Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 41
Public Health England Communicate national PPE and other guidance changes through incident-response governance, regional email cascades and onward local-authority distribution to care homes.
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Public Health England Establish a national team leading the organisational COVID-19 response in adult social care settings.
View source
Public Health England Compile a weekly digest of research evidence on preventing and controlling COVID-19 in home-care and care-home settings.
View source
Public Health England Participate in the SAGE Social Care Working Group to review emerging evidence and inform policy development.
View source
Public Health England Maintain national surveillance of COVID-19 incidents and outbreaks in care homes.
View source
Public Health England Communicate PPE guidance changes directly to local infection prevention and control teams and the North West Association of Directors of Adult Social Care.
View source
Public Health England Support delivery of the Adult Social Care Action Plan and Adult Social Care Winter Plan.
View source
Public Health England Develop the COVID-19 vaccination programme and prioritise vaccination for care-home residents and staff.
View source
Public Health England Work with adult social care stakeholders to develop guidance meeting sector needs, including PPE donning and doffing tutorials and an illustrated PPE guide.
View source
Public Health England Support care homes with infection prevention and control advice and outbreak response, including risk assessments, outbreak testing and additional control measures.
View source
Public Health England Liaise regularly with the Department of Health and Social Care, including weekly ministerial meetings, to inform care-home outbreak policy.
View source
Public Health England Coordinate the COVID-19 response through weekly meetings with Health Protection Teams and key partners to review intelligence, share learning and support outbreak practice.
View source
Public Health England Conduct epidemiological and genomic research on COVID-19 entry and spread in care homes to inform the public health response.
View source
Public Health England Participate in the Social Care Sector COVID-19 Support Taskforce and use its recommendations to inform government and sector advice.
View source
Public Health England Support development of adult social care guidance on admissions, hospital discharges, infection prevention and control, PPE and visiting.
View source
NHS Greater Manchester Integrated Care Board Monitor key learning points and recommendations to ensure they become embedded in practice.
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NHS Greater Manchester Integrated Care Board Deliver monthly infection prevention webinars explaining guidance, its scientific basis and best practice to care homes.
View source
NHS Greater Manchester Integrated Care Board Establish an Infection Prevention and Control Care Home Cell to interpret guidance and provide consistent messages to care homes.
View source
NHS Greater Manchester Integrated Care Board Share event learning at the scheduled quality improvement meeting with local authorities, commissioners, care homes and stakeholders.
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NHS Greater Manchester Integrated Care Board Present and share event learning with the Greater Manchester Quality Board.
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Care Quality Commission Publish COVID-19 guidance for adult social care providers to support implementation of current requirements.
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Care Quality Commission Continue monitoring regional ambulance performance and delays through engagement, performance reports, internal meetings, monthly meetings and national forums.
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Care Quality Commission Continue monitoring the care home and liaising with the local authority to review ongoing risks and provide feedback.
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Care Quality Commission Undertake an unannounced focused inspection of the care home covering infection control, risk management, falls, records and access to health support.
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Care Quality Commission Review the care home's systems and risk controls at the next inspection.
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Clarkson House Care Home Ltd / The Vicarage Care Home Review and update the admissions policy using current infection-control and public-health guidance, including testing requirements.
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Clarkson House Care Home Ltd / The Vicarage Care Home Prioritise documentation requirements in the induction programme for new staff.
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Clarkson House Care Home Ltd / The Vicarage Care Home Update the emergency waiting-time protocol so staff contact 111 or 999 at least hourly while awaiting emergency assistance.
View source
Clarkson House Care Home Ltd / The Vicarage Care Home Increase cleaning staff hours and use additional disinfection products for more frequent cleaning.
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Clarkson House Care Home Ltd / The Vicarage Care Home Deliver documentation training to staff through one-to-one, group and online sessions.
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Clarkson House Care Home Ltd / The Vicarage Care Home Arrange an infection-control and management audit with support from the Quality Improvement Team.
