Glenn Macmartin

CQC South 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

24 June 2022 

HM Coroner Ian Arrow  

Re: Regulation 28 response re Mr Glen MacMartin 

Dear HM Coroner Arrow  

We write to provide the formal response of the Care Quality Commission (CQC) to the 
Regulation  28  Preventing  Future  Deaths  report  made  by  HM  Coroner  Ian  Arrow 
following the inquest into the death of Glenn MacMartin (‘the Regulation 28 Report’).  

In the Regulation 28 report HM Coroner raised the following concerns:  

1.  The deceased was accommodated in a care home that was subsequently 

formally closed due to poor service 

2.  Review the selection and monitoring of care home provision and care given 
by private care   home providers who are funded by Devon Partnership  
3.  Review  what  actions  are  taken  when  care  homes  are  closed  to  ensure 

lessons are learnt from such closures. 

In our formal response to the Regulation 28 report the CQC deals with each concern 
in turn and sets out what action it has taken to date to address the concerns and/or 
what actions we are proposing to take to address them. 

1.  The deceased was accommodated in a care home that was subsequently 

formally closed due to poor service 

Mr MacMartin was accommodated at Annette’s Care on 7 September 2018. On that 
date the service was rated good. Following a comprehensive inspection on 20 March 
2019 the CQC rated Annette’s Care as Inadequate overall and subsequently took 
enforcement action that resulted in the cancellation of Annette’s Care Limited, and 
the closure of the care home, Annette’s Care. CQC working closed with the local 

 
 
 
 
 
 
 
 
 
 
 
 
 authority during this period. The circumstances of Mr MacMartin’s death are of great 
regret to the CQC and we offer our condolences to Mr MacMartin’s family.  

The CQC received low level information of concern in relation to the service location 
Annette’s Care. Between October 2018 and December 2018 there were two concerns 
raised.  On  each  occasion  CQC  reviewed  the  information  and  assessed  the  risk  to 
service users to inform what action CQC should take. In line with CQC methodology 
at the time we decided not to take regulatory  action following reassurances that we 
received from Annette’s Care, Plymouth County Council and the Local Authority Adult 
Safeguarding Team. In line with our methodology in relation to low level concerns, we 
noted  those  areas  of  concern  to  inform  a  future  inspection.  CQC  undertook  a 
comprehensive  inspection  of  the  service  in  March  2019  following  receipt  of  further 
concerns.  

These  concerns  came  from  the  inspection  in  February  2019  of  a  different  location 
owned by the same Registered Provider. That inspection resulted in the CQC taking 
civil enforcement action against the Registered Provider. In light of this information a 
decision  was  made  to  inspect  Annette’s  Care  in  March  2019.  The  comprehensive 
inspection looked at all five key questions (safe, effective, caring, responsive and well 
led).  The  inspection  methodology  included  speaking  with  and  pathway  tracking  the 
care  of  Mr  Glenn  McMartin.    The  CQC  found  multiple  breaches  of  the  Health  and 
Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated 
Inadequate  overall.    A  copy  of  the  report  can  be  found  on  our  website  at 
www.cqc.org.uk/Annette’sCareLimited   

The Local Authorities have a statutory duty to investigate allegations of abuse in line 
with their legal responsibilities pertaining to the Care Act 2014. Therefore, following 
the  inspection,  the  CQC  immediately  spoke  with  Plymouth  City  Council  to  share  a 
summary of their inspection findings as well as to raise safeguarding alerts, of both an 
individual  and  whole  service  nature.  One  of  those  individual  safeguarding  alerts 
related specifically to Mr. Glenn MacMartin.  

As part of CQC methodology, CQC also undertook an initial assessment of the specific 
incident concerning Mr McMartin to determine whether there were reasonable grounds 
to suspect that  a criminal offence may have been committed by the provider Annette’s 
Care Limited under Regulations 12(1)  and 22(2) of the Health and Social Care Act 
2008 (Regulated Activities) Regulations 2014. We determined there was insufficient 
evidence of provider level failure to provide safe care and treatment under Regulation 
12(1) resulting in avoidable harm to Mr McMartin or exposing him to a significant risk 
of such harm occurring. 

