Javed Iqbal Regulation 28 To Prevent further Deaths Recommendation Action plan Training Monitoring and Completed Outcomc +Appendix evaluation evidence Appendix 1 Prompt action was
6) All Care in One acted a)Completed The statements were the first 27/05/2024 taken to call in and to ensure all accounts of 27/05/2024 of call for all the hevolsepoir interview both incidents were looked at the care. So we as a company could Both carers and carers AK SH also b) Completed understand what occurred and what care-coordinatur GR care- we need to go ahead and check statements. coordinators It was an open atmosphere to the statement accounts, shock of the incident and we had to a8 soon aS thc support our staff too. To see them face incident occurred to face. Appendix 2 a) Consultants hired by b) We have appointed x2
3) Guidance of retraining Completed So the compariy is able to have a fresh 02/06/2024 the company to go consultants to oversee the staff, group work and ongoing pair of eyes to look at the processes through a implementation of these small groups completed To support and guide on incidents Consultants comprehensive training changes and to monitor see Appendix 3 such as this and how to improve Contract programme and support compliance with care Startcd performanccs from staff; what steps to Attached all in the standards on an ongoing To look al the Birdie 02/06/2024 lake and to confidence build for cOmpany. basis. This will include system and encourage the individual care staff and the team as a regular audits and management team to whole. reporting to ensure monitor and alerts improvements are highlighted on the system sustained The consultancy is called the Al staff due large staff logs

Domiciliary Care Consultancy Appendix 3 CPD Safeguarding training Dor Revisiting training staff to 03/06/2024 Staff can now identify early signs 03/06/2024 E-cerl online all staff involved in the be alert of home of mental distress and intervenc care for Mi JI environments and visually Certificates enclosed GR; SL, AK,SH look for hazards inside the cosisteatetyr_ Safeguarding care mcthods have been training property. implemented to ensure high-quality Safety of people and mental health support by our staff, Safety of People Certificates premises training Employees have gained skills in completed and Premises transparency and sensitive communication, fostering a more Again; we would look supportive environment for our into home environment citizens assessments for citizens All staff involved in Mr JI s care who present with GR, SI; and SH ~have given instability: support and improve their Service This is enclosed in the This policy was looked at This was important lof 3/1/2025- the understanding Of acute mental US; reason health issues. are now better Improvement action plan by lhe Director with the as this was a internal why the datc is in trained with best practices for care Plan Policy care team as it talks requirement, for US to 2025 as we followed and improved communication about the Mental Health robust monitoring the new policics. We protocols, ensuring & more Act 1983 systems and to read and Focused on HOT as structured and effective approach to refiesh ourselves. from this scenario Safeguarding: and lessons learned Honest, open and transparent and our carers should not Copies of Improvement plan given have pleased Mr JI to all staff: and logged all cvents in the daily AK, They adopt log:

Appendix 4 Safeguarding training, Group training, small Questions and answers 20/02/2025 This training has strengthened the 20/02/2025 real life example: groups and groups, worksheet complctcd by carers ability to provide safe, Birdie re-briefing for all slaff. informed, and responsive care, External training staff with an external 'Trainer had assessed the ensuring meet safeguarding brought in to support trainer: carers uderstanding of the standards cffcctively. Safeguarding all the team_ External Trainer has training through scenarios training for all shared specific exarples quizzes and feedback Through real-life examples and staff and case studies to give session which were held to case studies, staff gained a practical carers a practical address any uncertainties_ understanding of the challenges understanding of the cvidence Appendix 5 may face and the appropriate challenges may face responses t0 ensure effective care_ and the appropriate We want an external trainer SO our response care staff (2 x sessions were held staff could havc a variety of should take. the given dates please see training from paper to live face to attacked documents) face. were able to ask questions; talk about cxamplcs and give answers t0 the questions asked: Appendix 5 Guidance and Reflection and Learning: We are offering platform 27/05/2025 Staff showed their emotions at Supervision Development: We are we are providing an to review staff supervisions and were able to Ensuring that carers opportunity for staff to performance, ensure exprcss thcmsclves. This will Out staff are able and coordinators fully reflect on actions, compliance with policies continue as development strategies to express their understand their dulies, assess their practices, and of our Supervision, i.e. and has been on going since the thoughts, including in the identify areas for identifying solutions to company was founded: and lessons best interests of service improvement. problems, improving learned users and recognizing practise and increase Our main aim is tO promote positive signs of delerioraling It is to talk to get understanding of work work environments and to support our mental health. this information into the related issues: staff: In scenario for Mr Jl we needed open, reflect and improve to support and build on this case We for any future scenarios Through our supervision must look towards what can be our staff were offered improved by the company and even though relationships were great in the large they they they They past feelings acting better

