Dear HM Senior Coroner Alison Mutch OBE,

Prevention of future death report following inquest into the death of Alan Massam. Thank you for sending the Care Quality Commission (‘CQC’) a copy of the prevention of future death report dated 26 April 2021 following the sad death of Alan Massam.

We note the legal requirement upon the CQC was to respond to your report within 56 days, by the 14 June 2021.

Mr Massam was resident at Lisburne Court, a location registered with CQC at Alfreton Road, Offerton, Stockport, SK2 5LU. The Registered Provider in operation of Lisburne Court at the time of Mr Masson’s death was Borough Care Limited (The Provider). The Provider is registered for the regulated activity: Accommodation for persons who require nursing or personal care. There are conditions on the registration for this location, namely;

1) The Registered Provider must not provide nursing care under accommodation for persons who require nursing or personal care at Lisburne Court; and

2) The Registered Provider must only accommodate a maximum of 48 service users at Lisburne Court.

The registered manager at the time was who has been registered as the Registered Manager of Lisburne Court since 10/02/2020.

HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA

2

The role of the CQC & Inspection methodology

The role of the CQC as an independent regulator is to register health and adult social care service providers in England and to inspect and report on whether or not the fundamental standards are being met.

Our current regulatory approach involves inspectors considering five key questions. They ask if services are Safe; Effective; Caring; Responsive; and Well Led. Inspectors use a series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and reassurance of how providers perform against characteristics of ratings and how risks to people are identified, assessed and mitigated. Sources of evidence for the KLOEs can be found on our website along with our KLOEs and characteristics of ratings.

social-care-services

The regulatory framework requires registered persons to meet fundamental standards of care, standards below which care must never fall. We provide guidance to providers on how they can meet these standards (Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014) (the ‘Regulations’).

providers-managers

Regulatory History

Borough Care Ltd were registered to carry on a regulated activity at Lisburne Court in January 2011.

At our last comprehensive inspection of Lisburne Court (published 11 February 2020) the service was rated as Good and there were no breaches of regulation. Lisburne Court was rated Requires Improvement at the previous inspection (published 17 February 2017).

Matters of concern for CQC

On 20 January 2021 the CQC received information from the Coroner enquiring if we were investigating in this case. An initial assessment was carried out into the circumstances of Mr Massam’s death by Inspectors from both the adult social care directorate and the hospitals directorate. Both Inspectors concluded based on the information available to them at that time that there was insufficient evidence to suspect a failure to provide safe care or treatment at registered persons level (breach of Regulation 12(1) Health and Social Care Act 2008 (Regulated Activities) Regulations
2014. The Coroner was informed that the CQC was taking no further action at that time.

We noted Mr Massam’s preliminary cause of death was recorded to be;

1a) Lower respiratory tract infection 1b) Multiple rib fractures

3

1c) Falls II) Chronic subdural haematoma, advance dementia, recurrent falls

The specific matters of concern raised by the coroner in the Regulation 28 report issues to CQC are:

1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangements between agencies as to how to effectively share information in complex cases. In this case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised.

Whilst the CQC have no direct remit in developing policy and procedures to support integrated care and optimal communication, during inspection of a service the CQC will look at joint arrangements and how systems work to facilitate the transfer of care from one setting to another. This is considered against Regulation 12 (1) (2) (i) of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 which states;

CQC commenced a cross directorate process in May 2021, to ensure regulatory risks relating to the local health and social care systems are discussed, responded to and acted upon across CQC directorates within each of the seven local systems in the North. Representatives from operational directorates meet on a monthly basis in order; o To facilitate integrated cross directorate working within local systems. o To share information on key or potential cross directorate / system issues. o To ensure cross directorate consistency of regulation within a system. o To identify, collate and escalate risk themes and key connections within a local health and social care system. o To explore opportunities for greater regulatory effectiveness through coordinated activity, including inspections. o To report findings to the Regional Escalation & Co-ordination group. o To feed in effectively to ICS / systems meetings as appropriate for wider engagement opportunities.

In line with our future strategy, we make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care to improve.

Care and treatment must be provided in a safe way for service users. Where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other

4

appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.

Where the CQC find evidence that local systems are not as effective or robust as they should be, we would judge the failings in respect of the impact this may have on people, and work with registered providers, commissioners and other external stakeholders to strengthen and support effective communication and collaboration.

Internally, inspection managers from across all operational directorates within the CQC (adult social care, hospitals and primary medical services) meet monthly to ensure that regulatory risks relating to the local health and social care systems are discussed, responded to and acted upon across CQC directorates within each of the seven local systems in the North.

2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.

