Sylvia Prichard

Avery

Anna Crawford

Surrey Coroner's Service
HM Coroner's Court
Station Approach
Woking

Surrey

GU22 7AP

18'" December 2024

Dear Coroner,

Re: Regulation 28 Report into the Death of Mrs. Sylvia Prichard — Action to Prevent
Future Deaths

We write further to your report made under Regulation 28 of the Coroners and Justice Act
2009, dated 25 October 2024.

At the outset, we, along with everyone at Moorlands Lodge Care Home (“the Home’), wish to
express our deepest condolences to Mrs. Prichard’s family and friends for their loss.

This letter serves as our formal response to the concerns raised by His Majesty’s Assistant
Coroner for Surrey, Anna Crawford. We confirm that actions that have been taken by the
Home to address these concerns, are outlined below.

We acknowledge the gravity of the issues raised following Mrs. Prichard’s death and are
committed to immediate and sustained improvements to prevent future deaths. We reviewed
the senior operational structure and as a result we have recently appointed a new Regional
Director and Home Manager to enhance the operational and quality support for the Home and
a robust action plan has been developed alongside the personnel changes to address the
concerns.

After the incident, the Director of Quality conducted a Lessons Learned Workshop which was
delivered to all registered managers across the whole organisation to discuss the incident and
ensure the areas of concern were shared across all teams.

Below, we respond to each of the identified concerns:
1. Outdated and Conflicting Information in Mobility Care Plans
Actions Taken:

e A full audit of all residents’ care plans has been completed by the Regional Quality
Team to ensure they are accurate, up-to-date, and consistent.

e A Care Plan Tracker has been introduced. This is a live document which records all
care plans required for each resident and the date they were last reviewed. This is
checked daily by the Home Manager. The tracker is completed and reviewed in

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addition to rolling monthly audits of at least 10% of all care records
to ensure the quality and person-centred detail.

° All key staff have undergone additional training on care planning and record-keeping,
with 100% compliance achieved for falls-related training. Refresher training is
scheduled to address record accuracy, falls management, and risk recognition.

e All new starters receive falls training as part of their induction plan.

Ongoing Measures:

e All residents’ care plans and risk assessments are reviewed monthly in line with Avery
“Resident of the Day” policy.

e Any changes in a resident's condition and/or needs are assessed with appropriate
changes made within the care plans and risk assessments. Any changes are reviewed
within the daily meetings held by the team and immediately communicated to relevant
staff.

e The Person-Centred Software (“PCS”) electronic care planning system is utilised to
minimise human error and ensure version control. Care plans and risk assessments
are reviewed and updated monthly, and residents with capacity are involved in their
care plan reviews. Relatives are invited to care plan reviews with residents where
appropriate.

e Managers conduct regular audits of care records, providing feedback and further
training as necessary.

e The care plan tracker is checked by the Home Manager daily and reviewed by the
senior operations team weekly to ensure that improvements are sustained.

2. Lack of Falls Minimisation Plans
Actions Taken:

e Allresidents have a falls risk assessment completed on admission. For those residents
identified as having an increased risk of falls, a further multifactorial falls risk
assessment is indicated and completed on the electronic care planning system.

e Falls minimisation care plans are then completed for all residents identified at risk of
falls, utilising the information contained within the risk assessment to ensure all risks
identified have a mitigating action.

e All residents at the Home have been reassessed for their risk of falls and all residents
identified as being at risk have a multifactorial falls risk assessment and minimisation
plan in place.

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e The new General Manager has been trained in Avery Healthcare’s
falls minimisation protocols and policies to ensure proper implementation, consistency
and to continue to drive improvements.

e Further Falls risk training has been cascaded to specifically coach staff and develop
their knowledge, understanding and reasoning in respect of their completion of entries
in the care plans with a higher emphasis of the risk management to be embedded
within all the care documentation.

Ongoing Measures:

e Falls risk assessments and care plans are reviewed monthly or sooner if there are any
changes to the residents’ care needs and/or if there is an incident in respect to mobility.

e Weekly clinical risk meetings analyse the trends and patterns of falls that week and
oversee and evaluate the effectiveness of interventions.

e Monthly governance meetings, chaired by the General Manager and Deputy Manager,
oversee the implementation of these measures.

e The Home Manager conducts daily reviews of all incidents to ensure all actions are
taken and to actively identify any inconsistencies within the care plans and risk
assessments.

3. Delayed Call Bell Response Times
Background:

By way of background the Home was initially under the ownership of Signature Senior Living
but had been taken over by Avery Healthcare in June 2023. The Home Manager had
previously worked for Signature Senior Living, and she confirmed that at the time of the
incident she still believed the call bell response time was 10 minutes. The Home Manager
confirmed that she had received a notification via the Incident Management System (RADAR)
to embed new Avery policies but had not circulated this to staff or implemented them, so the
Home was still working from the 10-minute response time rather than Avery’s new policy of 2
to 5 minutes.

The policy in place at the time of Mrs Prichard’s death was that call bells should be responded
to as soon as possible, ideally within 2 to 5 minutes.

Actions Taken:

Call bell response times have been improving through the following:

e Staffing levels during peak hours have been reviewed to ensure they align with
residents’ care needs.

