PFD report

Miss Lucy Moffatt · Prevention of Future Deaths report

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Issued 10 Jun 2014•South Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised5

  1. Window restraint locks being easily defeated with scissors
  2. Lack of proper systems for restricting access to window restraint keys
  3. Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts
    Part of recurring concern: Unreliable dissemination of safety alerts to relevant recipients
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Undertake a detailed review to ensure Regulation 28 reports and other information systematically feed into intelligence monitoring, inspection and registration processes.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2014.
  2. Action

    Pilot pre-inspection methodology that assesses providers’ safety-alert policies, procedures and implementation of selected alerts.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2014.
  3. Action

    Discussed the report with the CQC and considered how to ensure Safety Alerts reach appropriate teams.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 10 June 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Providers, rather than the regulator, must determine the systems and equipment needed to address window restraint risks.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Window restraint locks being easily defeated with scissors

Wider context from the report

“(2) The lock on the window restraint could easily be defeated with a pair of scissors and this may be the case on many similar devices. ”

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 proper systems for restricting access to window restraint keys

Wider context from the report

“(3) Although the provider in question has now taken appropriate action, it may well be that many other such establishments have no proper system of window restraint key restriction. ”

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 ensure that CQC inspectors are properly aware of relevant Department of Health alerts

Wider context from the report

“(4) The CQC Inspectors had not apparently been made properly aware of the Dept of Health Alert on a matter that they were expected to check. ”

Is this part of a recurring concern?

Yes — Unreliable dissemination of safety alerts to relevant recipients.

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

Window restraints appearing secure despite not being locked

Wider context from the report

“(1) That the type of window restraint in question can appear secure to a 'pulling and tugging' check when it is not actually locked. This can mislead those unaware of the issue. ”

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 a system for passing on CQC knowledge of misleading window restraint lock conditions

Wider context from the report

“(5) There is no system to ensure that CQC knowledge of a potentially misleading situation with the window restraint lock was passed on, albeit in the belief that the restraint would be locked and that residents would be low risk. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 a detailed review to ensure Regulation 28 reports and other information systematically feed into intelligence monitoring, inspection and registration processes.

Verbatim wording from the response

“We greatly value the intelligence provided by your report and have endeavoured to address the concerns raised within it. The CQC is currently undertaking a detailed review designed to ensure that the valuable information provided by Regulation 28 reports, as well as from other sources of information, systematically and effectively feeds into our intelligence monitoring, inspection and registration processes.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 9 · response
Published 10 June 2014

Open published response

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

Pilot pre-inspection methodology that assesses providers’ safety-alert policies, procedures and implementation of selected alerts.

Verbatim wording from the response

“6. The CQC is also testing some pre-inspection methodology to provide additional intelligence to inspectors as part of inspection pre-planning and prior to going on site during the course of an inspection. We are currently piloting some pre-inspection where we will be testing the dissemination of safety alerts by assessing provider’s policies and procedures around alerts, and the implementation of a sample of alerts selected on the basis of low compliance rates on the CAS, or intelligence that alerts have not been well implemented. By way of illustration we enclose the question/prompts that are being proposed for inspectors to look for in the provider’s policy and procedures documentation, as well as the things to look for during inspection.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 9 · response
Published 10 June 2014

Open published response

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

Discussed the report with the CQC and considered how to ensure Safety Alerts reach appropriate teams.

Verbatim wording from the response

“I also note your concerns about communication between the Department of Health and the CQC. Officials at my Department have discussed your report with the CQC and considered how the CQC can ensure that these alerts are reaching the appropriate teams.”

Source location

2014-0261-Response-by-Department-of-Health
Page 2 · response
Published 10 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Providers, rather than the regulator, must determine the systems and equipment needed to address window restraint risks.

Verbatim wording from the response

“Under Regulation 16 of the Regulated Activities Regulations, the registered person, that is Sheffield Crisis in this case, must make suitable arrangements to protect service users and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided for the purposes of carrying out the regulated activity is properly maintained and suitable for its purpose, and used correctly. How this regulation is complied with will be taken into account by the CQC at registration and subsequent reviews of compliance. However, at this stage the CQC does not mandate exactly what systems or equipment systems should be in place while the burden falls on the provider to ensure that they take account of Alerts such as HTM 55 in devising the particular window restrictor or that is used.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 2 · response
Published 10 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Primary responsibility for managing patient safety and implementing safety alerts rests with health and social care providers.

