Care Home Health related deaths

Action Planned (AI summary) The Council is recruiting temporary qualified staff and training additional staff to perform the Best Interests Assessor function and is currently in the process of procuring external specialist support to undertake all of the assessments on the waiting list.

Action Planned (AI summary) The CCG developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. An action plan has been written to drive this work forward and progress will be monitored by their Patient Safety and Quality Committee.

Action Planned (AI summary) Dolby Vivisol is liaising with Salter Labs and Invacare to update product instructions regarding humidifier cap engagement, and will update their own training materials and patient instructions accordingly. Proposed amendments will be sent to NHS contract managers for approval. Invacare will update manuals provided to customers with concentrator units to include enhanced guidance on humidifier cap installation, with wording similar to confirming the cap is not cross-threaded. This update will be phased into all manuals within several months, with a technical update sent to customers in Europe. Salter Labs has offered to review Dolby Vivisol's updated literature and will ensure it includes reference to the safety valve. They are waiting for the humidifier to be returned for examination and will provide an updated Vigilance Report to the MHRA.

Action Planned (AI summary) Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.

Action Planned (AI summary) Springbank Nursing Home has produced a protocol for managing unconscious residents, including training for staff, clearer risk assessments, and mandatory summoning of emergency services in cases of doubt. The protocol has been provided for all staff working at Springbank Nursing Home.

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 concerns about care for people living with dementia and states that they are proposing to publish a report in May or June 2014 which will set out good practice and make recommendations about dementia care across different services.

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.