Lesley Hanson

Professor Chris Jones _
Dirprwy Brif Swyddog Meddygoi _ aa\
Deputy Chief Medical Officer

Llywodraeth Cymru
Mr P C Spinney Welsh Government

Area Coroner for South Wales Central
The Coroner's Court

Central Police Station

Cathay’'s park

Cardiff

CF10 3NN

15 December 2017
Dear Mr Spinney
Regulation 28 Report to Prevent Future Deaths — Lesley Hanson

Thank you for your letter enclosing your Regulation 28 report following your investigation into
the death of Lesley Hanson.

Since the sad death of Ms Hanson a number of changes have been introduced. Codes of
practice to assess and meet the needs of individuals with care and support needs have been
issued. These codes underpin the Social Services and Well-being (Wales) Act 2014, which
provides the Welsh Government’s statutory framework for improving the well-being outcomes
for people who require care and support. The codes set out a local authority's duty to assess an
individual’s eligible need for care and support and what those needs are. They provide clarity
on the assessment process and underline its purpose is to work with an individual, carer, family
and other relevant individuals to understand their needs, capacity and resources and the
outcomes they wish to achieve. The support must then be identified to achieve the specific
outcomes.

In the case of an adult who lacks capacity the codes set out the expectation the assessment
and review processes must involve any person authorised to make decisions about the
individual under the Mental Capacity Act 2005. Assessments must take account of an
individual’s capacity to engage in the process and make the necessary arrangements to ensure
where this is impaired, their needs and wishes are understood and are taken into account.
They must also recognise the reality of fluctuating needs and capacity and be responsive to
changing circumstances.

Any resulting care and support plan must be developed in partnership with the individual
concerned to ensure an agreed understanding of how the needs will be met and the personal
outcomes to be achieved. Local authorities should work with local health boards to agree
arrangements across the health board footprint area. A local authority must keep care and
support plans under review to ensure eligible needs and agreed outcomes are continuing to be
met.

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‘SAO Ffon/Tel: 029 2082 3914
BUDPSODDWRMEWNEOBL Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ
INVESTOR iN PEOPLE

Ebost/Email:PSChiefMedicalOfficer@wales.gsi.gov.uk

| hope you find this response helpful.

Yours sincerely
Chard

PROFESSOR CHRIS JONES

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My ref: PO/RU L Ae

14 March 201 ‘ pw
Mr P Spinn S

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"AERDYDD

Paul Orders

Chief Executive

Area Coroner rdiff) Prif Weithredwe
HM Coroner's Court .

. . . County Hall
Cardiff Central Police Station Cardiff, CF10 4UW
Cathays Park Tel: (029) 2087 2401

, Fax: (029) 2087 7081
Cardiff E; Paul. Orders@cardiff. gov.ule

Neuadd y Sir

Caerdydd, CF10 4UW
Ffon: (029) 2087 2401
Bfacs: (029) 20877081
E: Paul. Orders@caerdydd.gov.uk

www.cardiff.gov.uk
www.caerdydd.gov.uk

Dear Mr Spinney,

| write further to my correspondence of the 29" January 2018 and provide below a
response to section 6 of your report that details actions which should be taken by the
Council to prevent future deaths.

Since the tragic death of Lesley Hanson on the 13 March 2016, there has been an
extensive review undertaken by the Council which has resulted in improvements to policy
and processes involving council staff, services and our partners in Abertawe Bro
Morgannwg University Health Board (ABMU). The improvements made have been
communicated to the Health and Safety Executive and address the following actions
raised in your Regulation 28 Report:-

(1) Consideration should be given to reviewing the process of assessing risk to service
users in respect of the suitability of stairs and stair-gates in supported
accommodation schemes.

(2) Consideration should be given to reviewing the approach to risk, supervision and
control in supported living schemes to ensure clear guidance on roles and
responsibilities to ensure residents safety.

The various supporting documents referenced, although not included due to their volume
are available should you wish to review them. If particular documents are deemed worthy
of explicit consideration, | am happy to arrange for copies to be provided to your office for
your consideration.

1. Improved Risk Management Processes

1.1. Where a person is identified as requiring supported accommodation a
referral form is completed. This form was redesigned to ensure that all relevant
risks are captured. A supporting flowchart allows for all professionals involved to
identify what actions are required at each stage of the process. The use of a
‘Compatibility Criteria Checklist’ reinforces the need to consider physical
disabilities and or medical conditions, aids/adaptations, environment and risk
management.

1.2. Where a person is already residing in supported accommodation, it is the
responsibility of the Senior Support Worker to notify the Supported Living
Coordinator and Case Manager if a person’s needs have changed. This is done
either as part of the formal annual review process or more frequently if required in
individual circumstances.

1.3. Where assessments for environmental controls are required, the Senior
Support Worker (or delegated member of staff) will complete a referral form and
forward to ABMU Learning Disability Health Team or the Cardiff Communities
Occupational Therapy Team (CCOT) depending on the nature/size of the work
requested. A ‘Referral Pathway’ flowchart has been designed to ensure
consistency of process. This flowchart has been subject to consultation with the
ISL Manager Supported Living Coordinator, Learning Disability Social Services
Team Managers, ABMU Health Team Manager and Cardiff Occupational
Therapists.

1.4 The new Referral Pathway protocol reflects changes in process to ensure
clarity of roles and responsibilities across ABMU Learning Disability Occupational
Therapy staff, Cardiff Community Occupational Therapy Team, Case Managers
and the Registered Social Landlord. The final protocol has been agreed and signed
off by all parties.

4.5. Assessments for environmental controls are undertaken by ABMU health
colleagues for minor adaptations. Larger structural changes are undertaken by
Cardiff Communities Occupational Therapy Team (CCOT). The protocol stipulates
that where specific requests relate to stairgates a joint occupational therapy
assessment will be conducted.

1.6 To ensure that the protocol remains suitable for purpose, it has been and
will continue to be reviewed at least annually.

1.7. As a result of the fatal incident ABMU Learning Disability Occupational
Therapist has developed a Stairgate Factsheet and an Assessment Tool. These
documents identify that as far as can be ascertained (after extensive searches)
there is no specific guidance (from an appropriate Statutory Regulator) on use of
stairgates for adults. They have therefore been developed having regard to good
practice and advice provided by professional bodies in order to provide a thorough
checklist for staff that are undertaking assessments. These documents have been
consulted with Cardiff Communities Occupational Therapy colleagues, the
Supported Living Co-ordinator and Cardiff Council's Operational Manager for
Health and Safety.

. Review of Supported Living Accommodation in Cardiff City Council

2.1. In addition to the work completed by health colleagues, a comprehensive
review of Internal Supported Living (ISL) was undertaken between April and July
2016. An ‘Enhanced Monitoring Form’ was designed in collaboration with Cardiff
Council's Operational Manager for Health and Safety, to ensure that the scope and
breadth of the review was sufficient to identify and address any potential health
and safety risks.

2.2 Learning Disability Case Managers visited each scheme in the Internal
Supported Living (ISL) service and commenced a comprehensive monitoring
review using the ‘Enhanced Monitoring form’. As part of each visit, the Case
Managers also scrutinised relevant documents and paperwork pertaining to the
individuals. The visits were thorough and took on average 3 hours, with ISL staff
having to ensure in advance that files and documents were accessible to be
viewed. In total 29 visits were undertaken.

2.3. Based on the results of these reviews, the Supported Living Coordinator
compiled a report for the Director of Cardiff Social Services including actions for
each scheme. The actions were recorded in an ‘Action Tracker Spreadsheet’ for
monitoring and review purposes. The Supported Living Coordinator now meets the
ISL manager every 8 weeks. This was initially set up to update the tracker
spreadsheet. The tracker noted progress made against actions identified for the
schemes and actions identified for the organisation. Following the completion of all
actions, the meetings have continued to ensure ongoing monitoring and discussion
of any new concerns identified. The Learning Disabilities Operational Manager
responsible for the'monthly supervision of the Supported Living Coordinator and
ISL manager has formal oversight of the tracker and has formal oversight of
compliance.

2.4 In addition to the ‘Action Tracker’ the following changes have also been
made as a result of the review:

* A standardised ‘Positive Risk Assessment and Management Policy’ for alt
of Adult Services has been developed. The policy framework developed to
support this has been taken from Health and Safety legislation and is set
within the context of the Social Services and Well Being Act 2014 — using
Strength’s based approach rather than a deficit model — promoting
appropriate risk taking balanced against adult safeguarding.

Relevant Corporate Council Officers, confirmed that the policy appropriately
links to Corporate Health and Safety requirements and sits comfortably
within the Council's overall risk management framework; so there is a robust
and audited structural connection that links what Sacial Services are doing
at a Directorate level, with corporate and national legislative requirements,
have endorsed the policy.

e Amore robust risk assessment process has been implemented in Internal
Supported Living. Members of the Multi-Disciplinary Team contribute to the
Risk Management Plan. It is not signed off, until all members agree. Risk
assessments are on the staff supervision agenda as a standing item and
the team meeting agenda for discussion.

e Improved training and continuous professional development opportunities
for staff at all levels. Provision of specific courses to meet the needs of staff
working in supported accommodation.

