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. 15
NHS Greater Manchester Integrated Care Board
Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.
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NHS Greater Manchester Integrated Care Board
Present and share case learning with the Greater Manchester Quality Board.
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NHS Greater Manchester Integrated Care Board
Continue complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.
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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
Share investigation findings with Greater Manchester service commissioners for consideration within commissioned services.
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Department of Health and Social Care
Continue driving health and social care integration by removing data-sharing barriers and enabling joint decision-making.
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Department of Health and Social Care
Provide councils access to more than £1 billion of additional social care funding for 2021–22.
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Department of Health and Social Care
Publish and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
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Care Quality Commission
Meet the provider’s Chief Executive and new Nominated Individual to discuss the concerns and seek assurances about lessons learned.
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Care Quality Commission
Monitor Lisburne Court and liaise with the Local Authority to review ongoing risks and provide feedback.
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Care Quality Commission
Share the targeted inspection findings with the Coroner.
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Care Quality Commission
Operate monthly cross-directorate meetings to identify, coordinate and escalate risks across local health and social care systems.
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Care Quality Commission
Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
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Care Quality Commission
Continue monitoring the trust and conducting regular engagement calls to ensure improvements in urgent and emergency care remain embedded.
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Care Quality Commission
Review the trust’s information-sharing process after emergency-department treatment to determine whether regulatory action is required.
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× 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 understanding of when and how to use s.9 assessments for vulnerable adults
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” 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 clear inter-agency information-sharing arrangements for complex care
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases .in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised . This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” 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 defined escalation process for refusal of medication and fluids
Wider context from the report “3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on .
” 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 Shortage of suitable adult care beds for complex cases
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam .
” 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 Continuation of care in a home unable to safely meet complex care needs
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs . The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam.
” 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 guidance on ensuring a care home can accept a person back after discharge
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” 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 guidance on acute trust action when attempts to contact a care home are unsuccessful
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” 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 Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.
Verbatim wording from the response “For the wider Greater Manchester (GM) footprint, GMHSCP is working across the whole system to look at safe and appropriate discharges for people with complex needs. The Partnership is looking at a longer term support as part of the GM Discharge Programme and the Adult Social Care Transformation Programme. There is a programme of work underway to review this in detail and we are working with the 10 GM localities on this agenda.”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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 case 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 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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 complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.
Verbatim wording from the response “Additionally there is a Learning Disabilities Complex Needs programme which has been underway for 18 months and will continue for another year. As part of this programme of work, complex needs and discharge scoping is underway.”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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 investigation findings with Greater Manchester service commissioners for consideration within commissioned services.
Verbatim wording from the response “2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission.”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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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 driving health and social care integration by removing data-sharing barriers and enabling joint decision-making.
Verbatim wording from the response “I wish to reassure you that promoting integrated care is a priority for this Government. We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 1 · response Published 29 April 2021
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 councils access to more than £1 billion of additional social care funding for 2021–22.
Verbatim wording from the response “We support local authorities to manage their local markets effectively and are providing councils with access to over £1 billion of additional funding for social care in 2021-22.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 4 · response Published 29 April 2021
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 and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
Verbatim wording from the response “National guidance is available to support local health and care systems to facilitate good practice when patients are discharged from hospital. In March 2020, we published – and have since updated – the Hospital Discharge Service: policy and operating model⁴ guidance for NHS Trusts and care home providers, although this guidance predominantly applies to the discharge of patients who have been admitted to hospital, which does not appear to be the case here.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 2 · response Published 29 April 2021
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 Meet the provider’s Chief Executive and new Nominated Individual to discuss the concerns and seek assurances about lessons learned.
Verbatim wording from the response “In the interim period before we inspect, we are meeting with the Chief Executive and the new Nominated Individual of Borough Care Limited to discuss the issues raised and seek assurances around lessons they have learned. We are continually monitoring the service and liaising with the Local Authority to review any ongoing risks and feedback.”
