Manchester West

Action Taken (AI summary) GMP reviewed and implemented its Incident Response Policy (IRP) in Feb 2022 incorporating the THRIVE risk assessment approach. All FCC officers and staff received training on the IRP and THRIVE, supplemented by audits and briefings. The M-HUT pilot is testing processes to address mental health demand in partnership with other agencies.

Action Taken (AI summary) Salford City Council's Collision Investigation Team carried out a detailed investigation into the junction following the collision, and have undertaken and are implementing actions relating to the layout, speed limit, restricted view and provision of traffic signals at the junction of Fairhills Road with Cadishead Way.

Action Taken (AI summary) The Informatics Team is conducting ward spot audits to monitor IT equipment, a topic discussed at Ward Managers meetings in December 2021 and January 2022. A Steering Group was established to review ward round processes and competing demands on IT equipment, with expected completion by May 2022. Agency staff also now receive training on the EPR system before booking shifts.

Action Taken (AI summary) The Department of Health details actions taken by the MHRA to update warnings on opioid medicines regarding dependence, addiction, and tolerance, as well as issuing a patient safety leaflet. They also mention a Public Health England review of prescription drug dependence and NHS England's programme to implement the review's recommendations, plus the requirement for Primary Care Networks to prioritize patients on potentially addictive pain medication for structured medication reviews.

Action Taken (AI summary) Blackpool Teaching Hospitals addressed concerns about bed lever fitting at Thornton House by clarifying that Occupational Therapists, now correctly trained, will prescribe and fit them after a full assessment. The intermediate care team and LCC were informed of updated processes at a meeting on December 2, 2020, and the Trust shared findings with senior Allied Health Professionals across the Lancashire and South Cumbria Integrated Care System. Lancashire County Council updated their 'Bed Rail and Bed Lever Policy and Procedure' to clarify the escalation process for concerns, effective January 8, 2021, with a further review planned for April 2021. They also rectified a miscommunication regarding bed lever usage at Thornton House, agreeing with Blackpool Teaching Hospitals that bed levers can be used when appropriate and fitted only by trained Occupational Therapy staff. Mobility 2000 Ltd has carried out further training with staff on fitting bed levers and straps, and will now supply a hard copy of the manufacturer's instructions with every bed lever.

Action Taken (AI summary) The Trust developed a prescribing guideline to standardize and support the safe prescribing and administration of colecaliferol in adult patients, in response to concerns about monitoring following a high loading dose.

Action Taken (AI summary) The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development.

Action Taken (AI summary) Rosewood Healthcare has implemented an Accidents and Incidents file, follows a Triage system, and has online and face-to-face training for falls and manual handling. They also have a new training provider who will be providing SALT and MUST training and audit systems are in place. The CQC conducted a comprehensive inspection of Barley Brook, and found that appropriate referrals were being made to dieticians and the falls team. They are highlighting possible breaches of the Health and Social Care Act 2008 and CQC Registration Regulations 2009 to the provider and will carry out a further inspection within 12 months. Wigan Council has taken action following a safeguarding enquiry, including developing a protection plan defining expectations for service delivery at Barley Brook. Staff will receive training in record keeping, dementia, and nutrition, and the council will monitor the uptake and impact of this training.

Action Taken (AI summary) North West Boroughs Healthcare NHS Foundation Trust has developed a training package to support face-to-face refresher training for all Nursing staff and Health Care Assistants regarding therapeutic observations. The operational manager will also conduct monthly audits of the electronic clinical record to identify patterns of delayed record keeping.

Action Taken (AI summary) The Greater Manchester Mental Health NHS Foundation Trust has put staff through new risk assessment training and provided them with new advice on how to deal with similar situations.

Action Taken (AI summary) HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system.