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Actions Taken Record Keeping Review in response to the issue that documentation in relation to the pressure ulcer failed to reflect the deterioration, and that photographs were not used to track the progress. From a review of this case it is clear that record keeping was not of the standard would expect_ can confirm that staff at Fernlea Nursing Home now use photographs to track and monitor pressure ulcer development, Initial photographs are taken once a pressure ulcer is identified and the photographs are stored electronically on the nursing home system. Further photographs are then taken on a regular basis to allow comparison and highlight deterioration at an early stage. As a general rule photographs are taken every 2-4 weeks in line with individual Risk Assessments and Care Plans: In circumstances where a significant change is noted photographs are taken more frequently and referrals managed appropriately: am pleased to note that the nursing home has now adopted the Stockport NHS Foundation Trust pressure ulcer monitoring form to ensure consistent and regular monitoring of pressure ulcers_ Whilst this investigation has focused on an individual nursing home case, as the commissioner of services for the Stockport population we re-issued the pressure ulcer case review template to all Stockport Nursing Home Managers The proforma asks the reporter to consider safeguarding concerns and develop an Action Plan. The form is reviewed by the CCG's Designated Nurse Safeguarding Adults and Quality Improvement Nurses. Cases can then be escalated as safeguarding concern (if not already raised) or discussed with the quality team to determine if more targeted support such as 'React to Red' (pressure ulcer prevention initiative) training is required. Registration Requirements in response to the issue that documentation in relation to the pressure ulcer failed to reflect the deterioration Registered nurses, midwives and nursing associates must comply with the Nursing and Midwifery Councils professional standards that apply within their professional scope of practice , which includes communicating effectively, keeping clear and accurate records relevant to their practice The CCG's Designated Nurse Safeguarding Adults has developed a two page guide to effective record keeping: This document was emailed to all Stockport Nursing Home Managers on 24 January 2020. The CCGISMBC Quality Improvement Nurse is also going to share the guide and present it at Care Homes Forum in May 2020. Refresh of the requirements of the referral to Tissue Viability service process in response to the issues of the delay in escalation to the specialist Tissue Viability Nursing Team despite clear signs of deterioration, and No evidence of a robust system to track the status of a referral to the Tissue Viability Nursing Team The process of referral to the Tissue Viability Nursing has been reviewed and has nw been changed; Referrals to the tissue viability service are no longer submitted via fax. The referral form now includes prompt for nursing home staff to follow up any referral which is not actioned within 2 working days. the

It is now standard practice for Fernlea nursing home to ensure a read receipt is requested so that the referring home can check to ensure that the e mail has been accessed read by the Tissue Viability Team: In addition a follow up telephone call is made to the service the following day; irrespective of the pressure ulcer urgency status; during this call the date for a visit from the team is confirmed and added to the nursing home The Quality Improvement Nurse is monitoring that this change remains embedded as part of routine practice_ In addition; please note the additional actions to underpin the above changes React to Red Training training programme has been developed and rolled out across the Stockport Care Home community. The training includes the nationally NHS recognised React to Red training for pressure ulcer prevention within a care home environment The training commenced in 2018 and can confirm that since that time a total of 184 individuals from Stockport care homes and domiciliary care agency have undergone this training: In relation to Fernlea Nursing Home can confirm that the home currently employs registered nurses, all of whom have attended either React to Red or an alternative advanced wound care training courses. Development of Nursing ICare Home Pathways The Quality Improvement Nurse is also working with the Tissue Viability Nursing Service at Stockport NHS Foundation Trust to develop a number of pathways for care homes. Escalation Processes serious or thematic quality concerns relating to pressure ulcers are now escalated and discussed at the Multi agency Quality Issues and Concerns meeting attended by members of the CCG, SMBC , Public Health and CQC. After reviewing the completed actions, am satisfied that appropriate steps have been taken in response to your findings. If you require any further information please do not hesitate to contact me_

Dear HM Senior Coroner Prevention of future death report following inquest into the death of Mr Arnold Fletcher Ward Thank you for the prevention of future deaths (Regulation 28) report issued following the Inquest touching on the sad death of Mr: Arnold Fletcher Ward. We note the legal requirement upon Fernlea Care Home and the Care Quality Commission to respond to your report within 56 The registered providers of Fernlea Care Home are Olea Care Limited. The provider location registered with CQC is located at 20 Torkington Road, Hazel Grove, Stockport; SK7 4RQ. The provider is registered for the following regulated activities: Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury The role of the CQC & Inspection methodology The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to inspect whether or not the fundamental standards are being met days.