The  CQC  has  undertaken  an  internal  review  of  the  actions  it  took  in  relation  to 
Annette’s  Care  Limited  and  the  case  of  Mr  MacMartin.  We  are  satisfied  that  the 
decision taken to inspect Annette’s Care was timely, proportionate and justified, and 
complied with CQC methodology. We are also satisfied that the determination not to 
proceed  to  a  formal  criminal  investigation  following  the  initial  assessment  was  also 
proportionate, justified and in line with CQC methodology. These assessments will be 
reconsidered in light of any recommendations made or findings from the joint agency 
Learning Event, which we refer to later in this response. 

 Review the selection and monitoring of care home provision and care given by 
private care home providers who are funded by Devon Partnership.  

The CQC was established on 1 April 2009 by the Health and Social Care Act 2008 
(‘the  Act’).  The  CQC is the  independent regulator  of  Healthcare,  Adult  Social  Care, 
Hospital and Community Trusts and Primary Care Services in England. The CQC also 
protects the interests of vulnerable people, including those whose rights are restricted 
under the Mental Health Act. The Act introduced a single registration system which 
applies to both Healthcare and Adult Social Care Services.  

We recognise that the Local Authority also has a role in selection and monitoring of a 
service, as well as in relation to safeguarding. We anticipate the Local Authority will 
summarise this role in their response to the Regulation 28 report.  

We  also  recognise  the  importance  of  ensuring  the  cooperation  and  collaboration 
where appropriate between CQC and the Local Authority. In practice, as in this case, 
CQC proactively attend regular meetings with the Local Authority to share information 
about registered services.  This forms part of the intelligence we use to  inform CQC 
decisions  on  whether  and  what  regulatory  actions  CQC  might  consider.  CQC  also 
attend  safeguarding  meetings  where  safeguarding  issues  have  been  identified  and 
contribute to the safeguarding plan where appropriate.  

Once registered with the CQC, Registered Providers such as Annette’s Care Limited 
are required to comply with conditions placed on their registration and to comply with 
the  Health  and  Social  Care  Act  2008  (Regulated  Activities)  Regulations  2010 
(‘Regulated  Activities  Regulations  2010’)  and  the  CQC  (Registration)  Regulations 
2009 (‘the Regulations’). The Regulations set out the fundamental standards of quality 
and  safety  that  service  users  have  a  right  to  expect.  The  Regulated  Activities 
Regulations 2010 were replaced by the Health and Social Care Act 2008 (Regulated 
Activities) Regulations 2014 (RAR 2014) (‘the Regulated Activities Regulations 2014’) 
which came into effect from 1 April 2015. The Regulated Activities Regulations 2014, 
sometimes called the Fundamental Standards Regulations, include a requirement on 
the registered provider to undertake risk assessments, prior to and upon arrival of a 
service  user,  and  on  a  continuing  basis  thereafter,  to  ensure  that  the  provider  is 
capable of and is meeting, the needs of service users, including providing  safe care 
and treatment under Regulation 12(1) RAR 2014.  

The Regulated Activities Regulations 2014 apply to all Registered Providers in setting 
out  the  duties  they  must  meet  and  does  not  distinguish  between  private  or  Local 
Authority care services.  

The CQC are responsible for monitoring, inspecting and regulating services to make 
sure  they  meet  the  fundamental  standards  of  quality  and  safety  including,  where 
appropriate,  taking  civil  and/or  criminal  enforcement  action  in  line  with  CQC’s 
published enforcement policy. The Decision Tree is the judgment framework tool used 
to  determine  the  seriousness  of  breaches  of  Regulations,  and  to  determine  the 
appropriate regulatory action CQC should take, in accordance with CQC’s published 
Enforcement Policy.  Additionally, the CQC publish our findings which includes ratings.  

 Devon  Partnership  Trust  (DPT)  were  the  responsible  Commissioner  for  Mr  Glenn 
MacMartin’s care and support, and for the ongoing review of the quality of that care 
and support.   

The CQC have undertaken an internal review of the actions taken by CQC in relation 
to Annette’s Care Limited and in relation to the care provided to Glenn MacMartin. On 
the  basis of  that  internal review  CQC is satisfied  its  actions  were  taken  in  line  with 
CQC methodology, were timely, justified and proportionate. In line with our information 
sharing  and  safeguarding  procedures  those  actions  included  raising  individual 
safeguarding  alerts  with  Plymouth  Adult  Safeguarding  which  is the  lead  agency  for 
adult safeguarding under the Care Act 2014.  

