CQC

Noted (AI summary) The TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support Tool with the support of NFCC and LFB, but anticipate it will not be available until 2024. The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future deaths in relation to these services. The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated Adult Social Care Digital Skills Framework to support the development of digital skills across the adult social care workforce. The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003. The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems to smoke alarms during fire safety checks. The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors like being bed-bound and a smoker; a table detailing planned actions and timelines is attached.

Noted (AI summary) Wolverhampton City Council conducted an unannounced monitoring visit to Hibiscus House, suspended the service from new business, and implemented an improvement plan with the provider, including staff training reviews and relocation of one service user; they are also working with the CQC. The CQC details its role as regulator and its inspection processes. It acknowledges concerns around the safety of people’s care at Hibiscus DCA following a September 2022 inspection and that it is following internal enforcement processes. Following a CQC inspection Hibiscus drew up an action plan for the three areas of improvement which were identified by the CQC. Plans to upgrade systems which held vital information are under way.

Noted (AI summary) The GMC updated its prescribing guidance in February 2021 to place greater emphasis on good practice principles regardless of consultation method and highlights the need for dialogue with patients and obtaining adequate history, including current medication use. The GPhC outlines its role in setting standards for registered pharmacies and pharmacy professionals and taking enforcement action when standards are not met, including actions against online pharmacies supplying high-risk medicines and referrals to Fitness to Practise process. CQC has been in formal discussion with DHSC and submitted proposals for legislative changes to improve risk management of online primary care providers, and is working with regulatory partners to ensure that gaps in regulation are mitigated. DHSC acknowledges the concerns and describes the regulatory framework for medicines, including the roles of MHRA and GPhC, without outlining specific actions beyond existing oversight.

Noted (AI summary) The Department of Health and Social Care will include a link to falls and fractures guidance within its Coronavirus (COVID-19): admissions and care of people in care homes guidance. The Department will also seek clarification from Public Health England and NHS England and NHS Improvement regarding adjustments to falls and fractures guidance for self-isolating care home residents. The CQC acknowledges the PFD report and explains its role as a regulator, including inspection methodology and enforcement actions. It notes ongoing monitoring and liaison with the local authority, but does not outline specific actions taken or planned in direct response to the report.

Noted (AI summary) The CQC acknowledges the PFD report and details actions taken following a notification of death and whistleblowing concerns, including an inspection and review of falls management. They will continue to monitor information received about the service until the next inspection. Castlehill Specialist Care Centre has fitted individual door sensors in every bedroom, installed new monitoring screens linked to the external doorbell, and will make 111/999 calls following any fall. They will also raise safeguarding alerts and request 1:1 funding following any fall.