Manchester West

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 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.

Action Taken (AI summary) The Trust updated its electronic patient record system's ward-to-ward transfer document and circulated a safety alert to staff informing them of the changes. These changes have been fully implemented.

Action Taken (AI summary) The Trust has filled all substantive consultant appointments across inpatient areas within Manchester services and is developing proposals for forensic in-reach to support consultants and CMHTs; a rolling programme for all healthcare professionals promoting the importance of good record keeping is currently being delivered.

Action Taken (AI summary) Salford Royal NHS Foundation Trust implemented an 8-bed H6 Monitored Unit in June 2017 and is planning an Extended Recovery Unit to optimize post-surgical patient care, reduce complications, and facilitate appropriate use of critical care beds.

Action Taken (AI summary) Wrightington, Wigan and Leigh NHS Trust has notified emergency care staff that calls should not be put through to minors or majors, that treatment advice should not be given, and is reminding nursing staff of the requirement to document relevant care. The Accident & Emergency weekly mortality review will now include a review of any hospital attendances in the last four weeks.

Action Taken (AI summary) A "theme of the week" communication has been shared across the organisation regarding connectivity of electronic care systems. IAPT staff have received RiO training.

Action Taken (AI summary) Following the report, the council measured the pothole depth and repaired it, both temporarily and permanently. They assert this was done despite the pothole not meeting the threshold for intervention under their Highway Safety Inspection Policy.

Action Taken (AI summary) Salford Royal NHS Trust reviewed policies and confirmed existing protocols for rapid notification of unsuspected pathology. These protocols have been disseminated by email and discussed at the Orthopaedic clinical governance meeting on 29th March 2017.

Action Taken (AI summary) Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at Belong Atherton have received updated training about Dysphagia which will be cascaded throughout the organization.