Dear Ms Combes Re: Patrick Kelly (deceased) Further to the conclusion of the above inquest and your subsequent letter dated 17th April 201 9 and your request for a Regulation 28 report, please find our response below which details what actions we have taken in light of the findings and recommendations: We have implemented Resident of the Day procedure whereby each day of the month a resident is identified as Resident of the and the care file is updated that day, involving the resident and or relative_ AlI care plans are reviewed and evaluated a minimum of monthly and staff seek feedback from the residents and / or the relatives at that time to ensure they are updated regarding the health and well being of the resident as part of this process: The Home Manager then checks the care plan before close of business that day to ensure the file is updated and includes evidence of resident and or relative involvement. As part of the care planning process we have implemented diary record to capture, at glance, the dates residents last received dental care Regrettably we do experience residents with dementia are often resistive to the delivery of care and intimate treatment such as oral and dental care, the Resident of the Day procedure and the dental will highlight to the Home Manager when appointments are due and alert her should appointments be missed due to residents reluctance to attend. This will ensure prompt action and or advice is sought from the dental practice Staff have attended training provided by the Clinical Commissioning Group which has enhanced their knowledge and awareness of potential issues with dental hygiene of our vUlnerable residents so they know when to refer to the dental practices. We are seeking further training to be rolled out to the remaining staff_ We implemented these changes across our Group of care homes MaM Day living diary have

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