Dear sirs Thank you for the correspondence and report to prevent future deaths in relation to the tragic death of Mr. Robert Norman Howell, who had been residing at Elm Tree Court Care Home, Hull. Humberside Independent Care Association (HICA) would like to respond with the comments and actions detailed below. The MATTERS OF CONCERN are as follows. (1) Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring. It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents. As such vital information to those responsible for providing care was often not provided. HICA Response. HICA has always had a process in place that formal handovers occur between shifts for staff. Staff should attend the handover meeting, but we did not have a system in place to record attendance at handovers. We have now introduced a standard handover template and attendance sheet into all services. In addition to this, we have introduced electronic care planning, whereby staff have access to up to date care plans, records, and risk assessments for each resident, at the point of care delivery.
t. 01482 581000 w. www.hica-uk.com Humberside Independent Care Association Limited (Charitable Status) Anchor Court, Francis Street, Freetown Way, Hull HU2 SDT making a difference Company Registered Number IP27662R

(2) Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care. HICA Response It has always been imperative for staff to read care plans of residents within services, and this has always formed part of induction training when staff commence induction into the workplace. We have now introduced electronic care planning, and staff hold devices which contain care plans on them during care, which means staff have information at the point of care delivery, which is contemporaneous. This is also supported by a change in the handover process, and the introduction of 'Flash' meetings in all services, which occur daily to provide any further updates to staff in regard to care support of residents during the shift. (3) Evidence showed a lack of understanding about the falls policies in place. HICA Response HICA has a falls policy in place, which is cognisant of information contained within NICE Clinical Guideline CG 161(Reviewed 2019)- Falls in older people: assessing risk and prevention. Our falls policy has been further reviewed and we are in the process of rolling out the use of the iSTUMBLE platform, which will be available on all handheld devices within our services. The app provides information to support staff on procedures to undertake when a resident has a fall. This will work in partnership with the falls policy and will is available at the point of care for staff to utilise. Alongside the falls diaries that are currently in place in services, we are also introducing weekly service falls meetings, which will review any falls incidents and ensure that risk assessments, and referrals if required have been complete and actioned. The addition of iSTUMBLE and the introduction of weekly falls meetings has been added to the reviewed falls policy, which will be rolled out to all services throughout November 2022. (4) It was acknowledged that the home did have procedures introduced since Mr Howell's death however it became evident that there was still a breakdown in communication and vital information was not being shared. There appeared to be a lacuna in what information should be passed to all staff and how confirmation of understanding was checked. HICA Response We have reviewed the concern noted in relation to communication and information sharing. The measures discussed in the previous three points have been introduced to aid the sharing of information and facilitate better communication. This will be supported by the continued use of staff supervisions.

'1/!it. Sincerely Director of Operations, HICA