CQC

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.

Noted (AI summary) The trust summarises the key learning outcomes from the agency review, pertaining to medicine management policies and processes for care homes. It references NICE guidance and the Electronic Transfer of Prescriptions (EPS) systems being introduced.

Noted (AI summary) The Department of Health acknowledges the concerns and outlines the actions taken by other bodies (NHS England, NHS Improvement, CQC) but does not commit to any specific actions by the Department itself, beyond requiring trusts to publish data on avoidable deaths. The hospital acknowledges the concerns and outlines several actions, including reviewing the previous non-compliance with internal guidelines, but no specific actions are identified as already completed. The CQC response notes that the trust has already included items on its action plan to improve multidisciplinary communication and documentation and will monitor progress. The trust has also put forward a business case for a CT scanner on site, which the CQC will monitor.

Noted (AI summary) Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record. Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures. NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services. The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.

Noted (AI summary) NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to develop local multi-agency suicide prevention plans by 2017, supported by further national investment from 2018/19. The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a matter for local commissioners, addressed by NHS England's response. The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the Medicines Code by the end of November 2016. The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust and their impact of those actions on patients at the quarterly meeting with the Trust in December 2016.

Noted (AI summary) The CQC states it has no regulatory remit over non-therapeutic circumcisions performed for religious purposes by non-healthcare professionals, as the regulations would require amendment by the Secretary of State. The Department of Health acknowledges concerns about non-medical settings for male circumcision and notes that a change in legislation would require consultation. They will copy the letter to clinical leads of CCGs in England to highlight the case and reiterate the advice that circumcision should be carried out by a regulated healthcare professional.

Noted (AI summary) NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of working, and will work to increase the number of Physician Associate training programmes. HEE will also ensure that paramedic training provides an additional 16% growth. The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance Service in September 2015. They will also meet to monitor NEAS staffing levels and recruitment. The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.

Noted (AI summary) Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan.