Response by North Yorkshire County Council to a Report to Prevent Future Deaths for Dorothy Pegg (died 25 Oct 2019) made by Mr Jonathan Heath, Senior Coroner York and North Yorkshire dated 22 October 2021. Mr Heath concluded his investigation into the death of Mrs Pegg on 15 October 2021 and reached a narrative conclusion as follows: Dorothy Pegg slipped from a shower chair, whilst sitting on a sling, whilst fully clothed, having been transferred from the bedroom to the living room. She suffered bilateral leg fractures which have contributed to her death Mr Heath identified the following Matters of Concern in the Prevention of Future Deaths Report (PFDR):
1. There was no system of monitoring the compliance with instructions as to how equipment should be used.
2. There were no instructions as to the circumstances in which it is appropriate that specific prescribed equipment is used. The report provides that:  Point 1 to be addressed by , CEO Abbeyfields the Dales  Point 2 to be addressed by Corporate Director, Health and Adult Services, North Yorkshire County Council (NYCC). A response to point 2 above is provided by North Yorkshire County Council (NYCC) below. Occupational Therapy Involvement Within the NHS and social care system there are hospital or community Occupational Therapists (OT). Within the community, local authority OTs complete assessments to enable people to live as independently as possible in their home environment. One outcome may be to provide equipment or adaptations for the person or their carers/family to use. NYCC practice is that any identified equipment is trialled by the person and/or their carers (whether paid or informal). If required, a moving and handling risk assessment and plan is completed by the OT and left with the person and/or their carers using the equipment. This plan would always be provided for moving and handling equipment, for example hoists, slings, slide sheets and is a legal requirement in accordance with the Health and Safety at Work Act
1974. Carers (whether paid or informal) can then follow the plan as directed or, if required, training by the OT is provided in safe use of the equipment for the individual person. The person’s care provider would then incorporate the instructions from the moving and handling risk assessment and plan into the individual care plan, which is specific for the person and includes information regarding their needs, likes, dislikes and how their care will be delivered. OTs within NHS/hospital teams can transition people moving back into the community (such as from hospital) or who have experienced a deterioration in their health and physical needs and require intervention, equipment or rehabilitation. A moving and handling risk assessment and plan should be written for the person by the NHS OT, where appropriate, and in the same way as described above for local authority OTs. NHS and social care community teams can overlap and work together, they can also deliver discrete episodes of intervention as was the case with Mrs Pegg. In most instances a care provider will also have access to an appropriately trained person with moving and handling responsibility within their own organisation or externally sourced. The appropriately trained person will ensure staff are appropriately trained in moving and handling and are usually the point of contact within the organisation should the needs of the cared for person change. The appropriately trained person will complete a reassessment (on behalf of the care provider) to identify if a referral is required for NHS or local authority for intervention. OFFICIAL

Action proposed or taken by NYCC in response to the Report Action which NYCC has initiated or undertaken following receipt of the report is as follows:
• NYCC will change moving and handing risk assessment and plan templates to have a descriptor box at the top to clearly identify the task for which the equipment has been assessed and provided for by the OT. There will also be a point of note that if the equipment is to be used outside this scope, advice should be sought by the care provider from an appropriately trained person. The updated template will be uploaded to NYCC’s case recording system (LLA) and is to be used as from 31 January 2022.
• An agenda item was included in a NYCC Practice Review meeting on 29th November 2021 and attended by OT Team Managers, Senior OTs and Training & Learning representatives to ensure that when moving and transferring plans are completed and shared with the person and/or their carers, these include clarity on the task for which equipment is intended. When the revised moving and handling risk assessment and plan templates are uploaded onto NYCC’s case recording system, a reminder will be sent to all OTs to use the new template forms.
• There are a range of roles across the NHS and Local Authority that can prescribe equipment including physiotherapists and OT’s. The Integrated Community Equipment Service (ICES) is a jointly funded service between the NHS and Local Authority and will alert prescribers of equipment to the new moving and handling document through a newsletter. A notification is sent to each user of the ICES to make them aware of the newsletter which includes equipment updates and alerts. The next newsletter is scheduled for early 2022 and will contain an article to introduce the new templates. A prompt is included in the Equipment Request Form on the ICES database as a reminder to non-NYCC prescribers to complete a moving and handling risk assessment and plan. A quarterly dip sample audit of the Equipment Request From will be completed to monitor compliance with the new arrangement. This will be undertaken by the OT Lead for Local Authority.
• NYCC will ensure that contracts with care providers have reference within the terms and conditions that any equipment prescribed is used for the assessed purpose. NYCC will also ensure that any change to provision or use is to be incorporated and updated by providers within their care plans. These actions will be achieved by 31 March 2022.
• NYCC will utilise its care provider forums to share and reinforce correct practice (for example, around moving and handling plans always accompanying relevant equipment provision) and to share practice around care plans being updated at any equipment change. We propose to share such information via NYCC’s provider forums, provider bulletins and Care Connected (a regular online provider event). These actions will be achieved by 31 March 2022.
• NYCC have reminded ICES of the contractual requirement to deliver all equipment accompanied by an instruction leaflet. This requirement was included as an agenda item in The Vale of York’s (as lead commissioner) Performance and Quality meeting on 25 November 2021 attended by NHS and Local Authority commissioners and representatives from ICES. Following the meeting the contractual requirement was reiterated via an email from OT Lead for the Local Authority to ICES.
• In addition to the above, on 25 November 2021, NYCC has requested ICES to provide instruction leaflets for equipment on the equipment database for retrieval by Occupational Therapists to accompany moving and handling risk assessment and plans. This request has been followed up via email with ICES who have confirmed that work will start on this week commencing 20th December 2021.
• Future training for new or existing OTs is to include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans. The learning from OFFICIAL

