Dear Coroner, Re: Regulation 28 Report into the Death of Mrs. Sylvia Prichard Action to Prevent Future Deaths 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 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 Outdated and Conflicting Information in Mobility Care Plans Actions Taken: A full audit of all residents' care plans has been completed by the Regional Team to ensure are accurate, up-to-date, and consistent. A Care Plan Tracker has been introduced. This is a live document which records all care plans required for each resident and the date were last reviewed. This is checked daily by the Home Manager. The tracker is completed and reviewed in Avery Woking We We Quality they they

addition to rolling monthly audits of at least 10% of all care records to ensure the quality and person-centred detail. AlI 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. AIl new starters receive falls training as part of their induction plan: Ongoing Measures: All residents' care plans and risk assessments are reviewed monthly in line with "Resident of the policy. Any changes in resident's condition andlor needs are assessed with appropriate changes made within the care plans and risk assessments. changes are reviewed within the daily meetings held by the team and immediately communicated to relevant staff. 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_ Managers conduct regular audits of care records, providing feedback and further training as necessary. 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: AIl residents have a falls risk assessment completed on admission. For those residents identified as having an increased risk of falls, further multifactorial falls risk assessment is indicated and completed on the electronic care planning system; Falls minimisation care plans are then completed for all residents identified at risk of utilising the information contained within the risk assessment to ensure all risks identified have a mitigating action. All residents at the Home have been reassessed for their risk of falls and all residents identified as at risk have a multifactorial falls risk assessment and minimisation plan in place_ Avery key Avery Day" Any falls, being

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 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 higher emphasis of the risk management to be embedded within all the care documentation. Ongoing Measures: Falls risk assessments and care plans are reviewed monthly or sooner if there are any changes to the residents' care needs andlor if there is an incident in respect to mobility. Weekly clinical risk meetings analyse the trends and patterns of falls that week and oversee and evaluate the effectiveness of interventions_ Monthly governance meetings, chaired by the General Manager and Deputy Manager;, oversee the implementation of these measures 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 policies but had not circulated this to staff or implemented them, so 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: Staffing levels during peak hours have been reviewed to ensure they align with residents' care needs. Avery Avery the

Staff allocation has been optimised to improve efficiency. The updated call bell response policy has been relaunched, and all staff are now aware of the expected 2-5-minute response time. technology review within the Home has been undertaken to ensure all staff have access to the correct equipment ensuring are all notified of calls. During the times of the care managers support the team on the floor to ensure minimisation of response times. Staff are also reminded to check that all the call bell technology is in full working order: In the Home issued Significant Learning briefing regarding call bell response times and adherence to the policy. Ongoing Measures: 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 daily basis and shared with the senior Operations Team for further oversight Staff performance in responding to call bells is reviewed during regular performance reviews, with non-performance , other trends and patterns addressed during supervised sessions_ Reconfiguration of the call bell system and discontinuation of Wrist-Worn Emergency Watches Actions Taken: As of November 2024, wrist-worn emergency watches for high-risk residents have been discontinued. The decision followed the implementation of the correct call bell policy being in place anc improvements in call bell response times, 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 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: Avery fully they busy day May, Avery put

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: 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: 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. Weekly Clinical Risk meetings are held within the Home, chaired by the General Manager andlor Deputy manager to analyse falls, accident and incidents, infections, admission, weight loss and medication reviews. Actions are agreed with timescales and ownership_ Monthly Clinical Governance Meetings analyse data from the RADAR management incident system to provide immediate insights into clinical risks. All aspects f the governance review are shared with the Regional Director, for upward escalation as appropriate: Some areas included in the governance meeting are falls, accident and incidents, infections and medication reviews. These meetings are recorded, with summary submitted to the Quality Team each month: The Quality Team and Operational Director then review these minutes and if there are concerns, can address these with the Regional Director and provide further support where required. Ongoing Measures: Weekly clinical risk meetings, attended by staff; ensure formal reviews of residents" care plans and risks. areas reviewed include falls, infections, and accidentslincidents. 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. A Falls steering group has been introduced to the home. This takes place monthly with on preventative actions. "Resident of the Day" programme is operational within the Home, involving comprehensive review of resident' s care plan with their keyworker to ensure Avery key they key Key focus fully

remains person-centred and responsive to real-time risks to establish whether all necessary actions are in place to mitigate the risks_ 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_ Internal Compliance Inspections are conducted by the Quality Team, which oversee all audit findings and ensure thatactions are completed promptly and consider whether may prompt an inspection on emerging risks. 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 within the Incident Reporting System to ensure better analysis to a finer detail on falls trends and patterns_ 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. 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 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.