c) physical health
checks, (d) supervision and appraisal.

¢ Community Treatment Order (CTO) initiation at discharge: the Trust issued policy
guidance (Sept 2013) clarifying that the In-Patient Responsible Clinician (RC)
undertakes the CTO initiation, together with an Approved Mental Health Practioner
{AMHP) from the receiving community team, setting CTO conditions that have
previously been discussed with the receiving community RC.

e Trust Board Level feedback: Senior Trust staff have been extensively briefed both in
preparation, during and after this Inquest; concerns raised have been acknowledged
and taken forward, particularly around the area of planning, instigating and joint
working partnership arrangements for patients with severe mental health problems
and co-morbid (serious) physical health problems.

5.2 Care Co-Ordinator: Roles and responsibilities

The Trust acknowledges that the Care Co-ordinators role supporting patients suffering from
severe and enduring mental health problems is a challenging and vital role in effective
delivery of integrated health and social care.

Staff are required to be highly qualified (Band 6 grade and above), trained and supported to
undertake their duties; all Care Co-ordinators have comprehensive induction to the role,
including the statutory expectations for both health and social care and additional training is
offered, tailored to their specific needs.

All care co-ordinators within Trust community teams work within a Multidisciplinary (MDT)
setting; 1:1 clinical and performance supervision is provided by the community Team Leader
(average monthly; more frequent as required), with the expectation that Care Co-ordinators
additionally update other team members on important developments for individual patients
at both morning handover meetings, weekly clinical MDT clinical reviews and regular CPA
community reviews.

Team Leaders within community teams have a Co-Leadership role with the Consultant
Psychiatrist in overseeing the clinical care for all patients under the teams care; their role is
also to allocate patients to individual Care Co-ordinators, delegating responsibility to closely
manage those individuals under the Care Programme Approach (CPA) framework and
monitoring this process under 1:1 supervision.

All staff employed by the Trust are professionally accountable to the Trust and their
Professional regulators; they have a responsibility to escalate any concerns through the
supervision process and MDT structures and are made aware of this at induction and
through the supervision process.

Actions taken:

Page 5 of 8

Trust revised Supervision policy (Sept 2014); this recent policy update which covers
Trust and LBS staff, has been sent out to all staff and available on the Trust intranet
for reference, sets out clear expectations of staff supervision, recognising effective
supervision as an integral aspect of the working lives of all NHS clinical and social
work staff to support them to deliver the best care to patients and their carers,
provide opportunity to develop as competent parishioners and to develop their
skills.

Trust expectations of Band 6 Mental Health Practitioners and Social Workers are
consistently raised through supervision, and regular supervision for all staff is
constantly monitored.

Staff mandatory annual training is centrally monitored.

Performance concerns are managed through regular supervision, increasing the
frequency of supervision as required; annual appraisals of competencies, training
and support needs are closely monitored for compliance with Trust expectations

Individual failings identified in this case are being robustly managed under the
Trust’s performance management framework.

Case load management: Southwark community psychosis teams have active case-
loads between 250-300 patients, resulting in average Care Co-ordinator case-loads
of 25-30; the Trust continues to work with stakeholders in Primary care and the
Third sector to develop capacity within the active case load, aiming ideally to reduce
the average Care Co-ordinator case load to facilitate enhanced delivery of evidence
based interventions; case loads are monitored on an ongoing basis, both within 1:1
supervision, and across the community as a whole.

5.3 Trust Safety Net beyond supervision

The Trust has clear Policy guidance (acknowledged by the Coroner) around standards of
clinical communication (verbal/written) between (a) In-patient to Community (handover of
secondary care mental health responsibilities), (b) In-patient to Acute (KCH) to ensure
effective interface working around Physical Health care, (c) In-patient to Primary Care (GP:
Practice & District Nurses) in appropriately transferring for physical health clinical
responsibilities and (d) the Trust and Local Authority (under $75 responsibilities) for
delivering integrated health and social care.

Actions in process:

Clinical Commissioning: the Trust is currently involved in discussions with Southwark i
Clinical Commissioners with respect to changing the emphasis of services

commissioned, embedding principles of the Trust Adult Mental Health model
{recently introduced in Lambeth and Lewisham boroughs) including teams i
undertaking more structured clinical reviews and developing robust systems to
improve collaborative interface working with in-patient services, crisis services, local i

Page 6 of 8

authority and the third sector; the Trust expects to hear from the Southwark CCG in
early 2015 about their intentions. :

King’s Health Partners Physical Health developments; the Trust has an appointed
Physical Head Lead who is actively engaged in King’s Health partnership discussions
and developing service level agreements (SLAs) with our Acute and Primary sector
partners.

ICT harmony: there have been significant developments in increasing mutual access
between the Trust and Acute electronic patient record systems, with the
development of an ICT ‘Portal’ to review key clinical information; further
developments are underway to link these secondary care systems with Primary care
ICT (EMIS) systems; this work is further being supported by the Southwark CCG.

MDT Physical Health leads within community MDTs: teams are being encouraged to
identify and support individual team staff members to lead on developing support
for patients to engage with the assessment, treatment and support around their
physical health.

