Blackpool and Fylde

Action Taken (AI summary) • The RCGP agreed that clinical correspondence, including reports from NHS 111, must be reviewed by a clinician before any decision is made about further action. • The RCGP's curriculum reflects the responsibility of GPs to respond to clinical correspondence in a timely manner to maintain safe patient pathways. • The RCGP supports CQC guidance that where non-clinical staff are involved in workflow tasks, there must be appropriate safeguards, supervision, training, and audit in place. • The GP practice has revised its workflow so that all clinical documents received from providers, including NHS 111 and out-of-hours services, are now reviewed by a clinician rather than administrative staff. • All incoming 111 and out-of-hours documents are attached to the patient record and sent as a clear task directly to a clinician as part of their daily workflow. • The GP practice now ensures that all consultation notes and reports are added to the patient’s medical record, coded and free-texted by the clinician.

Action Taken (AI summary) • The organisation has instructed all relevant staff that if an ECG shows significant abnormalities that may warrant an A&E admission and an amendment is made that adds to the urgency, then in such cases, in addition to sending an email, they should also always try to call the surgery to notify them. • This message has been communicated to all relevant staff on the 20th April 2026. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that any amendments to ECG reports are recorded clearly within the patient’s medical records and reviewed by the On Call GP on the day they are received. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that any amended urgent ECG reports are logged as a Significant Event and immediately flagged to the Practice Manager for internal review. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that such incidents are also uploaded onto Ulysses, the ICB incident reporting system, to ensure commissioners are formally notified and wider system learning can take place.

Action Taken (AI summary) Barchester Healthcare has taken several actions including a review of training, refresher training on NEWS2, a new care planning digital system with guidance sheets, and themed supervision for staff. The falls policy has been reviewed and prompt sheets and guides have been created.

Action Taken (AI summary) The Trust has implemented improvements to sepsis management, including training, audits, and pathway adjustments, and received a high assurance rating from the Mersey Internal Audit Agency, leading to the removal of Section 31 licence conditions.

Action Taken (AI summary) Haddon Court Rest Home has reminded staff about the importance of accurate record keeping and the risks of using the "repeat functionality" of their software; the software provider is reviewing the functionality.

Action Taken (AI summary) The Trust is replacing its eDischarge system with a new integrated Nexus NPR platform which includes safeguards to prevent erroneous issuing of discharge summaries, requiring a password from the discharging clinician. The new system is being rolled out in phases, with full deployment expected by June 30, 2024, and a safety instruction regarding discharge summaries has been issued in the interim. DHSC notes that the medical director of Blackpool Teaching Hospitals NHS Foundation Trust has issued a letter to all medical staff regarding the population of discharge summaries with key messages to ensure discharge summaries are not prefilled. The trust also has an e-discharge project in place and ICB chief medical officers are asked to focus on and report their progress against recommendations on how to improve the interface between primary and secondary care.

Action Taken (AI summary) Lancashire and South Cumbria Integrated Care Board outlines actions taken by Blackpool Victoria Hospital, including revised communication protocols, staff training on triage and escalation, and direct GP referrals. They also detail how the ICB Primary Care Team is involved in communications with General Practices. DHSC acknowledges concerns about A&E wait times and refers to NHS England's 'Delivery plan for recovering urgent and emergency care services' which includes a target to improve A&E wait times. They cite dedicated funding to increase staffed hospital beds and improvements in performance at Blackpool Teaching Hospitals NHS Foundation Trust.

Action Taken (AI summary) Hospital passports are checked by two members of senior staff weekly, and Care Plans updated monthly or when any changes to care are required by a senior member of management. A hospital passport checklist has been implemented, and the provider contacted North West Ambulance Service to discuss the checklist.

Action Taken (AI summary) Blackpool Teaching Hospital Trust has ensured mandatory training on the risk of sepsis in Early Medical Terminations, introduced a sepsis educational programme, conducts monthly sepsis audits, and holds a monthly sepsis working group.

Action Taken (AI summary) Blackpool Victoria Hospital has implemented education and training sessions on PVL Staphylococcus Aureus, added a link to relevant guidelines on the Trust's intranet, and ensured all Critical Care Consultants received training on internal systems like Cyberlab. The CCG has discussed PVL-SA awareness at GP teleconferences, circulated information via its weekly bulletin to general practitioners, and noted that patient microbiology reports from Blackpool Teaching Hospitals now include a PVL-SA awareness message.

Action Taken (AI summary) Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies.

Action Taken (AI summary) The Trust has developed a protocol for handover from Spire Fylde Coast Hospital to the Emergency Department and then ophthalmology and has reminded ED staff that variable doses of medication should be written on the PRN section of the chart. Morphine elixir has been treated as a restricted drug since November 2018, with all doses recorded in the restricted drugs register.

Action Taken (AI summary) The Department of Health and Social Care detailed actions taken to raise awareness of co-sleeping risks, including releasing two short films with advice and incorporating safe sleeping advice into the Healthy Child Programme. Public Health England also plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, including safer sleeping discussions and highlighting potential harms, in Q3 2020/21.

Action Taken (AI summary) Rossendale Nursing Home has implemented Person Centred Software, walk around handovers, pre-admission falls risk assessments, motion sensors, staff presence in communal areas, a post-fall protocol, referrals to the Falls team, CCTV, and monthly environmental audits to reduce falls risk.

Action Taken (AI summary) The landlord confirms the adaptations to the windows in flat 10 have been replaced and all top floor flats windows have been checked for safety.

Action Taken (AI summary) The Trust has implemented an Accessible Information Standard Policy, an Interpretation and Translation Procedure, and guidelines for the care of people with learning disabilities. It flags Blackpool residents with learning disabilities on electronic patient records and is working to extend this to Lancashire residents. A Red Alert has been issued to staff reminding them of vigilance for peritonitis in post-operative PEG tube patients.