Dear Ms Marsh

Regulation 28 Report to Prevent Future Deaths following the inquest of Kesia Waller who died on the 25/01/2020.

I am writing to you in response to the concerns raised by your findings of the circumstance surrounding the tragic death of Kesia Waller. I will address the two concerns raised in turn.

A: I heard that whilst there has been additional training for the staff on areas of risk such as self- harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature.

In response to the above, and as I mentioned in the inquest, we have already revamped the first aid training provided to include first aid action in relation to suicide, self-harm and overdose. As an organisation, we have also added preventative training around suicide awareness and conversations for all front-line staff.

Additionally, we are providing ligature cutting kits in every office that provides any form of care and support provision and this will be fully rolled out by the end of July 2021. The kit includes a big fish safety knife which is recommended for ligature cutting. These kits will also have quick guides within them and are included in our audits for checking content. 33 Staple Gardens Winchester Hampshire SO23 8SR

a2dominiongroup.co.uk

Finally, we have liaised with Hampshire County Council, which commissions our contract and numerous others around the county, on the outcome of the inquest and our response to this report. We have updated them on training and equipment provision so that they can share this practice with other providers who also provide housing related support.

B: Although additional training and courses have been added to both the induction training and on- going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/ies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now in place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed.

I want to reassure you that we take our responsibilities over policies and procedures very seriously. All staff are formally inducted over a period of four months. During this they are required to read all relevant policies and procedures relating to their role. As an organisation, we carry out regular reviews during the probation and formal ones are recorded at 2 weeks, 2 months and 4 months. Staff also undertake ‘on the job’ face to face and online training and ‘buddying’ to ensure new starters understand the requirements of the role and the policies/procedures that they should follow.

As an organisation we update and amend our procedures at least every three years, if not sooner, if there is a change in best practice or legislation. We have a dedicated team who oversee this.

We involve staff in policy and procedure reviews to ensure that they work effectively on the ground. We also take on board operational feedback and ensure that this is reflected within changes. All staff receive a ‘purple ribbon’ email that highlights changes to any policy and procedure.

As a result of the inquest, we have supplemented the above to include an interim solution whereby once a ‘purple ribbon’ email is sent that the staff member has to confirm they have read and understood the changes. This is then recorded and held centrally. Policies and Procedures have

also been added to the agenda of all team meetings. Any changes and amendments are discussed at team meetings to check understanding and how these will be applied in practice, this is also minuted and audited.

As an organisation, we are also upgrading our HR software systems, which includes improved digital records of training undertaken and policies and procedures read. This will enhance the ‘purple ribbon’ process set out above by automating it. This is due to be implemented by 2022/23.

I hope that the information I have given provides suitable assurance that the findings of your investigations and the areas you have highlighted for the prevention of future deaths have prompted action and been the focus of continual improvement and our commitment to support the safety and well-being of those that we support.