Dear Mrs Hunt Re. Robert Arthur Davidson Deceased I write to thank You for your report dated Thursday 13 October 2016. You have made your report under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report is in response to the matters of concern identified during the inquest concerning the death of Mr Davidson who had been a resident at Jubilee Gardens Care Home from 20 March 2015 until his discharge to another care home Aran Court Care Centre on 3 April 2015, Our understanding is that Mr Davidson died on 27 January 2016. We have considered your report at length and understand that you have raised three matters of concern_ The particular matter of concern which is relevant to the actions of Jubilee Gardens Care Home is the third: The deceased PICA behaviour was not highlighted or identified on his transfer between care homes; Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred_ Whilst we understand that you have directed this matter of concern to be dealt with by the governing body (which we take to understand either the regulator the Care Quality Commission or the Department of Health or NHS England) we hope that you be reassured by the actions that we intend to take in respect of this matter: will

These actions are as follows: This incident and the lessons learnt from it i.e. to ensure effective communication at the point of resident's transfer or discharge to another provider will be raised in forthcoming issue of our quarterly Safety 1st bulletin which is shared across all of our Amore Care Homes: We will also highlight the requirement for our home staff to complete Form AM32 Transfer Discharge record. This form is completed in accordance with Policy AM2Z Admission, Transfer and Discharge (July 2016). The form contains prompts for staff to record information such as PICA behaviour. The completed form is then provided to staff at the receiving organisation at the point of the residents transfer or discharge We do hope that you will feel reassured by these actions. Please note that we are happy to provide you with copies of the documents outlined above if this would be of benefit to you and other parties involved in this matter.

Dear Ms Hunt, Following your Coroner's investigation and inquest into the death of Robert Arthur Davidson, the jury concluded that Robert's death was not an accident and was contributed to by neglect: During the course of the inquest the evidence revealed a number of matters of concern: have listed these numerically below to correspond to each point you have raised, for clarity.
1. Health care staff had not been trained on basic process; the Health Care Assistant (HCA) that was instructed to make the 999 call failed to demonstrate an awareness that to obtain an outside line the caller must first dial '9' . Subsequently her attempt to call emergency services was unsuccessful resulting in the nurse having to leave the patient; whom was choking, to make the 999 call:
2. The RGN and HCA staff involved in the incident had not received training on the CPR and the Choking Policy: They were unclear when to start CPR:
3. The two HCA's involved had no experience or basic training before starting work as HCA's. had limited understanding of conditions and processes and therefore consideration needs to be given as to whether there should be a mandatory training or minimum standards, which are objectively assessed, to ensure HCA's have the necessary skills and knowledge to undertake their role
4. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes, therefore some direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when a patient transfers. As a provider Healthcare does have appropriate systems and documentation in situ to address each of the above points. For example, with reference to point 1. Avery's orientation checklist would sufficiently provide evidence of staff awareness regarding how to use the phone systems, how to utilise the nurse call system, inclusive of emergency call bells and actions to take in an emergency_ Avery Healthcare Group 3 Cygnet Drive, Swan Valley Northampton NN4 9BS t: 01604 675566 01604 674410 enquiries@averyhealthcare co.uk HealthInvestor Residential care provider wwWaveryhealthcare co.uk Awards 2016 of the year WINNER Avery They Avery

With reference to point 2, Emergency first aidat work and basic life support training would provide an appropriate level of training for staff: With reference to point 3,Avery have a robust recruitment and induction process, inclusive of the care certificate. This is to ensure that staff have the correct qualities and aptitude to fulfil the role of an HCA within Avery Healthcare. With reference to point 4, Averv's documentation pertaining to pre-admission assessment and transfer of care is comprehensive and if completed correctly would indicate relevant clinical risk Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard: It remains an ongoing process to fully embed all of Avery's policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented: Kind Regards Regional Manager

