2017

Noted (AI summary) The practice has sent personal letters to patients on repeat prescriptions for Benzodiazepines asking them to contact the practice for a medication review. The practice has made a commitment not to add (or continue repeat prescriptions from patients registering from other practices) Benzodiazepines to a repeat prescription if not already on repeat. The GP has referred themselves to the Deputy Medical Director for appraisal. The Royal College of General Practitioners provides context on its role, describes its training and membership offerings, and references existing guidance on benzodiazepine prescribing. It supports a joint consensus statement on action needed to tackle addiction to medicines. NHS England will ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief pharmacists in mental health trusts in England to raise awareness of the risks associated with benzodiazepine prescribing and withdrawal. Devon LMC will remind practices about the review of patients receiving short-acting Benzodiazepines via its electronic newsletter and will make the information available on its website.

Noted (AI summary) The Department for Transport expresses condolences but states there are no current plans to limit engine capacity for young drivers. They highlight existing road safety initiatives and commissioned research on measures to improve young driver safety.

Noted (AI summary) Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and primary healthcare, and will discuss collaboration with CSSIW regarding communication between health services and care homes. Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients registering from nursing/care homes; they will audit the process in 6 months. Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the GP, and a specific proforma completed on discharge for patients from care homes; they investigated and addressed an incorrectly addressed discharge summary, noting improvements in access to the Welsh Clinical Portal. CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers relevant elements of care, and is satisfied that no additional policy change is required.

Noted (AI summary) CSSIW cannot impose a blanket ban on care workers assisting service users to smoke, but will issue general guidance to care providers on assessing and mitigating health and fire risks associated with smoking, and exploring alternatives. CQC acknowledges the concerns, notes the service falls under CSSIW jurisdiction, and states their current inspection process covers governance systems, supervision, and accident/incident reviews, but does not support a blanket prohibition on assisting with smoking, preferring a case-by-case risk assessment.

Noted (AI summary) The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches, and states that it can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. The council acknowledges the concerns and refers to previous reports and statements regarding beach management at Camber Sands, and states that restricting public use of beaches would be disproportionate. The Forum intends to update and expand the use of the WAID database and is seeking to identify suitable sources of funding for this development work. RoSPA states that it seeks to influence, inform, coordinate activity and advise within the existing structures for water safety, and states that significant landowners successfully manage sites with significant hazards to the public without noticeable impacts or blanket restrictions. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions, and will conduct an independent review of its accident prevention activity.

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) NHS England provides context regarding the use of CCTV in mental health units, referencing relevant guidance and the Sussex Partnership NHS Foundation Trust's consultation with patients and staff. They note the Trust's agreement to install CCTV in entrance areas. The Trust is implementing the installation of CCTV in the entrance areas of all 12 of its acute inpatient/PICU wards, including Woodlands.

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.