Frederick Brooker

, Cf q So 6tre .

Se

Walthamstow Coroners Court
Queens Road

Walthamstow

London

E17 8QP

File RSN: 9075
10 May 2019
Re: Mr Brooker - Bakers Court

Dear Miss Persaud,

| write to inform you of the actions taken at HC-One in @spenselOlVOUnREOUIGISRIZareporto

prevent future deaths.

Please find enclosed an action plan, which has been implemented at Bakers Court to address
the concerns you highlighted [Exhibit 1].

Since the date of Mr Brooker's death, HC-One has undertaken a lot of work internally on the
topic of falls and increased its focus on falls awareness and prevention. In particular, efforts
have been made to improve falls awareness across the organisation, minimise falls so far as
possible and to ensure the appropriate management of falls across the organisation.

Regrettably, it is not uncommon for older people to experience a fall, for a variety of reasons.
Such falls cannot always be prevented but as an organisation we are committed to supporting
people to maintain their safety wherever possible and to ensure that our Colleagues respond
appropriately in the event that a fall does occur.

HC-One is committed to enabling Residents to live a full and active life. We embrace the
concept of keeping Residents as independent and as mobile as possible whilst minimising the
tisk to their health, safety and welibeing.

a. Multi-factorial Risk Assessments

It is important to identify all Residents who may be at a risk of falling and as such,
thorough assessments should be conducted. A Multi-factorial Falls Risk Assessment
[Exhibit 2] will inform the development and implementation of a daily plan of care.
The risk assessment that is used in HC-One has ail of the factors indicated through
the National Institute for Health and Care Excellence (NICE).

HC-One

701325 351100 F 01325 351144

Correspondence & Registered Office: Southgate House, Archer Sireet, Darlington, County Durham, DL3 6AH

Registered in England and Wales: HC-One Limited, registration no. 07712656: Meridian Healthcare Limited, registration no. 01952719;

HC-One Beamish Limited, registration no. 05217764; HC-One Oval Limited, registration no. 10257888; RV Care Homes Limited, registration no. 07417290.

The falls guidance, risk assessment, policy and guidance has been developed using the Care
Inspectorate guidance, "Managing Falls and Fractures” and this has been implemented widely
across the UK.

All Residents must have a full and comprehensive Falls Risk Assessment completed prior
to admission. Residents identified to be ‘at risk’ on the Pre-Admission Assessment, must
then be re-assessed on admission in their new environment.

At HC-One we consider any risk within the Multi-factorial Risk Assessment as a potential
reason for people to fall and as such requires to be managed. It is clearly recorded on the
risk assessment that if any risks are identified then a Falls Care and Support Plan needs to be
developed.

Residents identified as having any of the factors that are considered to be a risk must
have a full review on a monthly basis, or more frequently as the Resident’s condition
dictates.

Our policies are clear that a new assessment must be completed following a fall
and/or if the physical or psychological condition of the Resident changes.

A plan of care must be in place for mobilising, including the use of mobilisation aids.

“ The use of walking aids and other equipment should be considered, after assessment
by a physiotherapist or occupational therapist where a potential risk has been
identified.

The use of assistive technology should be considered where appropriate. This can
include call mats, seating and bed sensors, room sensor beams, low beds, anti-roll
maitresses or non-standard equipment, which is recommended by external
professionals.

All assessments and reviews must be fully documented and recorded in the Resident’s
care file.

Our Risk Assessments will identify predisposing factors, which may lead to falls, such as
the use of a wheelchair which requires the use of lap straps.

b. Post Fall Protocol

Following a fall, immediate action must be taken to ensure the safety and comfort of
the Resident. Staff must not leave the Resident unattended and immediate assistance
should be summoned. It is important that the Resident is assessed and examined
promptly to see if they are injured. This will help to inform decisions about safe handling
and ensure any injuries are treated in a timely manner.

