Dear Catherine McKenna,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Furthermore, to your letter dated 27th of June 2024 which contained the Section 28, please refer to my response to the report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the death of Norman Leadbeater on 14th of January 2024.

Thank you for your input at the inquest and also for your identification of the matter of concern regarding the audit of MAR sheets for service users.

Since the Section 28 was issued to Evolve, the company have taken many remedial steps to address the content of your letter. The current RM has completed an audit of all MAR sheets for all the service users and the report is attached for your attention. Attachment 1

After many discussions with our in house senior team, and with our Contracts Officer at Bury Adult Services, , and also with other professionals, namely , who is the Medication Lead for Bury Adults Services, hence the improvements include: the Staff Induction has been revisited and greatly improved, with additional training, which covers the role of the SW in more detail, the Induction period includes more observations of staff during their shift, by other senior staff.

The Care Plans have been redefined inclusive of more details around the client's needs, choices and preferences, refer to attachment 2, also the training resources have been greatly updated, with an external training

provider brought in, to improve the training content and provision, there is increased medication observations for staff, and now all staff have the Care Certificate and NHS training on Administering Medication, attachment 3,which was recommended by has also been completed the four staff members and remaining staff members will aim to complete by the 6th of September 2024. We will ensure this training is refreshed every 12 months as our standard procedure. The Medication Lead for Bury Adult Services, has visited the office with , our Care Officer, this proved to be a very helpful meeting as has given further direction and guidance on how to improve our medication practices and assist the company and the staff to practice safe medication, all policies have been rechecked and updated now, our recruitment will be more detailed now.

, who replaced the previous RI, will undertake the Registered Manager Award, he will be enrolled and will complete with the current training provider that the RM, is training with. His role will involve more time in the office, but he will do ad hoc quality checks on staff and these checks will be recorded also. The exiting RI will still have involvement in the service until needed.

There will be monthly staff meetings whereby staff will be encourage and will be paid to attend, all discussions will be recorded and sent out to staff in a timely manner, as regards to the DBS for staff, then to ease the process, all staff are enrolled on the update service now and the checking of log sheets is managed also by ensuring that all entries are checked for accuracy and content.

The recent improvements made on handling, manging and administering medication safely and to ensure safe and effective delivery of care services for service users. The office now has a full list of all pharmacies that our clients get their medications from and a full list of all GP surgeries, from this list our communication has greatly enhanced our practices. Refer to attachment 4

The improvement measures are reflected through the implementation of best practices, enhanced training via FLEXEBEE delivered online on Medication administration, Speech and Language Therapy training also known as SALT, and Care Certificate containing 15 standards, which are:

1-Understand Your Role 2-Your Personal Development 3-Duty of Care 4-Equality and Diversity 5-Work in a Person-Centred Way 6-Communication 7-Privacy and Dignity 8-Fluids and Nutrition 9-Awareness of Mental Health, Dementia and Learning Disability 10-Safeguarding Adults 11-Safeguarding Children 12-Basic Life Support

13-Health and Safety 14-Handling Information 15-Infection Prevention and Control

All staff have completed the above training now. Some staff were offered group sessions where they attended the office and conferred with the RM and other staff, to learn effectively about the role. Refer to attachment 5

Further to regular meetings with our Care Officer from Bury Adult services, , and after meeting with the Medication Optimisation Team, , as directed by , all client MAR sheets are printed now, the introduction of printed MAR sheets, which will be from either the office or the chemist, this will reduce medication errors and ultimately provide better outcomes for service users. Refer to attachment 6

To ensure that safe medication is prioritised at all times, the MAR sheets will be continuously audited on a regular basis, after they are returned to the office.

Staff were informed of the outcome of the Inquest, in particular, the Section 28 applicable and the changes that were required to improve our practices and they were kept aware of the need to improve training, communication and their recording on the MAR sheets. The above was discussed with the individual staff that attended to NL as well as in other staff meetings, where other matters were raised like accuracy of log

entries, being mindful of client preferences on each visit and not to assume their choices etc. This meeting was helpful in sharing information and in outlining plans to ensure that staff comply with our Action Plan and all concerned are working towards the same goals.