Dear Sir Re: Malcolm Bennett (Deceased) Regulation 28 Report Please find below details of the action Borough Care has taken, or will be taking and the timetable in which actions will be taken, in response to the matters of concern stated within your Regulation 28 Report dated the 22nd June 2016_ AIl Home Managers in each of Borough Care's care homes were instructed t0 update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant; with an instruction to 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury: Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated. 2 The Home Manager at Silverdale met with the senior team to brief them of the matters of concern, and in addition individuals have received a formal 'note of concern' regarding their failure to follow the care plan for Mr Bennett: All care staff at the care home have been reminded of the importance of such matters through the staff supervision process In addition to the above action, Borough Care has also broadly reflected on the incident to identify if there are any other ways in which its best practice of caring for people prescribed anti-coagulants can be enhanced generally and has identified the following actions:
2.1 Each resident who has been prescribed with an anti-coagulant now has an anti- coagulant warning placed on their care plan and MAR sheet to highlight the fact that the resident is prescribed such medication_
2.2 Information about residents who are prescribed anti-coagulant medication is discussed at staff handovers and team meetings, including reference to the care plan;
2.3 General medication training for staff administering medication has been reviewed to include anticoagulant use and First Aid training has also been revised t0 include same.
2.4 Borough Care's 'Falls Prevention and Reporting of Accidents' policy and procedure will be reviewed and updated by the end of September 2016. Kalhryn Farmer Company Secrelary INVESTORS Silver Borough Coro Umltod k an Industial and Provldenl Suclely IN PEOPLE wln cholable slalus Retbttred Otfkt Kom Buxmu Part Heeton Lnt Stockpon Sk4 LAS Rogslered numbor 27788R 'i ring key

25 Borough Care's medication audit procedure will be reviewed and revised by the end of September 2016. would be grateful if you could acknowledge receipt: