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. 25
WESTMORLAND HEALTHCARE LIMITED
Provide further staff supervisions covering care quality, dignity, hygiene, infection control, safety checks, COSHH and safeguarding.
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WESTMORLAND HEALTHCARE LIMITED
Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
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WESTMORLAND HEALTHCARE LIMITED
Discuss two-hourly UCR information at staff handovers to communicate changes in residents’ health presentations.
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WESTMORLAND HEALTHCARE LIMITED
Enrol staff in further person-centred care planning training through Skills for Care.
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WESTMORLAND HEALTHCARE LIMITED
Implement daily staff safety huddles to improve situational awareness and escalation of resident concerns.
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WESTMORLAND HEALTHCARE LIMITED
Complete and document provider-led audits and checks to strengthen care-quality oversight and governance assurance.
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WESTMORLAND HEALTHCARE LIMITED
Develop the Clinical Lead’s leadership and management capability through an NVQ Level 5 course.
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WESTMORLAND HEALTHCARE LIMITED
Establish newsletters, staff messaging and social-media channels to disseminate guidance and improve communication with families and residents.
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WESTMORLAND HEALTHCARE LIMITED
Relocate DNAR information to resident-file front pages and provide staff with a checklist of critical resident safety information.
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WESTMORLAND HEALTHCARE LIMITED
Initiate more prompt advance-care-planning discussions with residents and their families where appropriate.
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WESTMORLAND HEALTHCARE LIMITED
Upgrade and refurbish the home environment, including fire systems, boilers, lift, carpets, rooms, corridors and other facilities.
View source
WESTMORLAND HEALTHCARE LIMITED
Provide basic life-support training for all senior staff and registered nurses.
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WESTMORLAND HEALTHCARE LIMITED
Conduct monthly mattress audits and reinforce staff checks of air-flow mattresses after interventions.
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WESTMORLAND HEALTHCARE LIMITED
Enrol four staff on Level 4 food hygiene training.
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WESTMORLAND HEALTHCARE LIMITED
Create and staff a Deputy Manager role to strengthen leadership, workforce oversight and governance.
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WESTMORLAND HEALTHCARE LIMITED
Change care-plan writing to support person-centred planning and proactive identification of health concerns or deterioration.
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WESTMORLAND HEALTHCARE LIMITED
Review and update the training matrix with training due dates for proactive course allocation.
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WESTMORLAND HEALTHCARE LIMITED
Complete independent health and safety audits and implement associated COSHH, legionella and fire-risk controls.
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Care Quality Commission
Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
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Care Quality Commission
Carry out a targeted inspection to assess the safety of other service users at the location.
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Care Quality Commission
Review the safeguarding alert and undertake further enquiries to assess whether additional regulatory activity is required.
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Nursing and Midwifery Council
Refer concerns about care at Westmorland Court and inaccurate healthcare records to the Employer Link Service and New Referrals team for enquiries.
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Nursing and Midwifery Council
Keep the decision not to impose an interim order under review pending new information.
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Nursing and Midwifery Council
Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
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Nursing and Midwifery Council
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
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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 Failure to provide consistently good quality care
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally.
” 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 maintain reliable clinical records
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally .
” 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 perform and respond appropriately to basic checks and signs of life during resuscitation
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions . Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 Unavailability of a defibrillator for attempted resuscitation in the care home
Wider context from the report “(2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be required?
” 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 retain and apply basic resuscitation training
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before . Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 Provide further staff supervisions covering care quality, dignity, hygiene, infection control, safety checks, COSHH and safeguarding.
Verbatim wording from the response “Further supervisions have taken place with care staff to cover care quality matters such as respect and dignity, oral hygiene, choice, infection control, health and safety, safety checks, COSHH, safeguarding, amongst other matters. Please see Appendix 2 for an example copy of the supervisions undertaken with care staff.”
Source location Response from Westmorland Court Care Home Page 5 · response Published 9 August 2024
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 daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
Verbatim wording from the response “Daily walk round audits are conducted which include testing staffs’ knowledge of the ABCDE assessment process to competently assess a resident and identify whether a person is in cardiac arrest.”
Source location Response from Westmorland Court Care Home Page 4 · response Published 9 August 2024
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 Discuss two-hourly UCR information at staff handovers to communicate changes in residents’ health presentations.
Verbatim wording from the response “• Two hourly UCR information is now discussed at staff handover to ensure staff confidence in utilising the service and that any changes in a person’s health”
Source location Response from Westmorland Court Care Home Page 3 · response Published 9 August 2024
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 Enrol staff in further person-centred care planning training through Skills for Care.
