Dorothy Pegg

Abbeyfield The  Dales  Ltd. 
Grove  House,  12  Riddings  Road,  llkley,  LS29  9SF 

Abbeyjield 

infoabbeyfieldthedaIes.co.uk  www.abbeyfieldthedales.co.uk 

Mr J  Heath, 
Senior Coroner York  and  North Yorkshire 
The  Old  Courthouse 
3  Racecourse  Lane 
Northallerton 
DL7  8QZ 

10th  December2021 

Dear Mr Heath 

Regulation  28:  Report to  Prevent  Future  Deaths 

I  write  in  response  to  the  concerns  you  raised  following  the  inquest  into  the  death  of  Mrs 
Dorothy Pegg,  and  your conclusion from  the evidence you  heard  during the  inquest. 

I  write  to  formally  respond to  the following  concern  raised  on  behalf of Abbeyfield the  Dales: 

There  was  no  system  of monitoring  the  compliance  with  instructions  as  to  how  equipment 
should be used. 

In  the statement I  provided to the  inquest,  I  was keen to demonstrate the Abbeylield The Dales 
has  a  continuous  review  process  in  developing  and  improving  policies,  procedures  and 
practices  within  our  organisation.  Our  aim  always  is  to  promote  a  person  centred  and  safe 
approach to  the support and  care we  provide for our residents. 

This  process  has  continued,  and  I  can  confirm  the  following  additional  improvements  have 
been or are  planned  to  be  introduced. 

New Care Plan  Format (already introduced) 
The  statement  I  provided  to  the  coroner  contained  details  of  the  new  care  plan  format 
introduced  across  all  sites  during  2020.  In  the  new  care  plan  format  (section  6  Mobility,
Fitness  and  Falls  Prevention) the  documentation  contains  an  image  of  all  equipment  used  to 
support  a  resident’s  mobility.  This  section  is  updated  by  either  the  Senior  Carer,  Assistant 
Manager  of  Registered  Manager  if  the  equipment  used  is  changed  or  discontinued.  The 
mobility section of a resident’s care plan also documents systems of work (a standard operating 
procedure) for all  equipment used.  The  completeness and  accuracy of this section  of the care 
plan  is  monitored for accuracy by the care staff or Senior Carer when the Resident of The Day 
is  completed  each  month for every  resident  and the  subsequent Care  Plan  review completed 
by either the  Senior Carer,  Assistant Manager of Registered  Manager each month. 

— 

Quality Manager Spot Check Audits  (re-introduced  in  2021) 
Part of the Quality Manager’s role  is to  provide audit assurance to the Registered Manager and 
Senior  Leaders  of Abbeyfield  The  Dales  that  care  delivery  and  record  keeping  is  in  line  with 
policy and best practice. This includes ensuring carers comply with  instructions as to  how/what 

We are a  member of The Abbeyfield Society 
Royal  Patron  HRH  The  Prince of Wales 

Registered  charity No.  1160258;  Registered  Company No.  9008680;  Homes  England  No.5066 
Registered  Office:  Grove  House,  12  Riddings  Road,  IIkIey,  LS29  9BF 
Registered  in  England  and  Wales 

 equipment  should  be  used.  Please  see  a  blank  copy  of  Audit  Form  the  Quality  Manager 
completes at appendix  1,  and the  audit  programme for winter 2021  at appendix 2. 

beytie Ed  The 

1•e 

The Quality Manager conducts an unannounced audit of care plans and observes care practice 
(the  carer delivering  care to  a  resident)  using  a  random  sample approach.  Feedback from the 
audit  is  given  directly to  the  Registered  Manager,  and  also  a  copy  is  sent to  senior  leaders to 
ensure any areas of improvement are complete. 

NB:  the  audit  programme  was  paused  in  2020  due  to  Covid-19  restrictions  and  safety 
measures,  and  restarted  in  October 2021  across all  registered  services. 

New Equipment (already introduced) 
A  record  of  new  equipment  delivered  to  support  a  resident’s  mobility  (a  delivery  note)  is  held 
in  a  resident’s  care  plan  (where  one  is  received).  The  care  plan  is  updated  with  an  image  of 
the  equipment,  so  it  is  clear what  equipment  must  be  used  when  supporting  a  resident  with 
their mobility and  clear instructions are set out in  the care plan  regarding the correct use of the 
equipment. 

Should  an instruction  regarding the correct technique and  use of the equipment be supplied  by 
a  health professional (such as an Occupational Therapist), this will  be included in the care plan. 
The  systems of work (noted  above) will  be  updated  accordingly. 

