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which was treated successfully, however the combination of injury and illness led in turn to his death on 1 October 2022. We understand that you heard that three safeguarding referrals were made in connection with the care provided to Mr Capstick: These related to:
1. concerns raised by the ambulance crew when Mr Capstick was admitted to hospital having sustained major chest injury; 2 concerns raised by friends who visited Mr Capstick at Westmorland Court in early 2022 about the quality of care given to Mr Capstick;
3. further concerns raised by the ambulance crew about Mr Capstick's appearance in September 2022 when he was admitted to the Royal Lancaster Infirmary. We have noted that you heard the first two referrals were closed by social services, and the third referral remains open_ In addition to the above, a General Practitioner gave evidence raising concerns about the care being provided to residents at Westmorland Court. He said that care had improved since Mr Capstick's death, but he has to visit regularly to check residents. There is a specific concern about entries made in Mr Capstick's notes as there was clear evidence that examinations entered in the notes were made at times when this was impossible because he was in hospital. A concern was raised about the absence of a defibrillator in the home at the time of the incident: It appears one has now been installed. Finally, you have raised with us specifically the concern about the registered nurse in charge of the home on the night of Mr Capstick's injury: There was a statement which said the nurse forgot their basic training and was confused about what to do: Basic checks and signs of life were ignored: You were told that a referral to us had been made and acknowledged and have asked us whether the referral has been closed_ Our role The NMC is the independent regulator of more than 808,000 nurses and midwives in the UK and nursing associates in England. We're here to protect the public by upholding high professional nursing and midwifery standards, which the public has a right to expect. We maintain the integrity of the register of those eligible to practise and we investigate concerns about professionals. Our Code_of Conduct contains the professional standards that registered nurses, midwives and nursing associates 2

must uphold. We will investigate alleged breaches of the Code when we become aware of them under our fitness to practise process_ We have two clear aims for fitness to practise: professional culture that values equality, diversity and inclusion, and prioritises openness and learning in the interests of public safety, and b nurses, midwives and nursing associates who are fit to practise safely and professionally: In appropriate circumstances we enforce the standards set out in the Code through fitness to practise proceedings _ Fitness to practise proceedings can result in a range of outcomes, ranging provision of advice to the registrant by the NMC to removal from the register: response to the concerns raised We can confirm that our investigations in relation to the concerns raised about the registered nurse in charge of the home on the night of Mr Capstick's injury are ongoing: We have shared your concerns as set out in the PFD with the investigating team_ We have also contacted Westmorland Court for further information and obtained details about the registered nurse's current practice. We have contacted the registered nurse to give them the ability to comment on the concerns and are waiting for their response. We expect to make a decision in the next two to three weeks on whether to progress our investigations further on the basis that we need to take action to protect the public or whether we can close the case on the basis that there are no public protection issues We also carried out a risk assessment upon receipt f the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual's practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest: We continue to keep this under review pending receipt of new information. We have also considered whether the PFD raises any other concerns which we need to act on. We have noted that concerns were raised about the care provided to Mr Capstick generally at Westmorland Court and a specific issue relating to inaccurate entries made within healthcare records_ We have noted that at the time of the inquest one safeguarding referral remained open. In relation to this we have passed this information on to our Employer Link Service (ELS) and to the New Referrals team to make enquiries in relation to these concerns. We will investigate any concerns which fall within our remit through our fitness to practise processes and share information with other organisations if necessary from the Our

Finally, we recognise that our processes can be very difficult for the friends and families of patients who are connected to our investigations. We have a Public Support Service (PSS) to help support people through the process and understand how the investigation process works. Through it, our public support officers can answer individual questions or provide one-to-one meetings and help explain the different decisions that could be made. More information about our PSS can be found here NMC_public support service The_Nursing and Midwifery Council: We have referred this case to the PSS team who will reach out to Mr Capstick's family: am sorry that this has not been actioned until now: Conclusion Thank you for raising your concerns with us. trust that our response sets out the action that we are taking as a result of the concerns raised to improve public health, welfare and safety. If you would Iike any further information or have any further questions concerning this case or the steps we are please do not hesitate to contact uS. Finally, would like to again offer my heartfelt condolences to Mr Capstick's family.

Dear Sir Westmorland Court Nursing and Residential Home provides the following response to the Regulation 28 Prevention of Future Death Report issued by HM Assistant Coroner, Dr Nicholas Shaw. As was identified within live evidence during the inquest; a number of improvements had taken place by the time of the inquest and since the sad death of Mr James Reginald ("Reg"_ Capstick: Improvements have been further and embedded in the intervening period between the Inquest conclusion and the date of this letter. This letter seeks to set out those improvements in care quality for the attention of the Coroner and provides a formal response to those concerns. Quality Improvement Plan One of the components to the improvement in the quality of our care has been the use of the quality improvement programme: A Quality Improvement Plan ("QIP") was in place in conjunction with Lancashire South Cumbria ICB ("ICB") and Westmorland and Furness Council
2024. The QIP and ongoing monitoring process consisted of regular meetings with colleagues from the ICB and Westmorland and Furness County Council: The purpose of the meetings was to Company number: 4009674 Nursing" key from May

