Tina Allen

Mr Guy Davies 
His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly 
The Coroner’s Court 
Pydar House 
Pydar Street 
Truro 
TR1 1XU 

27th January 2023 

Dear Mr Davies 

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS  

INQUEST INTO THE DEATH OF TINA JANE ALLEN  

I am writing in response to the Regulation 28 (Coroner’s and Justice Act 2009) Report to 
Prevent Future Deaths issued on 5 December 2022 following the inquest into the regretful 
death of Tina Allen. Tina was a resident at Valley View, a residential care service for five 
adults with learning disabilities, operated by HF Trust Limited ("HFT"). 

On behalf of everyone at HFT, I would like to express my deepest condolences to Tina's 
family. As Chief Executive, I am deeply saddened that Tina did not receive the quality of 
care that she should have expected. 

HFT conducted an immediate internal investigation into the events of the 13th June 2022 
and  the  underlying  contributory  factors  and  circumstances  surrounding  Tina’s  death. 
Working  closely  with  external  key  stakeholders  and  regulators,  HFT  has  made,  and 
continues to make, improvements to the quality of service provision and delivery at Valley 
View.  We have commissioned an independent review by a well reputed external consultant 
specialising  in  health  and  social  care  serious  incident  investigation  and  review,  with  the 
outcomes  expected  in  the  coming  months.  Additional  lessons  learned  following  this 
independent review, and any recommendations for further improvements, will be progressed 
at pace. 

 
 
 
 
 
 
 
 
 
 I set out below the matters of concern identified in section 5 of your report and our response: 

That the persistent understaffing at the care home is impacting upon the ability of 
staff to safely provide the care and treatment required. Further, the understaffing is 
impacting upon  the ability  of  the  care  home  management  to properly  monitor  the 
safety and appropriateness of the care given at the care home. 

The care home is invited to review the staffing levels at the home and the relevant 
recruitment and retention policies and strategy. 

HFT has faced a particular challenge in recruiting and retaining permanent members of staff 
at Valley View, which forms part of HFT’s St Teath service. This is, in part, due to its rural 
location. Between the period of January 2022 and December 2022, no new permanent staff 
were employed (despite HFT's efforts to recruit), and over the same period, two full time 
equivalent, permanent colleagues, left. 

In addition to Valley View’s permanent members of staff, we utilise a bank of relief workers 
who work solely for the St Teath service, who are inducted and trained in the same way as 
our permanent staff. Our relief workers cover vacant shifts, as do our permanent staff, who 
pick up additional shifts. It is only when our relief workers and permanent staff have covered 
gaps in the rota, that any remaining shifts are opened up to agency colleagues. 

Whilst the service is not yet fully recruited to at this time with permanent members of staff, 
safe staffing levels are being maintained with the combined use of permanent members of 
staff, consistent relief workers and block booked agency colleagues, who provide a level of 
stability, familiarity and continuity of care. Staffing levels and training compliance at Valley 
View are continually monitored by the senior management team, with information regularly 
shared with our external stakeholders and regulators. 

The management structure of the Valley View service has been reviewed, and appropriate 
senior  management  and  local  administrative  support  has  been  provided  to  oversee  the 
service in the short term, whilst we recruit a new Registered Manager. 

The  approach  to  shift  management  has  been  updated  to  include  a  formalised  handover 
attended by the management team daily. Effective checks and audits are carried out by the 
management  team  to  monitor  risk,  safety  and  appropriateness  of  the  care  given  to  the 
people we support. 

A  review  of  the  salary  structure  has  been  undertaken  and  implemented,  with  a  location 
specific  allowance  applied  to  Valley  View  payrates  to  assist  in  the  attraction  of  new, 
permanent staff. Our focused online recruitment campaign, physical presence at local job 
fairs and improvements in on-boarding processes are all evidence of concerted efforts to 

 
 
 attract, engage and retain new staff, significantly improving local recruitment opportunities 
in this rural area.  

