CQC

Noted (AI summary) CQC commenced an inspection of Downshaw Lodge on 16 October 2024 to review matters in relation to ongoing risk and to assess documentation; findings will be published on the CQC website. An initial assessment concluded there was no evidence of a registered provider level failure to meet the threshold at which criminal enforcement would be considered. No information provided.

Noted (AI summary) DHSC reports that Tameside and Glossop Integrated Care NHS Foundation Trust completed work on re-developing its urgent care and emergency departments in July 2024, including front-door streaming, an Urgent Care Transformation Programme, and a review of the emergency department to avoid hospital admissions for those patients living with frailty; The Lakes Care Centre is no longer registered for nursing, and is under new management. The CQC acknowledges concerns about care at The Lakes Care Centre. The provider has ceased to deliver the regulated activity of 'Treatment for Disease, Disorder or Injury' and the CQC will seek to register a suitable candidate for the registered manager role. Response consists of the text A1, A2, and A3. Unable to classify without further content.

Noted (AI summary) The NMC acknowledges the concerns and states they have passed information to their Employer Link Service and New Referrals team to make enquiries and will investigate concerns within their remit. They have also referred the case to the Public Support Service to reach out to the family. Westmorland Court Care Home states that a number of improvements have taken place since the death, including implementing a Quality Improvement Plan with the ICB and Westmorland and Furness Council. Staff training has been refreshed and updated, and reflective accounts of the incident were completed. The CQC acknowledges the concerns raised and outlines actions taken following previous notifications, including a targeted inspection. They state that mandating defibrillators in care homes falls outside their remit but expect providers to have appropriate policies for resuscitation.

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) NHS England is working with private sector organisations to trial the use of Summary Care Records in settings where they have previously been unavailable and will continue this work throughout 2024. They also note the responsibility of providers to share information under the Health and Social Care (Safety and Quality) Act 2015. The CQC states they cannot comment on the regulation of the private psychotherapist as the practice is not registered with CQC. They welcome the action taken by Surrey and Borders Partnership NHS Foundation Trust and will continue to monitor the trust and any new information received but state this is outside the scope of their regulatory powers. The UK Council for Psychotherapy outlines its role and regulatory responsibility, noting its register of psychotherapists and Complaints and Conduct Process. They state they will not take action in relation to the coroner's first concern, but note work with the Professional Standards Authority and the NHS in discussing opportunities for collaboration in support of suicide prevention strategies.

Noted (AI summary) Outlook Care has implemented an action plan including external feedback, stakeholder inclusion in reviews, and collaborative working with LBWF. They've revised their Missing Person policy, provided staff training, and conducted spot checks on 1:1 support, issuing guidance on maintaining a 'line of sight'. Future actions include business continuity tests, audits of risk management, and revised induction formats. The CQC reviewed information on Waterside Lodge Recovery Centre and requested a copy of Outlook Care's response to the coroner, noting changes across their remaining nine locations including review of missing person policy, training for staff, additional risk assessments and spot checks on community visits, and will request and review evidence of completion of these actions. The Metropolitan Police state that they have been unable to identify any other deaths in the area that would suggest any specific or ongoing risk to public safety, or significant criminal activity. They confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping and have increased engagement with local residents to encourage reporting of rough sleeping. The London Borough of Waltham Forest explains its processes for monitoring commissioned supported living services and managing parks/open spaces. They state that the support worker was not employed or commissioned by them. They outline referral pathways for vulnerable adults, rough sleeping monitoring, and vegetation management but do not commit to specific changes.

Noted (AI summary) The Integrated Care Partnership states that District Nurses share advice via a Communication Book and that the Trust has provided a timeline of communication with the care home. They describe the process for Tissue Viability Nurses to review and provide advice, including the use of wound photography and communication with the nursing service. CQC will follow up with Stockport NHS Foundation Trust at future engagement meetings to ensure that appropriate reflection has taken place and learning from this incident disseminated. CQC are continually monitoring the service and liaising with the Integrated Care Board to review any ongoing risks and feedback.

Noted (AI summary) Skills for Care recommends that every frontline care worker within a CQC regulated service should receive First Aid training, including basic life support as part of their initial induction to the sector, and ensure these skills are regularly refreshed. They highlight existing guidance and initiatives, but note that they cannot mandate training. Peabody has improved its training program for care workers in supported living environments, now requiring certified First Aid and Basic Life Support training before solo work. Existing care workers will also complete the new course within one year and the organisation has launched an Ofsted-registered Academy. CQC acknowledges the regulation regarding staffing qualifications and training and highlights that Peabody has revised protocols to ensure no support worker lone works without enhanced training in emergency first aid and basic life support, and is ensuring appropriately trained personnel on every shift. CQC will be considering the case under its framework for health and safety incidents.