Dear Ms Hunt; Mr Robert Arthur Davidson (deceased) Thank you for your letter 13"h October 2016 enclosing your Regulation 28 Report which follows investigation and inquest into the death of Mr Robert Davidson On behalf of NHS England would like to express our sympathy to Mr Davidson's family. It may be helpful, in replying to the Coroner's concerns_ if | explain that Section 1H of the National Health Service Act 2006 (as amended) ("the 2006 Act") created the National Health Service Commissioning Board. The Board is more commonly known as NHS England: The Board's functions and duties are set out in that both the 2006 Act as well as the Health & Social Care Act 2012. The legal responsibility of NHS England is to commission healthcare provision third party healthcare providers. NHS England does not provide healthcare itself. NHS England s regulatory role is limited to that of primary care practitioners. have reviewed and considered the concerns set out in your report and your report and address each as follows:- During the inquest heard evidence that Health care staff had not been trained on basic process as follows Making 999 calls to obtain an outside line caller's needed to first dial The HCA instructed to make the 999 call did not know this So the call was unsuccessful: The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient: When to start CPR The RGN & HCA (Health Care Assistants) staff had received no training on the CPR and choking policy. The concern is that Staff are not trained in basic processes and therefore not able to deal with emergency situations: Care organisations, including homes such as Aran Court Care Centre; are responsible for the induction and training of their staff: This should include the use of the telephone in emergency situations Basic CPR training is a minimal expectation of those working in care settings. It is the responsibility of the care home to provide this training and ensuring that staff maintains their competence through regular updates. It may be necessary for the care home to access training in the NHS to meet these requirements. from "9" _

The 2 HCA's had no experience or basic training before starting work as HCA's. They had limited understanding of conditions and processes: Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCA's have the necessary knowledge and understanding to undertake their role: Health Care Assistants (often referred to as nursing assistants or support workers) have traditionally received training from their employer This has caused a variation in standards of practice across the country_ The recent introduction of the National Care Certificate, developed jointly between Health Education England and Skills for Health, is a set of standards that social care and health workers stick to in their daily working life_ The new minimum standards should be covered as part of induction training of new care workers _ The Care Certificate was developed jointly by Skills for Care, Health Education England and Skills for Health: The deceased PICA behaviour was not highlighted or identified on his transfer between care homes: Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred: It is essential that information is communicated between organisations when a patient is transferred, In this case between Jubilee Gardens and Aran Court Care Centre. Had Court Care Centre been aware of Mr Davidson's condition they would have been aware of the need for additional, possibly 1:1 care The commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs_ The care home will be registered with and regulated by the Care Quality Commission, to whom this Regulation 28 report has also been sent; and may wish to comment in respect of this issue am grateful to you for highlighting this matter to NHS England and trust that; in so far as remedies are within our powers, NHS England has endeavoured to address the issues raised by you:

Dear HM Coroner Louise Hunt Ref: Robert Davidson Re: Regulation 28 Report Inquest touching on the death of Robert Arthur Davidson Thank you for sending the Care Quality Commission (CQC) copy of the Regulation 28 Report issued following the Inquest touching on the death of Mr Robert Davidson. are writing to you with our response to the matters of concern raised in relation to Aran Court Care Centre and Jubilee Gardens_ CQC received a notification from the registered manager of Aran Court Care Centre on 29 January 2016 notifying CQC of the death of Mr Robert Davidson on 27 January 2016, after he swallowed and choked on a vinyl disposable glove. As a consequence of receiving this information the CQC made further enquiries and gathered information about the incident including Mr; Davidson's care records_ CQC carried out a focussed inspection on 09 March 2016. At this inspection we focused on how the people known to be at risk of choking were being supported: We carried out a further comprehensive inspection at Aran Court Care Centre on 14 November 2016 in line with our inspection scheduling frequency: At this inspection we looked to see if the provider had acted appropriately to address the We

