“Harbour Healthca The evidence that | heard was that it is your responsibility as the…”

The coroner’s concerns

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— Harbour Healthca The evidence that | heard was that it is your responsibility as the Registered Person under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to comply with those Regulations. | understand that at present, the Guidance issued by the CQC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate how you must comply but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises ‘must be fit for purpose in line with statutory requirements. It was accepted by you during the inquest that there was a ‘blind spot’ in the risk assessment of the internal secure doors, in that you were not required by any regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the green emergency door release or otherwise. | accept that you have now implemented an alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare, am concemed that without the implementation of these alarms across your service provision there would continue to be circumstances that creale a risk of other deaths. | ‘would be grateful for an indication of when you expect this implementation to be completed by way of response. cac: The evidence that | heard was that under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 itis the Registered Persons responsibilty to | ‘comply with those Regulations. | understand that at present, the Guidance issued by the | CAC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate how they must comply with those Regulations but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises must be fit for purpose in line with statutory requirements. accept that on the present Regulations itis for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they | provide to service users. However, | ask you to review, in light of the evidence | have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel. | also ask you to review your inspection procedures in respect of a Registered Person's compliance with the Regulations in respect of the safety and security of internal secure doors. ‘Stockport NHS Foundation Trust: 1am concerned that the current Guidelines for Headineck injuries (as amended) may continue to provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment. The word ‘confusion’ remains under the general guidance (bullet point 5) but has been changed to ‘dementia’ under the guidance for those who are already being subject to a head scan. | ask that you consider reviewing your guidelines to ensure clarity and consistency of their clinical application, ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0322

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0