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Clarkson House Care Home Ltd / The Vicarage Care Home Attend local-authority and regional infection-control meetings and cascade relevant information to staff.
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Clarkson House Care Home Ltd / The Vicarage Care Home Disseminate changing Covid-19 guidance through electronic messages, memos and handovers, with senior staff observing practice and adherence.
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Clarkson House Care Home Ltd / The Vicarage Care Home Register staff for a level 2 infection-control and management qualification and support completion by the end of March 2021.
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Clarkson House Care Home Ltd / The Vicarage Care Home Undertake regular Covid-19 testing of residents and staff and maintain monitoring through the Safe Steps Covid app.
View source
Clarkson House Care Home Ltd / The Vicarage Care Home Provide updated documentation forms and proformas, and train staff to complete them after specified incidents or changes in residents’ health.
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Clarkson House Care Home Ltd / The Vicarage Care Home Implement correct PPE use and cascade PPE guidance changes through handovers, group email and WhatsApp.
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Clarkson House Care Home Ltd / The Vicarage Care Home Provide building-wide Wi-Fi capacity for digital clinical advice and support, with daily system testing.
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Clarkson House Care Home Ltd / The Vicarage Care Home Provide Covid-19 and infection-control training, including refresher training as guidance changes.
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Clarkson House Care Home Ltd / The Vicarage Care Home Continue the vaccination programme for residents and staff, including outstanding first and second doses.
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Clarkson House Care Home Ltd / The Vicarage Care Home Update and reissue the documentation and recording policy to all staff.
View source Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 8
Public Health England Documentation, observations, vulnerability assessment, COVID-19 transmission, and ambulance delay were outside the respondent’s remit, control, and responsibility.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Public Health England Established incident-response governance and communication cascades were used to disseminate PPE guidance updates to relevant health and social care partners.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Public Health England Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
NHS Greater Manchester Integrated Care Board Specific concerns are assigned to the named respondents responsible for addressing them.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Care Quality Commission Existing arrangements for communicating PPE guidance, training staff and maintaining PPE supplies are considered sufficient to manage PPE risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Care Quality Commission Existing post-fall and illness-management processes address the known risks, including appropriate observations, medical support and documentation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Care Quality Commission Existing admission controls, including government guidance, isolation and regular testing, are considered sufficient to manage infection risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Clarkson House Care Home Ltd / The Vicarage Care Home Existing documentation induction arrangements are considered sufficient for now; no further action is required, subject to continued monitoring.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to maintain staff clarity about PPE requirements
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Limited documentation of care home staff observations
Wider context from the report “1. The documentation available at the inquest from the home was limited in detail . As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to share and implement changes to PPE guidance
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for admission of new residents
Wider context from the report “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to undertake observations of sufficient quality
Wider context from the report “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability.
” Is this part of a recurring concern? Yes — Unreliable patient observation arrangements .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Insufficient ambulance availability for timely transport to an acute setting
Wider context from the report “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances . The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate national PPE and other guidance changes through incident-response governance, regional email cascades and onward local-authority distribution to care homes.
Verbatim wording from the response “Communication of changes to all national guidance, including the use of PPE, was (and continues to be) delivered under the established PHE incident response governance structures, which were activated in March at the outset of the pandemic. Regarding PPE guidance during March and April, partners in Health and Social care across the North West of England received written communication in a timely and proportionate manner via the PHE NW Incident Control Centre (ICC) email cascade on all updates and changes to guidance. This included all NW Directors of Public Health, Directors of Adult Social Care, with an onward cascade via Local Authority routes to Care Homes for which they had responsibility.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a national team leading the organisational COVID-19 response in adult social care settings.
Verbatim wording from the response “PHE has established a national team to lead the organisational response to COVID-19 in adult social care settings. This team is involved in a number of activities, including:” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Compile a weekly digest of research evidence on preventing and controlling COVID-19 in home-care and care-home settings.
