Dorothy Spiby

Primeljfe 

Primelife Limited 
Registered  in  England No 2779611 
Caenarvon  House, 121 Knighton Church  Road, 
Leicester LE2  3JN 
Tel: 

M/s Vanessa  McKinlay, HM Assistant Coroner for Birmingham and Solihull 
Coroner's Court Steelhouse  Lane  Birm ingham  B4  6BJ 

By  email only to: 

20 April 2022 

Dear M/s McKinlay 

Regulation  29 Response to Regulation  28 of the Coroners (Investigations) Regulations 2013 

Report to Prevent Future Deaths- Tanworth Court Nursing Home 

We  make this Regulation  29  response to the Regulation  28  Report to Prevent Future Deaths, 

received on  22.02.22.  We  understand the response  must contain detail of action taken or 
proposed to be taken, setting out a timetable for action.  Otherwise we must explain why no 

action is  proposed. 

We  address  each  MATTER OF  CONCERN  below. 

1.  Tanworth Court Nursing  Home staff reported to the hospital that Mrs Spiby became 

distressed and ran into collision with a wall when trying to leave her room,  before falling to 
the floor.  The  origin of this account was unclear from  the evidence. No  record was made of 
the incident in  the nursing records. 

The  following actions have been taken to improve the accuracy of nursing records and  reinforce 
good practice in  the recording of incidents within nursing records. 

•  Defensible  Documentation Training for Registered  Nurses initiated by  Nurse Advisor 

. Training included:  NMC Code,  Accountability,  Effective communication, 

Examples of good and  poor documentation,  NMC Hearings and  clinical  negligence. Training 
was  planned in to be  completed by 15.4.22  and actions have  been completed with all 

Tanworth Court nurses. 

• 

Further competency checks  are being conducted to ensure continued learning.  This will be 
completed by the nurse advisor/trainer on  a regular basis  (weekly at present) and  will cover 
a period of 3 months or longer if issues arise from the competency checks.  Competency 

checks will only be  ceased  if the advisor/trainer is  confident that the information has been 
retained and  good practice demonstrated . 

•  Training to be  given to all  staff (including nurses)  around clear and  concise  documentation, 

record keeping training to be  re  issued  (all  completed by 18.3.22), the record  keeping and 

documentation policy has been  re-issued to all  staff via  the Relias training system . Training 
delivered by an  external training provider and this was  conducted and  completed by 18.3.22, 

by all  care  staff.  The  Home  management team  review nursing records daily and  record their 

1 of 4 

INVESTOR IN PEOPLE 

 
 
 
 
 findings on the daily walk around document which also  encompasses  reviews of all 
supplementary documentation. 

•  Any shortcomings in  documentation are  addressed  immediately by the home management 

team.  Conversations with staff are formally recorded within supervisions and any 

disciplinary action taken, as  necessary.  Where there is  non-compliance found the staff 

members will  be given supervisions and  learning sheets will be  completed with them to 
encourage adherence to best practice.  Actions in this regard were completed by 18.3.22 as 
planned. 

•  Daily spot checks  by management of documentation and  record keeping are  being 

completed,  and  recorded to ensure the level of detail is  correct.  All  information contained 
within the daily records  (nurse records and  any records  made of information pertaining to 

service  users)  is triangulated with other supporting documents such  as food and  fluid charts, 

incident forms etc.  This  is  applicable to both the nursing and  wider care  records. 

•  Monitoring of the documentation is  undertaken at the commencement of the day shift 

(around 8am) and at around 4pm with regular spot checks  also  being undertaken during the 

day. This  process of monitoring will continue long term and  become part of each  day's 
routine activities. 

•  All  nursing and care staff to be  aware of Prime Life Accident/Incident Policies and 

Management of Falls  Policy- evidence to be  if staff have read and  understand these  policies. 
Actions to be  completed by  11.4.22 and timeframes met. 

• 

Falls  Management including Head  Injury Training for all  nurses.  Training to be  delivered by 
the nurse trainer/advisor and to include:  Body Mapping, vital observations including Neuro-

observations,  ReSTORE2(NEWS2),  Accident/Incident forms,  care  plans,  risk assessments, 
daily notes, communication record - MDT and  reducing the risk of falls . Actions to be 

completed by 22.4.22 (slight amendment to the original action plan  in  place due to annual 
leave and sickness amongst the nursing team) with the exception of the clinical lead who is 
currently on  long term sick. 

• 

Falls  prevention training to be  given to all  care  staff to aid  identifying risks  associated with 
falls,  how to minimize the risk  of falls and  how to support the clients  involved in such 

incidents. Training to be  completed by all  care  staff by 22.4.22 (slight amendment to the 
original action plan  in  place due to annual  leave and  sickness amongst the nursing team) . 

with the exception of the clinical  lead who is  currently on  long term sick. 

•  Training to be  completed with all  care staff on how to effectively complete an  ABC  chart, 

appropriate assessment of the situation and  how to share the information with nurses and 

senior management. Training to be completed by all  nurses by 22.4.22 with the exception of 

the clinical  lead who is currently on  long term sick. 

