Dear Mr Spinney Regulation 28 Report to Prevent Future Deaths Lesley Hanson Thank you for your letter enclosing Regulation 28 report following your investigation into the death of Lesley Hanson Since the sad death of Ms Hanson a number of changes have been introduced. Codes of practice to assess and meet the needs of individuals with care and support needs have been issued_ These codes underpin the Social Services and Well-being (Wales) Act 2014, which provides the Welsh Government's statutory framework for improving the well-being outcomes for people who require care and support: The codes set out a local authority's to assess an individual's eligible need for care and support and what those needs are_ provide clarity on the assessment process and underline its purpose is to work with an individual, carer, family and other relevant individuals to understand their needs, capacity and resources and the outcomes they wish to achieve_ The support must then be identified to achieve the specific outcomes In the case of an adult who lacks capacity the codes set out the expectation the assessment and review processes must involve any person authorised to make decisions about the individual under the Mental Capacity Act 2005. Assessments must take account of an individual's capacity to engage in the process and make the necessary arrangements to ensure where this is impaired, their needs and wishes are understood and are taken into account must also recognise the reality of fluctuating needs and capacity and be responsive to changing circumstances_ resulting care and support plan must be developed in partnership with the individual concerned to ensure an agreed understanding of how the needs will be met and the personal outcomes to be achieved_ Local authorities should work with local health boards to agree arrangements across the health board footprint area_ A local authority must keep care and support plans under review to ensure eligible needs and agreed outcomes are continuing to be met FfonfTel: 029 2082 3911 BUDDSODDWRMET NFODL Parc Cathays, Caerdydd CF1O 3NQ Cathays Park, Cardiff CF10 3NQ ENVESTORN FEOFLE Ebost/Email:PSChiefMedicalOfficer@wales-gsi gov.uk your duty They They Any

hope you find this response helpful.

Dear Mr Spinney, write further to my correspondence of the 29th January 2018 and provide below response to section 6 of your report that details actions which should be taken by the Council to prevent future deaths. Since the tragic death of Lesley Hanson on the 13 March 2016, there has been an extensive review undertaken by the Council which has resulted in improvements to policy and processes involving council staff;, services and our partners in Abertawe Bro Morgannwg University Health Board (ABMU): The improvements made have been communicated to the Health and Safety Executive and address the following actions raised in your Regulation 28 Report:- (1) Consideration should be given to reviewing the process of assessing risk to service users in respect of the suitability of stairs and stair-gates in supported accommodation schemes; (2) Consideration should be given to reviewing the approach to risk; supervision and control in supported living schemes to ensure clear guidance on roles and responsibilities to ensure residents safety. The various supporting documents referenced, although not included due to their volume are available should you wish to review them . If particular documents are deemed worthy of explicit consideration, am happy to arrange for copies to be provided to your office for your consideration. Improved Risk Management Processes
1.1 Where a person is identified as requiring supported accommodation referral form is completed This form was redesigned to ensure that all relevant risks are captured, A supporting flowchart allows for all professionals involved to identify what actions are required at each stage of the process. The use of 'Compatibility Criteria Checklist' reinforces the need to consider physical disabilities and or medical conditions, aidsladaptations, environment and risk management: ~ot & Alael Couuty Bovuk

