Dear Madam Regulation 28 Report: John Nichols refer to the Regulation 28: REPORT TO PREVENT FUTURE DEATHS dated 2 November 2017. In accordance with 'Section 7 , Your response' we set out below details of the action to address your concerns set out in 'Section 5, Coroner' we have taken currently s Concerns' , namely That the Fire Drills in place does not include sufficient safeguards to ensure that residents (and in particular those with dementia) are sufficiently monitored before, and after drills. Background The elements of the fire drill which impact on the routines of residents "normal" operations f a care home are identified over and above the as follows: sounding of the fire alarm , which could cause distress. 2 The automatic closing of fire doors, which could cause distress It should be noted automatic ofthe fire doors takes approximately that physical harm is minimal. This twenty seconds and the risk of time is based on a Doorgard being affixed Staff attending to the Fire Panel for & few minutes, which could delay residents when requested through the call bell system. attendance to We have also considered the sounding of the fire alarm the weekly testing of fire alarm The drill policy of European Healthcare Group PLC currently in place states that before the Home Manager is required to identify those residents that drill; fire drill: need to be looked after during the Action Kings Kings Thorpe Policy during fire key daily The closing during fire fire

Kings Lynn and Eastgate Residential Care Homes Kettlewell Lane, Kings Lynn; Norfolk, PE3O 1PH Tel: 01553 769098 Fax: 01553 818704/818 WWwehgukcom We have taken the following steps: Engaged the services of Steve Wiltshire AIFSM ("SW"), a Fire Consultant to observe and comment on the Group'$ fire drill procedures We enclose a copy of his report for your consideration ( The Report" ). Internally reviewed and amended where necessary the Group' s Fire Drill Procedure, the Pre- Assessment Procedure and the Personal Emergency Evacuation Plan ("PEEP") after carefully considering SW's Report and reviewing the of the residents. Evaluation We would make the following points regarding SW's Report: We consider that the observation of the fire drill at Bay Court; another of the Group'$ homes of the same type as Lynn Residential, was not a problem because the fire procedures are exactly the same across all the homes When the new procedures are bedded in we will undertake an operational audit at Lynn again. SW had seen the Regulation 28 Report prior to his visit and was aware of the concerns We discussed the mistakes observed during the drill set out in the Fire Evacuation Record Tree Court (see Appendix 2) with SW and were considered minor: We will implement his recommendations: Horizontal evacuation is documented in the Fire Risk Assessments ("FRA"). A copy of the FRA for Lynn is attached (Appendix 3). Please note that Lynn Residential Home is a single storey building: The Personal Emergency Evacuation Plans ("PEEPs") have been amended, see below. [The Fire Procedures set out by SW are already incorporated into those set out in our FRAs: We do not call 999 until we have verified that there is a fire:] Residents' bedroom doors are checked on a fortnightly basis to ensure that they close and operate properly as part of the maintenance procedures at the homes: The correct of doors is important at all times and not just during fire drills. We consider that the issue of distress arising from the sounding of the fire alarm should be raised with the next of kin at the pre-assessment stage, before the person is admitted to the home The alarm sounds regularly and should this cause distress, we may be unable to meee the needs of that person: We have amended the Pre-Assessment Form to make the enquiries: We enclose a copy ofthe new Pre-Assessment Form for consaderateoprGeer your (see Appendix 4). During the trial period of a resident stay, we will monitor their reaction to the sounding of the fire alarm and adjust the PEEP as required: We enclose a copy of the revised PEEP for your consideration (see Appendix 5). safety Tree Kings Kings fire Bay they fully Kings Kings fire closing

Lynn and Eastgate Residential Homes Kettlewell Lane, Lynn; Norfolk; PE3O 1PH Tel: 01553 769098 Fax: 01553 818704/818 WWehqukcom For those residents who already been admitted months, into our homes we will, over the next consult with next of kin and residents to see if require fire drill: assistance during a [The Fire Drill Procedures have been amended to make clear that the bells continues as normal:] Consequently, answering of Nursecall to reflect the we have amended the Group's Fire Drill Procedure changes to the above. This will be implemented across all the homes Procecher relevant training at each site. The annual Fire Awareness updaterWill also changes made. We enclose a copy of the revised Fire Drill re-iterate the (see Appendix 6). Procedure for your consideration We would be pleased to receive your comments on the actions addressed your concerns set out in the taken and confirmation that we have Regulation 28 Report.