Dear Mr Thomas We write in reply to your further letter and to the additional questions that you kindly invited the Commission to consider and clarifo. Before addressing those questions we would like to reiterate our sadness and great concern about the issues that were raised in your report aboui the circumstances leading to Mr Monis' death. We also wish to emphasise our very real commitment to address the concerns raised in your report, and to assist in improving ihe care provided not only generally but also with specific regard to patients living with dementia. We would also like to apologise for the delay in providing our response which has been due in part to careful consideration being given to changes that are currently taking place within the Commission in terms of its structure and the regulatory framework which underpins the our functions' In response to your questions we attempt to clariff our response as follows: '1. The Commission agrees that the extra care that is required for people living with dementia is sometimes underestimated by providers. The Commission is also very conscious of the difficulg in assessing the stafflng needs for people that live with dementia. For that reason when we are inspecting against the
- relevant sfafiing regulationr we do not only assess care plan lecords but also . .,.
- laFfu stailal welrasjatiEntsand-relatfircs-wlrcepossibH\lhen we inspeci care plan records we would expect to see a care plan for a person's needs at night, and particularly if that person had been assessed as needing support at night. During the course of an inspection visit we are only able to assess and ' track a selection of peoples' care pathways. That does regreftably raise the I Regutation 22 ofthe Healih and social care Act 2008 (Regulated Activities) Regulations 2010

possibility that the selection does not incorporate. someone who has cornplex needs at night.'Hor"uli, as part oi tn" inspection planning process we do take into account of intelligence thaiwLuU ndtp to focus the inspection' where for instance "on""int "bJut the tevets of staffing are raised' That intelligence would include ;"y iliif"ttions oi incidents ol inluries that providers are required to notif,i'tr- ot, "r well..any concerns..or.complaints that have been shared with us, and as a result'of ri"iting with the local authority and the Ctinical Commissioning GrouP'
2. The care provided to people that live with dementia is taken extrernely seriously bv tne commissiin. oi""t"r focus is being given to the ways in which we can i'ipiouu ine Commission's regulation of providers that offer care to people witn iementia. As p"tt oi that-development between Decernber 2013 and February 2014 atnemei prfq"tt" oiintRection on the quality of care for p"op[: il',ln dementia t[f-"pf."".. That. programme focussed in particular on tnJ "tp"ti"n""t 91 pt"pl-"-yt$1t^"T:.ntia as they move between hospitals "nO c"r"'not"t. The programmg involved inspections of 150 hospitals ano "ar"lor"g in 22 Oitiu*ri local authorities. understanding the experience of peopfe'with demenii", tf,"it families and carers has been the main focus of ihe ieview. Tne Commiision is also working w1h a number of dementia org";ir"tions to help inffi ano improve our approach to regulation by enhan.ing 'r-;l';-;iri'tOing' ot iuiiai *orks, what doesn't work and how dementia care cari be improv"U. inot" ortanisations include the Dernentia Action Alliance, Dementia nOvolacy fl"t*"otL, Age UK, the Race Equality Foundation "ni local Healthwatch dS9ryi9s..The results of that prograrnme not only includes the publication-ot iiOiuidual inspection reports but will also involve tne proJuciion'ot a national opoi in May or June 2014 setting out the good practice'tnJ'we have fouril'tdgether wjih improvements that can be made to dementia care across diff#;i services' Consideration of staffing levels will form part of that report'
3. and mental exPerience of those rhe Commission has also sousht to improve itsoglfl{t:l1"fjfl*l?,:: dementia bY imPlementing Deilrentia Awareness Training' That !raini.n9, !a1 ;:ff H?''":t["[i,"iffi 'Xi;"di#IJ'i""ilitv'";i::-le'.'':-l1T"1":"9:1?S:9 il1"ji,tTil",i.,TJriotn ,,"tr to sain "no conr.ifidate knowredqe. skills and support
-^I ^-r^t^ ^-^arianna nf H:?l"y?l'l;r,:d;ilid#ilffiJct of dementia on o6opre's experience of l:^^' rha+ *raininn haq i":J"fi Xtl'iffiffi;#^il;'1;t";'i'*qYt1qt.:dvli".'i,ll3l[1':,5?,.*:

