Dear Mr Coutts-Wood, Thank you for your report into the death of Walter Gordon Powley: The circumstances in which this gentleman died were indeed sad _ As you will be aware our inspectors regulate against the legislation laid down for us by the Government which is the Health and Social Care Act 2008 and subsequent regulations In assisting providers to understand the legal requirements we produce guidance about compliance, which sets out what we would expect providers to take into consideration: In this instance this issue would fall under Regulation 15 or Outcome 10 which says: Safety and suitability of premises
15. (1) The registered person must ensure that service users and others having access to premises where a regulated activity is carried on are protected against the risks associated with unsafe or unsuitable premises, by means of (a) suitable design and layout; (b) appropriate measures in relation to the security of the premises; and adequate maintenance and, where applicable, the proper operation of the premises, and use of any surrounding grounds,; which are owned or occupied by the service provider in connection with the carrying on of the regulated activity (2) In paragraph (1), the term "premises where a regulated activity is carried on" does not include a service user $ own home Our guidance states that the provider should also meet the requirements of the Health and Safety at Work Act 1974 and other relevant legislation_ We work closely with the Health and Safety Executive (HSE) in Leicestershire with inspectors reporting any issues that they note on their inspections in nursing homes. Whilst the Commission s (CQC) compliance inspectors do look at the premises they would not necessarily have a comprehensive knowledge of the Health and Safety Act. There are a number of outcomes and regulations which can be assessed it is rare that compliance inspectors look at them all: inspector chooses the outcomes to assess based on the service type, the needs and vulnerability of the people using the service and any prior knowledge we hold about the service. Therefore we may not look at the pipe work unless there had been a complaint or unless it stood out to them that the area was dangerous. Our inspectors do check that radiators are covered but will often only sample a selection of people's rooms: Chairman: David Prior Chief Executive: David Behan CBE Registered office_Finsbury Tower 103-105 Bunhill Row London ECIY 8TG Fax: The and

Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social and are piloting new methodology very soon. Instead of the current outcomes we will assess against five domains and ask five questions: Is this service safe? Certainly in this circumstance the service was not safe. Is this service effective? Is this service caring? Is this service responsive t0 people s needs? Is this service well-led? The provider has the ultimate responsibility for ensuring that know and monitor any unsafe conditions in the service and take the correct action. welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology; that our inspectors are checking high-risk areas such as this If you would to know more about the imminent changes in CQC, please do not hesitate to contact Head of Regional Compliance in Central West, or visit our website WWW cqc org Uk:

Dear Sir INQUEST INTO THE DEATH OF WALTER GORDON POWLEY 25TH MAY 2012 OCTOBER 2013 _ BURNS FROM CONTACT With HOT PIPES Your Regulation 28 letter dated 4t October 2013 has been passed on to me for reply as lead for HSE's Health and Social Care Services Unit on the topic of social care. was sorry to learn about the death of Walter Powley. You reported matters of concern to HSE under Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013_ You requested consideration be given to the following: 1 - Neither the pipes or the valves in the bedroom were covered readings taken at the Home indicated that temperatures ranged from 60 Degrees Celsius to over 70 Degrees Celsius. Evidence given suggests that pipes and valves may not be covered in other Homes in the area 2 _ There was no risk assessment of the physical circumstances of the room and whether it was safe for the resident: 3 _ The Home had been inspected by CQC and the LA and the matters referred to had not been recognised_ Mae HSE yn croesawu goheblaeth yn y Gymraeg HSE velcomes correspondence In Welsh and Leicester Citt & SOUTH LEI CesteRSHRE CORONERS DiSTRICT RECEIVED 4th and

HSE has guidance on the risks from hot water and surfaces on its Health and Social Care web pages (http Iwww hsegov_ukhhealthservices/scalding-burning_htm) , including Information Sheet 6. Further information can also be found in HSE booklet 'Health and safety in care homes' (HSG220) which is available on the website and is currently being reviewed and updated. It is hoped that the revised version will be available in early Spring 2014. totally understand your concerns but see CQC as the lead regulator and inspection body in England for health and social care providers and we believe they are better placed to proactively lead on service user safety issues note that you have also written to CQC HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance disseminating it to the sector HSE sees this as an appropriate forum to raise your concerns and it is our intention t0 raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting: It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards_ HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those concerning prevention of burns not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. will share this letter with local authority health and safety regulators via HSE's Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum. How health and social care is regulated across England is currently being reviewed following the Mid-Staffordshire Inquiry this may impact on how such concerns are taken forwards in the future. this addresses the concerns you have raised but please do not hesitate to contact me if you wish to discuss the matter further:

Dear Sir, refer to your report of 4t October 2013 concerning a Regulation 28 matter. The Registered Nursing Home Association is a trade association for owners of care homes providing nursing care (previously called nursing homes). There is no obligation placed upon home owners to join the Registered Nursing Home Association: The powers of the Association are limited to membership matters
i.e. removing membership where the standards expected of the Association are not met Western View Care Nursing Home is not & member of the Registered Nursing Home Association and, as such; there is nothing that can do, of a regulatory manner; in relation to Western View Care and Nursing Home. see that your report has also been sent to David Behan at CQC ad Steve Scott at HSE; both of whom have regulatory powers which am sure that they will now exercise as necessary: do, however; recognise the risk which you have identified and can report that as an Association, we regularly advise members of their responsibility under the Health & Safety at Work Act. We particularly draw their attention to the need to ensure that the pipes leading to a radiator; as well as the radiator itself, are suitably covered to prevent the risk of burns in the event of a patient falling against the radiator: We will continue to advise members of the need for risk assessments and actions to ensure that there are safe radiator temperatures, including pipework; within the home_ Yours NC Frank Ursell Chief Executive Officer QWLMN' VURSING CARE Registered in Engtand No. 982095 Jodn Disiril f and sinceraw SARS]