Andrew Clegg

Care Quality
Commission

HSCA Further Information
Citygate

Gallowgate

Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161
Fax: 03000 616171

H.M. Coroner for Wiltshire & Swindon
26 Endless Street

Salisbury

Wiltshire

SP1 1DP

For the attention of: Mr Nicholas Rheinberg — Assistant Coroner
17 May 2019

Our Reference: MRR1-6856666097
Dear Sir,

Regulation 28 report in relation to the Inquest touching on the death of Andrew
Clegg

Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation
28 report which we received on 03 April 2019 following the inquest into the death of
Mr Andrew Clegg. We are writing to you with our response to the section 5 matters of
concern raised within your report in respect of the Care Quality Commission,
specifically point 2:

Care homes and other healthcare premises are regularly inspected by the Care
Quality Commission. In recent years the inspection regime has included a duty on
inspectors to check on water safety. Expert evidence at the inquest suggested that
inspectors lacked training to help them identify risks relating to potential legionella
infection.

1 can confirm that water safety is considered by CQC inspectors prior to every
inspection we conduct. We use a planning tool to record information about the
location when preparing for an inspection. The Key Lines of Enquiry which inform the
planning tool make specific reference in the Safe domain. In the section $2 the
question is “How are risks to people assessed and their safety monitored and
managed so they are supported to stay safe and their freedom respected?” There
are then sub questions which include: $2.6 which asks “How are the premises and
safety of communal and personal spaces (such as bedrooms) and the living
environment checked and managed to support people to stay safe?” The guidance
for inspections suggests their evidence should include checking there are Legionella
Certificate/risk assessment and checks in place, and also checking
Provider/Manager arrangements for checking, identifying, and rectifying premises
issues.

| would point out that CQC inspectors are not technically qualified in water safety or
water systems generally (where these issues are known to develop) and therefore
are unable to hold themselves out to be experts in this field. As a regulator we are
not able or qualified to advise providers on how to deal with specific logistical water
safety issues on site. We do however refer all providers to the relevant industry
guidance in water safety as provided by the Health & Safety Executive. This can
be found at http://Awww.hse.gov.uk/legionnaires and
http://Awww.hse.gov.uk/pubns/books/I8.htm.

It is the CQC’s responsibility to draw the providers attention to the expected
compliance with these guidelines, it is not CQC’s role to make technical examinations
of water systems on registered provider sites during inspections. It is the
responsibility of the provider running the location to ensure they comply with the
water safety guidelines and provide a safe environment for their service users.

We have taken significant learning from the sad death of Mr Clegg and have already
spoken with CQC Academy which is responsible for developing and rolling out
training programmes within the Care Quality Commission, suggesting that a tailored
training course in Legionella awareness should be developed and cascaded down to
all inspectors nationwide to improve the inspectorate knowledge generally in this
area of risk.

If you have any further queries in respect of this issue please do not hesitate to
contact me.

Yours sincerely

Head of Inspection

HSCA Further Information

Care Quality

Commission ECEIVED Citygate
. Gallowgate
28 MAY 2019 Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161
Fax: 03000 616171

H.M. Coroner for Wiltshire & Swindon

26 Endless Street

Salisbury

Wiltshire

SP1 1DP

For the attention of: Mr Nicholas Rheinberg — Assistant Coroner
22 May 2019
Our Reference: MRR1-6856666097

Dear Sir,

Addendum to CQC response to Regulation 28 report in relation to the Inquest
touching on the death of Andrew Clegg

For completeness we have further information as an addendum to our response
dated 17 May 2019 to the Regulation 28 report made on 1 April 2019 following the
inquest into the death of Mr Andrew Clegg.. More specifically with reference to section
5 matters of concern raised within your report in respect of the Care Quality
Commission, specifically point 2:

CQC is currently in the process of agreeing an updated Memorandum of
Understanding (MoU) with Public Health England (PHE) to improve CQC's access to
water safety and water systems'-related technical expertise from PHE. Specific
provision in the revised MoU is being made to regularise and make more systematic
and efficient our access to PHE specialist expertise in circumstances where CQC
require it to inform its regulatory functions. These functions include monitoring,
inspection and civil and criminal enforcement actions. It is expected that the revised
MoU will be agreed between CQC and PHE in summer of 2019.

| wish to reiterate that if you have any further queries in respect of this issue please
do not hesitate to contact me.

Yours sincerely

Royal Institute of
British Architects

66 Portland Place,
London, W1B 1AD, UK

Tel: +44 (0)20 7580 5533
Fax: +44 (0)20 7255 1541
info@riba.org
www.architecture.com

Incorporated by Royal Charter No RC000484
Registered Charily No 210 566
VAT Registration No 232 351 891

RIBA WY

Royal Institute of British Architects

Nicholas Leslie Rheinberg

Assistant Coroner

H.M. Coroner for Wiltshire & Swindon
Wiltshire & Swindon Coroner's Court
26 Endless Street

Salisbury

Wiltshire

SP1 1DP

23 April 2019

Dear Mr Rheinberg,

Response to Regulation 28 Report
Re: Andrew Robert Frank Clegg deceased

Thank you for your letter of 1 April 2019 to the Royal Institute of British Architects
regarding the death of Andrew Robert Frank Clegg. | am responding as Executive
Director of Professional Services at the RIBA with overall responsibility for overseeing
professional guidance for our members.

