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The first webinar in our transformation series, this episode focuses on how we'll roll out our new regulatory approach and provider portal to all health and social care providers.
We also let you know when we expect to start using our new regulatory approach and the steps we’ll take to get there.
This one-hour webinar is led by Chris Day, our Director of Engagement, and Amanda Hutchinson, our Head of Policy, Regulatory Change. It’s an opportunity to hear the latest updates about our new regulatory approach.
There were some technical issues during this webinar and unfortunately, some of the presentation slides were cut off. Access the full slide deck.
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In September 2021, a service user was able to access and exit out of a first-floor window at an acute hospital. The service user fell from the window and received multiple spinal fractures. The investigation we completed concluded that there was a breach by the Registered Provider of Regulation 12(1) and 22(2)(a) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, resulting in avoidable harm to the service user. There was no window restrictor fitted, allowing unrestricted access as well as ineffective governance systems in that there was no planned preventative maintenance programme (PPM) in place. A Fixed Penalty Notice in the sum of £4,000 was issued to the Registered Provider.
We view breaches of the fundamental standards very seriously. The decision to issue a fixed penalty notice as an alternative to prosecution was based on the circumstances of this case and was not a decision taken lightly. Given the serious nature of this incident however, if an incident of this type were to happen again, we would have no hesitation in prosecuting accordingly.
Since the incident occurred, the hospital has taken steps to ensure it does not happen again. This included conducting a site-wide inspection of windows to ensure windows are adequately restricted. They have also implemented a 3-monthly PPM schedule for windows maintenance to be fully documented and audited. Further, twice annual reviews of windows by Estates Management has been introduced with PPM compliance and window restrictor governance reports completed.
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Historically, the Mental Health Act Commission took the view that Form 39 – now Form T3 – should not be over 2 years.
Our position is that there is no time limit for a Form T3, unless one is stated on the form by the Second Opinion Appointed Doctor (SOAD), or a change in circumstances renders the form ineffective. Paragraph 25.83 of the Code of Practice provides guidance on those circumstances.
Approved Clinicians (ACs) and staff responsible for administering treatments should continue to ensure that this is covered by a statutory certificate where this is required. ACs must also submit reports under Section 61 when required.
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