Source location 2021-0120-Response-from-CQC-Redacted Page 5 · response Published 29 April 2021
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 Lisburne Court and liaise with the Local Authority to review ongoing risks and provide feedback.
Verbatim wording from the response “In the interim period before we inspect, we are meeting with the Chief Executive and the new Nominated Individual of Borough Care Limited to discuss the issues raised and seek assurances around lessons they have learned. We are continually monitoring the service and liaising with the Local Authority to review any ongoing risks and feedback.”
Source location 2021-0120-Response-from-CQC-Redacted Page 5 · response Published 29 April 2021
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 the targeted inspection findings with the Coroner.
Verbatim wording from the response “Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted inspection of Lisburne Court. The findings of this inspection will be shared with the Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death do not reflect any ongoing risk to people currently living at the home.”
Source location 2021-0120-Response-from-CQC-Redacted Page 5 · response Published 29 April 2021
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 Operate monthly cross-directorate meetings to identify, coordinate and escalate risks across local health and social care systems.
Verbatim wording from the response “CQC commenced a cross directorate process in May 2021, to ensure regulatory risks relating to the local health and social care systems are discussed, responded to and acted upon across CQC directorates within each of the seven local systems in the North. Representatives from operational directorates meet on a monthly basis in order;”
Source location 2021-0120-Response-from-CQC-Redacted Page 3 · response Published 29 April 2021
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 targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Verbatim wording from the response “Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted inspection of Lisburne Court. The findings of this inspection will be shared with the Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death do not reflect any ongoing risk to people currently living at the home.”
Source location 2021-0120-Response-from-CQC-Redacted Page 5 · response Published 29 April 2021
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 trust and conducting regular engagement calls to ensure improvements in urgent and emergency care remain embedded.
Verbatim wording from the response “The acute hospital team carried out an inspection of Stepping Hill in January and February 2020 and found significant improvement was needed in several areas. For example, we found the emergency department did not have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and provide the right care and treatment at all times, and particularly during periods of heavy demand on the service. A warning notice was issued following the inspection. We inspected the hospital again on 24 and 25 August 2020 and found the trust had made improvements to urgent and emergency care. We needed to ensure improvements made were embedded in the service. Therefore, we continue to monitor the trust and have held regular engagement calls with them.”
Source location 2021-0120-Response-from-CQC-Redacted Page 4 · response Published 29 April 2021
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 trust’s information-sharing process after emergency-department treatment to determine whether regulatory action is required.
Verbatim wording from the response “They have informed us of a process now in place to monitor how information is shared after treatment in the emergency department. We have requested information from”
Source location 2021-0120-Response-from-CQC-Redacted Page 4 · response Published 29 April 2021
Open published response
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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 Existing reassessment and review arrangements are relied upon to address changes in patients’ care needs and placement suitability.
Verbatim wording from the response “Point 4 – suitability of placements against patient need.
Our aim is to ensure that all patients are able to access the care they need, when they need it and in the environment best able to deliver the care they need. The CCG works with colleagues in the Local Authority, Adult Social Care to ensure that care needs are appropriately assessed and met. In circumstances where care needs change there is a process of re-assessment and review and once it is identified that a patient’s needs have changed families are supported in the task of identifying alternative accommodation.”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 3 · response Published 29 April 2021
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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 Existing shared-system arrangements are considered effective for communicating current information between organisations involved in complex patient discharges.
Verbatim wording from the response “Point 1 – communication between organisations involved in discharge of complex and vulnerable patients.
Stockport CCG has confirmed that communication between the hospital, GP and wider Community Services has improved by the use of a common system allowing the various organisations to see each other’s work. This is reliant on patient consent but works well in practice as it allows information regarding changes in a patient’s circumstances to be updated and immediately accessible to other health and care colleagues. The expectation is that care needs are assessed in a timely manner and information shared to ensure that all involved are acting in the best interest of the”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 1 · response Published 29 April 2021
Open published response
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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 Existing arrangements requiring contact with the GP provide the escalation route when care-home patients refuse medication or fluids.