When Mr Massam arrived in hospital on 13 October 2019, there was no accompanying documentation or phone call made from the care home to advise the hospital team of the care home staff opinion that they could not meet his needs. As Mr Massam was seen and treated in the emergency department, the trust subsequently told us that a ‘discharge’ summary would not routinely be provided, as he was not admitted to a bed on a ward. It is however good practice to send a copy of a treatment summary back to someone’s place of care. We understand from the trust that a family member was present with him in hospital on 13 October and they did not express any concern about the care home managing his needs.

The acute hospital team carried out an inspection of Stepping Hill in January and February 2020 and found significant improvement was needed in several areas. For example, we found the emergency department did not have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and provide the right care and treatment at all times, and particularly during periods of heavy demand on the service. A warning notice was issued following the inspection. We inspected the hospital again on 24 and 25 August 2020 and found the trust had made improvements to urgent and emergency care. We needed to ensure improvements made were embedded in the service. Therefore, we continue to monitor the trust and have held regular engagement calls with them. They have informed us of a process now in place to monitor how information is shared after treatment in the emergency department. We have requested information from

5

the trust with regards to the above process and will review their response to identify if any regulatory action is required.

CQC is part of a system improvement board where the post inspection action plans are reviewed and monitored. Other partners include the Clinical Commissioning Group, NHSE/I and other care providers. This improvement board has a specific focus on patient flow and improvements in the emergency department.

3. The staff at the home were aware of the prescribing of medication including antibiotics. However, when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on.

Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted inspection of Lisburne Court. The findings of this inspection will be shared with the Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death do not reflect any ongoing risk to people currently living at the home.

The inspection will be focused in three key questions; Is the service safe? Is the service effective? And it the service Well-led? The inspection will focus on the specific areas raised in the Regulation 28 report. As part of the inspection we will consider the effectiveness of Lisburne Court’s pre-assessment process, the monitoring and management of falls, escalation protocols should people refuse to take fluids and medicines, how the service communicates with relatives and how the service works with other healthcare agencies to optimise people’s care.

We will also look at infection prevention and control (IPC) as part of the thematic inspection methodology CQC is undertaking as part of the response to the Covid-19 pandemic. This will be reported under the key line of enquiry; Preventing and controlling infection.

In the interim period before we inspect, we are meeting with the Chief Executive and the new Nominated Individual of Borough Care Limited to discuss the issues raised and seek assurances around lessons they have learned. We are continually monitoring the service and liaising with the Local Authority to review any ongoing risks and feedback.

4. Once the initial home could not manage Mr Massam and served notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam.

6

The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.

Should you require any further information then please do not hesitate to get in touch.

Dear Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Alan Massam 24/10/2019

Thank you for your Regulation 28 Report dated 26/04/2021 concerning the sad death of Alan Massam on 24/10/2019. Firstly, I would like to express my deep condolences to Alan Massam’s family.

The inquest concluded that Alan’s death was a result of 1a Lower respiratory tract infection; 1b Multiple rib fractures; 1c Falls; II Acute on sub-acute subdural haematoma, advanced dementia, frailty.

Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.

This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. This includes actions specific to the Stockport locality.

Point 1 – communication between organisations involved in discharge of complex and vulnerable patients. Stockport CCG has confirmed that communication between the hospital, GP and wider Community Services has improved by the use of a common system allowing the various organisations to see each other’s work. This is reliant on patient consent but works well in practice as it allows information regarding changes in a patient’s circumstances to be updated and immediately accessible to other health and care colleagues. The expectation is that care needs are assessed in a timely manner and information shared to ensure that all involved are acting in the best interest of the

patient, based on the most current information and that transfers between care providers are managed effectively.

Stockport CCG works closely with Local Authority colleagues and care home staff to deliver a high standard of service. Work is undertaken on the basis of a joint approach to consistently improve the quality of care and to gain an understanding of the various roles. This includes the CCG having recruited a Care Home Matron to drive the quality agenda and to support care home colleagues.

Point 2 – protocol around safe discharge planning. It is not the acute trust’s usual policy to transfer a patient back to the care home if no contact has been made with the home. On this occasion as there had not been any response from the care home despite several attempts, the decision for Mr Massam to return to his home was made following consultation with the Consultant, the FRESH assessor and with his daughter. As the contact attempts had been unsuccessful the trust were not aware of any concerns on the part of the home prior to the patient returning to them. The trust did make every effort to engage directly with the care home team before Mr Massam left the hospital and that when multiple attempts to communicate with the home failed, there was appropriate escalation within the hospital to approve the discharge.

