Leicester City and South Leicestershire

Action Planned (AI summary) An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be reminded to access clinical information before seeing Prisoners.

Action Planned (AI summary) Leicester City Council will investigate potential improvements to the junction, including advanced cycle stop lines, road markings, parking restrictions, and signal timing changes to reduce conflict between cyclists and vehicles, with a view to including improvements in future works programmes.

Action Planned (AI summary) University Hospitals of Leicester NHS Trust's Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and their Director of Estates and Facilities will remind the switchboard staff of their responsibilities to keep the on-call rota updated. The Trust is in the process of procuring a trust-wide web-based system to manage on-call rotas, expected to be available for use throughout the Trust by the end of this calendar year.

Action Planned (AI summary) The Trust is implementing a competency assessment for HCAs by the end of October 2015 and moving towards electronic recording of observations with automatic EWS calculation and alerts. Clinical handover will include a check that observations have been taken.

Action Planned (AI summary) The trust plans to implement several changes, including a proforma for communications during labour, reinforcement of the escalation policy, consultant presence at the LRI, and an annual emergency drill to test the escalation policy. They will also include the informal 'SOS' system in the strengthened Escalation policy.

Action Planned (AI summary) DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations.

Action Planned (AI summary) My Mil Ltd instructed a Structural Engineer to look into the balustrading at Syston Lodge and make recommendations to ensure they comply, which will be undertaken once the report is received. CQC is reviewing its approach to registration, considering checks to confirm compliance with building regulations for new or altered locations where providers seek to accommodate people. They will share the report with inspectors and managers within the Commission.

Action Planned (AI summary) The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection methodology checks high-risk areas, though their inspectors do check that radiators are covered but will often only sample a selection of people's rooms. HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the letter with local authority health and safety regulators and arrange for discussion at the next national local authority practitioner forum. The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue to advise members on risk assessments and safe radiator temperatures.

Action Planned (AI summary) OFGEM will monitor suppliers' performance regarding non-domestic disconnections and work with the coroner on reviewing the Safety Net provisions, considering how to promote them to non-domestic suppliers. They also provided context about existing protections for domestic consumers facing disconnection. Energy UK revised the Energy UK Safety Net to clarify protections for vulnerable domestic consumers using a shared non-domestic supply, publishing the updated version on their website. Signatories aim to implement required systems and processes by the end of 2014, with ongoing reviews and audits planned. Npower has briefed affected teams on process changes, organized face-to-face training with annual refresher, and introduced a trial period ceasing disconnection of shared commercial and domestic supplies during winter months. These measures are in addition to existing safeguards for vulnerable customers.