Dear Mr Siddique,

I write to inform you of the actions taken at HC-One in response to your Regulation 28 report to prevent future deaths, following your investigation into the death of Mrs Melia.

In response to the matters of concern highlighted, we took the following actions:

We reviewed our policies and practices as an organisation in relation to our pre-admission and admission processes.

We reviewed the current Admission process checklist.

The action we have taken as a result:

On reviewing our practices, we identified that if a delay occurred between the pre-admission assessment conducted, there needed to be clearer guidance set out for colleagues within our Admission, Transfer and Discharge Procedure (Appendix 1). We have now included practice that in the eventuality the pre-assessment was completed more than five days prior to admission to the home, further information should be sought from the hospital ward/care home/social worker as soon as possible. This will include the update of any medication changes or outcome of any recent healthcare professional reviews of the person during this period, to avoid any misunderstanding that could result in harm.

The changes to practice have been cascaded across the organisation via our Homes’ Bulletin, which is sent to our homes.

Our Admission process checklist (Appendix 2), which is available within all our homes to ensure all aspects of the organisation’s pre-admission and admission processes are completed, has been updated to reflect this improvement in practice.

I do hope this information is helpful and offers you the reassurance that we, at HC-One, have taken the issues raised seriously and have taken appropriate action with the intention of improving the care and safety of our Residents.