Dear Sir, Regulation 28 report in relation to the Inquest touching on the death of Andrew Clegg Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 28 report which we received on 03 April 2019 following the inquest into the death of Mr Andrew Clegg: We are writing to you with our response to the section 5 matters of concern raised within your report in respect of the Care Quality Commission specifically point 2: homes and other healthcare premises are regularly inspected by the Care Quality Commission. In recent years the inspection regime has included duty on inspectors to check on water safety. Expert evidence at the inquest suggested that inspectors lacked training to help them identify risks relating to potential legionella infection. can confirm that water safety is considered by CQC inspectors prior to every inspection we conduct_ We use planning tool to record information about the location when preparing for an inspection. The Lines of Enquiry which inform the planning tool make specific reference in the Safe domain: In the section S2 the question is 'How are risks to people assessed and their safety monitored and managed SO are supported to stay safe and their freedom respected?" There are then sub questions which include: S2.6 which asks "How are the premises and safety of communal and personal spaces (such as bedrooms) and the living environment checked and managed to support people to safe?" The guidance for inspections suggests their evidence should include checking there are Legionella Certificatelrisk assessment and checks in place, and also checking ProviderlManager arrangements for checking, identifying, and rectifying premises issues_ RECEIVED 2 2 MAY 2089 Care Key they stay

would point out that CQC inspectors are not technically qualified in water safety or water systems generally (where these issues are known to develop) and therefore are unable to hold themselves out to be experts in this field. As a regulator we are not able or qualified to advise providers on to deal with specific logistical water safety issues on site_ We do however refer all providers to the relevant industry guidance in water safety as provided by the Health & Safety Executive_ This can be found at http Ilwww hse gQv uklleqionnaires and http IIwwwhse goV UklpubnslbooksII8 htm: It is the CQC's responsibility to draw the providers attention to the expected compliance with these guidelines, it is not CQC's role to make technical examinations of water systems on registered provider sites during inspections_ It is the responsibility of the provider running the location to ensure they comply with the water safety guidelines and provide a safe environment for their service users_ We have taken significant learning from the sad death of Mr and have already spoken with CQC Academy which is responsible for developing and out training programmes within the Quality Commission, suggesting that tailored training course in Legionella awareness should be developed and cascaded down to all inspectors nationwide to improve the inspectorate knowledge generally in this area of risk If you have any further queries in respect of this issue please do not hesitate to contact me_ Yours sincerely Head of Inspection how Clegg rolling Care

CareQuality HSCA Further Information Commission RECEIVED Citygate Gallowgate 2 8 MAY 20,9 Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171 H.M: Coroner for Wiltshire & Swindon 26 Endless Street Salisbury Wiltshire SP1 1DP For the attention of: Mr Nicholas Rheinberg Assistant Coroner 22 2019 Our Reference: MRR1-6856666097 Dear Addendum to CQC response to Regulation 28 report in relation to the Inquest touching on the death of Andrew Clegg For completeness we further information as an addendum to our response dated 17 May 2019 to the Regulation 28 report made on April 2019 following the inquest into the death of Mr Andrew More specifically with reference to section matters of concern raised within your report in respect of the Care Quality Commission, specifically 2: CQC is currently in process of agreeing an updated Memorandum of Understanding (MoU) with Public Health England (PHE) to improve CQC's access to water safety and water systems'-related technical expertise PHE: Specific provision in the revised MoU is being made to regularise and make more systematic and efficient our access to PHE specialist expertise in circumstances where CQC require it to inform its regulatory functions. These functions include monitoring; inspection and civil and criminal enforcement actions_ It is expected that revised MoU will be agreed between CQC and PHE in summer of 2019. wish to reiterate that if you any further queries in respect of this issue please do not hesitate to contact me. Yours sincerely May Sir , have Clegg: point the from the have

RIBA # 25 Royal Institute of British Architects Nicholas Leslie Rheinberg Assistant Coroner H.M. Coroner for Wiltshire & Swindon Wiltshire & Swindon Coroner's Court 26 Endless Street Salisbury Wiltshire SP1 IDP 23 April 2019 Dear Mr Rheinberg; Response to Regulation 28 Report Re: Andrew Robert Frank Clegg deceased Thank you for your letter of 1 April 2019 to the Royal Institute of British Architects regarding the death of Andrew Robert Frank Clegg: am responding as Executive Director of Professional Services at the RIBA with overall responsibility for overseeing professional guidance for our members_ In responding to your concerns, the RIBA intends to develop a concise knowledge resource to explain to our members the need to consider water safety, particularly in coordinating the design of care homes and healthcare buildings We intend to publish this as an article by the end of July to raise awareness of the water safety issues highlighted in your report It is important to explain that architects do not generally design the public health (plumbing) systems in buildings, this is usually undertaken by building services engineers in most medium or large projects like care homes or healthcare buildings On most smaller projects these systems will be designed by the contractor or a subcontractor. Architects will provide architectural design and depending on the services they are appointed to undertake, may coordinate the design of building services engineers Royal Institute of with the overall architectural design and if acting as Principal Designer, under the British Architects Construction (Design and Management) Regulations, will have a duty to 66 Portland Place _ coordinate health and safety information for the construction and maintenance of the London, WIB 1AD, UK building: Tel: +44 (0)20 7580 5533 Fax: +44 (0)20 7255 1541 info@riba org

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RIBA 4 note that the Regulation 28 letter was not sent to the Chartered Institution of Building Services Engineers. We advise that the Regulation 28 report is also circulated to this body and the Construction Industry Council for wider dissemination.