Service  Delivery Audit (launched with  Managers in  September 2021) 
The  service delivery  audit has  recently  been  introduced  and  standardises a variety of formats 
and  content of similar audits that have been  in  use  up  until  recently.  The  audit checks that the 
service delivered  by a member of the care team is  in  line with what is  required  in  the care  plan, 
and  expected from  an Abbeyfield The  Dales employee.  Please see a  blank version of the form 
at appendix 3. 

The  Registered  Manager  or  Assistant  Manager  predominantly  conducts  the  audit,  and  the 
Registered  Manager follows up any actions required  in  a supervision with that member of staff, 
perhaps  retrain  the  individual  or  monitor  their  performance  more  closely  until  it  reaches  a 
satisfactory level  and  maintained. 

New  Equipment Process (to  be  implemented  in  January 2022) 
We  have developed  a  process to  ensure staff are  clear of the correct  use for and  operation of 
a  new  piece  of  equipment  that  is  introduced  by  an  Occupational  Therapist  or  other  Health 
Professional to  support the safe transfer and movement of a resident. This process is  intended 
to  ensure there is no ambiguity in  how and in what circumstances a  piece of equipment is  used, 
and  also there  is  clear accountability and  checking  that staff are  knowledgeable and  confident 
in  the use of the equipment to  support that resident.  Please see a  blank version of the process 
at appendix 4. 

In  conclusion.  I  hope  these  measures  satisfy  the  requirement  on  Abbeyfield  The  Dales 
contained  in  the  Regulation  28  Report;  a  copy of this response has been sent to  CQC on their 
request. 

Yours Sincerely 

Chief Executive 

Page  2of2

Response by North Yorkshire County Council to a Report to Prevent Future Deaths for Dorothy 
Pegg (died 25 Oct 2019) made by Mr Jonathan Heath, Senior Coroner York and North Yorkshire 
dated 22 October 2021. 

Mr Heath concluded his investigation into the death of Mrs Pegg on 15 October 2021 and reached a 
narrative conclusion as follows: 

Dorothy Pegg slipped from a shower chair, whilst sitting on a sling, whilst fully clothed, having been 
transferred from the bedroom to the living room. She suffered bilateral leg fractures which have 
contributed to her death 

Mr Heath identified the following Matters of Concern in the Prevention of Future Deaths Report (PFDR): 

1. There was no system of monitoring the compliance with instructions as to how equipment should be 
used. 

2. There were no instructions as to the circumstances in which it is appropriate that specific prescribed 
equipment is used. 

The report provides that: 

  Point 1 to be addressed by 

, CEO Abbeyfields the Dales 

  Point 2 to be addressed by 

 Corporate Director, Health and Adult Services, North 

Yorkshire County Council (NYCC). 

A response to point 2 above is provided by North Yorkshire County Council (NYCC) below. 

Occupational Therapy Involvement 

Within the NHS and social care system there are hospital or community Occupational Therapists (OT). 
Within  the  community,  local  authority  OTs  complete  assessments  to  enable  people  to  live  as 
independently as possible in their home environment.  One outcome may be to provide equipment  or 
adaptations for the person or their carers/family to use. NYCC practice is that any identified equipment 
is trialled by the person and/or their carers (whether paid or informal).  If required, a moving and handling 
risk assessment and plan is completed by the OT and left with the person and/or their carers using the 
equipment.  This plan would always be provided for moving and handling equipment, for example hoists, 
slings, slide sheets and is a legal requirement in accordance with the Health and Safety at Work Act 
1974.  Carers (whether paid or informal) can then follow the plan as directed or, if required, training by 
the OT is provided in safe use of the equipment for the individual person.  The person’s care provider 
would then incorporate the instructions from the moving and handling risk assessment and plan into the 
individual care  plan,  which  is specific for the person  and includes information regarding  their needs, 
likes, dislikes and how their care will be delivered. 

OTs within NHS/hospital teams can transition people moving back into the community (such as from 
hospital)  or  who  have  experienced  a  deterioration  in  their  health  and  physical  needs  and  require 
intervention, equipment or rehabilitation.  A moving and handling risk assessment and plan should be 
written for the person by the NHS OT, where appropriate, and in the same way as described above for 
local authority OTs.  NHS and social care community teams can overlap and work together, they can 
also deliver discrete episodes of intervention as was the case with Mrs Pegg. 

In most instances a care provider will also have access to an appropriately trained person with moving 
and  handling  responsibility  within  their  own  organisation  or  externally  sourced.  The  appropriately 
trained person will ensure staff are appropriately trained in moving and handling  and are usually the 
point  of  contact  within  the  organisation  should  the  needs  of  the  cared  for  person  change.  The 
appropriately trained person will complete a reassessment (on behalf of the care provider) to identify if 
a referral is required for NHS or local authority for intervention. 

