CQC

Noted (AI summary) NHS England notes the Trust's response and states it is promoting the free online Just and Learning Culture training to NHS employers. The Trust acknowledges failings in care and communication and has implemented several changes, including red flag identification, a revised Serious Incident Panel process for 12 months, and a local Serious Incident Panel to review serious incidents requiring further response, and implementation of Patient Safety Incident Response Framework (PSIRF). A mortality review process is also embedded at Trafford General Hospital. The CQC acknowledges the concerns and explains the statutory notification process. While stating that current reporting processes are adequate, it will review existing notifications guidance to determine if it could be clearer about reporting requirements relating to the circumstances of a person’s death. The Trust has updated its falls investigation template to include more detailed guidance around immediate action, including checking and documenting the environment of a fall. The CQC will review its existing notifications guidance in light of the findings from the death.

Noted (AI summary) The CQC acknowledges the report and details its role as a regulator. It notes actions taken by the care home and Tameside Local Authority, including new handover sheets and risk assessments, and states the CQC is satisfied appropriate steps have been taken. The response acknowledges the concerns and refers to the CQC's review and satisfaction that sufficient action has been taken. It then discusses national guidance on PPE disposal, waste management, care plan reviews, and dementia training.

Noted (AI summary) The MHRA has convened a stakeholder group to design educational resources for healthcare professionals and the public, aiming to launch a toolkit in 2020 with a press release and stakeholder propagation of key messages. NICE acknowledges the concerns but states that overseeing medicine safety, product warnings, and running safety awareness campaigns do not fall within its remit; they refer to existing BNF guidance for prescribers. Public Health England reviewed the report but defers to the Medical and Healthcare products Regulatory Agency (MHRA) as the concerns relate to medicines.

Noted (AI summary) The CQC confirms that water safety is considered by its inspectors and that they check for Legionella risk assessments. The Construction Industry Council is pressing for all aspects of life safety to be included in building safety regulatory reform.

Noted (AI summary) The CQC conducted inspections of Lisson Grove Health Centre but ultimately did not find concerns in the areas identified in the prevention of future death report. They rated the health centre 'Good' overall.

Noted (AI summary) The trust is developing a drug strategy to address illicit substance use in the medium secure unit including risk assessments, educational sessions, opiate replacement consideration and potentially making Naloxone available on discharge; it is anticipated to be in place from January 2020. The CQC clarifies its role in inspections, stating they did not ask the trust to relax rules on takeaways, but did ask for review of blanket restrictions and active risk assessment for patients returning from leave. They review actions taken by organisations if informed of drug problems.

Noted (AI summary) HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison service to take any specific action.

Noted (AI summary) The CQC reviewed the facts and evidence in relation to the death and completed an inspection at the service. The nursing home was found to have achieved beacon status with the Gold Standard Framework for end of life care. The Department of Health and Social Care acknowledges the concerns raised regarding end-of-life care and outlines existing frameworks, guidance, and initiatives aimed at improving care and decision-making in this area. They expect the CQC to respond as regulator of health and adult social care.

Noted (AI summary) The DHSC acknowledges the lack of a statutory process for recording consent to medication for voluntary mental health patients. They state that the Trust will implement additional safeguards, including pharmacist reviews of medications and capacity assessments, with concerns raised to the responsible clinician and clinical director. The CQC notes the concerns but states some relate to specific circumstances so they are unable to comment, but intends to follow through some areas of concern in more detail during an inspection later in the year.