Dear Madam I am writing in response to, and as required by, your letter of 23 July 2021. The action plan which you requested is attached, as are explanatory notes with background details. The manager and I are both fully aware that we were not fully prepared for the inquest and can only offer our apologies. Despite having worked in the sector for over 30 years and my involvement in providing care across 5 care homes for 16 years, neither of us had ever been involved in an inquest before. This gap in our knowledge led to our not considering fully the documents to be disclosed: there are records which are whole-home and contain details of all residents which are not included in care plans. These include the written shift handovers, the meal-time check lists, the visiting records, the computerised nurse call bell records for bedrooms, and the twice daily covid symptom checks: their presence in the disclosure would not have negated the inconsistencies between the room charts and other records but would have filled in many of the lacunae identified. Unfortunately, we were not aware that there had been any concern about anything other than The late Mr Dickinson's pressure are care, until took the stand at the inquest. We had received a phone call querying pressure wounds on 2 August 2020; however, no concern was raised, and we were informed by the consultant geriatrician assigned to our community care beds that this had been resolved as the as the hospital's tissue viability nurse conducted an examination and noted that the skin problems were not pressure wounds but caused by moisture. We do not know why a safeguarding concern was not raised about the other aspects of care as we have no access to GP or hospital records. Neither were we made aware of the area of concern during our conversations with coroner's office about providing our records and attending the inquest. We had rung the coroner's office to ask if we required legal advice and we had consulted the Royal College of Nursing who informed us that this was not necessary as we had not been notified that we were

persons of interest. We fully accept the coroner's comments about inconsistencies and confusion arising from our documents, for which we apologise, but believe that we may have been better able to respond to questioning if we had been better prepared and had received legal advice and preparation. More importantly, if we had been advised of the concern more timeously by a complaint or safeguarding alert being received from the hospital, it would have enabled an improved investigation by the care home while memories were fresh, and staff were still in post; and would have enabled any learning to be identified while we were still providing Community Care Beds. As stated at the inquest, we had given notice of our intention to withdraw from the contract in April 2020 and the contract ceased accordingly in April 2021. We have shared our action plan with at the Care Quality Commission.

Dear Madam, Report to Prevent Future Deaths: Touching on the inquest into the death of Mr. John Dickinson. I write further to the prevention of future death report issued following the inquest looking into the death of Mr. John Dickinson, who sadly died on 9th August 2020 after a period of care at Sunnyside Nursing Home. Prior to submitting this response, I can confirm that the Care Quality Commission (CQC) has contacted the registered provider that operates Sunnyside Nursing Home, Bluebell Care Services Limited, to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report. We have now received this information and we are assured with the actions taken by the registered provider to address the specific concerns found during the inquest. The provider is no longer providing care under the Community Care Bed contract which required the use of standardised paperwork that differed from the one usually used by the provider. The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training. The provider has also indicated they have held individual and group staff meetings where the importance of quality care records were addressed, including advice from healthcare professionals. HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA

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The provider has showed a willingness to learn lessons from the investigation into Mr Dickinson’s death and implement changes that will improve the safety of residents living at Sunnyside Nursing home.

As indicated in our previous letter to the HM Coroner on 10 November 2020, CQC gathered further information from the provider and the local safeguarding team in relation to the concerns surrounding Mr Dickinson’s death.

It may be helpful for us to set out the result from previous inspections in respect of this Provider and Sunnyside Nursing Home. In May 2017 we inspected the service and rated it “Good” overall, rating the service “Good” in all areas i.e. safe, caring, effective, responsive and well led.

A further comprehensive inspection of the service was completed on the 12th and 18th of December 2019, with the report published on the 4th of February 2020. Again, the overall rating following this inspection was ‘Good’ overall and good in all areas.

We have since visited the home again on the 20 August 2020, to complete an inspection focused on the safety of the Infection Control policies and procedures carried out at the home and we did not find any concerns. For further information about our inspection’s findings, please read the full reports here:

attached to this letter.

We believe it is important to note that the failures you describe in your matters of concern were not failures that had previously been ascribed to this service during our previous inspections. At the time of this gentleman’s sad death, nursing homes and care homes generally were under huge pressure due to the Covid 19 pandemic. During the first 6 months of the Covid pandemic (and beyond) the focus at such places of care was very much on infection protection control, to try and stop the spread of the virus to keep vulnerable service users protected and safe. There was a focus on maintaining staffing levels in order to care for service users during lockdown, which raised previously unprecedented practical challenges for providers of care in this sector. This does not necessarily mean that sub-standard care was provided to service users during this period. However it is possible and indeed probable as Mr Dickinson’s case highlights, there were failures in the day to day recording of the care provided to service users, which may not necessarily reflect the quality of care they actually received at that time.

In line with CQC’s regulatory responsibilities, we continue to monitor statutory notifications and enquiries related with this service. Having considered the evidence and information available in this case, we have made the decision not to commence a formal Registered Provider investigation into Mr Dickinson’s death. Whilst we acknowledge there were some apparent failures in the recording of care,

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these appear to be individual in nature, and most likely committed by individuals who lie outside of the scope of the CQC’s enforcement powers.

If you have any further queries, or require additional information in respect of this matter, please do not hesitate to contact the inspector for Sunnyside Nursing Home directly, their email address is or alternatively you can contact the Inspection Manager