Margaret Austin

Dear Madam Inquest into the death of Margaret Austin Regulation 28 Report to Prevent Future Deaths Response We write in response to your Regulation 28 report dated 27 November 2023 following the investigation into the death of Margaret Austin For the purpose of responding to your specific concerns raised, shall address each one in turn The deceased was known to be at high risk of falls and the documentation in relation to how to manage that known high risk of falls was not comprehensive and contained significant discrepancies as to what should, in fact, be in place, and contained no rationale for why further measures which may have been considered appropriate were not in situ or considered approprate or necessary Stanley Park has taken a number of steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making: The steps taken are as follows: The management team, with the support of the organisation's Quality Development manager, undertook a comprehensive review of the components of our risk management plans and ensured that staff fully understand expectations around completion of documents and requirements for them to be reviewed and updated_ b_ Specific focus was given to bed rails assessments, ensuring that staff were competent in utilising bed rails assessments and that were properly reflecting the decision making and clinical rationale in the care record. To ensure that the learning was appropriately shared, the following steps were taken: a; A Head of Department meeting was held on 6 December 2023 with a senior staff meeting on 12 December to discuss the learing from this case and the actions required. The senior leadership team was then able to cascade the learning to the rest of the teams through the weekly clinical review meetings_ b, The learning was also developed through 1:1 sessions with each member of staff as part of their annual performance review discussions, held between and Care UK Community Partnerships Lid Registered In England Registratio Number 02644862 Registered olfice Connaught House 850 The Crescent Colchester Business Park Colchester Essex CO4 9QB key they along

December 2023. Compliance and quality in terms of falls documentation will remain review in annual appraisals going forward. 2, There was no evidence that the risk management plan was reviewed as the deceased's risks changed nor in the aftermath of documented falls. As part of the review and discussions outlined in respect of (1) above, during these same processes the Home Manager has ensured that staff are appropriately recognising when fallslrisk assessments and management plans need to be reviewed and updated and that the reviews are carried out in a timely manner: The specific actions in relation to this point are as follows: Staff have been reminded of the trigger points for reassessment;, with specific inclusion of reassessing risk post hospital discharge and return to the home. b The management team are reviewing all accident and incident reports to ensure that appropriate actions in response have been identified, including any further mitigation steps such as sensory equipment; roll mats and requests to the GP for a secondary care falls referral. Accidents and incidents are being discussed during the weekly clinical review meetings, with specific actions being assigned to staff members around ensuring that the individual's assessment and management plan is updated:
d. Assessments and plans are reviewed by the Deputy Manager to ensure triangulation of care and to confirm that actions set in the clinical review meetings have been fully completed. To ensure that the learning from points (1) and (2) above has been fully embedded, an audit was carried out (starting first with high risk patients to ensure timely review) with the purpose of verifying that care needs have been appropriately assessed and that the assessment and subsequent management plan is properly documented This audit was completed on 31 December 2023 and demonstrates that staff are compliant with the standards expected of them. There is planned programme of ongoing audit to ensure that the improved standards are maintained, Staff training in relation to falls risk remained outstanding at the date of the Inquest for the majority (3/4) of staff at the care home. Whilst at the time of inquest hearing the training numbers for the specific falls risk package were as stated, wish to provide reassurance that all staff had undertaken their mandatory both in terms of induction and annual refresher training: This includes elements of falls risk assessment and management as part of the moving and handling; emergency first aid at work and basic life support training: Atthe time, the falls prevention module was development training to enhance staff understanding rather than a mandatory requirement In any event; the training compliance has significantly improved since the time of the hearing and is operating above the corporate expectation for refresher training of 90% (currently 96% with additional sessions planned for 29 January and 14 February 2024).

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In order to maintain training completion standards going forwards, we now incorporated the falls specific package into the mandatory training programme to ensure that all new starters receive this training within the 2 week induction period and then as an annual refresher for all colleagues_ We hope that the information provided offers you the necessary assurances that Stanley Park has taken steps to improve standards in terms of falls risk management We also hope that the above demonstrates that we have invested time, effort and resource into investigating the issues you have highlighted with view to improving care and reducing the risk of any adverse incidents or outcomes in the future. Should you have any additional queries, we would be to assist by providing further clarification. Finally, we wish to again acknowledge the deeply sad outcome and the impact this has had on Mrs Austin's family and friends and take a further opportunity to offer sincere condolences on behalf of Stanley Park