Care Home Health related deaths

Noted (AI summary) NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. The Department of Health and Social Care extends condolences and explains the JCVI's role in vaccine prioritisation, highlighting the initial focus on reducing mortality and protecting healthcare staff. It also mentions support for hospital discharge pathways and ongoing reviews of COVID-19 deaths.

Noted (AI summary) The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a protocol to address placing people outside of the Trust’s geographical area. CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that the CQC will participate in a 'learning event' with the local authority and Devon Partnership Trust. The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement and participation of the family.

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.

Noted (AI summary) Norfolk County Council Adult Social Services expresses concerns about the inquest process, stating they were not asked to provide a report or contribute to the inquest. The response focuses on providing context and disputing some of the findings, particularly regarding the availability of suitable placements. Norfolk and Norwich University Hospitals NHS Foundation Trust is seeking funding for a ward-based Dementia Support Worker, and has been providing regular support by the Dementia Support Team. They have reviewed the Falls Risk and Safety Sides assessments, with a final draft completed and at the final adjustment/review stage, with plans for staff education to support the changes.

Noted (AI summary) The GP confirmed that it is now his practice to carry the equipment with him whenever he attends a patient away from the practice and he will now carry the mobile technology with him and will update patient records immediately following consultation/visit. The CQC acknowledges the concerns, outlines its role as a regulator, and states that a review found insufficient evidence of a breach of regulations regarding the care provided to Mr. Taylor. They will continue to monitor the service and liaise with the local authority. The Department expresses condolences and highlights existing guidance and training related to hydration and nutrition in care homes, referencing the Care Certificate and CQC oversight, but doesn't describe any new actions in response to the PFD.

Noted (AI summary) The Clinical Commissioning Group has already introduced changes to the process of requesting 1-to-1 care by care providers in November 2020, including routing requests to a senior nurse assessor for a response within 2 hours and requiring further evidence for extensions. They are also adding a safeguard to ensure that requests for 1 to 1s are submitted to the brokerage team and are escalated to a senior clinician, to be built into their electronic systems by the end of February 2021. The Department of Health and Social Care acknowledges the concerns raised and states that the CCGs are responsible for commissioning 1:1 care and have provided a response detailing actions taken. The Department will work with NHS England to consider the circumstances of the case but does not consider a change in national policy is required.

Noted (AI summary) NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve ambulance turnaround times. PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that other concerns raised are outside of PHE's remit and defers to other organisations. CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the next inspection. They also remained in regular contact with the Provider during the Covid 19 pandemic to ensure awareness of guidance and signpost support. Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly webinars for care homes, and have invited local stakeholders to share learning at a quality improvement meeting. The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency services. They have also reviewed wifi capacity.