Verbatim wording from the response “• The Registered Manager has enrolled staff with “Skills for Care” so they can attend further person-centred care planning training.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 Implement daily staff safety huddles to improve situational awareness and escalation of resident concerns.
Verbatim wording from the response “We have implemented safety huddles with staff daily to improve resident safety and care. The safety huddles will improve situational awareness, create an environment where staff feel safe to raise concerns and integrate information to develop a comprehensive picture of the status of residents in our care at a particular time.”
Source location Response from Westmorland Court Care Home Page 5 · response Published 9 August 2024
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 Complete and document provider-led audits and checks to strengthen care-quality oversight and governance assurance.
Verbatim wording from the response “• Provider led audit and checks are now being completed and clearly documented to ensure that there is suitable oversight in respect of care quality and to maintain ongoing provider assurance of good governance of the service.”
Source location Response from Westmorland Court Care Home Page 4 · response Published 9 August 2024
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 Clinical Lead’s leadership and management capability through an NVQ Level 5 course.
Verbatim wording from the response “• The Clinical Lead has enrolled and currently undertaking the NVQ Level 5 in Leadership and Management course.”
Source location Response from Westmorland Court Care Home Page 3 · response Published 9 August 2024
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 newsletters, staff messaging and social-media channels to disseminate guidance and improve communication with families and residents.
Verbatim wording from the response “• A Home “Newsletter”, WhatsApp group and Facebook pages are in place and working well to assist in smoother communication within the staff group and/or dissemination of updated guidance/policies; and/or engaging family and friends to enhance communications between home and family/friends; greater involvement of residents re person-centred care and celebrating their activities. The CQC has provided guidance regarding consent and the need for a social media policy which is ongoing.”
Source location Response from Westmorland Court Care Home Page 3 · response Published 9 August 2024
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 Relocate DNAR information to resident-file front pages and provide staff with a checklist of critical resident safety information.
Verbatim wording from the response “DNAR’s are now located on the inside front page of the resident files for ease of access, which they were not prior to regulation 28. All staff have access to a safety checklist which details which residents have DNAR’s, allergies, cognitive impairments and other pivotal information.”
Source location Response from Westmorland Court Care Home Page 4 · response Published 9 August 2024
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 Initiate more prompt advance-care-planning discussions with residents and their families where appropriate.
Verbatim wording from the response “We have initiated further and more prompt advanced care planning discussions with residents (as appropriate) and their families and loved ones.”
Source location Response from Westmorland Court Care Home Page 5 · response Published 9 August 2024
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 Upgrade and refurbish the home environment, including fire systems, boilers, lift, carpets, rooms, corridors and other facilities.
Verbatim wording from the response “• A range of environmental matters have been attended to: The dishwasher is now working and the fly zapper has been fixed; there are new stair and corridor carpets now in place which is further evidence of the comprehensive audits/assessments of and actions taken to embed improvements into the home environment; a new fridge has been bought and is in place; work has been completed on the roof; more than 12 rooms and corridors are being updated; the top floor has been completely refurbished; some windows have been replaced; there has been the installation of 3 brand new boilers with one more to be changed; the Home’s lift has been upgraded; a new fire alarm system is in place; and the staff room and some other areas of the Home have been refurbished.”
Source location Response from Westmorland Court Care Home Page 3 · response Published 9 August 2024
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 basic life-support training for all senior staff and registered nurses.
Verbatim wording from the response “As a Home, we are keen to drive “lessons learned” improvements across our care quality and practice. Ongoing discussions have been taking place and have been had with all staff about the case and understandably the concerns outlined by the Coroner in relation to basic life support and accuracy of record keeping. All senior staff and registered nurses now have the appropriate training in place for basic life support.”
Source location Response from Westmorland Court Care Home Page 4 · response Published 9 August 2024
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 monthly mattress audits and reinforce staff checks of air-flow mattresses after interventions.
Verbatim wording from the response “Monthly mattress audits are in place and staff now have increased awareness and understanding of the importance of checking the air-flow mattresses after each intervention for those that are using air-flow mattresses.”
Source location Response from Westmorland Court Care Home Page 4 · response Published 9 August 2024
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 Enrol four staff on Level 4 food hygiene training.
Verbatim wording from the response “• Health and safety audits have been completed independently and no asbestos or structural issues have been noted. Four staff have been enrolled on level 4 food hygiene. A COSHH folder is in place with an additional risk assessment and a legionella survey was completed last year with no concerns raised. Furthermore, fire risk assessments have been updated.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 Create and staff a Deputy Manager role to strengthen leadership, workforce oversight and governance.