•  Upon the clinical  lead's return we will  prioritise the training required for the clinical  lead to 

be  completed. 

2.  No  incident form  was completed. 

The  response to point 1 of the MATTERS OF CONCERN  provides the majority of our response to 
point 2 and we  refer you to the response to that point.  In addition regarding the completion of 
incident forms we have done the following: 

•  Nurses to have training/supervision in  Incident Form  completion including body mapping. 

Training and supervisions to be  undertaken by nurse trainer/advisor and timeframes set to 
15.4.22. This  has  been  completed  by all  nurses with the exception of the clinical  lead who  is 

2 of 4 

 currently on  long term sick.  Upon the clinical lead's return we will prioritise the training for 
the clinical  lead to be  completed. 

3.  No  investigation of the accident or the circumstances giving rise to it was undertaken. 

We  have taken the following actions to emphasise the importance of investigating accidents 
and incidents: 

•  Senior management undertake daily spot checks to ensure that any incidents are  identified, 
and  any subsequent actions are  noted and addressed .  This  is  overseen  by the regional 
operational team  and  home management team. The associate director for elderly services is 
currently supporting the home 3-4 days  per week and  is  responsible for ensuring governance 
in  this area . Daily spot checks  commenced on  18.3.22  and  continued oversight and 
monitoring needed  in  the future.  Monitoring of the documentation will be  undertaken at 
the commencement of the day shift (around 8am)  and  at around 4pm  with regular spot 
checks also  being undertaken during the day.  This  process of monitoring will continue long 
term and  become part of each  day's routine activities. 
Investigations into incidents are undertaken presently if practice within the Home meets the 
threshold which warrants investigation.  There  is  in  place enhanced monitoring of daily 
activity within the Home and this will encourage timely escalation of matters to a full 
investigation as  necessary. 

• 

•  Human  Resources team to undertake training with senior management to ensure they are 
aware of their responsibilities with regards to investigations into staff conduct,  how to 
demonstrate equality and  fairness to employees,  how to reach  resolution  into inappropriate 
conduct/competency, the options available for formal action for continued non-compliance 
etc. Was originally expected to have been  completed by  15.4.22  but due to unforeseen 
circumstances, this timeframe has  not been  met but will be  completed by 22.4.22 
•  New policy to be  devised about how to conduct an  effective investigation into poor care 

practice and  any safeguarding incidents. Must be  able to demonstrate how to conduct 
investigations, how to take statements,  how to correlate with documentation etc.  Following 
discussion at recent operational  board meeting, this policy will  be  in  situ and  disseminated 
to all  Prime  Life sites  by 30.04.22. 

4.  There  was no evidence of a commitment to learning from  this incident with a view to 

safeguarding residents in  the future. 

We are committed to continually improving as  an  organisation and safeguarding remains at the 
top of our list of priorities .  Please find attached actions completed to demonstrate our 
commitment to learning: 

•  Safeguarding training has  been  delivered by the internal quality team, this included 

reportable incidents, incident reports and  auditing of incidents.  It is  now the responsibility 
of the regional  operations team to ensure that any reportable incidents are  being sent 
through to the local authority and other interested parties without delay.  The  manager's 
review of incident reports will be  completed and overseen  by the regional operational team. 
Training to be  delivered by the providers Quality Matters Team. This initial action was 
completed by 25 .3.22 . 

• 

Learning and  practice reviews after incidents/ safeguarding concerns have been completed 
and can  be  evidenced.  Incident and safeguarding audits to include an  action plan  of any 
lessons learned and a clear plan  of how learning and  practice can  be  improved.  These 
reviews will  be  undertaken each  month by the home manager with close  monitoring and 

3 of 4 

 observation form the regional  operational team. All  safeguarding concerns will then be 

disseminated to the  Lead  Operation Director for monthly collation of the company 

safeguarding incidents and  reflected on the monthly risk matrix which  is  shared with the 
Board of Directors. 

•  A new lessons  learned document will be sent to each  Prime  Life  location every month to 

share  both good and  bad  practice.  This will encompass any new documentation/procedure 

put into place as the result of internal reviews of practice across the group.  This will  be 

completed each  month by 

, lead  operational director, to commence 1 May 2022 

and  monthly thereafter. 

Conclusion 

As  a Provider we are committed to continual improvement and  have reflected on  the circumstances 

surrounding the death and the terms of the report issued  by the Coroner carefully.  We  hope that 

this  response adequately addresses the concerns set out in the  Regulation  28 report issued on 
22.02.22 and  demonstrates that action has  been taken to address the matters raised therein with 

further actions in support to embed improvements in the way that care  is  monitored and  delivered 

at Tanworth Court Nursing Home. 

For clarity, the nurse involved in this incident and subsequent coroner's inquest, was  suspended 

from  her nursing duties at the home and  has  since  left our employment but has  been  referred to the 

NMC for further review. 

We  hope that the information above in  our response assists  in  assuring the Coroner, the family and 

the wider public that improvements have  been  made, embedded and  sustained at the service to 

address the areas of concern set out in the regulation 28  report. 

If any further information or clarification is  required  kindly let us  know by return. 

4 of 4