OFFICIAL 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 Action proposed or taken by NYCC in response to the Report 

Action which NYCC has initiated or undertaken following receipt of the report is as follows: 

 NYCC  will  change  moving  and  handing  risk  assessment  and  plan  templates  to  have  a 
descriptor box at the top to clearly identify the task for which the equipment has been assessed 
and provided for by the OT.  There will also be a point of note that if the equipment is to be 
used outside this scope, advice should be sought by the care provider from an appropriately 
trained person. The updated template will be uploaded to NYCC’s case recording system (LLA) 
and is to be used as from 31 January 2022. 

 An agenda item was included in a NYCC Practice Review meeting on 29th November 2021 and 
attended  by  OT  Team  Managers,  Senior  OTs  and  Training  &  Learning  representatives  to 
ensure  that  when  moving  and  transferring  plans  are  completed  and  shared  with  the  person 
and/or their carers, these include clarity on the task for which equipment is intended. When the 
revised moving and handling risk assessment and plan templates are uploaded onto NYCC’s 
case recording system, a reminder will be sent to all OTs to use the new template forms. 

 There are a range of roles across the NHS and Local Authority that can prescribe equipment 
including physiotherapists and OT’s. The Integrated Community Equipment Service (ICES)  is 
a  jointly  funded  service  between  the  NHS  and  Local  Authority  and  will  alert  prescribers  of 
equipment to the new moving and handling  document through a newsletter.  A notification is 
sent to each user of the ICES to make them aware of the newsletter which includes equipment 
updates and alerts. The next newsletter is scheduled for early 2022 and will contain an article 
to introduce the new templates. A prompt is included in the Equipment Request Form on the 
ICES database as a reminder to non-NYCC prescribers  to complete a moving  and handling 
risk assessment and plan.  A quarterly dip sample audit of the Equipment Request From will 
be completed to monitor compliance with the new arrangement. This will be undertaken by the 
OT Lead for Local Authority. 

 NYCC  will  ensure  that  contracts  with  care  providers  have  reference  within  the  terms  and 
conditions  that any equipment prescribed  is  used for the assessed purpose. NYCC will also 
ensure  that  any change  to  provision  or  use  is  to  be  incorporated  and  updated  by  providers 
within their care plans. These actions will be achieved by 31 March 2022. 

 NYCC will utilise its care provider forums to share and reinforce correct practice (for example, 
around moving and handling plans always accompanying relevant equipment provision) and to 
share  practice  around  care  plans  being  updated  at  any  equipment  change.  We  propose  to 
share such information via NYCC’s provider forums, provider bulletins and Care Connected (a 
regular online provider event). These actions will be achieved by 31 March 2022. 

 NYCC  have  reminded  ICES  of  the  contractual  requirement  to  deliver  all  equipment 
accompanied by an instruction leaflet.  This  requirement was included as an agenda item  in 
The Vale of York’s (as lead commissioner) Performance and Quality meeting on 25 November 
2021  attended  by  NHS  and  Local  Authority  commissioners  and  representatives  from  ICES. 
Following the meeting the contractual requirement was reiterated via an email from OT Lead 
for the Local Authority to ICES. 

 In  addition  to  the  above,  on  25  November  2021,  NYCC  has  requested  ICES  to  provide 
instruction  leaflets  for  equipment  on  the  equipment  database  for  retrieval  by  Occupational 
Therapists to accompany moving and handling risk assessment and plans. This request has 
been  followed  up  via  email  with  ICES  who  have  confirmed  that  work  will  start  on  this  week 
commencing 20th December 2021. 

 Future training for new or  existing  OTs  is  to include  a dedicated module  with examples and 
scenarios for completing moving and handling risk assessments and plans.  The learning from 

OFFICIAL 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 the Inquest for Mrs Pegg will be included.  The proposed training has been agreed with NYCC’s 
Training and Learning representative and the Moving and Handling Trainer on 29th  November 
2021 and will be implemented in February and March 2022. 

 A specialist moving and handling training event for NYCC OTs is scheduled for February and 
March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment 
and moving and handling plans 

The above actions have been incorporated into an implementation plan that will be kept under review 
by the OT Lead for the Local Authority. 

We also feel it important to highlight that in July 2021, NYCC transferred its OTs into dedicated teams 
with OT qualified Team Managers.  This provides a forum for continuous learning and reviewing practice 
via regular supervision, team meetings and practice forums to strengthen OT practice and delivery. 

May we take this opportunity to offer our sincere condolences to Mrs Pegg’s family. We hope that the 
above actions will provide assurance to the family that NYCC has taken robust measures in response 
to the PFDR. 

OFFICIAL