Cornwall and the Isles of Scilly

Action Planned (AI summary) CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online prescribers, working with other regulators and government organizations to address current and emerging threats. The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from a review focusing on medicines associated with dependence, including structured medication reviews for patients.

Action Planned (AI summary) Cornwall Council has agreed to fund a scheme to improve visibility at the farm access, with Cormac's Safety Engineering team having begun the design process and work planned for autumn.

Action Planned (AI summary) The Department for Business, Energy & Industrial Strategy (BEIS) has asked the Office for Product Safety and Standards (OPSS) to engage with manufacturers, retailers, consumer groups, and government bodies to discuss effective communication about potentially dangerous appliances and develop an action plan. OPSS will also assess the gas appliance market, consumer trends, and whether further research is needed to change consumer behaviour towards greater gas safety.

Action Planned (AI summary) The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members are required to attend a corporate welcome day induction and complete statutory training depending on their role. A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to GPs, with draft letter to be subject to a process of consultation. The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services throughout the Trust, and the Trust is involved in a national project to improve access to patient information.

Action Planned (AI summary) The care home will encourage residents with seizures to be escorted in the bathroom. The home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff. All staff will attend face to face medication training on the 10th December 2019.

Action Planned (AI summary) Cornwall Council is developing a multiagency strategy (2019-23) to improve support for people with complex needs, including mental health and substance use issues. A task and finish project will review prevention services, domiciliary care, and supported housing, aiming to develop specialist supported housing and address gaps in service provision by April 2021.

Action Planned (AI summary) NHS Kernow CCG, CFT and Cornwall Council are undertaking a review of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT. The review of the strategy and comprehensive development of the implementation plan will be completed by the end of July 2019.

Action Planned (AI summary) Addaction has reviewed and improved how they record confidentiality and consent reviews. They will provide the Health Centre with client numbers, have a designated worker attend practice multi-disciplinary team meetings with access to SystemOne, and inform GPs earlier about plans to cease structured treatment where consent exists. NHS Kernow is working with partner agencies to implement a multi-agency strategy, including developing a dynamic risk register for individuals with dual diagnosis, with priority given to immediate actions. Contract requirements for new contracts commencing April 2019 are being reviewed to strengthen monitoring of engagement with the implementation plan.

Action Planned (AI summary) The CCG acknowledges the concerns about ADHD diagnosis and treatment and states that it has committed to developing a new adult ADHD pathway for Cornwall, due to be established in 2019, to address the identified gaps in service provision.

Action Planned (AI summary) The organisation is looking into whether it is possible to have an alarm which is audible to carers and identifies which stairgate is open.

Action Planned (AI summary) Commissioners plan a total overall investment of £13.8m to support achievement of the ARP standards. SWASFT have provided a draft business case and performance standards are expected to be met by September 2020, with Category 2 in June 2021. NHS Kernow will be working with current providers to extend their current contracts, as the procurement process was not successful. The CCG will finalise future commissioning arrangements for one universal non-emergency patient transport service.