Mary Walker

Dear Ms Lomax acknowledge receipt of your letter dated 21 April 2016 and the Regulation 28 Report to prevent future deaths. The report confirms that the conclusion of the inquest was that the cause of death of Walker who resided in Belong Wigan, was natural causes namely bronchopneumonia note the Coroners matters of concerns and would like to provide my response: At the inquest there was no specific evidence about what was revealed during the night checks The global summary stated the times of checks but there was no information about resident's condition during the checks. have noted that the report provided a general summary of the residents condition the night and therefore it was difficult to determine the exact time of her deterioration_ This was a breach of the organisation's 'Safe Management of records' procedure_ Actions taken: Refresher training has been provided by the management team to all staff in Belong Wigan , on 'Safe management of records' policy and procedures with an emphasis on the importance of accurate recording of progress against dates and times_ Meetings have been held with all senior staff to identify the uses of an approved audit tool to ensure sure safe and correct procedures are being followed. Nurses are required to follow policy and procedure and will record any professional advice and direction provided within the customers' individual records Belong is part of: CLS Care Services Limited Registered in England & Wales, Industrial & INVESTORS Provident Society No, 27346R VAT No. 887 1375 81 Registered Office as above_ IN PEOPLE Belong Mary the the during the

2 During the inquest we failed to provide you with clarity about the procedures that are used by Support Workers to escalate health concerns. Actions taken: All Support Workers have been reminded of the correct procedures to follow and how to seek advice from outside professionals for non-nursing customers in their care , when need t0 escalate health concerns_ This is incorporated into the care practice training for all staff, to include staff induction; supervision, life plan review and audit. trust that my response will provide you with the reassurance that we have reviewed and communicated our procedures following the Coroner's concerns over the death of Walker, and therefore improved the safety of our practice

Dear HM Coroner

We are writing in response to the 21 April 2016 Regulation 28 Prevention of Future Death Report issued by Alison Mutch, Assistant Coroner to Belong Central Office, Pepper House, Market Street, Nantwich, Cheshire CW5 5DQ and to

, CQC Inspector, Bolton Wigan and Salford Team following the Inquest into the death of Mary Walker. This letter is the CQC’s response to the Report issued to

.

Following receipt of this Report we held a management review meeting to look at the information we held in relation to this case. At this meeting we took the decision to:  firstly, undertake a comprehensive ratings inspection at Belong Wigan Care Village where Mary Walker resided prior to her unfortunate death and to specifically look at actions the provider had taken in response to the Report findings; and  secondly, to request copies of the documentation you held so we could also consider if we needed to undertake a criminal investigation.

As you are aware from 1 April 2015 CQC is the lead enforcement body for health and safety incidents in the health and social care sector. As Mary Walker’s death occurred after 1 April 2015 CQC considered when undertaking its inspection whether further investigations or criminal enforcement were appropriate.

We noted the response provided to you by the registered provider, CLS Care Services Limited known as Belong on 27 April 2016. In light of this response it was not felt necessary for CQC to contact the registered provider to request written confirmation and Her Majesty’s Coroner Manchester West H M Coroner’s Court Paderborn House, Howell Croft North, Bolton, BL1 1QY

BY EMAIL

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evidence of the action they have taken to date following this death and any additional action they intended to take in response to the prevention of future death report. However, we did consider the response sent to you during the course of proceedings as part of the comprehensive inspection we undertook.

We undertook an inspection at Belong Wigan Care Village across two days, the 06 and 16 May 2016. We found steps had been taken by the provider to respond to the concerns identified in the Regulation 28 report. The detail relating to this can be found in the ‘safe’ and ‘well led’ sections of the report.

We found a flow chart for unexpected changes in health had been developed and given to every member of staff and was displayed within each household at the service. On the 2nd day of the inspection all the night staff were spoken with, and all were able to describe the procedure that was in place.

We found that a night time record sheet had been introduced. The record was time specific and was completed by staff as people's care and support needs were met. This meant clear and concise records were now being maintained throughout the night, which enabled management to illicit information regarding people's health and care needs and the specific time at which things had occurred. We spoke to 11 night staff who confirmed the records had been implemented immediately following the issue being identified.

As a result of our inspection we have provisionally rated the service as ‘good’ subject to the factual accuracy process. The report of our inspection is currently in draft form.

We have provided this draft report as an attachment to this letter as a disclosure permitted under S.79 of the Health and Social Care Act 2008. We would respectfully request that this draft report is not widely published at this time. We will publish a final report of our inspection as soon as it is possible for us to do so.

Thank you for providing us with disclosure during the Coronial investigation. We can confirm that following our inspection and a review of these documents we do not intend to undertake further investigations in relation to the death of Mary Walker or the provision of regulated activities by CLS Care Services Limited.