Commissioning intentions (2015/16); appropriately supporting community patients
to manage their physical health are being prioritised in the next round of CQUINs;
there is a range of collaborative initiatives including consideration of pilots with GPs
undertaking outreach clinics in community team bases to increase the numbers of
patients receiving appropriate physical health assessments, investigations and
interventions.

Southwark Diabetic services; discussions are underway to scale up the award
winning Diabetic Liaison service currently running at KCH to assist patients with
severe mental health disorders, with additional training being developed for
community mental health staff.

Community District Nurses: the Trust is working with our partners to ensure District
Nurse provision to ensure safe community diabetes management.

Partnership working around social care and support: discussions are currently
underway reviewing housing and community support needs for patients to
appropriately address physical health care once living independently in the
community

Additionally, there is a further Serious Case Review underway, managed through the
Safeguarding Adult Partnership Board, which will further understand the issues
raised by this case and develop our learning.

Page 7 of 8

6. Governance

Robust discharge planning and follow up and support to care coordinators are supported by
the actions outlined in this report. However, the Trust will undertake an audit in March 2015
to assure itself and partners that implementation has been effective.

The audit results will be reported and reviewed by the Trust Adult Safeguarding Committee
and the London Borough of Southwark’s Safeguarding Adults Partnership Board, and with
final review and sign off by the Trust Board’s Quality Subcommittee.

7. Conclusion

This report has set out a range of actions already under taken by the Trust and further action
proposed that seeks to address the concerns raised by Coroner’s conclusions issued in her
PFD report.

The Trust acknowledges that important lessons have been learnt from this specific case that
are being taken forward in improving integrated working; the Trust is otherwise confident
that there is no systemic problems with regard to discharge and community follow up of
similar patients with complex mental and physical health problems.

22.12.2014

Page 8 of 8

SUNRISE
SENIOR LIVING

JOY OF EVERY DAY

3" February 2015 THE

Mr Pollard

Coroners Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Sir

Please find below the response to your request for information relating to the Regulation 26 Report
for Dr Rhys Williams.

There appeared to be a lack of training (in a number of areas) of the carers having immediate care
of Dr. Williams, | was told that they should all undertake eLearning but it was far from clear as to

how or whether this was monitored and checked.

All staff working in Sunrise Senior Living are required to complete training appropriate to their job
role upon induction and at specific refresher dates if not identified before.

in relation to training on bed placement and safe use of profiling beds {including using brakes on such
beds), we now have incorporated this into our manual handling training which is mandatory for all
care and nursing staff. Compliance is monitored via manual handling training compliance reports,
which are reported weekly to the business. Any concerns on compliance are acted upon by the

Director of Operations.

The company’s training programme consists of a combination of eLearning modules by an
accredited provider, bespoke in-house classroom learning delivered by qualified trainers, and
practical assessments to check competency together with completion of workbooks to confirm the
that staff understand their role and responsibilities in caring for residents.

Training of all our team members is monitored and reported with full access provided to our
managers to ensure compliance of their teams’ training.

In any complex cases where reasons are identified for placing a bed against a wall despite the
resident being at risk of falls, a Regional Training Officer now attends homes to provide face to face
training to support the home and ensure the safety of the resident.

Despite the assurances of the Managing Director, who was very frank and helpful in her evidence,
| remained far from satisfied that all the team members were aware of the rules relating to the
positioning of the ‘profile beds’ which are on caster wheels. Because of this lack of certainty
amongst the staff members, Dr. Williams’ bed was placed, allegedly, against the wall when
apparently this should not have been the case. Are all the staff members now clear as to the Rules
relating to the positioning of the profile beds? Is there a rule about the need for crash mats and

sensor mats on both sides of the bed?

Sunrise Senior Living Limited

2 SUNRISE

SENIOR LIVING
If a person is at risk of falling from the bed and does not have bed rails, there is a clear general rule
that beds will no longer be placed against walls and will have crash mats and sensors on both sides
of the bed. This has been clearly communicated to staff across the group. Exceptions will be rare but
may include cases where the resident has capacity and insists on the bed being placed against the

wall. Any such cases will be fully risk-assessed and, as explained above, will involve the input of a
regional training officer.

A blanket ban against placing beds against walls for those who are not at risk of falls is not
proportionate. However, all staff are trained regarding the safety issues of placing beds against
walls. This is now included in our moving and handling training and as such every carer and nurse
team member is trained on an annual basis. Similarly there is not a rule of a need for sensor or crash
mats on the side of each bed as this would be unnecessary for many residents who may be at low risk
of falls. Risk of falling is assessed on admission and monthly at a minimum thereafter. As explained
above, however, crash mats and sensor pads are now placed on both sides of the bed when a

resident is at risk of falling unless exceptional circumstances apply.