Verbatim wording from the response “PHE collates a weekly digest of research evidence in relation to the prevention and control of COVID-19 in home care/care home settings to inform the public health response.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the SAGE Social Care Working Group to review emerging evidence and inform policy development.
Verbatim wording from the response “• Membership of the Scientific Advisory Group for Emergencies (SAGE) Social Care Working Group to review emerging scientific evidence and inform policy development” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain national surveillance of COVID-19 incidents and outbreaks in care homes.
Verbatim wording from the response “• National surveillance of COVID-19 incidents and outbreaks in care homes” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate PPE guidance changes directly to local infection prevention and control teams and the North West Association of Directors of Adult Social Care.
Verbatim wording from the response “In addition, PHE NW's ICC communicated directly with local Infection Prevention and Control Teams and North West Association of Directors of Social care (ADASS) to minimise the risk that guidance was missed.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support delivery of the Adult Social Care Action Plan and Adult Social Care Winter Plan.
Verbatim wording from the response “• Supporting DHSC in the delivery of the Adult Social Care Action Plan and Adult Social Care Winter Plan” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the COVID-19 vaccination programme and prioritise vaccination for care-home residents and staff.
Verbatim wording from the response “PHE has been heavily involved in the development of the COVID-19 vaccination programme and the prioritisation of vaccination for care home residents and staff.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with adult social care stakeholders to develop guidance meeting sector needs, including PPE donning and doffing tutorials and an illustrated PPE guide.
Verbatim wording from the response “Guidance on the use of PPE has continued to develop in line with increasing scientific knowledge. PHE has worked with stakeholders in the adult social care sector to ensure that developing guidance meets the needs of the sector. As an example, PHE has developed video tutorials on the donning and doffing of PPE, and an illustrated guide to PPE for community and social care settings.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support care homes with infection prevention and control advice and outbreak response, including risk assessments, outbreak testing and additional control measures.
Verbatim wording from the response “Throughout the pandemic, PHE HPTs have been working with local partners, including directors of public health, local authorities and clinical commissioning groups to support individual care homes during the pandemic. This has included providing advice on infection prevention and control measures to prevent incursion of infection into care homes, and supporting care homes in response to outbreaks. Outbreak response has included conducting risk assessments, arranging outbreak testing and advising on additional infection prevention and control measures.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise regularly with the Department of Health and Social Care, including weekly ministerial meetings, to inform care-home outbreak policy.
Verbatim wording from the response “• Regular liaison with DHSC, including a weekly meeting with the Minister for Social Care to take a deep dive into issues relating to care home outbreaks to inform policy making” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Coordinate the COVID-19 response through weekly meetings with Health Protection Teams and key partners to review intelligence, share learning and support outbreak practice.
Verbatim wording from the response “• Coordination of the PHE response to COVID-19 in adult social care settings, including holding a weekly meeting with Health Protection Teams (HPTs) and key partners from the Department of Health and Social Care (DHSC) to review intelligence, share learning and support policy and public health practice in relation to outbreaks and incidents in care homes” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct epidemiological and genomic research on COVID-19 entry and spread in care homes to inform the public health response.
Verbatim wording from the response “PHE research teams have conducted a number of research projects, including epidemiological and genomic research, to help understand key issues in relation to the entry and spread of COVID-19 in care homes to inform the public health response.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the Social Care Sector COVID-19 Support Taskforce and use its recommendations to inform government and sector advice.
Verbatim wording from the response “• Membership of the Social Care Sector COVID-19 Support Taskforce to learn from the first phase of the COVID-19 pandemic and inform advice and recommendations to government and the social care sector. The recommendations from this taskforce informed the development of the government’s Adult Social Care Winter Plan 2020-2021
https://www.gov.uk/government/publications/adult-social-care-coronavirus-covid-19-winter-plan-2020-2021/adult-social-care-our-covid-19-winter-plan-2020-to-2021” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of adult social care guidance on admissions, hospital discharges, infection prevention and control, PPE and visiting.