Our policies are clear that all falls must be properly recorded and investigated.
As soon as possible, after the fall, an incident report should be logged on our Datix

incident reporting system. The incident report should be comprehensive and give a
clear picture of what happened and what immediate action was taken.

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The incident must be investigated in order to identify what happened, how it happened and
why it happened. The intention is to learn from the incident and take action in order to
reduce the likelihood of further fails and/or minimise the risk of harm in the future. Care plans
and tisk assessments will be reviewed and reformulated as necessary.

Particular attention should be given to Residents who have experienced more than one fall in
a week or more than three in a month. The more falls a Resident has had the greater the falls
risk.

Even if a fall is minor and causes no injury, it is our policy that the Home Manager must still
investigate and try to prevent it happening again.

A Post Fall Protocol Flow Chart [Exhibit 3] is available and provides useful at-a-glance
guidance for staff teams to remind them of the steps to follow after a fall. In order to
ensure compliance with the process, a checklist has been developed to provide
prompts fo the care home team on documentation and process [Exhibit 4] and to
ensure that our staff teams are actively thinking about each of the actions required
after a fall.

c. Trend analysis

Datix can be utilised in order to carry out trend analysis. An analysis of falls will help
Home Managers to identify any trends and any areas of concern to target, from which
they can take suitable action. They can also monitor whether the preventative actions
they have taken are having the desired effect in reducing the number of falls and the
harm caused following a fall.

Home Managers are able to analyse the falls of a particular Resident or look at alll falls
ina home. Datix can show many things, including where falls are happening, their
location, the time of falls and the level of harm caused. For example, a fall analysis
may identify that many falls are taking place in a particular location around the same
time of day. Home Managers are encouraged and supported to use these tools.

d. Review of care practices, specifically relating to falls

Following any incident that has affected Resident health or well-being, an incident
record must be uploaded onto the Datix system. This system captures any untoward
event that occurs, whether it causes harm or not — predominately this is falls, ill health,
medicine errors, safeguarding and complaints.

Once the incident is entered on Datix, the appropriate area and specialist teams are
notified and depending on the nature/severity of the incident, this will advise who will
undertake the investigation.

Falls are reported at group level, area level, home level and finally to Resident level

through our internal reporting systems where we can ultimately see how the individual
Resident's care is supported.

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At home level there is a three monthly full audit of falls, including falls team meeting and a
monthly review through the Key Clinical Indicators report, which will identify key high risk
Residents for the home to follow up on, and as part of the Resident of the Day monthly review
process the care plan will be checked. We have implemented a monthly clinical review
where falls are a key part of the review with the senior team at home level — the Area Quality
Director supports with this and monitors outcomes.

At area level, the Area Director/Area Quality Director's review falls as part of their
home visits and our internal inspection team of Quality Regulation Managers review
this on their inspection visits. We believe that the governance around falls
management broke down through poor reporting and have looked at re training and
shared learning for the home team and manager's with oversight to drive this forward
to improvement.

Falls and serious incident trends are discussed quarterly at the Quality Governance
Group comprising members of senior management and lessons are shared across the
organisation.

We continually review the NICE guidance in relation to falls and implement new
technologies to support Residents.

e. Further support

All of the falls processes have been summarised onto one page documents called
“Here's How To...”. These are available to all care teams and will be reviewed twice a
year [Exhibit 5].

The Clinical Quality Team supports with falls root cause analysis for any fracture or
serious injury sustained following a fall. They support with the investigation and
outcomes, and report back through the quality governance structure.

Where any shortfalls in individual practice or non-compliance with the process are
identified, this will be followed up and appropriate actions taken.

Falls training is provided to all direct care teams in the form of an online module and
face to face falls awareness training sessions.

Actions and oversight by the company is ongoing in respect of the above matters, to
ensure ongoing compliance with company expectations.

| do hope this information is helpful and offers you the reassurance that we, at HC-One,
have taken the issues raised very seriously and have taken appropriate action with the
intention of improving the care and safety of our Residents.

Yours sincerely,

een a 7 fh -

Head of Quality and Regulation
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