current regulatory approach involves inspectors considering five key questions: ask if services are Safe; Effective; Caring; Responsive; and Well Led. Inspectors use a series of key lines of enquiry (KLOEs) and prompts to lseek and corroborate evidence and reassurance of how the provider performs against characteristics of ratings and how risks to people are identified, assessed and mitigated. Sources of evidence for the KLOEs can be found 0n our website along with our KLOEs and characteristics of ratings The regulatory framework includes providers being required to meet fundamental standards of care, standards below which care must never fall; We provide guidance to providers on how can meet these standards (Regulations 4 to 2OA of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). Fernlea Care Home was inspected by CQC on 13 May 2019 and the comprehensive inspection report was published on 5 June 2019. The provider was rated Good overall across all our five domains; Safe, Effective, Caring, Responsive and Well Led, Since the last inspection in 2019 CQC had not received any information of serious concern in relation to this care home and the next comprehensive inspection was scheduled for December 2021. At the time of the inspection CQC was not aware of the circumstances of Mr Ward's case or subsequent death_ This response relates to the concerns expressed in your report that: Within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoringluse of photographs to track its progress_ This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability nursing team for expert wound management input: As a result the type of wound dressings Mr Ward required were not utilisedlavailable_ It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October 2018. There was no system in the home t0 chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case. 2 Our They they May

The matters of concerns which arose from the preventing future deaths report were reviewed by CQC and decision was made to undertake an unannounced, focused inspection of the Fernlea Care Home. This was because the concerns indicated that the registered provider may have beenlmay still be in breach of the following fundamental standards: Regulation 12 (1) Care and treatment must be provided in safe way for service users Regulation 17 (1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part (Part 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014): The inspection commenced on the 27 January 2020. The inspection team consisted of an inspection manager and lead inspector: The inspection was focused on two specific key questions; Is the service effective? and Is the service Well Led? Within the context of each domain our inspection team focused on the specific areas of concern raised in the report: We particularly looked at people's pressure ulcer management and management oversight of the home_ In addition, the registered provider had not submitted a statutory notification to us in respect of Mr Ward's pressure ulcer, as required under Regulation 18(2) of the Care Quality Commission (Registration) Regulations 2009. Failure to notify is statutory offence and we looked at whether there were other incidents that had occurred where the registered provider had failed to notify us. We will consider further enforcement action regarding this matter in due course. Initial findings from the inspection have been fed back informally to the registered manager. Whilst the inspection team could see that some measures had been put in place to mitigate future risks to people using the service, we were not satisfied at this stage that the systems were sufficiently robust The inspection further highlighted some additional lines of enquiry and following further management reviews on 28 January and 4 February 2020 decision was made to extend our initial focussed inspection into a full comprehensive inspection. On completion of the inspection we will review the evidence and if we identify breaches in the regulations we will take appropriate and proportionate action in line with our enforcement policy: The inspection report will be published in due course and we are to provide copy of the report to HM Coroner_ Finally, CQC proposes to make further enquiries as t0 the circumstances of Mr Ward's treatment prior to his death: As you are aware from 1st April 2015 the Commission has lead responsibility for investigating and where appropriate prosecuting breaches of fundamental care standards contained within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes 3 happy'

a failure to provide safe care or treatment resulting in avoidable harm or a significant risk of exposure to avoidable harm: If you have any further questions or require further information please do not hesitate to contact uS quoting the reference number MRR1-8119778830

Dear Ms Mutch Re: Your ref: 12108/CH hereby acknowledge receipt of your letter and report dated 16/12/19. Since the incident concerning AFW we have arranged for all our Registered Nurses to undertake third party wound management refresher training (either through a certified tissue viability course or the NHS "React to Red" training course) We have also extended this training to our care staff and to date 87% of the care team have undertaken the "React to Red" training recommended by the Local Authority: This training has now been implemented into our induction program for all new staff: After discussions with the NHS Tissue Viability Nurse (TVN) we have adopted the NHS wound management document within our Quality Management System to ensure continuity between ourselves and NHS professionals During the time of the incident with AFW, the TVNs were in the process of transfering referrals from to email: have acknowledged that there was a number of issues around that time with referrals and follow ups. We have since changed our processes to ensure all referals to TVNs are via e-mail or telephone followed up by a summary e- mail. All referrals are followed up by a phone call the after irrespective of urgency status and prompts are placed in the and on a referral audit sheet for the care management team to follow up. After discussions with the GP it has been agreed that we will notify the GP of all referrals to the TVN and wound management will form part of the weekly GP ward-round. As part of our continual improvement strategy, the group has taken the decision to move INVESTORS forward with the implementation of an electronic care planning system that uploads IN PEOPLE information and photographs in real time: This will improve oversight and auditing and will further improve our wound management processes For your information the Registered Nurses involved in this issue are no longer employed by Olea Care Ltd. If you require any further information, please do not hesitate to contact me Part of the Olea