the Inquest for Mrs Pegg will be included. The proposed training has been agreed with NYCC’s Training and Learning representative and the Moving and Handling Trainer on 29th November 2021 and will be implemented in February and March 2022.
• A specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans The above actions have been incorporated into an implementation plan that will be kept under review by the OT Lead for the Local Authority. We also feel it important to highlight that in July 2021, NYCC transferred its OTs into dedicated teams with OT qualified Team Managers. This provides a forum for continuous learning and reviewing practice via regular supervision, team meetings and practice forums to strengthen OT practice and delivery. May we take this opportunity to offer our sincere condolences to Mrs Pegg’s family. We hope that the above actions will provide assurance to the family that NYCC has taken robust measures in response to the PFDR. OFFICIAL

Dear Mr Heath Regulation 28: Report to Prevent Future Deaths I write in response to the concerns you raised following the inquest into the death of Mrs Dorothy Pegg, and your conclusion from the evidence you heard during the inquest. I write to formally respond to the following concern raised on behalf of Abbeyfield the Dales: There was no system of monitoring the compliance with instructions as to how equipment should be used. In the statement I provided to the inquest, I was keen to demonstrate the Abbeylield The Dales has a continuous review process in developing and improving policies, procedures and practices within our organisation. Our aim always is to promote a person centred and safe approach to the support and care we provide for our residents. This process has continued, and I can confirm the following additional improvements have been or are planned to be introduced. New Care Plan Format (already introduced) The statement I provided to the coroner contained details of the new care plan format introduced across all sites during 2020. In the new care plan format (section 6 Mobility,
— Fitness and Falls Prevention) the documentation contains an image of all equipment used to support a resident’s mobility. This section is updated by either the Senior Carer, Assistant Manager of Registered Manager if the equipment used is changed or discontinued. The mobility section of a resident’s care plan also documents systems of work (a standard operating procedure) for all equipment used. The completeness and accuracy of this section of the care plan is monitored for accuracy by the care staff or Senior Carer when the Resident of The Day is completed each month for every resident and the subsequent Care Plan review completed by either the Senior Carer, Assistant Manager of Registered Manager each month. Quality Manager Spot Check Audits (re-introduced in 2021) Part of the Quality Manager’s role is to provide audit assurance to the Registered Manager and Senior Leaders of Abbeyfield The Dales that care delivery and record keeping is in line with policy and best practice. This includes ensuring carers comply with instructions as to how/what We are a member of The Abbeyfield Society Royal Patron HRH The Prince of Wales Registered charity No. 1160258; Registered Company No. 9008680; Homes England No.5066 Registered Office: Grove House, 12 Riddings Road, IIkIey, LS29 9BF Registered in England and Wales

beytie Ed The 1•e equipment should be used. Please see a blank copy of Audit Form the Quality Manager completes at appendix 1, and the audit programme for winter 2021 at appendix 2. The Quality Manager conducts an unannounced audit of care plans and observes care practice (the carer delivering care to a resident) using a random sample approach. Feedback from the audit is given directly to the Registered Manager, and also a copy is sent to senior leaders to ensure any areas of improvement are complete. NB: the audit programme was paused in 2020 due to Covid-19 restrictions and safety measures, and restarted in October 2021 across all registered services. New Equipment (already introduced) A record of new equipment delivered to support a resident’s mobility (a delivery note) is held in a resident’s care plan (where one is received). The care plan is updated with an image of the equipment, so it is clear what equipment must be used when supporting a resident with their mobility and clear instructions are set out in the care plan regarding the correct use of the equipment. Should an instruction regarding the correct technique and use of the equipment be supplied by a health professional (such as an Occupational Therapist), this will be included in the care plan. The systems of work (noted above) will be updated accordingly. Service Delivery Audit (launched with Managers in September 2021) The service delivery audit has recently been introduced and standardises a variety of formats and content of similar audits that have been in use up until recently. The audit checks that the service delivered by a member of the care team is in line with what is required in the care plan, and expected from an Abbeyfield The Dales employee. Please see a blank version of the form at appendix 3. The Registered Manager or Assistant Manager predominantly conducts the audit, and the Registered Manager follows up any actions required in a supervision with that member of staff, perhaps retrain the individual or monitor their performance more closely until it reaches a satisfactory level and maintained. New Equipment Process (to be implemented in January 2022) We have developed a process to ensure staff are clear of the correct use for and operation of a new piece of equipment that is introduced by an Occupational Therapist or other Health Professional to support the safe transfer and movement of a resident. This process is intended to ensure there is no ambiguity in how and in what circumstances a piece of equipment is used, and also there is clear accountability and checking that staff are knowledgeable and confident in the use of the equipment to support that resident. Please see a blank version of the process at appendix 4. In conclusion. I hope these measures satisfy the requirement on Abbeyfield The Dales contained in the Regulation 28 Report; a copy of this response has been sent to CQC on their request.