Stockport established the Discharge Concerns Panel in October 2020 due to several discharge concerns being raised with the Head of Discharge Services and Stockport NHS Foundation Trust Adult Safeguarding Team from external partners and providers. To compound the situation further, the number of discharge concerns increased following the implementation of the National Guidance regarding Discharge. The intention of the Panel is around finding practical solutions aimed at improving discharge outcomes for patients and reducing discharge concerns across the Trust. There was some delay in the full implementation of the panel due to the second wave of COVID-19 and the subsequent increased workload on teams to support timely discharge from hospital, despite which a number of achievements have been made. These include;

• A review of the D2A document has been undertaken with associated audit.
• A review and update of the transfer document used by ward staff when discharging patients back to an established placement, or a new placement, has been undertaken.
• Engagement with the ward staff to better understand specific themes and identify actions to improve.
• A review and update has been undertaken with regard to the Rapid Discharge checklist (End of life Discharge).
• A Task and Finish Group has been established with out of area colleagues to improve relationships, understand their discharge offers and improve the discharge journey for patients.

Future actions will include the implementation of Trusted Assessment training for all staff. Point 3 – escalation process in care homes for patients refusing medication. In any situation where a patient is not accepting prescribed medication and is declining fluid intake then contact should be made to the patient’s GP so that a decision can be

made in relation to next steps. GP services can be accessed 24 hours day either via the patient’s local GP or via Mastercall Out of Hours primary care provision.

Point 4 – suitability of placements against patient need. Our aim is to ensure that all patients are able to access the care they need, when they need it and in the environment best able to deliver the care they need. The CCG works with colleagues in the Local Authority, Adult Social Care to ensure that care needs are appropriately assessed and met. In circumstances where care needs change there is a process of re-assessment and review and once it is identified that a patient’s needs have changed families are supported in the task of identifying alternative accommodation.

For the wider Greater Manchester (GM) footprint, GMHSCP is working across the whole system to look at safe and appropriate discharges for people with complex needs. The Partnership is looking at longer term support as part of the GM Discharge Programme and the Adult Social Care Transformation Programme. There is a programme of work underway to review this in detail and we are working with the 10 GM localities on this agenda.

Additionally there is a Learning Disabilities Complex Needs programme which has been underway for 18 months and will continue for another year. As part of this programme of work, complex needs and discharge scoping is underway.

Actions taken or being taken to prevent reoccurrence across Greater Manchester.

1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission.

The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.

I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Mutch,

Thank you for your correspondence of 26 April 2021 to Matt Hancock and the Prevention of Future Deaths report relating to the death of Alan Massam. I am replying as Minister with responsibility for adult social care and I am grateful for the additional time in which to do so.

Firstly, I would like to say how sorry I was to learn the circumstances of Mr Massam’s death and I would like to take this opportunity to offer my sincere condolences to his family, friends and loved ones.

I wish to reassure you that promoting integrated care is a priority for this Government. We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making. I have noted carefully your concerns about information sharing between agencies involved in providing complex care and the approach to managing risk, and communication between acute hospitals and care homes regarding the discharge of patients. Your letter also raises concerns about escalation processes when care home residents refuse medication and fluids; and the availability of care home beds for adults with complex care needs. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE & NHSI) and their regional and local partners; and the Care Quality Commission (CQC).

All regulated providers of adult social care have a key role in safeguarding adults and should promote the wellbeing of the people in their care within safeguarding arrangements.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 91 sets out the actions that care providers must take to ensure all users receive appropriate care and treatment based on an assessment of their needs and preferences. Providers must also work within the requirements of the Mental Capacity Act 20052, which includes the duty to consult others such as carers, families and/or advocates where appropriate. Under the Care Act 20143 local authorities and their relevant partners have reciprocal responsibility to cooperate to promote the wellbeing of adults with care and support needs. This integrated approach to person-centred care will bring together actors in health and social care, alongside local and voluntary partners, to support people to retain their independence, health and wellbeing for longer. The Act requires each local authority to establish a Safeguarding Adults Board (SAB) to provide assurance that local safeguarding arrangements and partners are acting to support and protect adults who may be at risk of abuse or neglect. These Boards have the authority to carry out a Safeguarding Adult Review (SAR) in instances when serious harm or a fatality has occurred and there is concern that providers could have worked more effectively to have better protected the vulnerable adult.

If it has not already been done, the relevant SAB may wish to undertake a SAR, to identify effective learning and improvement action across all relevant local agencies. We are therefore copying this response to Stockport Metropolitan Borough Council for information.

In relation to communication between acute hospitals and care homes at the point of discharge, I understand from your report that Mr Massam was seen and treated within the emergency department at Stepping Hill Hospital, Stockport before returning to Lisburne Court residential home the same day. Mr Massam was not admitted to hospital and I understand from information provided by the CQC that the hospital was unaware of any concerns about the home being unable to continue to meet Mr Massam’s care needs.

