PFD report

Dorothy Pegg · Prevention of Future Deaths report

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Issued 22 Oct 2021•North Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of instructions on the circumstances for using specific prescribed equipment
    Part of recurring concern: Failure to ensure clear and followed instructions for safe equipment use
  2. Lack of monitoring of compliance with equipment-use instructions
    Part of recurring concern: Failure to ensure clear and followed instructions for safe equipment use
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. Action

    Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.

    Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
  2. Action

    Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.

    Stated by Abbeyfield The Dales LimitedStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
  3. Action

    Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.

    Stated by Abbeyfield The Dales LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Monitoring compliance with equipment-use instructions is assigned to Abbeyfields the Dales rather than North Yorkshire County Council.

    Stated by North Yorkshire CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of instructions on the circumstances for using specific prescribed equipment

Wider context from the report

“2. There were no instructions as to the circumstances in which it is appropriate that specific prescribed equipment is used. ”

Is this part of a recurring concern?

Yes — Failure to ensure clear and followed instructions for safe equipment use.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of monitoring of compliance with equipment-use instructions

Wider context from the report

“1. There was no system of monitoring the compliance with instructions as to how equipment should be used. ”

Is this part of a recurring concern?

Yes — Failure to ensure clear and followed instructions for safe equipment use.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Record new mobility equipment, images and correct-use instructions in residents’ care plans, including instructions supplied by health professionals.

Verbatim wording from the response

“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.”

Source location

2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct standardized service delivery audits comparing care delivered with care plans, and follow up deficiencies through supervision, retraining or closer performance monitoring.

Verbatim wording from the response

“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.”

Source location

2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a process clarifying new equipment use, circumstances, staff accountability and competency checks for equipment introduced by health professionals.

Verbatim wording from the response

“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.”

Source location

2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use the new care plan format to document mobility equipment, operating procedures and equipment changes, with monthly completeness and accuracy checks.

Verbatim wording from the response

“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.”

Source location

2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 1 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct unannounced Quality Manager spot-check audits of care plans and observed care practice to verify compliance with equipment-use instructions and address improvements.

Verbatim wording from the response

“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”

Source location

2021-0358-Response-from-Abbeyfield-The-Dales-Ltd_Published
Page 1 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Revise moving-and-handling assessment templates to identify the assessed equipment task and require advice before use outside that scope.

Verbatim wording from the response

“➢ NYCC will change moving and handling 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Request that ICES make equipment instruction leaflets retrievable from its database for occupational therapists.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Notify equipment prescribers through the ICES newsletter about the new moving-and-handling templates.

Verbatim wording from the response

“➢ 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 Form will be completed to monitor compliance with the new arrangement.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reinforce with ICES the contractual requirement to supply equipment with instruction leaflets.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce dedicated occupational-therapy training on completing moving-and-handling assessments and plans, incorporating learning from the inquest.

Verbatim wording from the response

“➢ 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”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require care-provider contracts to specify that prescribed equipment is used for its assessed purpose and that changes are reflected in care plans.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver specialist moving-and-handling training for NYCC occupational therapists focused on equipment purpose and moving-and-handling plans.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 3 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use a practice review meeting to reinforce clarity about the intended task when moving-and-handling plans are completed and shared.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share and reinforce correct equipment, moving-and-handling-plan, and care-plan practices through care-provider forums, bulletins, and online events.

Verbatim wording from the response

“➢ 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use the revised templates in NYCC’s case-recording system and remind occupational therapists to adopt them.

Verbatim wording from the response

“➢ NYCC will change moving and handling 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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitoring compliance with equipment-use instructions is assigned to Abbeyfields the Dales rather than North Yorkshire County Council.

Verbatim wording from the response

“1. There was no system of monitoring the compliance with instructions as to how equipment should be used.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 1 · response
Published 1 November 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Add a prompt to the ICES Equipment Request Form reminding non-NYCC prescribers to complete moving-and-handling assessments and plans.

    Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
  2. 2

    Complete quarterly sample audits of Equipment Request Forms to monitor compliance with the new arrangement.

    Stated by North Yorkshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 November 2021.
  3. 3

    Transfer occupational therapists into dedicated teams led by occupational-therapy-qualified managers to strengthen practice and continuous learning.

    Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 1 November 2021.
  4. 4

    Keep the implementation plan for these measures under review through the Local Authority OT Lead.

    Stated by North Yorkshire CouncilStated in progressThe respondent said that this action was in progress when they made their response on 1 November 2021.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Add a prompt to the ICES Equipment Request Form reminding non-NYCC prescribers to complete moving-and-handling assessments and plans.

Verbatim wording from the response

“➢ 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 Form will be completed to monitor compliance with the new arrangement.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete quarterly sample audits of Equipment Request Forms to monitor compliance with the new arrangement.

Verbatim wording from the response

“➢ 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 Form will be completed to monitor compliance with the new arrangement.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 2 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Transfer occupational therapists into dedicated teams led by occupational-therapy-qualified managers to strengthen practice and continuous learning.

Verbatim wording from the response

“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.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 3 · response
Published 1 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Keep the implementation plan for these measures under review through the Local Authority OT Lead.

Verbatim wording from the response

“The above actions have been incorporated into an implementation plan that will be kept under review by the OT Lead for the Local Authority.”

Source location

2021-0358-Response-from-North-Yorkshire-County-Council_Published
Page 3 · response
Published 1 November 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026