Birmingham and Solihull

Noted (AI summary) HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document. G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody and consider lessons learned to inform best practice across their establishments.

Noted (AI summary) By 2023/24, anyone experiencing a mental health crisis will be able to call NHS 111 and access 24/7 age-appropriate mental health community support. By 2020/21 no acute hospital will be without a mental health liaison service for all ages in A&E departments and inpatient wards. The CCG acknowledges the coroner's concerns, noting that there appear to have been failings in care delivery which impacted on the ability for a bed to be located for Mr Watson, which BSMHFT have identified and taken actions to rectify.

Noted (AI summary) The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of contact for mental health crises. They also reaffirm commitment to suicide prevention and will continue measures through the existing suicide reduction programme. The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during 2019/20. A Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder is being led by the Trust's Chief Psychologist. The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.

Noted (AI summary) The trust is developing a drug strategy to address illicit substance use in the medium secure unit including risk assessments, educational sessions, opiate replacement consideration and potentially making Naloxone available on discharge; it is anticipated to be in place from January 2020. The CQC clarifies its role in inspections, stating they did not ask the trust to relax rules on takeaways, but did ask for review of blanket restrictions and active risk assessment for patients returning from leave. They review actions taken by organisations if informed of drug problems.

Noted (AI summary) The CCG provides background and context on mental health commissioning, including funding increases, but does not explicitly state actions taken or planned in direct response to the concerns raised in the report. The CCG will be meeting the local authority to address differences in opinion regarding provision of services for alcohol, drug and substance misuse and homelessness. The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018.

Noted (AI summary) Avery Health Group states they will continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.

Noted (AI summary) The Trust confirms that it has worked with Al-Hijrah school to provide a full response, and that its comments have been incorporated into the school's letter. This response is not classifiable as it appears to be a scan of a coversheet only. The content is unreadable and does not contain any meaningful information about actions taken or planned.

Noted (AI summary) Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; management staff are also monitoring records to address any issues arising. CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for a registered manager and ongoing assessments.