Noted (AI summary) NHS England acknowledges the concerns and refers to the Association of Anaesthetists and Royal College of Anaesthetists. They mention national guidance and local policies and guidance, and mentions internal discussions of PFD reports. The RCoA and AoA highlight existing guidelines for tracheostomy care developed with NTSP and other organisations. They will highlight learning from the death and re-promote guidance to members via publications. The CQC acknowledges the concerns but states that writing specific guidance is outside of their remit. They assess the application of national guidance within a trust.

Noted (AI summary) West Midlands Ambulance Service acknowledged the ECG was abnormal and that policy wasn't followed; clinicians received a case review, participated in a Serious Incident process, completed reflective practice, and are scheduled for additional ECG/ACS training. Additional actions include updating policies and providing additional equipment/training to improve chest pain management and ECG interpretation. The Health and Care Professions Council acknowledges the concern but states that the individual in question is not registered with them, so the concerns do not fall within their remit for further investigation, but the individual's name has been added to a watchlist. The Health Services Safety Investigations Body is undertaking exploratory work regarding paramedic interpretation of ECGs in the community and will consider the scope for a formal investigation by the end of January 2024. The University of Wolverhampton will present case evidence to students, incorporate ECG interpretation into Objective Structured Clinical Examinations, liaise with coronary care units for anonymised ECG readings, add an ECG interpretation workbook to the virtual learning environment, and organise continuing professional development ECG masterclasses. The CQC has reviewed WMAS's actions following the death and found no evidence of provider-level failings, although they identified concerns regarding the timeliness of addressing the training needs of staff involved. The training needs of one staff member have been addressed, and the second staff member's training will be met upon their return to work.

Noted (AI summary) The CQC states that the location where the death occurred was not registered with them and appears to fall outside the scope of registration and regulation by them. They have requested interested person status and an extension to gather further information. The CQC states that the sheltered accommodation where the deceased resided is not registered with them and therefore not regulated by them, so they cannot comment on the specific concern raised.

Noted (AI summary) The IOPC expresses condolences and explains its role in the police complaints system. It details the recommendations made to Durham Constabulary, their response, and the IOPC's follow-up actions to seek further clarity on the acceptance of recommendations. DWP expresses condolences and states that existing guidance and support are adequate for vulnerable customers. They describe the call-back procedure followed and note that the ESA agent did not stop Ms Holmes’ benefit pending receipt of a PW1 form, indicating recognition of her vulnerabilities. TEWV acknowledges concerns and details actions taken including confirming assessment methods, developing an interim policy to address disputes between police and mental health services, and preparing a patient safety briefing on actions to take when disputes arise with partner agencies. The Police and Crime Commissioner acknowledges receipt of the report and expresses condolences. They state they have discussed the concerns with the Chief Constable, who has implemented an interim escalation policy with TEWV pending the roll-out of the national ‘Right Care Right Person’ approach. The constabulary has worked with TEWV to develop a strong partnership plan, implemented an interim escalation policy, and will train frontline officers with a national training package and local guidance.

Noted (AI summary) Aria Care will direct all future requests for riser/recliner chairs to Shackleton's, ensuring lockable handsets, and inform newly admitted residents of this requirement from December 1st, 2023. They are also working to replace existing chairs without lockable handsets and will reduce the use of riser/recliner chairs across the organization. HSE outlines the regulatory regimes applicable to the circumstances. HSE has contacted CQC on the patient safety aspects and notified OPSS regarding consumer product safety. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs.

Noted (AI summary) NHS England notes the Trust's strengthened training and improvement work following the death. They highlight ongoing work nationally on maternity services, and dissemination of learning through the Regulation 28 Working Group. The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. The CQC has requested information from University Hospitals Sussex NHS Foundation Trust regarding actions taken and intended in response to the report. They will monitor the Trust's progress and compliance, including implementation of the national medical examiner system and processes for equipment isolation. St Richard's Hospital describes their Maternity Improvement Program developed with the Maternity Safety Support Program and the achievement of year 4 requirements of the Clinical Negligence Scheme for Trusts (CNST). They have also reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB. Health Education England expresses condolences but states the concerns fall outside its remit, highlighting work on patient safety training and collaboration on broader NHS improvements.