National guidance is available to support local health and care systems to facilitate good practice when patients are discharged from hospital. In March 2020, we published – and have since updated – the Hospital Discharge Service: policy and operating model4 guidance for NHS Trusts and care home providers, although this guidance predominantly applies to the discharge of patients who have been admitted to hospital, which does not appear to be the case here.

The guidance covers the discharge of patients from hospital to care homes, including confirming that the care provider is able to receive the patient. In addition, information essential to the continued delivery of care and support must be communicated and transferred to the relevant care provider on discharge.

1 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (legislation.gov.uk) 2 https://www.legislation.gov.uk/ukpga/2005/9/contents 3 https://www.legislation.gov.uk/ukpga/2014/23/contents 4 Hospital discharge service: policy and operating model - GOV.UK (www.gov.uk)

Additional guidance available includes the High Impact Change Model5 – developed in 2015 by the Local Government Association (LGA), the NHS and other key partners – which provides a framework for a practical approach to supporting local health and care systems to manage patient flow and discharge. The LGA also provides online tools and guidance on Working with hospitals6. The National Institute for Health and Care Excellence (NICE) published national guidance in 2015 on the Transition between inpatient settings and community or care home settings for adults with social care needs7. This guidance includes the over-arching principles of care and support and the importance of communication and information sharing between agencies involved in a person’s care. Turning to the matter of patients’ refusal of medication and fluids, NICE’s guidance on Managing Medicines in Care Homes8 recommends that health and social care practitioners should ensure care home residents have the same opportunities to be involved in decisions about their treatment and care as people who do not live in care homes, and are supported to take a full part in making decisions. The guidelines state that health professionals prescribing a medicine, must assess a care home resident’s mental capacity in line with the Mental Capacity Act 2005. The guidance states that care home staff should record the circumstances and reasons why a resident refuses medication in the resident's care record and medicines administration record, unless there is already an agreed plan, in the event that a resident refuses their medicines. If the resident agrees, care home staff should tell the health professional who prescribed the medicine about any ongoing refusal and inform the supplying pharmacy, to prevent further supply to the care home. Whilst NICE guidelines are not mandatory, health and care commissioners are expected to take them fully into account. I understand that the Greater Manchester Health and Social Care Partnership recommends that where a patient is not accepting prescribed medication or fluids, then contact should be made to the patient’s GP so that a decision can be made in relation to next steps. You also raise the matter of available adult social care beds for residents with complex care needs. Local authorities are best placed to understand and plan for the care needs of their populations. That is why under the Care Act 2014, local authorities are required to shape their local markets, and ensure that people have a range of high-quality, sustainable and person-centred care and support options available to them, and that they can access the services that best meet their needs. This includes ensuring adequate local provision of adult social care beds for residents with complex care needs.

5 https://local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems- resilience/refreshing-high 6 Working with hospitals | Local Government Association 7 https://www.nice.org.uk/guidance/ng27 8 https://www.nice.org.uk/guidance/SC1/chapter/1-Recommendations#care-home-staff-administering-medicines-to- residents

A wide range of guidance and support about commissioning and market shaping- developed by my Department with the Association of Directors of Adult Social Services (ADASS), LGA, the care sector and other partners is available on the GOV.UK website9. We support local authorities to manage their local markets effectively and are providing councils with access to over £1 billion of additional funding for social care in 2021-22. I understand Greater Manchester Health and Social Care Partnership have provided a detailed response regarding Mr Massam’s care, which I will not repeat here, with learning shared with the Greater Manchester Quality Board and local commissioners of services.

I have been informed that the Partnership have outlined a number of actions to prevent future deaths in similar circumstances, notably the introduction of a common system to allow various system partners to see each other’s work. Work is also underway to review and update transfer and discharge processes.

The CQC made an inspection of Stepping Hill hospital in January and February 2020 and found improvements were required in several areas. These were found to have been acted upon during a further inspection in August 2020. Following receipt of the Regulation 28 notice, the CQC have also decided to undertake an unannounced inspection of Lisburne Court. I am reassured that the CQC is to meet with the Chief Executive of Borough Care Ltd in the interim, to discuss these matters and to seek assurances around the lessons learned from this incident. Improving the lives of people living with dementia continues to be a top priority for this Government. Later this year, we plan to bring forward proposals for a new Dementia Strategy to set out how we will continue to support people living with dementia and their carers in England for future years. I hope this response is helpful. Thank you for bringing these concerns to my attention.

HELEN WHATELY

9 https://www.gov.uk/government/publications/adult-social-care-market-shaping/adult-social-care-market-shaping