Lucy Moffatt
10 Jun 2014 · Coroner Christopher Dorries · South Yorkshire (West)
The coroner's concerns
1. window restraint can appear secure but not locked
“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.”
2. window restraint lock defeat with scissors
“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.”
3. lack of proper window restraint key restriction in many establishments
“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.”
4. CQC Inspectors not informed of Dept of Health Alert
“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.”
5. no system to pass CQC knowledge of misleading restraint situation
“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.”
Responses
2014-0261-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“consider that your concerns touch upon the broader question of the implementation and inspection of Safety Alerts more generally. Accordingly, in addressing your concerns we set out the steps that the CQC is undertaking to improve the effective implementation of Safety Alerts”
2014-0261-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care