WESTMORLAND HEALTHCARE LIMITED "Spesiolieing i Gare Westmnorland Court, High Kriott Road, Arnside, Via Carnforth, LAS OAW Telephone: 01524 761291 Fax: 01524 762640 Email: Mvlanager @wesimorlandcouri.co uk assess our improvements ad compliance with the QIP, to obtain updates from quality colleagues including the CQC, By way of update to the Coroner, the QP identified that the following improvements/ actions were in place and ongoing at the meeting held on 24 July 2024. The meeting held on 23 September 2024, marked the conclusion of our meetings. The ICB ad Westmorland and Furness Council recognised the significant improvements observed following their visit to the care home on September 3, 2024. Furthermore, acknowledged the improvements in both the quality and content of the care plans We are currently awaiting the minutes from this meeting: A new role of Deputy Manager was created to increase resilience, review of the workforce culture, and generally ensuring high level of service within the home_ The Deputy Manager also supports with ongoing governance, management ad running of the Home. The Deputy Manager has been in post since the 30th of July 2024 An external consultant has been reviewing the Home's training matrix with the Registered Manager and recommended some adaptations including adding a clear training due date to ensure staff are pro-actively allocated to training courses on an ongoing basis. These recommendations have been accepted and completed; Health and safety audits have been completed independently and no asbestos or structural issues have been noted_ Four staff have been enrolled on level 4 food hygiene COSSH folder is in place with an additional risk assessment and legionella survey was completed last year with no concerns raised. Furthermore, fire risk assessments have been updated. The Registered Manager has enrolled staff with "Skills for Care" so can attend further person-centred care planning training: There has been change in the way care plans are being written, with the intention of making them more person centred, to ensure that members of care staff are able to better proactively consider health concerns or any deterioration in health . Company number: 4009674 Nureing they they

WESTMORLAND HEALTHCARE LIMITED "Epeciqliging ix Care Westmcrlarid Court, High Knott Road, Arriside, Via Carnforih, LAS OAW Telephore: 01524 76129] Fax: 01524 762640 Email: Manager@wesimorlandcourt co.uk Home "Newsletter" WhatsApp group ad Facebook pages are in place and working well to assist in smoother communication within the staff group ad/ or dissemination of updated guidance/ policies; and/ or engaging family and friends to enhance communications between home and family/ friends; greater involvement of residents re person-centred care and celebrating their activities. The CQC has provided guidance regarding consent and the need for a social media policy which is ongoing family survey has been sent out and feedback has been obtained please see further comments below about the positive feedback obtained and the compliments The Clinical Lead has enrolled and currently undertaking the NVQ Level 5 in Leadership and Management course. The Community Mental Health Team has provided challenging behaviour training to staff. There have been improvements noted by the ICB following submission of the IPC audit. A range of environmental matters have been attended to: The dishwasher is now working and the fly zapper has been fixed; there are new stair and corridor carpets now in place which is further evidence of the comprehensive audits/ assessments of and actions taken to embed improvements into the home environment; a new has been bought and is in place; work has been completed on the roof; more than 12 rooms and corridors are being updated; the floor has been completely refurbished; some windows have been replaced; there has been the installation of 3 brand new boilers with one more to be changed; the Home's lift has been upgraded; a new fire alarm system is in place; and the staff room and some other areas of the Home have refurbished, Two hourly UCR information is now discussed at staff handover to ensure staff confidence in utilising the service and that any changes in person' $ health Company number: 4009674 Nursing log: good fridge top been

WESTMORLAND HEALTHCARE LIMITED "Speoiobising i (are Westmoriard Court, High Kriott Road, Arnside, Via Cerniorli, LAS OAW Telephone: 01524 761291 Fax: 01524 762640 Emzil: Manager@westmorlandcourtco.uk presentation is appropriately handed over to staff and that there is a continued drive to sustain and embed improvement to care quality: Provider led audit and checks are now completed and clearly documented to ensure that there is suitable oversight in respect of care quality ad to maintain ongoing provider assurance of governance of the service. Compliments The improvements in relation to care quality have been feedback to the Home by relatives and residents. A range of positive comments are included within the compliments log from August/ September 2024 please see attached document (Appendix 1). Lessons learned As a Home, we are keen to drive "lessons learned" improvements across our care quality and practice. Ongoing discussions have been taking place and have been had with all staff about the case and understandably the concerns outlined by the Coroner in relation to basic life support and accuracy of record keeping: All senior staff and registered nurses now have the appropriate training in place for basic life support. DNAR'$ are now located on the inside front page of the resident files for ease of access, which were not prior to regulation 28. All staff have access to a safety checklist which details which residents have DNAR'$, allergies, cognitive impairments ad other pivotal information, Daily walk round audits are conducted which include testing staffs' knowledge of the ABCDE assessment process to competently assess resident and identify whether person is in cardiac arrest Monthly mattress audits are in place and staff now have increased awareness and understanding of the importance of checking the air-flow mattresses after each intervention for those that are air-flow mattresses. Company number: 4009674 Nussing being good log very they using