1.2 Where a person is already residing in supported accommodation, it is the responsibility of the Senior Support Worker to notify the Supported Living Coordinator and Case Manager if a person's needs have changed, This is done either as part of the formal annual review process or more frequently if required in individual circumstances_
1.33 Where assessments for environmental controls are required, the Senior Support Worker (or delegated member of staff) will complete a referral form and forward to ABMU Learning Disability Health Team or the Cardiff Communities Occupational Therapy Team (CCOT) depending on the naturelsize of the work requested_ 'Referral Pathway' flowchart has been designed to ensure consistency of process. This flowchart has been subject to consultation with the ISL Manager Supported Living Coordinator, Learning Disability Social Services Team Managers, ABMU Health Team Manager and Cardiff Occupational Therapists_ 1,4 The new Referral Pathway protocol reflects changes in process to ensure clarity of roles and responsibilities across ABMU Learning Disability Occupational Therapy staff, Cardiff Community Occupational Therapy Team, Case Managers and the Registered Social Landlord, The final protocol has been agreed and signed off by all parties:
1.5 Assessments for environmental controls are undertaken by ABMU health colleagues for minor adaptations. Larger structural changes are undertaken by Cardiff Communities Occupational Therapy Team (CCOT) The protocol stipulates that where specific requests relate to stairgates a joint occupational therapy assessment will be conducted_
1.6 To ensure that the protocol remains suitable for purpose, it has been and will continue to be reviewed at least annually: 1,7 As a result of the fatal incident ABMU Learning Disability Occupational Therapist has developed a Stairgate Factsheet and an Assessment Tool. These documents identify that as far as can be ascertained (after extensive searches) there is no specific guidance (from an appropriate Statutory Regulator) on use of stairgates for adults. They have therefore been developed having regard to good practice and advice provided by professional bodies in order to provide a thorough checklist for staff that are undertaking assessments. These documents have been consulted with Cardiff Communities Occupational Therapy colleagues, the Supported Living Co-ordinator and Cardiff Council's Operational Manager for Health and Safety. 2 Review of Supported Living Accommodation in Cardiff Council
2.1 In addition to the work completed by health colleagues, comprehensive review of Internal Supported Living (ISL) was undertaken between April and July
2016. An Enhanced Monitoring Form' was designed in collaboration with Cardiff Council's Operational Manager for Health and Safety, to ensure that the scope and breadth of the review was sufficient to identify and address any potential health and safety risks. City -

2.2 Learning Disability Case Managers visited each scheme in the Internal Supported Living (ISL) service and commenced comprehensive monitoring review the 'Enhanced Monitoring form' As part of each visit, the Case Managers also scrutinised relevant documents and paperwork pertaining to the individuals_ The visits were thorough and took on average 3 hours, with ISL staff to ensure in advance that files and documents were accessible to be viewed. In total 29 visits were undertaken: 2,3 Based on the results of these reviews, the Supported Living Coordinator compiled report for the Director of Cardiff Social Services including actions for each scheme: The actions were recorded in an 'Action Tracker Spreadsheet' for monitoring and review purposes. The Supported Living Coordinator now meets the ISL manager every 8 weeks: This was initially set up to update the tracker spreadsheet; The tracker noted progress made against actions identified for the schemes and actions identified for the organisation. Following the completion of all actions, the meetings have continued to ensure ongoing monitoring and discussion of any new concerns identified The Learning Disabilities Operational Manager responsible for the'monthly supervision of the Supported Living Coordinator and ISL manager has formal oversight of the tracker and has formal oversight of compliance_
2.4 In addition to the 'Action Tracker' the following changes have also been made as a result of the review: A standardised 'Positive Risk Assessment and Management Policy' for all of Adult Services has been developed. The policy framework developed to support this has been taken from Health and Safety legislation and is set within the context of Social Services and Well Being Act 2014 strength's based approach rather than deficit model promoting appropriate risk balanced against adult safeguarding: Relevant Corporate Council Officers, confirmed that the policy appropriately links to Corporate Health and Safety requirements and sits comfortably within the Council's overall risk management framework; s0 there is a robust and audited structural connection that links what Social Services are doing at a Directorate level, with corporate and national legislative requirements, have endorsed the policy. A more robust risk assessment process has been implemented in Internal Supported Living: Members of the Multi-Disciplinary Team contribute to the Risk Management Plan. It is not signed off, until all members agree. Risk assessments are on the staff supervision agenda as standing item and the team meeting agenda for discussion_ Improved training and continuous professional development opportunities for staff at all levels. Provision of specific courses to meet the needs of staff working in supported accommodation_ new training matrix has been developed in collaboration with Business Support; to assist with the recording of staff training providing alerts when training is due_ using having the using taking