4. In terms of night time inspections the Commission does currently carry out inspections at night if we have a concern about the care being provided at night, and we will be undertaking more out-of-hours inspections in the future. Satisfying ourselves of the compliance of a service provider over 24 hours is something that is being given careful consideration and is likely to change as our methodology changes. Following the inquest into the tragic death of Mf Morris, and the concerns that were raised into care at night, an inspection was undertaken at WilloMhorpe Care Home during the evening of 3 March 2014. The resultant report was published on 20 March 2014 and can be found on the Commission's website, www.cqc.orq.uk. For completeness we enclose a copy of that report to this letter. However, we also set out the relevant section dealing with staffing levels below: "Our judgement 'The provider was meeting this standard. "There were enough qualified, skilled and experienced staff to meet people's needs. "Reasons for our judgement We inspected Vviilov,lthorye because we had received concerns that there were insufficient numbers of staff available to meet people's needs, and keep people safe at night. "During our inspection on 03 March 2014 we found there were enough experienced staff to meet people's needs at night. Overall we found that there was a calm atrnosphere in the home, buzzers were answered in a timely manner and people were not calling out for help. Staff appeared calm and organised. There were a group of people still up socialising in the lounge when we anived at the home. People in the residential unit were able to talk with us and said they were happy with the time they went to bed and were able to choose when thls was. 'We spoke with two members of staff, two people who used the service and looked at the night care records for two people who used the seruice. The manager provided us with records of the tnining undeftaken by two of the night members of sfaff sobseguent to our visit. This demonstrated to us that staff had received regular training in areas such as moving and handling, dementia care, administration of medicines and safeguarding. Willowthorpe provides care to people in two separate units. We found that
- .
---_ ='---: netsegi and they were usually suppofted by an additional carer between 4pm and 10pm in the evening. People we spoke with told us that there were sufficient numbers of staff available to provide their care and support. "However, the provider may find it useful to note that on the night of our inspection one carer had called in sick at shoft notice and their shift had not

been covered. We looked at the rotas for the preceding wegk and"noted' this was a one off occunence. ii"rl i" sp2k9 wiih dui1T,,our inspection told us that although they were oiii tn"v ielt they were able to support people's needs aPProPiatelY. "we .ooked at the care records for two people who used the seruice who were at risk of devetoping p,"'"ii-;;' W" tien checked they received the care ;r:;;; th;-;;;,;;;inat nai oeen documented as req'uired' For one person who used the service *" i'iiinii nad been plac.ed'on an appropriate air 'i;:;;;i;;; iii n" i"tt'ne "" app.ropiate !?!-t!:,t: needs' However' we found for another person th;t the sefting was very .stightly t.oo high fo,r ,their ';;t;',;."w";;"cusiea trrrs'wiirr 'ih' '"i"gur the fotlowins dav' Thev totd us i;;i';i"ii h;;-p*iiiea ru"ii"ii ti inein at handover and that thev had adiusted the setting. fne1-nta is that they had .also..spoken with the carer i;;;r;; ;;; fl;;tr?.""t i"'ti''s" uia nit was to be discussed with att starr in a ieam meeting "The two people's care records we looked at identified that they required two ilhfi,ipZiiiitii a,,iiJ i"' iignt . 2t?!^ :?:!:\"d thev checked and repositioned them every tio hoursluing the night' applying cream to areas at risk ofpressrre ,,""'""ii'" Juii ii peoptfs rooms confirmed that this tool place. Staff totd ,t tnii"tii ii"". i"'ii\ 9't-:y" hourtv checks of att people in the dementia.uiii'a-i'J''ouu provide supportto people if this was required. slaff we tporu"iiiiniii u" ihaf thev offered.p"'oPt" !!:k:^:!L provided personat care as ieeded' Records we looked at for one peopte .showed us that they h"; ';:;;; "'-ii'i'u' of two hourlv checks with ir"queit nourty checks and care provided' "Aswetouredthebuildingwefoundthatthe.patiodoorleadingtothe.o'utside from the lounge on tne ieliita init could be opened from the inside' we opened the door and ", iii*'iii'i"d' The stafi reacted immediately to the door alarm sounding and';;;"-;;in';stigate- We also checked another door on the dementia unit ana tiii nit ii i" alarmed' This meant that at night there were sufficient numO'ei of staff and safety measures ln place to ensure 'ii"ii'tiiii,ii"i iandering did not leave the home'"
5. Regrettably, it is extremely difficuh for the Commission to say definitively whether tvvo memDers ;i ktff ;;'" sufficient in numbers in a unit where p"lij" *itii a.t"nti" t""L iesioent n tne circumstances of this very sad case' Those circumst"nt"t to,iri-i-nJf'le itte rayout of the home' the needs oJ the service usels at tne noini ai'tne iime"tne skills and experienc€'of the members of staff that *"i" "t o'ty and what tl'" :i?I-t111"j,":: llY,y:i,: ffilliffi"d'o;]id;'t#iJ.i: ;Ju" nau".enoeavoured to set out above we qre nronosino to oublish t #tLn.ii"port in May or June 2014 whichwiil s-e1 out t(le geuu Pravrrve areful consideration of O" ."OE lo dementia care across different services' c; the sufficiency of staffins llt.'G *irr ro- pqt 9f-111^:^",^t:t-ti::1"11|,';1ll :F"#ilffi;It:.il?;iy;;"rc in t"'ttbt our approach and methodolosv il ffil"ii"s;rwiJers tnat care for people with dementia'

We hope that the contents of this letter address the areas on which you sought further clarification. Please do not hesitate to contact us if we can be of any further assistance.