Dear Mr Winter 12th January 2021 Further to the Regulation 28 Report to Prevent Future Deaths received on 1Oth December 2020 in respect of the late Mr Edward Mallaby; aS per the terms of that report wish to confirm that actions taken to reduce the risk of future deaths at Alexandra View Care Home and across the Roseberry Care Centres portfolio of homes wish to reassure yoU that action has been taken to improve our policies and tighten our procedures considering the accident and the outcome of the inquest We have discussed the accident involving Mr Mallaby at our Group Care and Clinical Governance meetings and agreed number of changes to policy Please find enclosed updated policies in respect of: Residents Belongings Admission of a Resident Management and Prevention of Falls These polices have been issued to the homes throughout the Group with 'read and sign' sheets to ensure and evidence that all staff have read the changes to policy. Specifically, in Alexandra View these updated policies have been introduced in small group supervision sessions s0 staff have the opportunity to discuss their understanding and raise any questions. This process, at Alexandra View, was completed on 31st December 2020. ROSEBERRY CARE CENTRES GB LTD 1st Floor; Valley View Care Centre, Penshaw; Houghton-Le-Spring, Tyne & Wear, DH4 7ER 0191 549 0506 Directors Company Secretany L 0191 385 4001 Company Registration Number: GB 6281674 headoffice @roseberrycarecentres co.uk WWW roseberrycarecentres co.uk have

The policy updates cover the areas as highlighted during the inquest and as detailed in the report received 1Oth December 2020: Management of residents property, which may be hazardous Sensor mat monitoring Frequency of observations, including whether bedroom doors should be open or closed In addition, have introduced an Observation and Monitoring form (also enclosed) to be used in accordance with the updated Management and Prevention of Falls policy and updated the Falls Risk Assessment to reference this new record (attached). At the time of Mr Mallaby'$ accident, sensor mats were checked at each shift changeover and recorded on the handover by the person in charge: The introduction of this form will ensure sensor equipment is checked for its position and that it is in working order throughout the shift and a minimum of hourly. This amendment to policy and additional checking is being monitored daily at Alexandra View by on site senior management; The staff at Alexandra View have also repeated their Prevention and Management of Falls training to refresh their knowledge; all staff successfully completed this by 7th January 2021 . Should yoU require any further information please do not hesitate to contact me_