Methods of recording have improved: All communication/staff information books are presented in a double page format and now include 'Action' and 'Outcome' sections, so that there is an accountability trail for seeing through particular directivelmessage Improved supervision agenda for Support Workers allows managers to follow more structured agenda, where performance can be monitored more effectively and directly relates to objectives set within Professional Performance and Development Reviews (PPDR's): Improved and more thorough completion of Best Interest paperwork;, assisted by the attendance of staff at Mental Capacity Act training- Introduction of working and laptops for Senior Support Workers_ Senior Support Workers are now able to access emails whilst are at an individual's home (and not on 'hands on' duty): This means they can make referrals; complete Risk Assessments/Capacity and Best interest paperwork and share relevant information that needs an immediate response , rather than have to wait until they are next in the office to complete vital paperwork: In addition , laptops will be located in all supported living schemes to facilitate the completion of assessments, involving the clients in the process: Reinforcing a 'pro-active' culture, as opposed to 'reactive' . Although this is difficult to quantify, managers and staff alike have reflected on 'lessons- learned' and have drawn on previous experience, to help shape how we deal with situations that may arise. The fact that risk assessments are a standing item on agenda for team meetings provides an opportunity for people to continue to reflect on safe practice: 3 Risk Management Controls Ensuring they are Suitable; Effective and Maintained
3.1 The Internal Supported Living Service (ISL) has a prescribed system of checks for which all senior support staff are trained by the Compliance Officer; Housing and Neighbourhood Renewal, These are recorded in the 'Fire, Health and Safety and General Maintenance Log Book' In.addition to this, a comprehensive monthly 'Health and Safety Checklist' has been enhanced in collaboration with Cardiff Council's Operational Manager for Health and Safety. This includes reference to stairs and stair gates with additional prompts to staff regarding specific issues to consider.
3.2 Case Managers 'Enhanced Monitoring Tool' has also been developed in consultation with the Operational Manager for Health and Safety: This provides an additional layer of monitoring, carried out on an annual basis, to complement the day-to-day and monthly monitoring outlined above_
3.3 The Occupational Therapy 'Assessment Tool' makes clear reference to the importance of reporting faulty equipment and reviewing equipment and the process agile they fully the

to follow if this occurs and is underpinned by Standard 32 of the Welsh Government Guidance Document; 'Community Equipment Services , The Introduction of National Minimum Standards (2011)
4. Training for Staff involved in Assessing the Risk from the use of Stairs
4.1 Cardiff Council Training Academy commissioned 'Health and Safety Laboratory' (a division of HM Health and Safety Executive) to deliver training to fifteen health and social service staff on the 19ih January 2017 . The training was commissioned as a direct result of the review following the fatal incident that occurred within supported accommodation. The training helped Officers understand the design features of stairs, which can give rise to a risk of falling, and to identify simple remedial improvements to reduce the likelihood of a fall, and included: - How to undertake a stair fall assessment Common design issues that give rise to a risk of falls on stairs Examples of HSL stair investigations and the findings Simple tools for assessing common stair features (stair assessment tools be provided to take away as part of the training)
4.2 The training provided staff with the knowledge and skills to assess basic stair safety in supported living accommodation, enabling them to identify examples of good and bad practice: This will allow appropriate changes to working practices and the work environment to be considered and planned having regard to risk and all relevant matters We are now exploring options to deliver ongoing training for appropriate staff in a sustainable way: The processes set out in the report above are overseen by the Operational Manager of Learning Disability Services in their role of Responsible Individual for the 11 houses managed by the Council_ The Council has taken into account the new regulations within the Regulation and Inspection of Social Care (Wales) Act 2016 and the role includes oversight of health and safety and accountability for determining assurance arrangements and setting benchmarks within the service. The Operational Manager is responsible for ensuring processes regarding risk, supervision and controls in supported living are monitored closely and any concerns identified and acted on. hope the response provided adequately addresses the actions required of Cardiff Council as detailed in the report pursuant to Regulation 28.