Verbatim wording from the response “• A new role of Deputy Manager was created to increase resilience, review of the workforce culture, and generally ensuring a high level of service within the home. The Deputy Manager also supports with ongoing governance, management and running of the Home. The Deputy Manager has been in post since the 30th of July 2024.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 Change care-plan writing to support person-centred planning and proactive identification of health concerns or deterioration.
Verbatim wording from the response “• There has been a change in the way care plans are being written, with the intention of making them more person centred, to ensure that members of care staff are able to better proactively consider health concerns or any deterioration in health.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 training matrix with training due dates for proactive course allocation.
Verbatim wording from the response “• An external consultant has been reviewing the Home’s training matrix with the Registered Manager and recommended some adaptations including adding a clear training due date to ensure staff are pro-actively allocated to training courses on an ongoing basis. These recommendations have been accepted and completed.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 Complete independent health and safety audits and implement associated COSHH, legionella and fire-risk controls.
Verbatim wording from the response “• Health and safety audits have been completed independently and no asbestos or structural issues have been noted. Four staff have been enrolled on level 4 food hygiene. A COSHH folder is in place with an additional risk assessment and a legionella survey was completed last year with no concerns raised. Furthermore, fire risk assessments have been updated.”
Source location Response from Westmorland Court Care Home Page 2 · response Published 9 August 2024
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 Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
Verbatim wording from the response “CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic life support training for all staff, and a referral to the NMC regarding the individual nurse’s conduct. CQC followed up these actions and were reassured that staff had received refresher training in basic life support and that the provider had taken appropriate actions in relation to the registered nurse involved in the incident.”
Source location Response from CQC Page 1 · response Published 9 August 2024
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 Carry out a targeted inspection to assess the safety of other service users at the location.
Verbatim wording from the response “Following receipt of notification of the death of Mr Capstick a targeted inspection was carried out on 13 October 2022. This provided assurance regarding the safety of other service users at the location.”
Source location Response from CQC Page 2 · response Published 9 August 2024
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 safeguarding alert and undertake further enquiries to assess whether additional regulatory activity is required.
Verbatim wording from the response “On 30 September 2022 CQC were notified of an allegation of abuse made by ambulance staff relating to concerns of neglect in relation to Mr Capstick whilst a resident at Westmorland Court Residential and Nursing Home. The concerns were identified by ambulance staff on 13 September 2022 when called to transport Mr Capstick to hospital. CQC are in the process of reviewing information related to this”
Source location Response from CQC Page 1 · response Published 9 August 2024
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 Refer concerns about care at Westmorland Court and inaccurate healthcare records to the Employer Link Service and New Referrals team for enquiries.
Verbatim wording from the response “We have also considered whether the PFD raises any other concerns which we need to act on. We have noted that concerns were raised about the care provided to Mr Capstick generally at Westmorland Court and a specific issue relating to inaccurate entries made within healthcare records. We have noted that at the time of the inquest one safeguarding referral remained open.”
Source location Response from NMC Page 3 · response Published 9 August 2024
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 Keep the decision not to impose an interim order under review pending new information.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”
Source location Response from NMC Page 3 · response Published 9 August 2024
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 Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”
Source location Response from NMC Page 3 · response Published 9 August 2024
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 the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Verbatim wording from the response “We can confirm that our investigations in relation to the concerns raised about the registered nurse in charge of the home on the night of Mr Capstick’s injury are ongoing. We have shared your concerns as set out in the PFD with the investigating team. We have also contacted Westmorland Court for further information and obtained details about the registered nurse’s current practice. We have contacted the registered nurse to give them the ability to comment on the concerns and are waiting for their response. We expect to make a decision in the next two to three weeks on whether to progress our investigations on the basis that we need to take action to protect the public or whether we can close the case on the basis that there are no public protection issues.”
Source location Response from NMC Page 3 · response Published 9 August 2024
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 Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Verbatim wording from the response “Where equipment such as defibrillators are not installed, we would expect a provider to be able to demonstrate that they have suitable policies and procedures in place to ensure appropriate resuscitation methods can be carried out if required by suitably trained staff.”
Source location Response from CQC Page 2 · response Published 9 August 2024
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 Requiring care homes to install defibrillators falls outside the regulator’s role and remit.
Verbatim wording from the response “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.”
Source location Response from CQC Page 2 · response Published 9 August 2024
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 Care providers are responsible for deciding how to deliver care safely and demonstrating compliance to the regulator.
Verbatim wording from the response “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.”
Source location Response from CQC Page 2 · response Published 9 August 2024
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 An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”
Source location Response from NMC Page 3 · response Published 9 August 2024
Open published response