We also now monitor the number of beds placed against the wall on a monthly basis. This data is
monitored by the Care and Quality team which liaises directly with homes where concerns may be
identified. Such concerns included particularly high or low numbers, upward trends or statistics that
do not match visual checks. Any concerns or queries are addressed as an immediate and urgent
matter by the Care and Training Support Nurses. The care team then addresses any inappropriate
locations of beds and supports homes to ensure beds are located in the safest possible position. The
data will also be shared at the company Health and Safety Meeting every quarter.

| was told about the way in which Care Establishments must now assess their clientele and based
on that assessment, they should determine how many staff members are required at any time. |
remain unconvinced that a proper assessment had taken place but in any event I was told that the
night staff members had to perform additional tasks of cleaning and laundry. Has this assessment
of the number of staff and the additional duties to be taken by them, been addressed?

Staffing levels are based on an evidence-based model, determined by how much care and support
residents need, The care team at Bramhall and throughout Sunrise Senior Living are not required to
provide laundry and housekeeping duties in their entirety, but rather a small proportion. The laundry
and housekeeping hours for each Sunrise Senior Living home are calculated per resident and are
added to the hours of care needed by residents, Staff are required to respond to the residents’ needs
first, and at no time have they been instructed to ignore these in place of delivering domiciliary
duties. It is however considered reasonable to use any quiet time throughout the 24 hour period to
support the residents with their laundry or by cleaning or tidying their personal spaces. This is
standard practice across the care sector. Housekeeping and laundry teams are hired in every Sunrise
home to manage the bulk of the domestic cleaning and commercial laundry.

During the course of the evidence it became apparent that public money was being sent to Sunrise
Senior Living for the provision of nursing care for Dr. Williams. Whilst | accept that a nurse was
present on site albeit in the other part of the Home, this was accepted by the Managing Director
as not amounting to the provision of nursing care. The payment was apparently ‘credited’ against
the account of Dr. Williams, but | am concerned that as a result of this apparently flawed system,
he was not in fact allocated to the correct type of care. Has this system now been reviewed and

any change brought about?

3). SUNRISE |

SENIOR LIVING
The accounts team now provides information about who is receiving FNC each month to the
Operations Director for those homes. Each Operations Director manages approximately nine homes.

As part of their monthly reviews, they check with the managers of each home that those listed as
receiving FNC do in fact receive nursing care.

We now also run a monthly companywide report to compare the number of nursing hours in each
home against the number of residents receiving FNC. Where there is a noted disparity, enquiries will

be made by the operations team.

It should be emphasised that in the vast majority of cases, the manager of the home will be involved
in any assessments or reassessments of residents and will know which residents are eligible for
nursing care. However, these new systems have been put in place to manage those few cases where i
for whatever reason, the NHS has not communicated directly with the home.

The requirement for bed brakes to be properly applied when the staff members are not in the
room should be an absolute requirement and this should be reinforced in writing to all staff.

This is now a key part of the bed safety training which is included in manual handling training for all
care & nursing staff. Further details about monitoring compliance with and effectiveness of, training |

is addressed above.

There was an apparent failure by the staff (notably the managers who changed on a number of
occasions) to pass relevant information to their successors, and the daughter of Dr. Williams had
to reiterate the same information several times. This led to a lack of confidence by the family of
the deceased that his care needs were properly being made known to those having care of him.

Following on from 6 above, the system for providing relevant information to the relatives was
flawed as the necessary files were archived and inaccessible. Has this been changed or is it
intended that is should so be? This is relevant to the future deaths, because it may hamper the
ability to ensure that the patient is receiving optimum care in the most appropriate establishment

We have undertaken a full review of our Care documentation. The revision proposes that when care
plans are updated, all information will carry forward to the new plan. That includes all information
obtained from all sources since the fast update. This will remove the need for repeated
communication of contact and background information when the new assessment is released. We
had already commenced the process of contracting with an external archiving organisation which
will enable a far more robust process of storing and retrieving residents’ historical documentation.

Care notes were completed for the full period of the night shift of the 3" to the 4 March 2014, at
the beginning of that shift, i.e. before the visits had actually taken place. This was clearly
unacceptable. Has anything been put in place to prevent this happening in the future?

Repositioning charts used in the company are clear in that they require the team to complete once an
episode of care has been given. The Director of Operations disclosed immediately and without
request, prior to external scrutiny, that there appeared to be breach of process regarding this
particular care note discrepancy. The individuals responsible were suspended, interviewed formally
and the responsible person dismissed once this breach of process was confirmed. A communication
has been sent to all staff outlining clearly the expectations of Sunrise when completing these forms.

SUNRISE

SENIOR LIVING

4]...

Some members of staff were clearly under the impression that they should not call an ambulance
but should contact the nurse on site who would then do so. This could lead to unacceptable delays
in the attendance of potentially life-saving emergency services. Has this misapprehension been

addressed?

A communication has been sent to staff (with instruction to be discussed and signed for at handover)
that the emergency services must be called by the person discovering the incident if the situation
warrants it, and to clarify that there is no need to delay this process by finding the nurse. To ensure
that this communication is embedded into the organisation it has been added to the General
Managers’ training which is in turn delivered to all team members as they join Sunrise.

Yours sincerely

Managing Director
Sunrise Senior Living UK