The CQC are participating in a ‘learning event’ with Devon and Cornwall Police, Devon 
Partnership  Trust  and  Plymouth  County  Council  (Commissioning  and  Adult 
Safeguarding) as  part  of  our  continuing  effort  to  improve  coordination  of  CQC  and 
Local  Authority  actions,  and  to  learn  any  relevant  lessons,  individually  and/or 
collectively.  Following  the  conclusion  of  the  learning  event  we  will  consider  any 
recommendations.  Unfortunately,  the  family  have  not  been  available  to  participate 
which has had an impact on the progress of the learning event. We look forward to 
meeting with the family when they are available.  

Review what actions are taken when care homes are closed to ensure lessons 
are learnt from such closures.  

In  line  with  the  CQC’s  enforcement  policy,  civil  enforcement  action  was  taken  and 
CQC  issued  a  Notice  of  Proposal (NOP)  to  cancel  the  providers  registration  on  23 
April 2019. The Registered Provider submitted representations to the CQC to appeal 
the proposal to cancel registration. The written representations were not upheld and 
the Notice of Decision (NOD) was served on 23 August 2019. The Registered Provider 
appealed  to  the First Tier  Tribunal (Care  Standards)  in  October  2019.  Their appeal 
was  refused  and  did  not  proceed  to  a  hearing  because  it  was  out  of  time.  The 
cancellation of the provider’s registration took effect on 28 February 2020.  

As  part  of  the  internal  review  undertaken  in  this  case,  CQC  considered  whether  it 
revealed areas for improvement in CQC’s monitoring, inspection and/or enforcement 
methodology.  We  determined  that  the  case  did  not  reveal  gaps  or  areas  for 
improvement  and  that  CQC’s  actions  were  timely,  justified  and  proportionate.  In 
particular, partner agencies (Local Authority and Commissioners) made the necessary 
contingency arrangements to find residents living at Annette’s Care alternative homes; 
during this process the CQC worked closely with our partner agencies.  

CQC  seeks  to  continually  improve  monitoring,  coordination  and  the  sharing  of 
information with Local Authority and Commissioners. In relation to this case, CQC will 
participate  with  the  ‘learning  event’  taking  place  with  the  local  authority  and  Devon 
Partnership Trust.   

 
 Once the learning event has taken place and any recommendations or learning has 
been identified and agreed, we would be delighted to share such recommendations 
and learning with HM Coroner Arrow.   

Signed  

Head of Inspection 

Adult Social Care, South Network

OFFICIAL 

Strategic Priorities: 
Partnership 
Engagement 
Learning 
Assurance 

Plymouth Adult Safeguarding Partnership  

Date 
Name 
Agency 
Report subject 
Strategic Plan 
ref: 
SAB Sub-Group 

Purpose of 
report:  

Content:  

Report to PSAP 

09.06.21  

NHS Devon CCG; Chair of SAR sub group 
SAR sub group recommendation 
N/A 

SAR 

To provide a recommendation to the Plymouth Safeguarding Adults 
Partnership (PSAP) following a referral for a Safeguarding Adult Review 
(SAR)  
Context:  
Once in receipt of a referral, the purpose of the SAR sub-group is 
to review the information held by agencies and make a recommendation 
to the Independent Chair of the PSAP as to whether a SAR should be 
commissioned, in line with the Care Act 2014 statutory guidance and the 
SAR sub group policy. Decisions for referrals must gain the support of a 
majority of the SAR sub-group members. Should they not be able to 
reach a majority decision, reasons for not agreeing are recorded and the 
decision referred to the PSAP Chair. In the event of the referral for a 
SAR not progressing, the SAR Sub-group will ensure the reasons will be 
recorded in writing, decision shared with the referrer and other 
stakeholders as appropriate. In addition, the SAR Sub-group may make 
alternative recommendations to the referrer. 

Referral for Glenn MacMartin:  
The NHS Devon Clinical Commissioning Group (CCG) was asked to 
chair the group for this referral in order to provide independence for the 
decision process, as both the usual chair of the SAR subgroup and Devon 
and Cornwall Police had been involved in the Coronial process.  