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e Staff allocation has been optimised to improve efficiency.

e The updated call bell response policy has been relaunched, and all staff are now fully
aware of the expected 2-5-minute response time.

e A technology review within the Home has been undertaken to ensure all staff have
access to the correct equipment ensuring they are all notified of calls. During the busy
times of the day care managers support the team on the floor to ensure minimisation
of response times.

e Staff are also reminded to check that all the call bell technology is in full working order.

e In May, the Home issued a Significant Learning briefing regarding call bell response
times and adherence to the policy.

Ongoing Measures:

e Managers now receive daily log reports on call bell response times, allowing immediate
intervention for delays and further investigation for non-compliance. The call bell logs
are reviewed by the Home Manager on a daily basis and shared with the senior
Operations Team for further oversight.

e Staff performance in responding to call bells is reviewed during regular performance
reviews, with non-performance, other trends and patterns addressed during
supervised sessions.

4. Reconfiguration of the call bell system and discontinuation of Wrist-Worn Emergency
Watches

Actions Taken:

e As of November 2024, wrist-worn emergency watches for high-risk residents have
been discontinued.

e The decision followed the implementation of the correct Avery call bell policy being put
in place and improvements in call bell response times,

e Furthermore, there has now been a full review and reconfiguration of the call bell
system. This work will ensure that any call bell activated from any source, i.e. pendant
or call point will ring for 3 minutes on the ordinary tone. If the call bell is not answered
within 3 minutes, the call bell will be automatically escalated and change to an
emergency call bell which has a different tone. The team are aware that emergency
bells must be answered immediately, and this response is a whole home approach.
This new system has made the use of the wrist-worn emergency watches
unnecessary.

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e Staff have been fully briefed in the change in policy and the changes
have been embedded into the induction training on the use of call bells.

Ongoing Measures:

e Daily audits are undertaken by the home manager to review any non-compliance with
the Avery call bell policy. Any delays in call bell response times are investigated by the
Home Manager to identify causation with appropriate actions taken.

5. Oversight and Auditing Failures
Actions Taken:

e The Falls Prevention Policy and Multi -Factorial Falls Risk Screening Tool was sent to
all Home Managers and General Managers to read and familiarise themselves with
the changes and to update their staff and teams.

e Weekly Clinical Risk meetings are held within the Home, chaired by the General
Manager and/or Deputy manager to analyse falls, accident and incidents, infections,
admission, weight loss and medication reviews. Actions are agreed with timescales
and ownership.

e Monthly Clinical Governance Meetings analyse data from the RADAR management
incident system to provide immediate insights into clinical risks. All aspects of the
governance review are shared with the Regional Director, for upward escalation as
appropriate. Some key areas included in the governance meeting are falls, accident
and incidents, infections and medication reviews. These meetings are recorded, with
a summary submitted to the Quality Team each month. The Quality Team and
Operational Director then review these minutes and if there are concerns, they can
address these with the Regional Director and provide further support where required.

Ongoing Measures:

e Weekly clinical risk meetings, attended by key staff, ensure formal reviews of residents’
care plans and risks. Key areas reviewed include falls, infections, and
accidents/incidents.

e There is a clinical risk register in place for each home, which identifies resident risks
including that of falls. This is reviewed weekly as part of the clinical risk meeting and
supports the team to ensure that all of the correct care plans are in place for each
resident.

e A Falls steering group has been introduced to the home. This takes place monthly with
a focus on preventative actions.

e A “Resident of the Day” programme is fully operational within the Home, involving a
comprehensive review of a resident's care plan with their keyworker to ensure it

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remains person-centred and responsive to real-time risks to establish
whether all necessary actions are in place to mitigate the risks.

e A new internal audit framework has been introduced, focusing on critical areas such
as call bell response times and falls minimisation plans. All audit results will be shared
transparently with staff to foster accountability.

e Internal Compliance Inspections are conducted by the Quality Team, which oversee
all audit findings and ensure that actions are completed promptly and consider whether
they may prompt an inspection on emerging risks.

e The RADAR Incident Reporting System has been fully reviewed to ensure clear
visibility and analysis of falls within the Home. This has included creating a falls
category within the Incident Reporting System to ensure better analysis to a finer detail
on falls trends and patterns.

e Weekly Regional Director visits occur, and there is a weekly performance call with the
home to monitor progress against actions, attended by the Senior Operations and
Quality Team.

e Monthly calls take place with the Director of Quality and Operations Director to review
all the clinical KPIs and serious incidents within all of the Homes.

Conclusion

We are committed to providing the highest standards of care and believe the measures
outlined above will significantly enhance the quality and safety of services at Moorlands Lodge
Care Home.

The steps we have taken are designed to prevent a recurrence of the issues observed in Mrs.
Sylvia Prichard’s case. We will continue to monitor these improvements to ensure their
sustained effectiveness.

We hope this correspondence provides reassurance to the Coroner and Mrs. Prichard’s family
that the identified issues have been comprehensively addressed. We remain committed to
continuous improvement in care quality.

Yours sincerely,

Chief Executive Officer
Avery Healthcare Group