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colleagues from each profession and was launched April-May 2017 . Colleagues are already reporting that the system is now easier to navigate. Clinical records and any recording templates are now much easier t0 input data into and for clinicians any changes in the patient's condition are now more visible. For example, multidisciplinary review template is available on the patient record within all community clinical professional modules such as nursing, physiotherapy and occupational therapy: This review template is now completed whenever the patient is reviewed or where there are changes in the patient's condition. Other improvements on our electronic records system include for community nursing services reintroduction of the "nursing process" (Roper model) and care plan documents as well as SBAR (Situation, Background Assessment and Recommendation) reporting frameworks which provides clearer structure for communicating deterioration of improvement in patient: Every care plan and assessment within the electronic system has a section for the review date to be recorded. This re-engineered record system now has a patient "non-adherence" questionnaire available which is another important tool for clinicians to monitor any changes in patients' condition, which was previously not available. If a patient is not compliant with the care that is offered, the questionnaire prompts the clinician to explore this several questions including whether the patient has the mental capacity to make decisions_ Refresher training for the National Early Warning Score (NEWS) is being undertaken; as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward "deteriorating patient" quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non- qualified clinical workforce to be able to detect a deterioration in patient's health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in standardised way using this evidence based approach for patient care_ The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis: This policy is due for ratification at the Trust's Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within community and hospital teams across the Trust; a "Clinical Lead' has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services_ Monitoring of any deteriorating patient has been embedded in our recently reengineered clinical record (SystmOne): An easy to use NEWS calculator score is now available and within this there are prompts to remind clinicians of the "Sepsis Six" indicators. using

Workload capacity and its effective management within our clinical services also needs to be satisfactory for patients to be effectively monitored. "capacity and demand" model was introduced into Community Nursing in Gloucester in October
2016. This was developed by clinicians and supports the planned and timely allocation of patients who receive care. This resource allocation tool supports suitable time allocation for wound care and colleagues have been strongly advised to apply rating score and work to a standard operating procedure that supports patient care. An 'unscheduled care' ledger (on SystmOne) was also introduced to reduce the impact on those workloads associated with unplanned visits which are referred into our nursing team for an urgent patient contact_ This ensures that there are nurses holding the position of shift lead each day and who have an overview of all colleagues' workloads, demands and unpredicted care requirements. To enhance communications nurses are now supported to attend GP practice based meetings on planned basis to discuss those patients with more complex needs and those that are identified to be an unplanned hospital admission risk, as well as those at the end of their life. In addition all teams have a process for linking with their affiliated GP practice at least daily, either by telephone or in person. We are also progressing with having more scheduled multidisciplinary cluster meetings which will act as an open forum for nurses, physiotherapists and occupational therapists to discuss and care plan for particular patients on their caseloads_ Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally): The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care_ We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment_ In addition, constructive discussions are currently in place with Gloucestershire Clinical Commissioning Group to determine the scope of a new district service specification that is both sustainable and coherent with the plans and vision of the Gloucestershire' Service Transformation Programme (STP): We also continue a8 an organisation to provide specialist Practitioner Training for nurse colleagues at degree and masters level in order for them to achieve their District Nurse qualification this is long term approach with regards to our succession planning i.e. growing staff within _
2. That the district nursing service carry out regular top to toe skin assessments, including the regular checking of pressure areas, nutrition, weight and hydration status. Our Professional Leads for Community Nursing run monthly Continuous Professional Development sessions for community nurses across the localities; the Braden Risk Chair: Inarid Barker Chief Executive: Katie Norton Understandina ou nursing "One

