Care Quality Commission

“the CQC inform us that they are monitoring the service to ensure that children residing there are not exposed to risk or unsafe care, which is of utmost importance so deaths such as [the deceased]'s can be prevented. CQC regulates the premises and the care provided, and they are reviewing any information received to help inform the next inspection.”

“NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response.”

“The Government is supportive of the review on the duty it inherited from the previous administration and will consider the findings, recently published on 26 November, following a call for evidence in April this year. The government will consider these findings alongside findings from the ongoing manager regulation consultation as it continues to develop policy on candour in healthcare.”

“On 18th October 2023 CQC requested the outcome of the external investigation from the registered manager at TCT. This wasn't available, but TCT shared the findings with CQC of the internal investigation. Alongside the evidence of findings from the Ofsted inspection the CQC made the decision to await the external investigation findings before scheduling an inspection.”

“the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient's responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions”

“I will therefore provide some further information on the work NWAS is undertaking with its partner agencies who are also often called upon to assist mental health patients.”

“The Training Manager for GMP's Force Contact Crime and Operations Branch (FCCO) has confirmed that the Mental Health induction input for their staff is 3.5 hours long. This is included in all new recruit training into Call Handling and Dispatch.”

“England will review and consider carefully the other responses in due course.”

“We have introduced six new evidence categories to organise information under the statements; these are 'Feedback from people', 'Feedback from staff and leaders', 'Feedback from partners', 'Our observations', 'Processes' and 'Outcomes'. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make”

“the Greater Manchester NHS Foundation Trust agrees that, although it can take time to complete all the necessary arrangements for a safe and appropriate transfer of care for someone with complex needs, the time from a decision that Mr [name redacted] was medically optimised (18 December 2023) to his actual transfer to Hilltop Hall Nursing Home (11 January 2024) was too long.”

“continuation of 'front-door streaming', which identifies the most appropriate care pathway for each patient at initial assessment. Patients are streamed from A&E to suitable services such as urgent treatment centres, community services, same day emergency care and virtual wards to reduce long waits in A&E”

“Urgent Care Transformation Programme which aims to support patient flow. The programme has helped the Trust to identify priority areas, such as digitally recording of initial time-to-treatment, and has improved waiting times”

“review of the emergency department consultant rota to include 7-day working and extended working hours to support safety in the Department, and all waits over 12 hours are analysed to assess whether clinical harm was caused”

“the Trust's Chief Operating Officer working with Adult Social Care, locality and Integrated Care System colleagues to improve discharge from wards to reduce numbers of patients in beds with 'no criteria to reside'”

“any form of abuse or neglect is unacceptable. The department has legislation and policies in place for escalating concerns if provider action plans are not addressing safeguarding issues effectively”

“The Care Quality Commission (CQC) has also been sent a copy of this Regulation 28 report and will be issuing a response”

“We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr [name redacted] spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit.”

“we have passed this information on to our Employer Link Service (ELS) and to the New Referrals team to make enquiries in relation to these concerns.”

“We are grateful for the details provided in your report and confirmation of the outcome following inquest. With regards your query in relation to CQC making further enquiries, we have taken action as outlined below. CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic”

“We have reviewed all our records and cannot find that we received a statutory notification for serious injury to Mrs [name redacted] in relation to the grade 3 pressure injury identified at the point it was identified in October 2022.”

“The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. Consequently, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.”

“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”

“We will continue to monitor WMAS's progress in making improvements to their serious incident management and learning from deaths through our ongoing monitoring activities and engagement.”