Dear Mr. Bricknell, Ref: John Patrick MacGregor I am writing in response to the regulation 28 report to prevent further deaths dated 6th March
2024. The following action has been taken:
• Credenhill Court Rest Home no longer facilitates respite residents. After reviewing the respite care plan we feel, although affective in its short term use it is not as robust as our caredocs care planning system.
• Senior care staff have been supported through weekly discussions to ensure they are confident in documenting the needs of each resident, they are able to capture everything on a day to day basis and any concerns raised are being addressed and documented. The notes are being regularly reviewed and audited.
• The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home admin group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes.
• I have reviewed our weekly ward round and a list of residents that need to be seen are emailed to the GP surgery 24 hours in advance. Once the residents have been seen we now receive a record of actions taken by the GP/ECP that visited. These actions are then added to the individual resident's health notes within their care plan and any omissions can be identified.
• The medication processes for residents taking blood thinners has been reviewed by the GP surgery and there are no concerns with the process we have in place although we ourselves have added an additional safeguard by including an alert sheet that can be found within the medication administration sheet.

• In addition to our verbal handover and residents information board on display to all care staff in the office, to facilitate and capture more extensive notes for the daily records we have implemented a written daily handover sheet that care staff will complete and this will then be added to each residents daily records.
• Care plans continue to be regularly reviewed and audited monthly or when required.
• I will carry out daily audits of the daily notes that have been written and continue to support staff to ensure that the quality of our written documentation is upheld. If you require any further information please do not hesitate to contact me.