Verbatim wording from the response “PHE has supported DHSC and NHS England in the development of a number of guidance documents to support the adult social care sector in responding to the pandemic, including guidance on admission and care of residents, discharge of residents from hospital, infection prevention and control, personal protective equipment and visiting.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor key learning points and recommendations to ensure they become embedded in practice.
Verbatim wording from the response “The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly infection prevention webinars explaining guidance, its scientific basis and best practice to care homes.
Verbatim wording from the response “3. A monthly webinar has been organised, attended by over 100 care homes, to explain the science that supports the guidance, the interpretation of the guidance and to share best practice. The 5th Webinar is to be broadcast on 23rd February. This webinar and all the previous webinars are available to view on YouTube.” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an Infection Prevention and Control Care Home Cell to interpret guidance and provide consistent messages to care homes.
Verbatim wording from the response “2. A Greater Manchester Infection Prevention and Control Care Home Cell has been established to interpret guidance and ensure a clear and consistent message to the care homes across Greater Manchester.” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share event learning at the scheduled quality improvement meeting with local authorities, commissioners, care homes and stakeholders.
Verbatim wording from the response “4. Tameside Local Authority, CCG and the care home have been invited to share the learning from this event at a quality improvement meeting on the 15th March 2021. The Quality Improvement Group meet monthly to share best practice and lessons learned. This group is attended by all 10 CCGs and LAs from across GM along with care home providers and key stakeholders” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present and share event learning with the Greater Manchester Quality Board.
Verbatim wording from the response “1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish COVID-19 guidance for adult social care providers to support implementation of current requirements.
Verbatim wording from the response “With regards to The Vicarage Residential Care Home, CQC expects registered persons to keep up to date with, take on board and implement government guidance. We have during the Covid 19 pandemic remained in regular contact with the Provider. This included engagement calls in March, April and May 2020. These were supportive calls to ensure that the Provider was aware of any updates to guidance and to signpost appropriate support if needed. CQC also published COVID-19 related guidance for ASC providers on the CQC website. From mid-March 2020 the Provider also received daily updates from TMB which included updates on guidance, resources and support.” Source location 2020-0264-Response-from-CQC-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring regional ambulance performance and delays through engagement, performance reports, internal meetings, monthly meetings and national forums.
Verbatim wording from the response “We are continually monitoring the regional ambulance picture, through ongoing engagement, performance reports and internal meetings.” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the care home and liaising with the local authority to review ongoing risks and provide feedback.
Verbatim wording from the response “In order to ensure that this risk is minimised to the lowest possible level and to ensure service users are not placed at risk at The Vicarage Residential Care Home, we are continually monitoring the service and liaising with the Local Authority to review any ongoing risks and feedback.” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake an unannounced focused inspection of the care home covering infection control, risk management, falls, records and access to health support.
Verbatim wording from the response “Following receipt of the concerns raised by the Coroner at the conclusion of the inquest into the death of Mr. Slack which resulted in the prevention of future deaths report, CQC undertook an unannounced, focused inspection of The Vicarage Residential Care Home. This was undertaken to ensure that the circumstances of Mr. Slack’s death did not raise concerns about any ongoing risk to current service users” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the care home's systems and risk controls at the next inspection.
Verbatim wording from the response “In summary, CQC have reviewed systems in place at The Vicarage Residential Care Home and we are assured that the Provider has taken action to improve and further reduce risks within this care home. This will be reviewed at our next inspection of the service.” Source location 2020-0264-Response-from-CQC-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the admissions policy using current infection-control and public-health guidance, including testing requirements.
Verbatim wording from the response “We have reviewed our admission policy and are keeping it under regular review adding to it based on new guidance being provided by the local authority, PHE and our local infection prevention team based at Tameside General hospital. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise documentation requirements in the induction programme for new staff.
Verbatim wording from the response “We have included documentation as above as a high priority in our induction document for new staff. | No Further Action Required at the moment / continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the emergency waiting-time protocol so staff contact 111 or 999 at least hourly while awaiting emergency assistance.