The SAR sub-group received a referral in respect of Mr MacMartin, and 
the Chair can confirm that 2 sub-group meetings were held to discuss in 
depth the relevant information. All 3 statutory partners were 
represented, Plymouth County Council, NHS Devon CCG and Devon 

1 

                                                                        
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Strategic Priorities: 
Partnership 
Engagement 
Learning 
Assurance 

and Cornwall Police; therefore the meeting was quorate, and the 
decision unanimous.   

Following review of all of the relevant information, it was agreed by the 
SAR subgroup that this referral did not meet the criteria for a SAR for 
the reasons stated below:  

  There was evidence of good multi-agency working in order to 
protect the adult with care and support needs, though there 
were some gaps in communication identified. 

  The events prior to Mr MacMartin’s death were thoroughly 
investigated by Devon & Cornwall Police, who found no 
evidence of a crime or abuse or neglect. This was reviewed and 
all agreed with the decision made by the police. 

  All safeguarding concerns and enquiries raised prior to Mr 

MacMartin’s death were reviewed and the group concurred with 
there being no abuse or neglect identified in them.  

  The whole service concern process regarding the care home in 
which he resided was reviewed, and it was clarified that whilst 
the parallel CQC process resulted in the home later being 
closed, this was a result of the lack of ability to comply with the 
requirements of the process, rather than any indication of 
neglectful care. 

  There was evidence that his care provider sought appropriate 
medical support in the days leading up to Mr MacMartin being 
admitted to hospital. 

  There was evidence of a timely and appropriate health response 
to the requests from the care home for a health assessment. 

  After his initial good response to treatment received in the 
hospital he sadly deteriorated and despite all their efforts to 
treat him, he very sadly passed away.  

  The pathologist’s report does not indicate any signs of abuse or 

neglect.  

  The group acknowledged there was a lack of communication 

between the care home and Mr MacMartin’s family. 

While the recommendation is that a SAR is not the appropriate response 
to this referral, there is recognition of an opportunity for learning and 
this will be taken forward as a multi-agency response to the HMCO 
Regulation 28 request. 

2 

                                                                        
 
 
 
 
 
 
 OFFICIAL 

Formal response 
from PSAP 
Independent 
Chair  

Strategic Priorities: 
Partnership 
Engagement 
Learning 
Assurance 

Following the initial discussions at the PSAP Executive Group meeting on 
1 June 2021, I have now received the SAR referral decision for the case 
of Mr Glenn MacMartin. I note the recommendation of the SAR sub 
group, under the Chair of 
, not to commission a SAR 
process. This decision was based on a full and thorough multi-agency 
analysis of the circumstances and contextual factors surrounding Mr 
MacMartin’s death, including a police investigation and post mortem 
examination. 

I endorse the recommendation not to proceed to a SAR process based 
on the detailed rationale set out above. However, I fully support the 
commissioning of a multi-agency learning review, independently 
facilitated, to ensure that multi-agency learning is identified in terms of 
strengths and weaknesses, and subsequently translated into improved 
ways of working across the system. This should be a transparent process 
involving the engagement and participation of Mr MacMartin’s family, 
with the learning shared as widely as possible. 

I understand that planning for the learning review is underway, and the 
following details of this will be communicated to Mr MacMartin’s family 
and to HMCO as the response to the Regulation 28 request. 

 

Inform relevant partner agencies of the proposal, and secure 
engagement 

Identify and commission an independent facilitator (IF) 
IF to set out plan to family, accept questions, parameters etc 
IF meet before and after with family 

  Agree Terms of Reference and scope with partners 
 
 
 
  Capture learning/record, feedback, report to the Coroner  
  Share learning 

Independent Chair 
Plymouth Safeguarding Adults Partnership 

3

Trust Headquarters 
Wonford House Hospital 
Dryden Road 
Exeter 
EX2 5AF 

Web: www.devonpartnership.nhs.uk 

21 May 2021 

Mr Ian Arrow 
HM Senior Coroner for the County of Devon 
1 Derriford Park 
Derriford Business Park 
Plymouth 
PL6 5QZ 

Dear Sir 

Glenn MacMartin (deceased) 
Inquest date: 15 and 24 March 2021 

I  write  on  behalf  of  the  Devon  Partnership  NHS  Trust  (“the  Trust”)  further  to  the  Inquest 
touching  the  death  of  the  above  named  and  the  Regulation  28  Report  to  Prevent  Future 
Deaths (“the Report”) issued by you on 7 May 2021.  

