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Our in-depth knowledge of the areas in which we work in, allows us to provide considered advice on development and investment strategies, risk management, procurement strategy and design development. A team of Chartered Surveyors, engineers and project management professionals, NRP’s construction arm delivers projects across both the public and private sector. Whether building new infrastructure and housing to regenerating an existing asset, we look to maximise our clients return on investment through pragmatic solutions. Customer focused, professional, courteous and enthusiastic are words we are proud to have been quoted by our clients, and we work hard to maintain them. For example, providers must still comply with regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that relates to the provision of safe care and treatment, including infection control. In a letter to care providers(2) in March, CQC wrote: ‘We encourage you to use your discretion and act in the best way you see fit.’ This could be taken as indicating there will be some leeway in how the regulator assesses compliance during these exceptional circumstances – but the question becomes, how much? When inspection activity resumes, there is the possibility that CQC may make criticisms in inspection reports or pursue enforcement action if they consider that, despite all the pressures they were facing, a provider did not do enough to comply with the applicable guidance. However, it is unclear quite what lies ahead. While some deviation from ‘usual’ standards may be tolerated, where will the bar be set? Further guidance from CQC on this would certainly be welcome.

As well as finding artistic inspiration from the weathering of buildings, Howard loves to depict the impact of weather on landscapes that are largely devoid of buildings. Paintings such as ‘A Break in the Cloud’ and ‘Still Some Snow on the Tops’ are illustrative of this obsession. Casting his eye over these paintings, he said, ‘I think my landscape paintings which take contours and weather as their subject are slowly becoming more abstract in appearance.’

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So far, so good, but the world of commercial illustration was beginning to undergo a profound revolution that would see drawings produced by skilled graphic artists replaced by increasingly sophisticated computer-generated images. Howard realised that now was the time to put to good use the techniques of landscape painting that he had learned from ‘Tub’ Williams and turn his attention to the kind of creative painting and drawing that he had been producing for some time either for his own enjoyment or for some private commissions.

Infection control – guidance from Public Health England on required infection controls has evolved frequently as the outbreak has progressed title = {Measurement of the dijet transverse thrust distribution in proton - anti-proton collisions}, During the intubation procedure, we could not pass the fibrosis with the insertion cord of the flexible scope nor tracheal tube, which is an unusual situation. This problem, however, caused acute laryngospasm and airway obstruction that mandated emergency coniotomy. NAPICU is also pleased to report the outcomes of a collaboration to systematically evaluate the performance of PPE used during physical intervention. A brief summary of this project is included in Appendix 2. The full manuscript and data are currently submitted for peer review and publication. In the interim, the learning from the evaluation has been used to inform developments in this Guidance which may be of assistance to Inpatient Services considering this difficult area.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878910/Emergency_MCA_DoLS_Guidance_COVID19.pdf https://www.hsj.co.uk/emergency-care/exclusive-the-three-vital-lessons-italian-hospitals-have-learned-in-fighting-covid-19/7027220.article? After anatomical and histological examination of the specimen by the pathologist, it was reported that the smallest airway diameter was four mm, and the trachea showed signs of oedema and fibrosis. There were signs of recurrent laryngeal carcinoma and osteoradionecrosis of the tracheal rings and thyroid bone. 3. Discussion https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians The problem is that the three-way win probabilities depend not just on the average abilities of the horses, but also on how reliable they are. A horse that's very unreliable (sometimes runs really fast and sometimes runs really slow) will generally do better in a 3-way race than in a 2-way race, because if they run really fast against one of their opponents they'll run really fast against both of them! Notice that my three horses all finish the course in the same amount of time on average, but horse A still wins out by being unreliable.

Increased costs – care providers have faced dramatically increased costs at this highly difficult time, particularly in relation to staffing, agency costs, and the additional costs of PPE. Joint guidance(1) from the Local Government Association, Association of Directors of Adult Social Services (ADASS) and the Care Providers Alliance indicated that providers would be reimbursed by commissioners for extra costs, but, again, this has been mixed to date. The Covid-19 pandemic has stretched all parts of the health and social care system to the limit as they have battled with the challenges posed. Within this, care homes have been described by some as an ‘epicentre’ of the disease in the UK. Public, and political, support and respect for the social care sector has never been higher as it has pulled out every available stop to provide the best possible care for service users. However, despite the recognition of the unprecedented challenges, and Care Quality Commission (CQC)’s introduction of the Emergency Support Framework, care providers need to be mindful that the legal frameworks – and the possibility of regulatory scrutiny for failing to meet them – remain in place.

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During bronchoscopy, it may be difficult to visually estimate the severity of an airway obstruction, because of augmentation through the lenses of the bronchoscope. Structures appear much bigger than they really are. This holds especially true for situations in which a suboptimal view is obtained due to mucous or blood. In contrast, during direct laryngoscopy or videolaryngoscopy, it is easier to estimate if the tip of the tube can pass the obstruction because both targets, the glottis and the tip of the tube, appear in the same field of vision. During fibreoptic intubation however, it is not possible to visualize the outside of the tube during intubation, because the tube is railroaded over the insertion cord. Sometimes it may be easier to use a guiding catheter through the suction canal of the bronchoscope. This way it can be seen whether a small catheter can be passed through a small opening and also if the remaining space around the catheter will be sufficient to accommodate a larger tracheal tube [ 11, 12]. The NRP construction consultancy arm is the origin of our organisation. Operating since 1947 the company has thrived through generations of changes to building standards, practices and methodologies. Capturing and learning as the industry changes, we have delivered almost every type of construction project across all sectors. Along with their obligations to service users, providers must also discharge their responsibilities to staff under the Health & Safety At Work legislation. The issue of PPE is prominent again here, if members of staff feel that they have not been provided with all the equipment they needed to keep them safe. Inevitably, situations could arise where there is a tension between a provider’s obligations towards their service users and towards their staff. Similarly, in a letter written more recently(3)(in May) to ADASS, Mr Justice Hayden, vice president of the Court of Protection, issued a reminder around continuing obligations under the Mental Capacity Act. A concerning emerging issue during the crisis has been relatives seeking to take their loved ones out of homes due to infection concerns, raising mental capacity and best interest issues. In addition, providers need to consider(4) whether changes to a person’s care or treatment arrangements as a response to the outbreak constitute a new deprivation of liberty. Justice Hayden wrote that any belief that deprivation of liberty processes could be deviated from because of the crisis was ‘entirely misconceived’. He noted that there had been a ‘troubling drop’ in Mental Capacity Act 2005 s.21A applications. Clearly, the number one priority of the entire care sector remains to deal with the crisis in front of it right now. However, as well as dealing with day-to-day operational issues, providers need to ensure they keep an eye on compliance and have robust audit trails covering the steps they have taken in terms of infection control with risk assessments against the relevant (and changing) guidance; and maintain appropriate documentation around deprivation of liberty authorisations. They would also be advised to obtain legal advice immediately if faced with emergency situations – such as families seeking to remove residents without the necessary authorisations in place, or enforcement action from their regulators.