Verbatim wording from the response “We acknowledge that the delays from the emergency services in periods of high need could impact on vulnerable and unwell residents. We have updated our protocol as regards waiting times whereby in the event of an emergency e.g. fall or a resident becoming very unwell, then staff to be proactive and keep updating 111 or 999 on at least an hourly basis.” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase cleaning staff hours and use additional disinfection products for more frequent cleaning.
Verbatim wording from the response “We have increased cleaning staff duty hours over the past 6 months to cater for more regular cleaning and disinfection in addition to new products being used for desanitation. | Review 18/10/20 | Review 27/12/20 | Review 22/01/21 | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver documentation training to staff through one-to-one, group and online sessions.
Verbatim wording from the response “Documentation training in house has been completed. This has been carried out by senior staff on a 1:1 basis with all staff. | All staff completed” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange an infection-control and management audit with support from the Quality Improvement Team.
Verbatim wording from the response “Infection control audit to be planned as the next due audit was the end of 2020 but due to the demands on the infection prevention team who normally carry out | Date of audit to be confirmed by the quality improvement team by the end of January 2021” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attend local-authority and regional infection-control meetings and cascade relevant information to staff.
Verbatim wording from the response “We as Managers follow and attend meetings organized by the Local Authority (manager’s forums) and Greater Manchester infection control meetings and cascade down any new information we come across. | Continue to attend” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate changing Covid-19 guidance through electronic messages, memos and handovers, with senior staff observing practice and adherence.
Verbatim wording from the response “In April 2020 the situations that we were presented with were new and unexpected. Since then we have learnt a lot about Covid-19. Drawing from regular guidance provided by the local authority, public health England, CQC we keep our staff updated with new and updated changing advice through memos. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Register staff for a level 2 infection-control and management qualification and support completion by the end of March 2021.
Verbatim wording from the response “We have sourced out a new course specific to infection control and management leading to a level 2 qualification. This is due to start by the 15/2/2021 and the objective is for all staff to complete by the end of March 2021.” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake regular Covid-19 testing of residents and staff and maintain monitoring through the Safe Steps Covid app.
Verbatim wording from the response “Included in the above is PCR testing and lateral flow testing as guided by the Local Authority and government guidance. We undertake regular testing of residents and staff and keep the safe steps Covid app updated and this is monitored by the NHS regularly. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide updated documentation forms and proformas, and train staff to complete them after specified incidents or changes in residents’ health.
Verbatim wording from the response “We have reissued relevant documentation for forms and sourced out relevant and more up-to-date document proformas from The Quality Improvement Team to be completed by staff following a fall, resident being unwell, loss of appetite, loss of weight and ensured staff are conversant with them and how to complete them through 1:1 where relevant and small group sessions at handovers. | Monitoring continues” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement correct PPE use and cascade PPE guidance changes through handovers, group email and WhatsApp.
Verbatim wording from the response “In March/April 20 the guidance of the requirement and use of PPE was limited. We are implementing the use of correct PPE as guided by the local authority and infection control team. Any changes or new advice provided by the local authority and other relevant authorities are specifically cascaded down to the staff electronically and through memos and handovers. We can confirm we have stock of PPE’s that could last us for 4-6 weeks at the very least.” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide building-wide Wi-Fi capacity for digital clinical advice and support, with daily system testing.
Verbatim wording from the response “In addition we have reviewed our dispositions in terms of wifi capacity to enable us to seek advice and support digitally via skype or business whatsapp accessible from every corner of the building and every room of the building. The system is tested daily via an app by the manager.” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Covid-19 and infection-control training, including refresher training as guidance changes.
Verbatim wording from the response “All our staff on site except for a few new starters have undertaken a specific Covid-19 course provided online by social care T.V and have all undergone infection control training provided by the Local Authority on a weekly basis (previously twice weekly). We ensure that staff have refreshers as new information and guidance are regularly added onto the course. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the vaccination programme for residents and staff, including outstanding first and second doses.
