Dear Mr Davies REGULATION 28: REPORT TO PREVENT FUTURE DEATHS INQUEST INTO THE DEATH OF TINA JANE ALLEN I am writing in response to the Regulation 28 (Coroner’s and Justice Act 2009) Report to Prevent Future Deaths issued on 5 December 2022 following the inquest into the regretful death of Tina Allen. Tina was a resident at Valley View, a residential care service for five adults with learning disabilities, operated by HF Trust Limited ("HFT").

On behalf of everyone at HFT, I would like to express my deepest condolences to Tina's family. As Chief Executive, I am deeply saddened that Tina did not receive the quality of care that she should have expected. HFT conducted an immediate internal investigation into the events of the 13th June 2022 and the underlying contributory factors and circumstances surrounding Tina’s death. Working closely with external key stakeholders and regulators, HFT has made, and continues to make, improvements to the quality of service provision and delivery at Valley View. We have commissioned an independent review by a well reputed external consultant specialising in health and social care serious incident investigation and review, with the outcomes expected in the coming months. Additional lessons learned following this independent review, and any recommendations for further improvements, will be progressed at pace.

I set out below the matters of concern identified in section 5 of your report and our response: That the persistent understaffing at the care home is impacting upon the ability of staff to safely provide the care and treatment required. Further, the understaffing is impacting upon the ability of the care home management to properly monitor the safety and appropriateness of the care given at the care home. The care home is invited to review the staffing levels at the home and the relevant recruitment and retention policies and strategy. HFT has faced a particular challenge in recruiting and retaining permanent members of staff at Valley View, which forms part of HFT’s St Teath service. This is, in part, due to its rural location. Between the period of January 2022 and December 2022, no new permanent staff were employed (despite HFT's efforts to recruit), and over the same period, two full time equivalent, permanent colleagues, left. In addition to Valley View’s permanent members of staff, we utilise a bank of relief workers who work solely for the St Teath service, who are inducted and trained in the same way as our permanent staff. Our relief workers cover vacant shifts, as do our permanent staff, who pick up additional shifts. It is only when our relief workers and permanent staff have covered gaps in the rota, that any remaining shifts are opened up to agency colleagues. Whilst the service is not yet fully recruited to at this time with permanent members of staff, safe staffing levels are being maintained with the combined use of permanent members of staff, consistent relief workers and block booked agency colleagues, who provide a level of stability, familiarity and continuity of care. Staffing levels and training compliance at Valley View are continually monitored by the senior management team, with information regularly shared with our external stakeholders and regulators. The management structure of the Valley View service has been reviewed, and appropriate senior management and local administrative support has been provided to oversee the service in the short term, whilst we recruit a new Registered Manager. The approach to shift management has been updated to include a formalised handover attended by the management team daily. Effective checks and audits are carried out by the management team to monitor risk, safety and appropriateness of the care given to the people we support. A review of the salary structure has been undertaken and implemented, with a location specific allowance applied to Valley View payrates to assist in the attraction of new, permanent staff. Our focused online recruitment campaign, physical presence at local job fairs and improvements in on-boarding processes are all evidence of concerted efforts to

attract, engage and retain new staff, significantly improving local recruitment opportunities in this rural area. In the longer term, these improvements within the Valley View service will be further enhanced by the development of both local and organisation wide improved retention strategies. Initiatives include the development of a new Pay, Reward and Recognition Strategy addressing both local and organisational challenges. These newly developed strategies will be underpinned by a talent management framework, which includes revised people systems and apprenticeship pathways to drive robust succession planning. Apprenticeship development pathways support the breadth of roles from Level 2 and 3 Adult Care Worker progressing though to Level 5 Leaders in Adult Care and beyond. The aim is to cultivate a culture which will support inclusivity, innovation, creativity and a sense of belonging whilst ensuring services are safe and of a high quality. A review of policies and procedures is being undertaken in response to the learning identified from the investigation into the incident. This includes an update of the Nutrition and Hydration Policy, and the introduction of a specific Dysphagia and Choking Procedure, which were undertaken in October 2022. These new processes are being embedded within working practices via dissemination at team meetings, and knowledge of, and compliance with, these processes, is being assessed via supervision and audit. In addition to enhanced service specific training, both HFT and agency colleagues are being provided with intensive training in relation to the provision of person-centred care and support. HFT's Learning and Development team will continue to support, train, and provide opportunities for new, existing, and block booked agency colleagues. This ensures they are appropriately skilled, equipped with the requisite knowledge, and are competent to undertake their roles. For example, in January 2023, both HFT and agency colleagues in Valley View received training in total communication, Makaton and Person Centred Active Support (PCAS). Regular agency colleagues have HFT IT accounts and are assigned e- learning in the same way as colleagues employed directly by HFT. To ensure all Valley View colleagues, be they HFT and / or agency, have the opportunity to contribute and feedback to the senior management team on a regular basis; formal and informal team meetings have been diarised twice a month, for either virtual or in-person attendance. Colleagues will also have the opportunity to discuss key areas of care and support, development of the service, and share experiences. Regular supervisions are also scheduled for all Valley View colleagues, to provide a confidential time with the manager to discuss colleague health, safety and wellbeing, training and development, ideas or suggestions to improve the service.

HFT has a Partnership Forum which offers an independent space where HFT colleagues can connect with their local representative, and discuss ideas and/or concerns. We also have an up to date Whistleblowing Policy, which has been shared with colleagues. To ensure clear visibility across the Organisation, HFT have procured a new digital care planning system (Access Care Planning). This system provides assurances for reviewing, monitoring, auditing of data and working practice at the service in real-time, quickly identifying any areas of potential non-compliance. The system will also enable clear reporting, providing oversight to both local and national teams, internal Quality/Audit and Risk Committee, our Executive Committee and Board. HFT has a Quality Assurance Framework, which aims to deliver a combined system of internal audit undertaken by the quality and improvement team, and self-assessment undertaken in local areas. This will help to better understand and improve the quality of our service provision, and ensure regulatory compliance. Valley View has been receiving enhanced support via this process, and a comprehensive improvement plan has been put in place. This plan is being overseen by a Steering Group chaired by myself, and the Chief Quality and Governance Officer and the Chief Care and Support Officer are leading on the delivery of key work streams. There are weekly update/action review meetings between the management team at Valley View, and HFT’s Safety and Quality teams, for ongoing oversight and monitoring purposes. I would like to take the opportunity to provide reassurance to the Coroner, that HFT, as a social care provider and responsible employer, who prides itself on supporting its service users with the utmost integrity, are fully committed to continuous operational and organisational improvement.