Dear Mr Timothy Brennand, Further to the Regulation 28 regarding the death of Kathleen Joan Devine, have enclosed comprehensive information on how further deaths can be prevented in the future, these are the changes that have been contrived: At Arden Court resident who has a crash mat and/or sensor mat now has a precise care plan purely for maintaining safety with regards to the crash mat and sensor mat Within the care plan documentation, this meticulously gives guidance to staff to ensure that the crash mat and sensor mat are in the correct place, certifv that all equipment is used precisely, in good working order and the fundamental aim of this care plan is to reduce the risk of falls and promote safety: Therefore, all staff must comply to this care plan to know exactly how to safely care for a resident with a crash mat and/or sensor mat (Appendix 1: Care Plan): A new system that has now been enforced, is that every resident who has a crash mat and/or sensor mat has this included on the daily handover sheet in bold capital letters next to the residents name. The daily handover sheet is a typed document that provides a brief overview of each resident: Therefore, by having this on the daily handover sheet will ensure that new staff or agency staff are vigilant to which residents depend upon a crash mat and/or sensor mat (Appendix 2: Most updated handover anonymised): Another new process that is now applied by the staff, is an additional column on the daily mattress check sheet: On a basis the staff check that the air mattresses are on the correct settings in relation to their weight: The staff document this on the mattress check list which each resident has in their rooms, therefore, the staff now checking daily that; if needed, the resident has a crash mat and/or sensor mat in place and the staff have to test that the equipment is working correctly and document this. Therefore, this firstly prompts the staff to ensure that the equipment is in their bedroom and secondly, ensures that the staff test and inspect the equipment, to ensure that it is working correctly (Appendix 3: Mattress, Bedrails and Sensor mat check): Additionally, the in house moving and handling training, now includes the importance of not unplugging sensor mats Or moving crash mats, this is aimed at all staff, especially staff members such a5 domestics The every any daily flow are

Arden Court 76 Half Edge Lane Eccles BIOaM M3O 9BA T: 0161 240 3273 moving and handling training also highlights the seriousness of ensuring that equipment is in the correct place when the resident is sleeping in bed and stress the dangers of not being compliant with this. Changes have also been made to the accident forms, as Kathleen did not receive regular observations after the fall, whereas the new accident forms will ensure regular checks and observations will be made. Therefore, factures or other complications would be addressed prompted and ensure that the correct treatment is provided rapidly (Appendix 4: Accident Form): At Arden Court, we have dramatically reduced the levels of agency staff that are used, therefore, we now have regular staff who are aware of the equipment that needs to be in place for each of the residents_ Although, if an agency staff member is needed to be used, then they receive a robust handover and clear guidelines of the needs of the residents There was no documentation from the times between 06.30-08.30,at Arden Court we now have hourly observation charts for residents who require more frequent checks, such as someone mobile like Kathleen Devine and these are now actively used (Appendix 5: Hourly check form): These are the changes that have been implemented at Arden Court, feel that we have learnt immensely from the death of Kathleen Devine and hope that these changes demonstrate how dedicated we are to prevent events such as this occurring in the future and we also hope that these changes provide closure for the family of Kathleen Devine Please do not hesitate to let me know if you require any further information.