Dear Mr Wilson write in response to the Regulation 28 report received following the inquest for Jean Dorothy Gillispie. can confirm the following actions have been taken to help prevent future deaths. Senior Care Assistants in the home have received further medication training & Competency assessments, Supervisions have been completed highlighting the importance of ordering, receiving and dispensing medications, following the inquest a further supervision has been completed to reinforce the polices and procedures of medication management: The manager took sole responsibility for managing the medication at the time of the incident to ensure no residents ran out of their medication. The Home Manager completes medication audits to ensure any issues identified can be dealt with swiftly: There are tools available to assist staff with concerns or medications/conditions they are not familiar with i.e BNF book, external professionals and our internal Quality team. Each member of staff is accountable & responsible for their own actions and how they implement/use the tools & resources available to them: Registered Olfice; Maria Mallaband Care Group Lid Westcourt Gelderd Road Leeds LS12 6DB Tel: 0113 238 2690 Fax: 0113 238 2691 email: admint mmcgco.uk INVESTORS WwYW maria mallaband co.uk IN PEOPLE Company Number; 03135910 The

Alexandra Court has a new manager who has introduced handover sheets and medication count down sheets; this will assist the staff to recognise any issues or shortfalls with medication stock control and using the handover sheets to document actions taken or needed will improve communication.