* A new training matrix has been developed in collaboration with Business
Support, to assist with the recording of staff training providing alerts when
training is due.

« Methods of recording have improved. All communication/staff information
books are presented in a double page format and now include ‘Action’ and
‘Outcome’ sections, so that there is an accountability trail for seeing through
a particular directive/message.

e Improved supervision agenda for Support Workers allows managers to
follow a more structured agenda, where performance can be monitored
more effectively and directly relates to objectives set within Professional
Performance and Development Reviews (PPDR's).

e Improved and more thorough completion of Best Interest paperwork,
assisted by the attendance of staff at Mental Capacity Act training.

e Introduction of agile working and laptops for Senior Support Workers.
Senior Support Workers are now able to access emails whilst they are at
an individual's home (and not on ‘hands on’ duty). This means they can
make referrals; complete Risk Assessments/Capacity and Best interest
paperwork and share relevant information that needs an immediate
response, rather than have to wait until they are next in the office to
complete vital paperwork. In addition, laptops will be located in all
supported living schemes to facilitate the completion of assessments,
involving the clients fully in the process.

e Reinforcing a ‘pro-active’ culture, as opposed to ‘reactive’. Although this is
difficult to quantify, managers and staff alike have reflected on ‘lessons-
learned’ and have drawn on previous experience, to help shape how we
deal with situations that may arise. The fact that risk assessments are a
standing item on the agenda for team meetings provides an opportunity for
people to continue to reflect on safe practice.

3. Risk Management Controls — Ensuring they are Suitable, Effective and
Maintained

3.1 The Internal Supported Living Service (ISL) has a prescribed system of
checks for which all senior support staff are trained by the Compliance Officer,
Housing and Neighbourhood Renewal. These are recorded in the ‘Fire, Health and
Safety and General Maintenance Log Book’. in.addition to this, a comprehensive
monthly 'Health and Safety Checklist’ has been enhanced in collaboration with
Cardiff Council’s Operational Manager for Health and Safety. This includes
reference to stairs and stair gates with additional prompts to staff regarding specific
issues to consider. :

3.2. Case Managers ‘Enhanced Monitoring Tool’ has also been developed in
consultation with the Operational Manager for Health and Safety. This provides an
additional layer of monitoring, carried out on an annual basis, to complement the
day-to-day and monthly monitoring outlined above.

3.3. The Occupational Therapy ‘Assessment Tool’ makes clear reference to the
importance of reporting faulty equipment and reviewing equipment and the process

to follow if this occurs and is underpinned by Standard 32 of the Welsh Government
Guidance Document, ‘Community Equipment Services, The Introduction of
National Minimum Standards (2011)

4. Training for Staff involved in Assessing the Risk from the use of Stairs

4.1 Cardiff Council Training Academy commissioned ‘Health and Safety Laboratory’
{a division of HM Health and Safety Executive) to deliver training to fifteen key
health and social service staff on the 19!" January 2017. The training was
commissioned as a direct result of the review following the fatal incident that
occurred within supported accommodation. The training helped Officers
understand the design features of stairs, which can give rise to a risk of falling,
and to identify simple remedial improvements to reduce the likelihood of a fall,
and included:-

«How to undertake a stair fall assessment

* Common design issues that give rise to a risk of falls on stairs

« Examples of HSL stair investigations and the findings

« Simple tools for assessing common stair features (stair assessment
tools will be provided to take away as part of the training)

4.2 The training provided’ staff with the knowledge and skills to assess basic stair
safety in supported living accommodation, enabling them to identify examples of
good and bad practice. This will allow appropriate changes to working practices
and the work environment to be considered and planned having regard.to risk
and all relevant matters.. We are now exploring options to deliver ongoing training
for appropriate staff in a sustainable way.

The processes set out in the report above are overseen by the Operational

Manager of Learning Disability Services in their role of Responsible Individual for the 14
houses managed by the Council. The Council has taken into account the new regulations
within the Regulation and Inspection of Social Care (Wales) Act 2016 and the role includes
oversight of health and safety and accountability for determining assurance arrangements
and setting benchmarks within the service. The Operational Manager is responsible for
ensuring the processes regarding risk, supervision and controls in supported living are
monitored closely and any concerns identified and acted on.

| hope the response provided adequately addresses the actions required of Cardiff City
Council as detailed in the report pursuant to Regulation 28.

Yours sincerely

Fo. [

Paul Orders
Chief Executive
Cardiff Council