WESTMORLAND HEALTHCARE UMITED "Ipeoioliging 13 (ape Westmiorland Court, High Knott Road, Arriside, Via Carnforth, LAS OAW Telephone: 01524 761291 Fax: 0152" 762640 Erail: Manager@wesimorlandcourt.co Uk We have implemented safety huddles with staff daily to improve resident safety and care The safety huddles will improve situational awareness, create an environment where staff feel safe to raise concerns and integrate information to develop a comprehensive picture of the status of residents in our care at a particular time. We have initiated further and more prompt advanced care planning discussions with residents (as appropriate) and their families and loved ones. Further supervisions have taken place with care staff to cover care quality matters such a5 respect and dignity, oral hygiene, choice, infection control, health and safety, safety checks, COSHH, safeguarding, amongst other matters: Please see Appendix 2 for an example copy of the supervisions undertaken with care staff: Action was taken in relation td and, following the incident with Mr Capstick, she was immediately taken off front line nursing duties. was investigated in line with the Company s employment procedures, A formal disciplinary meeting was held, and no disciplinary action was taken against however range of actions were required and undertaken beforel could return to duties. Basic life support training was refreshed and updated. This has been consistently refreshed please see Appendix 3 was required to work on day shifts only and undermine or the Clinical Lead' s supervision until her competency had been appropriately ad satisfactorily assessed as being suitable to provide nursing care safely to residents; As the Coroner was aware, referral was made to the NMC, and this was acknowledged. Beyond that acknowledgement, it is not known to us the exact status of the NMC' s investigation post-triage, however currently has a live PIN and is not subject to any NMC conditions on her nursing registration. The NMC has confirmed to us that it will contact us to confirm the outcome of the investigation. In the meantime, (remains under supervision and, as above, has undertaken further training and will continue to do so on the required basis_ Company number: 4009674 Nursing her, nursing our

WESTTMORLAND HEALTHCARE LIMITED "Speciolising in Gere Westrnorland Court, High Knott Road, Arnside, Via Carnforrh, LAS QAW' Teiephore: 01524 781291 Fax: 01524 762640 Erail: Mlanzger@wesimorlandcourt.co.uk The Coroner will no doubt be receiving an update from the NMC direct, as recipients of the Regulation 28 report: We understand thath has completed reflective account of the incident relating to Mr Capstick and that this has been submitted to the NMC Ongoing monitoring We trust that the above information provides the Coroner with reassurance that action has been taken over a period of time in relation to a range of care quality matters including staff training, leadership and governance, staff competence, environmental and auditing matters. We also remain engaged with the ICB and Westmorland and Furness Council; having made the notable and vast improvements which led to the cessation of the quality improvement process, together with regulation by our overarching regulators, including as the CQC and the NMC for nursing staff.

Dear HM Senior Coroner Kally Cheema and Assistant Coroner Dr Nicholas Shaw, Regulation 28 Prevention of Future Deaths Report following Inquest into the death of James Reginald CAPSTICK Thank you for sending Care Quality Commission (CQC) a copy of the prevention of future deaths report issued following the sad death of James Reginald Capstick We note the legal requirement upon CQC to respond to the report within 56 days, that being by 27 September 2024, and would like to thank You for agreeing to our request for an extension until 04 November 2024. We are grateful for the details provided in your report and confirmation of the outcome following inquest. With regards your query in relation to CQC making further enquiries, we have taken action as outlined below_ CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident; a refresher of basic life support training for all staff, and a referral to the NMC regarding the individual nurse's conduct CQC followed up these actions and were reassured that staff had received refresher training in basic life support and that the provider had taken appropriate actions in relation to the registered nurse involved in the incident: On 30 September 2022 CQC were notified of an allegation of abuse made by ambulance staff relating to concerns of neglect in relation to Mr Capstick whilst resident at Westmorland Court Residential and Nursing Home. The concerns were identified by ambulance staff on 13 September 2022 when called to transport Mr Capstick to hospital. CQC are in the process of reviewing information related to this Our

safeguarding alert and are undertaking further enquiries to assess whether any further regulatory activity should be considered: Following receipt of notification of the death of Mr Capstick a targeted inspection was carried out on 13 October 2022. This provided assurance regarding the safety of other service users at the location. We have given careful consideration to the concerns raised in relation to whether it should be requirement for care homes to have defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around best to deliver care safely and assure us of the same There is no legal requirement for care homes to install equipment such as defibrillators but if were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely. Where equipment as defibrillators are not installed, we would expect a provider to be able to demonstrate that have suitable policies and procedures in place to ensure appropriate resuscitation methods can be carried out if required by suitably trained staff: We hope this response provides sufficient information on the matters raised. Should you require any further information from CQC then please do not hesitate to contact uS_