Verbatim wording from the response “Future actions will include the implementation of Trusted Assessment training for all staff.
Point 3 – escalation process in care homes for patients refusing medication.
In any situation where a patient is not accepting prescribed medication and is declining fluid intake then contact should be made to the patient’s GP so that a decision can be”
Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted Page 2 · response Published 29 April 2021
Open published response
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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 Local authorities are responsible for shaping markets and ensuring adequate adult social care provision for residents with complex needs.
Verbatim wording from the response “You also raise the matter of available adult social care beds for residents with complex care needs. Local authorities are best placed to understand and plan for the care needs of their populations. That is why under the Care Act 2014, local authorities are required to shape their local markets, and ensure that people have a range of high-quality, sustainable and person-centred care and support options available to them, and that they can access the services that best meet their needs. This includes ensuring adequate local provision of adult social care beds for residents with complex needs.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 3 · response Published 29 April 2021
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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 relevant Safeguarding Adults Board may undertake a review to identify learning and improvement actions across local agencies.
Verbatim wording from the response “The Act requires each local authority to establish a Safeguarding Adults Board (SAB) to provide assurance that local safeguarding arrangements and partners are acting to support and protect adults who may be at risk of abuse or neglect. These Boards have the authority to carry out a Safeguarding Adult Review (SAR) in instances when serious harm or a fatality has occurred and there is concern that providers could have worked more effectively to have better protected the vulnerable adult.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 2 · response Published 29 April 2021
Open published response
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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 When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
Verbatim wording from the response “I understand that the Greater Manchester Health and Social Care Partnership recommends that where a patient is not accepting prescribed medication or fluids, then contact should be made to the patient’s GP so that a decision can be made in relation to next steps.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 3 · response Published 29 April 2021
Open published response
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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 Hospital discharge guidance predominantly applies to admitted patients, and this case did not appear to involve hospital admission.
Verbatim wording from the response “In relation to communication between acute hospitals and care homes at the point of discharge, I understand from your report that Mr Massam was seen and treated within the emergency department at Stepping Hill Hospital, Stockport before returning to Lisburne Court residential home the same day. Mr Massam was not admitted to hospital and I understand from information provided by the CQC that the hospital was unaware of any concerns about the home being unable to continue to meet Mr Massam’s care needs.”
Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted Page 2 · response Published 29 April 2021
Open published response
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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 Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Verbatim wording from the response “Whilst the CQC have no direct remit in developing policy and procedures to support integrated care and optimal communication, during inspection of a service the CQC will look at joint arrangements and how systems work to facilitate the transfer of care from one setting to another. This is considered against Regulation 12 (1) (2) (i) (j) of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 which states;”
Source location 2021-0120-Response-from-CQC-Redacted Page 3 · response Published 29 April 2021
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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 Insufficient evidence of unsafe care or treatment meant no further regulatory action was taken at that time.
Verbatim wording from the response “On 20 January 2021 the CQC received information from the Coroner enquiring if we were investigating in this case. An initial assessment was carried out into the circumstances of Mr Massam’s death by Inspectors from both the adult social care directorate and the hospitals directorate. Both Inspectors concluded based on the information available to them at that time that there was insufficient evidence to suspect a failure to provide safe care or treatment at registered persons level (breach of Regulation 12(1) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Coroner was informed that the CQC was taking no further action at that time.”
Source location 2021-0120-Response-from-CQC-Redacted Page 2 · response Published 29 April 2021
Open published response
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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 Cases where registered-service staff cannot safely meet someone’s needs are referred to the Local Authority under safeguarding protocols.
Verbatim wording from the response “The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.”
Source location 2021-0120-Response-from-CQC-Redacted Page 6 · response Published 29 April 2021
Open published response
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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 number of suitable adult social care beds for complex cases is outside the regulator’s direct remit.
Verbatim wording from the response “The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.”
Source location 2021-0120-Response-from-CQC-Redacted Page 6 · response Published 29 April 2021
Open published response