In  the  longer  term,  these  improvements  within  the  Valley  View  service  will  be  further 
enhanced  by  the  development  of  both  local  and  organisation  wide  improved  retention 
strategies.  Initiatives  include  the  development  of  a  new  Pay,  Reward  and  Recognition 
Strategy  addressing  both  local  and  organisational  challenges.  These  newly  developed 
strategies will be underpinned by a talent management framework, which includes revised 
people  systems  and  apprenticeship  pathways  to  drive  robust  succession  planning. 
Apprenticeship development pathways support the breadth of roles from Level 2 and 3 Adult 
Care Worker progressing though to Level 5 Leaders in Adult Care and beyond. The aim is 
to  cultivate  a  culture  which  will  support  inclusivity,  innovation,  creativity  and  a  sense  of 
belonging whilst ensuring services are safe and of a high quality.  

A  review  of  policies  and  procedures  is  being  undertaken  in  response  to  the  learning 
identified from the investigation into the incident. This includes an update of the Nutrition 
and Hydration Policy, and the introduction of a specific Dysphagia and Choking Procedure, 
which were undertaken in October 2022. These new processes are being embedded within 
working practices via dissemination at team meetings, and knowledge of, and compliance 
with, these processes, is being assessed via supervision and audit.  

In addition to enhanced service specific training, both HFT and agency colleagues are being 
provided  with  intensive  training  in  relation  to  the  provision  of  person-centred  care  and 
support. HFT's Learning and Development team will continue to support, train, and provide 
opportunities for new, existing, and block booked agency colleagues. This ensures they are 
appropriately  skilled,  equipped  with  the  requisite  knowledge,  and  are  competent  to 
undertake their roles. For example, in January 2023, both HFT and agency colleagues in 
Valley View received training in total communication, Makaton and Person Centred Active 
Support (PCAS). Regular agency colleagues have HFT IT accounts and are assigned e-
learning in the same way as colleagues employed directly by HFT.  

To ensure all Valley View colleagues, be they HFT and / or agency, have the opportunity to 
contribute  and  feedback  to  the  senior  management  team  on  a  regular  basis;  formal  and 
informal  team  meetings  have  been  diarised  twice  a  month,  for  either  virtual  or  in-person 
attendance.  Colleagues  will  also  have  the  opportunity  to  discuss  key  areas  of  care  and 
support, development of the service, and share experiences.  

Regular  supervisions  are  also  scheduled  for  all  Valley  View  colleagues,  to  provide  a 
confidential time with the manager to discuss colleague health, safety and wellbeing, training 
and development, ideas or suggestions to improve the service.  

 
 
 HFT has a Partnership Forum which offers an independent space where HFT colleagues 
can  connect  with  their  local  representative,  and  discuss  ideas  and/or  concerns. We  also 
have an up to date Whistleblowing Policy, which has been shared with colleagues.  

To  ensure  clear  visibility  across  the  Organisation,  HFT  have  procured  a  new  digital  care 
planning system (Access Care Planning). This system provides assurances for reviewing, 
monitoring,  auditing  of  data  and  working  practice  at  the  service  in  real-time,  quickly 
identifying  any  areas  of  potential  non-compliance.  The  system  will  also  enable  clear 
reporting,  providing  oversight  to  both  local and  national teams,  internal Quality/Audit  and 
Risk Committee, our Executive Committee and Board. 

HFT  has  a  Quality  Assurance  Framework,  which  aims  to  deliver  a  combined  system  of 
internal  audit  undertaken  by  the  quality  and  improvement  team,  and  self-assessment 
undertaken in local areas. This will help to better understand and improve the quality of our 
service  provision,  and  ensure  regulatory  compliance.  Valley  View  has  been  receiving 
enhanced support via this process, and a comprehensive improvement plan has been put 
in place. This plan is being overseen by a Steering Group chaired by myself, and the Chief 
Quality and Governance Officer and the Chief Care and Support Officer are leading on the 
delivery of key work streams. There are weekly update/action review meetings between the 
management  team  at  Valley  View,  and  HFT’s  Safety  and  Quality  teams,  for  ongoing 
oversight and monitoring purposes. 

I would like to take the opportunity to provide reassurance to the Coroner, that HFT, as a 
social care provider and responsible employer, who prides itself on supporting its service 
users  with  the  utmost  integrity,  are  fully  committed  to  continuous  operational  and 
organisational improvement.  

Yours sincerely, 

Chief Executive Officer 
for HF Trust Limited (HFT)