In responding to your concerns, the RIBA intends to develop a concise knowledge
resource to explain to our members the need to consider water safety, particularly in
coordinating the design of care homes and healthcare buildings. We intend to publish
this as an article by the end of July to raise awareness of the water safety issues
highlighted in your report.

It is important to explain that architects do not generally design the public health
(plumbing) systems in buildings, this is usually undertaken by building services
engineers in most medium or large projects like care homes or healthcare buildings.
On most smaller projects these systems will be designed by the contractor or a
subcontractor.

Architects will provide architectural design and depending on the services they are
appointed to undertake, may coordinate the design of building services engineers
with the overall architectural design and if acting as Principal Designer, under the
Construction (Design and Management) Regulations, they will have a duty to
coordinate health and safety information for the construction and maintenance of the
building.

RIBA Wy

| note that the Regulation 28 letter was not sent to the Chartered Institution of
Building Services Engineers. We advise that the Regulation 28 report is also
circulated to this body and the Construction Industry Council for wider dissemination.

Yours sincerely,

A: 2 AD

Adrian Dobson
Executive Director Professional Services

RECEIVED
19 JUN 2049

BUILT ENVIRONMENT
PROFESSIONS TOGETHER

Nicholas Rheinberg

HM Assistant Coroner for Wiltshire and Swindon

Wiltshire & Swindon Coroner’s Court

26 Endless Street

Salisbury

Wiltshire

SP1 1DP 18 June 2019

Re: Andrew Robert Frank Clegg (deceased

Thank you for your letter of 2 May 2019 and the accompanying report under Regulation 28 of the
Coroners (Investigations) Regulation 2013.

The first matter to report in response is that the Construction Industry Council does not have any
locus or authority over the education, training, accreditation or continuing professional
development of architects, construction (or building services) engineers or others designing water
systems for care homes. And so, the particular action that you suggest in relation to providing
relevant education and training for architects, construction (or building services) engineers or others
designing water systems in this regard, is not within our direct remit but those of the
relevant professional and statutory registration bodies. We will, of course, do what we can to
encourage them to take the action suggested.

We are deeply involved in the very necessary work that is required in the post-Grenfell improvement
of life safety competences for all those who commission, design, construct, maintain and manage
higher risk residential buildings. We have actively participated in the Independent Review of the
Building Regulations and Fire Safety, carried out by Dame Judith Hackitt — | was privileged to serve
her Review as Chair of the Competence working group. We fully support the outcome of that
review, Building A Safer Future, which was published in May 2018 and have been working with the
MHCLG, the Home Office and others to ensure that Dame Judith’s recommendations are
implemented.

lam pleased to report that, on 6 June 2019, the Government published its proposals to take these
recommendations forward towards legislation (Building A Safer Future: Proposals for reform of the
building safety system).

On the day prior to the publication of Building A Safer Future, | was appointed chair of the
Competence Steering Group, which is a comprehensive alliance of more than 130 organisations
across the construction industry, the fire safety sector, the built environment professions and those
bodies representing building owner/managers in the public and private sectors, including Housing
Associations.

Construction Industry Council | 26 Store Street | London WC1E 7BT | United Kingdom
T +44 (0)20 7399 7400 | E enquiries@cic.org.uk | www.cic.org.uk
VAT Registration Number 668391491 | Company Registration Number 02388396

Our report — Raising the Bar — proposes enhanced competence levels for Engineers, Installers, Fire
Engineers, Fire Risk Assessors, Fire Safety Enforcement Officers, Building Control, Building Designers
(including Architects), Building Safety Managers, Site Supervisors, Project Managers, Procurement
and Products; and has been written with their direct participation and willingness to implement the
new competence frameworks. The interim report is due to be published for consultation at the end
of this month but, having worked closely with MHCLG and the Home Office throughout, the
proposed recommendations dovetail with those included in Building A Safer Future: Proposals for
reform of the building safety system.

| would be happy to send you a copy of the interim report when it is available. In the meantime, |
attach a copy of an opinion piece that | have recently written for Building magazine, which explains
more about our work.

The key issue here is that the initial focus of the Hackitt Review was very much on fire safety,
following on from the Grenfell tragedy, but we have pushed for this to be increased to all aspects of
life safety. In its proposals, the government has accepted the argument that matters of structural
safety are to be included within the legislative package for reform of the building safety regulatory
system, but not water safety. We are continuing to press this point and your Investigation Report
into the tragic death of Mr Clegg is timely to help us ensure that ALL aspects of life safety are
considered in this package of reforms.

| hope that this is of interest.

Graham Watts OBE
Chief Executive

Construction Industry Council | 26 Store Street | London WC1E 7BT | United Kingdom
T +44 (0)20 7399 7400 | E enquiries@cic.org.uk | www.cic.org.uk
VAT Registration Number 266 8002 01 | Company Registration Number 02388396