John Nichols

Kings Lynn and Eastgate Residential Care Homes
Kettlewell Lane, Kings Lynn, Norfolk, PE30 1PH
Tel: 01553 769098 Fax: 01553 818704/818

www.ehguk.com

PRIVATE AND CONFIDENTIAL

Ms J Thompson

Assistant Coroner for Norfolk
69-75

Thorpe Rd,

Norwich

NR11UA

27" December 2017

Dear Madam

Regulation 28 Report: John Nichols

| refer to the Regulation 28: REPORT TO PREVENT FUTURE DEATHS dated 2 November 2017.

In accordance with ‘Section 7, Your response’, we set out below details of the action we have taken
to address your concerns set out in ‘Section 5, Coroner’s Concerns’, namely “... That the Fire Drills
Policy currently in place does not include sufficient safeguards to ensure that residents (and in
particular those with dementia) are sufficiently monitored before, during and after fire drills........ 7

Background
The key elements of the fire drill which impact on the daily routines of residents over and above the
“normal” operations of a care home are identified as follows:

The sounding of the fire alarm, which could cause distress.

2. The automatic closing of fire doors, which could cause distress. It should be noted that
automatic closing of the fire doors takes approximately twenty seconds and the risk of
physical harm is minimal. This time is based on a Doorgard being affixed.

3. Staff attending to the Fire Panel for a few minutes, which could delay attendance to
residents when requested through the call bell system.

We have also considered the sounding of the fire alarm during the weekly testing of fire alarm.
The fire drill policy of European Healthcare Group PLC currently in place states that before a fire drill,
the Home Manager is required to identify those residents that need to be looked after during the

fire drill.

Action

Kings Lynn and Eastgate Residential Care Homes
Kettlewell Lane, Kings Lynn, Norfolk, PE30 1PH
Tel: 01553 769098 Fax: 01553 818704/818

www.ehguk.com

We have taken the following steps:

1. Engaged the services of Steve Wiltshire AIFSM (“SW”), a Fire Consultant to observe and

comment on the Group’s fire drill procedures. We enclose a copy of his report for your
consideration (“The Report”).

Internally reviewed and amended where necessary the Group’s Fire Drill Procedure, the Pre-
Assessment Procedure and the Personal Emergency Evacuation Plan (“PEEP”) after carefully
considering SW’s Report and reviewing the safety of the residents.

Evaluation

1. We would make the following points regarding SW’s Report:

2.

¢ We consider that the observation of the fire drill at Bay Tree Court, another of the
Group’s homes of the same type as Kings Lynn Residential, was not a problem
because the fire procedures are exactly the same across all the homes. When the
new procedures are bedded in we will undertake an Operational audit at Kings Lynn
again.

¢ SW had seen the Regulation 28 Report prior to his visit and was aware of the
concerns.

¢ We discussed the mistakes observed during the fire drill set out in the Fire
Evacuation Record — Bay Tree Court (see Appendix 2) with SW and they were
considered minor. We will implement his recommendations.

¢ Horizontal evacuation is fully documented in the Fire Risk Assessments (“FRA”). A
copy of the FRA for Kings Lynn is attached (Appendix 3). Please note that Kings Lynn
Residential Home is a single storey building.

¢ The Personal Emergency Evacuation Plans (“PEEPs”) have been amended, see below.

e [The Fire Procedures set out by SW are already incorporated into those set out in
our FRAs. We do not call 999 until we have verified that there is a fire.]

° Residents’ bedroom fire doors are checked ona fortnightly basis to ensure that they
close and operate properly as part of the maintenance procedures at the homes.
The correct closing of doors is important at all times and not just during fire drills.

We consider that the issue of distress arising from the sounding of the fire alarm should be
raised with the next of kin at the pre-assessment stage, before the person is admitted to the
home. The alarm sounds regularly and should this cause distress, we may be unable to meet
the needs of that person. We have amended the Pre-Assessment Form to make the proper
enquiries. We enclose a copy of the new Pre-Assessment Form for your consideration (see
Appendix 4).

During the trial period of a resident stay, we will monitor their reaction to the sounding of
the fire alarm and adjust the PEEP as required. We enclose a copy of the revised PEEP for
your consideration (see Appendix 5);

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Kings Lynn and Eastgate Residential Care Homes
Kettlewell Lane, Kings Lynn, Norfolk, PE30 1PH
Tel: 01553 769098 Fax: 01553 818704/818

www.ehguk.com

4. For those residents who have already been admitted into our homes we will, over the next
few months, consult with next of kin and residents to see if they require assistance during a
fire drill.

5. [The Fire Drill Procedures have been amended to make clear that the answering of Nursecall
bells continues as normal.] Consequently, we have amended the Group’s Fire Drill Procedure
to reflect the changes to the above. This will be implemented across all the homes with the
relevant training at each site, The annual Fire Awareness update will also re-iterate the
changes made. We enclose a copy of the revised Fire Drill Procedure for your consideration
(see Appendix 6).

We would be pleased to receive your comments on the actions taken and confirmation that we have
addressed your concerns set out in the Regulation 28 Report.

Yours sincerely

Registered Home Manager

cc. or
ernard Freeman, Chief Executive Officer, European Healthcare Group PLC