Dear Sir Response to Regulation 28: Report to Prevent Future Deaths Inquest touching the death of Terrence James White am writing in response to the Regulation 28: Report to Prevent Future Deaths in order to set out the actions laken in response and additionally proposed to be taken following the death of Mr Terrence James White. The Coroner stated the matters of concern were a5 follows: "The Care Centre records documented the presence of the pressure sore appropriately but there was & very substantial absence of documentation recording measures in place to treat the pressure sore and in particular a very substantial absence of turning charts making it impossible for Senior Staff to know if the condition was being treated properly. Having considered the findings of the Coroner we have taken the following actions_ The Home has made several changes to ensure that record keeping for resident's care plans are more thorough staff are accountable for the records produced during their shift - The daily records that the carers complete such as food and fluid intake, turning/repositioning; general wellbeing and activity charts are now kept in individual folders for each resident easily accessible on each floor; Every chart contained within the individual folder is then signed off by the nurse responsible for the shift before the evening handover: This sign off is recorded and signed for with any additional notes on the Daily Allocation sheet for each unit; We enclose a copy by way of demonstration_ The Allocation sheets are then checked the following morning by either the Manager or Deputy Manager to ensure that all documents are duly completed and to an appropriate standard Kic > hcllm .tt" RH and

Rico Healthcare RH BScuulc;ua Hottsc 18 Lclge Rcwuel [4uddcn; VI/ MF Tik: 0208 2202 2277 Fax; 0208 905 55,51 EJn;ul: iulo@vicohcaldlucare €o.uk In addition to the changes in relation to the documentation we have also introduced further measures to ensure pressure sores are suitably identified: A "Skin Integrity Board" has been created for each of the urits, with clear guidelines and pictures identifying the grades of pressure sores the potential causes of the same: This ensures that staff are familiar with pressure sores and will be able to identify and report any type of pressure sore to a senior member of staff; Staff have been undergoing supervision and refresher training in respect of skin integrity with the Home Manager who is a qualified Tissue Viability Link Nurse There have also been changes with regards to archiving documentation:- A new Home Administrator was appointed in early May 2016. He now ensures that all relevant documentation is archived correctly in a neat orderly manner which can then be retrieved as and when required Archiving boxes are now used and marked up accordingly. We are currently working through the old archives to put it in order and easily accessible should they need t0 be accessed Notwithstanding the improvements to the archiving system, we have been carrying out further searches and have located further records for Mr White. have attached these records to confirm that although a robust system was not in place at that time, the relevant records were in existence. On behalf of the Company would Iike lo apologise for the delay in providing these additional records Should the Coroner require additional information in respect of the actions taken or planned please do not hesitate to get in touch with me