concerns raised during your inquest and were meeting the The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 ("The Regulations"). Aran Court Care Centre is a care home with nursing operated by Avery Homes RH Limited The home has been registered to carry on the regulated activities of: accommodation for persons who require nursing or personal care , diagnostic and screening and treatment of disease, disorder or injury at the location of Aran Court Care Centre from 02 March 2015_ Prior to this Aran Court Care Centre was operated by another provider: CQC's response to the specific concerns you have raised in the Regulation 28 Report are taken in turn and set out below: Health care staff had not been trained on basic process as follows: Making 999 calls to obtain an outside line caller's needed to first dial "9"_ The health care assistant (HCA) instructed to make the 999 call; did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient When to start CPR_ The RGN and HCA staff had received no training on the CPR and choking policy: The concern is that staff was not trained in basic processes and therefore not able to deal with emergency situations. The registered provider is responsible for ensuring there are sufficient numbers of suitably, qualified, competent; skilled and experienced persons deployed and appropriately trained as is necessary to enable them to carry out their duties_ (Regulation 18, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The provider should have procedures to follow in an emergency and staff should be trained in these procedures: The CQC inspects a provider's compliance with the requirements of Regulations during the course of an Inspection During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid_ Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities_ the

system had been in place so that all staff received the training they needed and this ensured that there was always staff trained in first aid on each shift: Staff were able to give us a satisfactory explanation and told us about the actions they needed to take, and would take, in the event of a similar incident of choking At our inspection of the 14 November 2016 to Aran Court Care Centre, we observed that at the shift handover staff were reminded of the need to dial '9' for an outside line Staff spoken with confirmed their understanding of how to make 999 calls and what action to take in the event of a medical emergency The CQC provider guidance requires that when members of staff are registered with a professional body, for example the Nursing and Midwifery Council (NMC) , and this is requirement of their role, providers must ensure that nurses are able to meet the requirements of the relevant professional regulator throughout their employment; such as requirements for continuing professional development Where providers follow this guidance, registered nurses employed will have the up to date skills and knowledge required to meet service users' needs safely, including basic life support. During the 09 March 2016 inspection we looked at the system that had been in place to ensure that nurses had the required training- At the inspection of 14 November 2016, we saw records that showed what training people had received and were scheduled to receive. On the 10 November 2016 we inspected Jubilee Gardens_ All staff had received first aid training commensurate with their role and all of the staff spoken with knew how to respond to medical emergency, including how to make emergency 999 calls_ 2 The two HCA's had no experience or basic training before starting work as HCA's. They had limited understanding of conditions and processes. Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCAs have the necessary knowledge and understanding to undertake the role. The Care Certificate was developed jointly by Skills for Care, Health Education England and Skills for Health, and introduced on 01 April 2015. These Care Certificate standards apply across both social care and health; and link to the national occupational standards The Care Certificate is designed for new HCA staff, it also offers opportunities for existing staff to refresh or improve their knowledge_ The new standards encapsulated in the Care Certificate should ensure that the health and social care workers have the required values, behaviours, competences and skills to provide high quality, compassionate care The Care Certificate clearly sets out the learning outcomes that should be achieved whether this is through training or alternative learning and development activities There is a clear requirement for providers to demonstrate that staff has put put

been assessed in the workplace with regard to their competence and safety to practice_ For example: Standard 11 of the Care certificate covers basic life support The expectation is that the learner will be able to carry out basic life support and complete practical basic life support training that meets the UK Resuscitation council guidelines Standard 13 of the Care Certificate requires the learner to understand procedures for responding to accidents and sudden illness, including the procedures to be followed if an accident or sudden illness should occur: CQC refers to the Care Certificate in the 'Guidance for providers on meeting the regulations. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014' The guidance states That providers must have an induction programme that prepares staff for their role. It is expected that providers that employ healthcare assistants and social care staff support workers, should follow SA the Care Certificate standards to make sure new staff are supported, skilled and aa assessed as competent to carry out their roles"_ CQC therefore on inspection looks to see if the provider's induction incorporates the Care Certificate standards_ If as an organisation the provider chooses on staff inductions to ask staff to complete something other than the Care Certificate or not complete all of the outcomes in the Care Certificate, they will need to demonstrate to CQC how the induction meets the needs of the employ and the needs of the people they support: At the Inspection of Aran Court Care Centre on 14 November 2016 we checked to see that the induction training provided to new staff followed the Care Certificate standards and we were able to see that it did_ In addition information provided by the provider in the provider information return (PIR) showed that to date nine new staff had completed the Care Certificate induction standards training At the inspection of Jubilee Gardens on 10 November 2016, we saw that new staff complete induction training that incorporated the Care Certificate standards The provider's PIR also reflected that some new staff has completed the Care Certificate induction standards_
3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred: staff they