Assessment tool and Malnutrition Universal Screening Tool (MUST) are refresher topics that frequently occur and colleagues are encouraged to attend The Braden tool is used to assess the risk of a patient developing a pressure ulcer and is used in conjunction with the nurses' clinical judgement. It consists of six subscales which measure elements of risk that contribute to either higher intensity and duration of pressure , or lower tissue tolerance for pressure
i.e: sensory perception, moisture , activity, mobility, friction, and shear: The MUST assessment involves measuring height and weight to obtain body mass index and together with other risk factors such as patient's current medical conditions establishes an overall risk for malnutrition_ Braden MUST and physical top-to-toe assessments are now incorporated into our clinical record system (SystmOne): For example, for documenting wound care the improved record system provides the facility for wounds to be better described including the date the wounds started, were reviewed and healed. Another example is the top-to-toe assessment which is question-prompt template with blank boxes for different parts of the body which are required to be completed: Clear professional guidance has been issued to all nurses regarding the need to conduct these assessments at admission to the caseload and re-assessed at frequency according to need. This clinical practice is now reviewed as part of quality assurance visits across all localities to ensure it is carried out_ Weighing scales have been issued to each locality and where a patients weight cannot be obtained to calculate the MUST score the ulnar measurement is used as advocated by Trust policy: In view of the issues raised at the inquest in terms of the availability of scales and other equipment the time of RW's death; our deputy director of nursing is currently seeking assurance from all localities that there are no issues with the accessing or using of essential clinical equipment: No problems have been identified but should any be found then measures will immediately be in place to rectify them: It should also be noted that pressure ulcer prevention and awareness is recognised risk for the organisation and is one of our quality priorities for 2017-18. A quality improvement group to address this is in place. Since May 2017 we have moved towards implementing a range of actions to raise awareness of pressure ulcers and their prevention across services_ We are currently observing an increase in the reporting of grade (very low grade pressure ulcers) which indicates growing awareness of the risks of developing pressure ulcers and the need for early detection. The Trust's incident reporting system (Datix) is also a tool clinician's use for raising concerns for patients whose status has changed quickly and or unexpectedly unexpected deaths or cardiac events The "learning assurance framework" that is then subsequently employed (which includes a low threshold for requesting root cause analyses) aims to ensure that as much learning as possible is obtained and embedded the organisation in order to improve practice: fully during put
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3 That the district nursing service has effective handover procedures in place and protected time t0 carry these out: A Standard Operating Procedure for handovers was produced in August 2016, two months after RW's death_ This now provides structure and expectation for handovers within each of our community nursing teams_ Time to complete the handover is applied to the SystmOne ledgers previously mentioned and colleagues are strongly encouraged to attend them. A quality review visit has identified that occasionally due to operational pressures nurses have not been able to attend some handovers_ However, this is currently being actively monitored by our operational managers to determine whether this is a significant issue_ We have two approaches for handovers that clinicians are directed to use:
1) A situation report ('sit-rep') which is a concise handover similar to what is in place in ward environments
2) A 'deep dive' caseloads review. standard operating procedure (SOP) provides steer for when to use either format. Our Professional Leads now endeavour to attend these handovers and support decision making, patient care progression and; clinicians are directed to record handover discussions into our SystmOne record for the patient. Recent quality review visits have identified that some teams occasionally do not achieve the requirements of the SOP for handovers this has been identified as risk in the quality review report for the Trust and because of this, team managers and professional leads are currently managing the issue and are required to provide assurance that compliance is being met. This response and the issues and learning that have been highlighted from the inquest;, will be discussed at the Trusts Quality and Performance Committee on 31 August 2017 _ This is Trust Board sub-committee , chaired by Non-Executive which examines the performance, quality and safety measures of all aspects of the Trust's performance, holding managers and leaders to account in order t0 ensure where identified, actions and improvements are completed_ We hope that this response although detailed provides you with the assurance that we have taken and continue to take learning from incidents like these seriously: We also hope goes significant way towards addressing the issues you have highlighted for the prevention of future deaths , and that this evidences our commitment to providing the best possible care and support for our patients. We would like to take the opportunity to again offer our sincere condolences to the family of RW for their loss last year: Chair: Inarid Barker Chief Executive: Katie Norton Understandina ou they

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