I note that the Report is addressed to the Trust, the Care Quality Commission (“the CQC”) and 
Plymouth Safeguarding Adult Partnership.  

I note that in section 5 you have raised the following matter of concern: 

“The deceased was accommodated in a Care Home that was subsequently formally closed 
due to poor service. 

The selection of the accommodation was made without a physical inspection of its suitability 
for  the  deceased  by  the  organisation  with  responsibility  for  providing  the  accommodation 
before the deceased took up residence.”  

Further I note that in section 6 of the Report that you set out action should be taken as follows: 

“In  my opinion action  should  be taken  to  prevent  future  deaths  and  I believe  you have the 
power to take such action. 

Please review the selection and monitoring of care home provision and care given by private 
care home providers who are funded by Devon Partnership Trust. 

Please review what action to take when care homes are closed to ensure lessons are learned 
from such closures.  

Please indicate when a report on such a review may be forthcoming.” 

We had not understood on the conclusion of the inquest that you were intending to issue the 
Report, and  it  would be helpful  to  understand  the  subsequent  information  or  concerns  you 
have received that has resulted in this. Notwithstanding this, the Trust sets out its response 
below.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response of Devon Partnership NHS Trust 

I understand at the Inquest you admitted into evidence the witness statement of 
dated 5 March 2021 and also heard oral evidence from 

 on 15 March 2021. 

 is the Head of Profession for Social Work and Directorate Manager for Social Care. 
As  such,  she  is  in  a  position  to  address  the  extensive  questions  in  relation  to  the 
commissioning of Mr MacMartin’s placement raised by the family and yourself at Inquest.  

Selection of accommodation without physical inspection 

In  line  with  the  evidence  set  given  by 
  at  the  Inquest,  in  the  time  since  Mr 
MacMartin’s death, a decision has been made that mental health social care will not contract 
with new providers without visiting the facilities to gain assurance of suitability.  

I hope that this reassures you that where the Trust is responsible for commissioning care at a 
new placement, that a physical inspection of that placement is undertaken to ensure that it is 
a suitable and appropriate environment according to the person’s assessed care needs.  

Selection and monitoring of placements 

You will, I am sure, appreciate that it is not only the Trust which commissions individuals’ care 
with  private  care  home  providers.  Furthermore,  in  respect  of  the  ongoing  monitoring  and 
regulation of those providers, I can only provide reassurance on behalf of this Trust. 

The Trust does reasonably rely on the inspections and ratings provided by the CQC in terms 
of quality assurance and adherence to any relevant regulations. I understand that at the time 
of  Mr  MacMartin’s  placement  at  Annette’s  Care  Home  (“the  Care  Home”)  in  Plymouth  the 
corresponding CQC report was reviewed. It was confirmed that the Care Home was rated by 
the CQC as “Good”. Furthermore, at the time Devon County Council had an existing contract 
in  place  with  the  Care  Home.  The  contract for  services entered  into  included the following 
provisions around quality assurance: 

  The provider shall provide the service in accordance with its obligations under the contract 
and with the skill, care and diligence to be expected of a competent provider of a residential 
care home service. 

  The provider must comply with all requirements of the Care Standards Act 2000 and the 

National Minimum Standards. 

  To provide and supervise the proper provision of the  service and to meet the assessed 
needs  of  the  service  users,  including  outpatient  appointments,  emergency  hospital 
admissions and to partake in other activities outside of the home. 

The Trust was further reassured by the fact that Mr  MacMartin had periods of formal leave 
under section 17 Mental Health Act 1983 (“the MHA”) to the Care Home from 17 to 20 May 
2018; 24 to 30 May 2018; 8 June 2018; 13 to 15 June 2018; and 13 to 28 August 2018. All of 
these periods of leave went ahead without incident, allowing Mr MacMartin to become familiar 
with  the  Care  Home  and  its  staff  and  enabled  the  Care  Home  to  become  familiar  with  Mr 
MacMartin’s individual needs.  

At  the  time therefore the  Trust’s  Mental  Health Social  Care Panel  were  reassured  that  the 
Care Home was an appropriate service with which to contract and place Mr MacMartin. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Such  processes  will  continue  to  take  place  in  order  to  ensure  that  patients  who  are  being 
discharged from liability to be detained under the MHA receive suitable and appropriate care 
in the placement to which they are being discharged. 