Verbatim wording from the response

“In accordance with the evidence that was given at the inquest neither the registration assessor nor the compliance inspector in this case were specifically aware of the Department of Health Alert concerning the strength of window restraints referred to in Health Technical Memorandum (HTM) 55. The reason for this lies in the regulatory framework in which health and social care providers are registered to operate, and in accordance with the current registration and inspection CQC methodology. Under the current statutory and regulatory framework the primary responsibility for managing patient safety, and ensuring that such alerts are actioned, lies with the provider of health and social care providers.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 1 · response
Published 10 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Providers, rather than the Department or CQC, are responsible for managing patient safety, actioning alerts, and selecting suitable window restrictors.

Verbatim wording from the response

“The CQC have confirmed that neither the registration assessor nor the inspector in this case were specifically aware of the Department of Health alert concerning the strength of window restraints. However, under the current statutory and regulatory framework of the primary responsibility for managing patient safety and ensuring that such alerts are actioned lies with the provider.”

Source location

2014-0261-Response-by-Department-of-Health
Page 2 · response
Published 10 June 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Review the registration process to strengthen assessment and consider adding specific questions about managing patient safety alerts.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2014.
  2. 2

    Introduce a composite safety-alert compliance indicator into the NHS acute Intelligent Monitoring System.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 10 June 2014.
  3. 3

    Explore giving greater prominence to safety alerts in the revised surveillance and inspection model.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2014.
  4. 4

    Operate the revised five-domain regulatory assessment system, supported by key lines of enquiry, prompts and intelligent monitoring indicators.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 June 2014.
  5. 5

    Include compliance with safety alerts in the assessment framework and inspection prompts.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 June 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The regulator has no role in distributing safety alerts to independent healthcare or adult social care providers.

    Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
  2. 2

    The regulator does not oversee providers’ individual safety-alert decisions or actions, but assesses their capability and performance.

    Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.

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 registration process to strengthen assessment and consider adding specific questions about managing patient safety alerts.

Verbatim wording from the response

“5. As part of the CQC’s commitment to continuous improvement the registration process is currently under review to ensure greater robustness of assessment. The inclusion of specific questions relating to the management of patient safety alerts is currently being considered as part of this review. Whether or”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 8 · response
Published 10 June 2014

Open published response

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

Introduce a composite safety-alert compliance indicator into the NHS acute Intelligent Monitoring System.

Verbatim wording from the response

“4. Compliance with safety alerts (from all sources) features in the assessment framework and is one of the things CQC inspectors are prompted to consider when undertaking an inspection. However, the initial version of the Intelligent Monitoring System did not include an indicator relating to compliance with safety alerts as the system was largely in abeyance due to the transfer of safety related responsibilities from the NPSA to NHS England. This has since been reviewed and by July 2014, a new composite indicator is to be included in the NHS acute Intelligent Monitoring System pertaining to compliance with safety alerts. The exact composition is yet to be finalised, but is likely to include components relating to:”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 8 · response
Published 10 June 2014

Open published response

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

Explore giving greater prominence to safety alerts in the revised surveillance and inspection model.

Verbatim wording from the response

“3. Steps being taken by the CQC to address the concerns set out in your report.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 7 · response
Published 10 June 2014

Open published response

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

Operate the revised five-domain regulatory assessment system, supported by key lines of enquiry, prompts and intelligent monitoring indicators.

Verbatim wording from the response

“2. In 2013, CQC overhauled its approach to regulation and introduced a new system of assessment based around the 5 domains of safety, effective, caring, responsive and well led. This is underpinned by an assessment framework containing key lines of enquiry and prompts and an Intelligent Monitoring System of sentinel indicators to help identify risk.”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 8 · response
Published 10 June 2014

Open published response

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

Include compliance with safety alerts in the assessment framework and inspection prompts.

Verbatim wording from the response

“4. Compliance with safety alerts (from all sources) features in the assessment framework and is one of the things CQC inspectors are prompted to consider when undertaking an inspection. However, the initial version of the Intelligent Monitoring System did not include an indicator relating to compliance with safety alerts as the system was largely in abeyance due to the transfer of safety related responsibilities from the NPSA to NHS England. This has since been reviewed and by July 2014, a new composite indicator is to be included in the NHS acute Intelligent Monitoring System pertaining to compliance with safety alerts. The exact composition is yet to be finalised, but is likely to include components relating to:”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 8 · response
Published 10 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The regulator has no role in distributing safety alerts to independent healthcare or adult social care providers.

Verbatim wording from the response

“3. Other providers”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 4 · response
Published 10 June 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The regulator does not oversee providers’ individual safety-alert decisions or actions, but assesses their capability and performance.

Verbatim wording from the response

“1. The Care Quality Commission is currently exploring how it can give greater prominence to safety alerts in its revised surveillance and inspection model. However care is needed to be clear that providers retain accountability for implementing patient safety alerts. As set out already it is not the currently the”

Source location

2014-0261-Response-by-Care-Quality-Commission
Page 7 · response
Published 10 June 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026