counselling through package of care we need to enhance Avcnsure; an agency on the reporting and recording: This was looked at in depth with the supervisions Appendix 6 Ongoing This has been given to Clear glidelines have been Completed Staff arc awarc and look towards Process change One to one briefing staff in the office. established for recognising 20/02/2025 the Chart which is readly available within the with staff;, GRlother and responding to acute in the office, GR also sign posts company staff member in the mental health issues and other staff to this process in 20/02/2025 office. any types of issues_ place and support office staff and Staff are now required to care staff: New ways of immediately escalate Director SI is always readily working pin concerns to healthcare available in person or over the chart providers and document phonc to support and look towards these concerns in writing: the policies and procedures to get Follow through with a guidance. papcr trail as evidence Follow thc pin chart, take all action, check and double check appropriate action has been taken_ Get more support from the MDT. Appendix Ongoing- term We are revising our IT Company 02/05/2025 Staff now follow structured confidence build contract protocols to ensire that Bespoke Computing Ongoing term protocols for timely and clear through IT all communication with company has been conlracl interactions with IT matters, support healthcare providers is engaged to provide reducing misunderstandings and clear; timely, and well- comprehensive support to ensuring accountability. documented_ Staff will all my office staff; this will Training will cnable staff to record receive specific training cnhance their ability to essential details meticulously, l0 reinforce the record and report preventing omissions and importance of accurate information via e-mail this inconsistencies in patient records put Jong long

records and reporting: initiative aims to update Wc will follow our communication process policies and procedures and ensure accuracy in and processes and look at documentation. Bespoke new ways of working: Computing can on (remote access) and support staff if get stuck at any in their daily_work appendix 8 Wc have revised our Access to this policy is The updated policies are Staff now have well-dcfined Reviewed new internal policies to granted to all staff and disscminated across protocols for identifying and policies and ensure align with encouraged to read part the organization, and staff escalating acute mental health procedures of the best practices, by part and sent via email will receive detailed issues, ensuring tinely inlervention safeguarding: regulatory to all staff: briefings to ensure full and structured record-keeping: requirements, and the understanding and specific needs of our This policy has compliance These improvements have created & service users_ Clearer highlighted we can get Enhanced procurcment more structured and inlormed protocols have been support fromn GP; districl protocols are approach to safeguarding and introduced to nurses, Ambulance embedded into our service delivery, empowering staff staff in recognising and services, social works operations to maintain with the necessary tools and responding to acute and work jointly to consistent quality and protocols to provide high-qualily mental health issues, achieve outcomes_ We accountability care. including escalation must adapt open attitudes forward. procedures and record- from the MDT so joint British Red Cross have been keeping standards_ working can be achieved_ contacted by our team for We aiIIL to follow this additional Mental health training in We have touched on the guidance and improve the coming months. We have Care Act 2014 with all further to achieve researched out to this company: staff after following outcomes for our They start of discussing and this policy. cilizens training with what is anxiety? How can stress be defined ? and what are the tell tell signs and give a blown- log they point being they being guide moving

out picture of the full extent of Mental health and its impact on individuals. We are due to some dates for training at our offices for all the team in grOup numbers from five to six: I will enclosc the email as appendix 9 get