Verbatim wording from the response “We have undergone vaccinations (1st Dose) most of our residents and staff in December 2020 and now await the second dose and a few more requiring the 1st dose. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and reissue the documentation and recording policy to all staff.
Verbatim wording from the response “The documentation and recording policy has been updated and reissued to all staff both hard copy and via group email. | Continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Documentation, observations, vulnerability assessment, COVID-19 transmission, and ambulance delay were outside the respondent’s remit, control, and responsibility.
Verbatim wording from the response “It is not appropriate that this response provides detail regarding points in the Regulation 28 Report on the limited details in documentation available at the inquest from the home, the quality of observations and assessment of vulnerability of Mr Slack, the route of transmission of COVID-19 into the home and the delay of the ambulance, as these are outside the remit, control and responsibility of PHE.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Established incident-response governance and communication cascades were used to disseminate PPE guidance updates to relevant health and social care partners.
Verbatim wording from the response “Communication of changes to all national guidance, including the use of PPE, was (and continues to be) delivered under the established PHE incident response governance structures, which were activated in March at the outset of the pandemic. Regarding PPE guidance during March and April, partners in Health and Social care across the North West of England received written communication in a timely and proportionate manner via the PHE NW Incident Control Centre (ICC) email cascade on all updates and changes to guidance. This included all NW Directors of Public Health, Directors of Adult Social Care, with an onward cascade via Local Authority routes to Care Homes for which they had responsibility.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Verbatim wording from the response “PHE understands that the Regulation 28 Report has been sent to the Care Quality Commission, The Vicarage Residential Care Home, NHS England, Greater Manchester Health and social care partnership who will be able to comment on the remaining concerns. Additionally, PHE has shared this report with the DHSC who will provide further comment.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific concerns are assigned to the named respondents responsible for addressing them.
Verbatim wording from the response “I have noted that your Regulation 28 letter has also been sent to The Vicarage Residential Care Home, Public Health England and NHS England. Whilst I may summarise some of the actions taken by these organisations, I will leave it to the named respondents to address the specific concerns relevant to them which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP.” Source location 2020-0264-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing arrangements for communicating PPE guidance, training staff and maintaining PPE supplies are considered sufficient to manage PPE risks.
Verbatim wording from the response “We have confirmed, through engagement conversations with the Provider in March, April and May 2020, and at our inspections in July 2020 and January 2021 that the Provider was accessing the government guidance current at that time on use of PPE. On all of these occasions the Provider demonstrated that they were aware of current guidance and were ensuring staff were made aware of any changes via a staff WhatsApp group, emails and staff handovers. The Provider confirmed they were receiving updates from TMBC which included links to any changes in guidance to PPE use.” Source location 2020-0264-Response-from-CQC-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing post-fall and illness-management processes address the known risks, including appropriate observations, medical support and documentation.
Verbatim wording from the response “CQC expects all services to have robust systems to ensure the quality of service and monitors that policies and procedures are being followed. We found there were a variety of checks and audits carried out in the home to ensure it was safe for the people living there. These included reviews of action taken following accidents and incidents, care record entries and observation records. These were overseen by the Provider to ensure any actions were completed.” Source location 2020-0264-Response-from-CQC-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing admission controls, including government guidance, isolation and regular testing, are considered sufficient to manage infection risks.
Verbatim wording from the response “Throughout the Covid 19 pandemic government guidance has been issued to providers on admissions to care homes and testing of staff. This did not at the time of Mr Slacks death include the requirement to test staff or residents before admission.” Source location 2020-0264-Response-from-CQC-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing documentation induction arrangements are considered sufficient for now; no further action is required, subject to continued monitoring.
Verbatim wording from the response “We have included documentation as above as a high priority in our induction document for new staff. | No Further Action Required at the moment / continue to monitor” Source location 2020-0264-Response-from-Vicarage-Care-Home-Redacted
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