The  Trust’s  discharge  policy  also  includes  a  seven  day  follow  up  directly  with  the  patient. 
Although not a formal review, it is an opportunity to “touch base” with the person and act upon 
any identified needs. No concerns were raised in Mr MacMartin’s case.  

Again, this seven day follow up is a process which continues to take place in line with good 
practice.  

As a person who had been detained under section 3 MHA, Mr MacMartin was in receipt of 
section 117 MHA aftercare. As identified in the evidence provided by Ms Adams, the Trust’s 
policy for section 117 MHA aftercare requires a review of the care and care plan at six months. 
I understand that in Mr MacMartin’s case, this review in fact took place after three months. 

Again, this is a process which continues to date, not only giving assurance that the person is 
adequately cared for but also to ensure there is appropriate clinical input for the individual and 
to address any concerns or change in the person’s needs.  

Learning lessons 

Where  concerns  about  an  individual’s  care  are  raised  with  the  Trust,  whether  by  the  care 
provider, family members, professionals or the individual themselves, the Trust is under a duty 
to consider whether a safeguarding referral needs to be made to the relevant Local Authority. 
It is then for the relevant Local Authority under section 42 Care Act 2014 to identify whether 
further investigations ought to be undertaken and if so by whom. This provides further safety 
netting in respect of any concerns which could be raised by or on behalf of the individual.  

As above, it is otherwise for the CQC to monitor, review and if necessary enforce any of the 
relevant regulatory provisions of the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014. 

Insofar as any incidents relating to any individuals for whom the Trust responsible, the Trust 
will consider whether the relevant thresholds are reached for it to undertake its own review by 
way of a Root Cause Analysis investigation. This entails a detailed review of the incident(s), 
identification  of  the  root  cause(s)  and  recommendations  and  actions  to  be  taken.  It  also 
identifies  who  is  responsible  for  undertaking  those  actions  and  by  when.  This  enables  the 
Trust  to  learn from  incidents  (which  could  include,  but not  limited  to,  the  closure  of a  care 
home) and ensure actions are implemented.  

Improvements in service delivery 

Again, I can otherwise reassure you that additional improvement measures have, or will be 
taken as follows: 

  A redesign of social care delivery within the Trust is now complete, with dedicated social 
workers in each community mental health team, who are responsible for both the sourcing 
and review of social care placements and support; 

  There is a comprehensive, Care Act compliant assessment completed with the person. 
This  documents  the  person’s needs,  strengths, wishes and family and  social networks. 
This is used in conjunction with health assessments to inform both care and support plans 
and commissioning; 

 
 
 
 
 
 
 
 
 
 
 
   Social workers form a system with the social care contract and review team and associated 
processes. The senior commissioning officers and the locality social work managers work 
closely together and have scheduled monthly meetings; 

  The community social work managers have linked with the forensic social work team at 
Langdon  Hospital  (a  secure  service  for  which  the  Trust  is  responsible,  and  where  Mr 
MacMartin had been detained) to strengthen links and ensure that processes and practice 
relating to the sourcing and review of social care is uniform across all services and that 
the  contract  and  review  team  are  fully  cited  on  all  proposed  placements  prior  to  any 
contracting taking place; 

  Funding  has  been  secured  for  a  Local  Authority  assigned  social  worker  to  join  the 
community  forensic  team  from  1  April  2021.  This  social  worker  will  provide  a  vital  link 
between the social care teams and forensic services at the point of transition; 

  A protocol to specifically address the placing of people outside of the Trust’s geographical 
area has been developed. This will strengthen our existing practice by providing a clear 
guide for our teams and follows the guidance within the advice note for directors and of 
adult social services commissioning out of area care and support services produced by 
ADASS. It also highlights the need to ensure the provider has arrangements in place and 
contains provisions to assure of suitability of service and face to face reviews. The Trust 
has also developed an Out of County Care Provider Monitoring form as part of its provider 
assurance service. I attach the protocol and Monitoring form for your information.  

We trust that the above provides you with the reassurances that you seek but if you have any 
queries please do not hesitate to contact me. 

Yours sincerely 

Executive Director of Nursing and Professions