CQC expects that providers should actively work with others, both internal and external; to make sure the care and treatment remains safe for people using the service_ When people move between services or providers , Regulation 12(2) (The Regulations) requires providers to undertake appropriate risk assessments to make sure service users safety is not compromised This includes when move between or to other bodies who may not be registered with CQC. At the inspection on 14 November 2016 at Aran Court Care Centre , we looked at Avery Homes RH Limited admission assessment document: This is the provider's transfer document Whilst we did not look specifically at Mr Davidson's transfer document; We saw that if this admission document was completed appropriately and with sufficient detail; the information needed to ensure that where people were known to be at risk would be captured. This would enable the provider to take appropriate steps to minimise this risk At the inspection of Jubilee Gardens on 10 November 2016, we reviewed the provider's revised handover document which is called passport and if this document was completed appropriately then the known risk to a person would be recorded so that plans could be in place to minimise these risk Should_Vou require anv further information please do not hesitate to contact me on Tel:

Dear Mrs Hunt; Thank you for your letter of 13th October 2016, following the inquest into the death of Mr Robert Davidson. I was sorry to hear of his death and wish to extend my condolences to his family. The Department of Health acknowledges that improving the capability ofthe care workforce through continued skills development is a vital investment in the future, and helps other people to recognise social care as a skilled career option: The characteristics of the workforce, including opportunities for learning and development; have a direct relationship with the quality of the care that services users receive. In April 2015,the Government introduced the Care Certificate (as recommended by Camilla Cavendish in her July 2013 review), which is helping to ensure that support workers and their employers can deliver a consistently high quality standard of safe, effective and compassionate care. It includes 15 standards and outcomes that health and social care workers in hospitals, care homes and people'$ own homes should know and be able to deliver in their daily work. Regarded as best practice' for the induction of new health and care assistants, it is also offering existing staff an opportunity to refresh or improve their knowledge. The Care Certificate standards include: Awareness of mental health; dementia and learning disability; Basic life support; and Health and safety: Our

While not mandatory, all new healthcare assistants and social care support workers are expected to attain the Care Certificate: It is a benchmark by which service providers can demonstrate meet Care Quality Commission *staffing' and fit and proper persons employed' requirements, and evidence of its use may be actively sought by inspectors. The Department is providing significant levels of funding to support training and development for the care workforce: In 2016/17,DH will invest El2m through the Workforce Development Fund which provides support to employers on modules and qualifications for their workers in adult services in the private and voluntary sectors. The Department is also continuing to work closely with our delivery partner; Skills for Care; partner in the sector skills council social care; to improve the level of skills of the adult social care workforce. Skills for Care has developed a comprehensive suite of standards and qualifications to help workers develop the skills and knowledge need to support people who use services, including specialist pathways in dementia, diabetes, managing challenging behaviour and learning disabilities As a government we take the safety of patients and quality of care very seriously; Many measures have already been introduced to ensure providers improve standards including how the Care Quality Commission (CQC) assesses providers the new fundamental standards of safety and quality which care should never fail. CQC has made unannounced inspections in November 2016 of both Aran Court Care Centre and Jubilee Gardens Care Home. Iam informed by CQC that its initial findings indicate that staff now have a better_ understanding ofwhat action to take in an emergency. However its assessment of the findings following both inspections is still underway and, once completed, full inspection reports will be published I hope this response is helpful and I am grateful to you for bringing the circumstances of Mr Davidson's death to my attention: