Herefordshire

Action Taken (AI summary) Herefordshire Worcestershire NHS states that the Community Service Manager has worked with Herefordshire MIND to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in Herefordshire, which has been implemented in draft form. MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’.

Action Taken (AI summary) The Trust has implemented several measures including clearer documentation of call bell checks, reviewing incident reporting, adding falls risk to nursing handovers, implementing 'Falls Friday', using yellow socks/wristbands to identify falls risk, and trialing secured bed rails.

Action Taken (AI summary) The Trust has developed two Standard Operating Procedures (SOPs), one for within working hours and one for out of hours, to ensure the process for disclosing colleagues' mental health difficulties is clear and followed routinely; these SOPs are now in place and will be added to their Position of Trust Policy.

Action Taken (AI summary) The care home has stopped offering respite care, enhanced documentation procedures for senior staff, reviewed and reinforced the falls protocol, improved communication during weekly ward rounds, added safeguards to medication processes for residents on blood thinners, implemented a written daily handover sheet, and increased care plan audits.

Action Taken (AI summary) Hereford Medical Group implemented a new process allowing clinicians to listen to phone calls when online forms are unavailable, changed the staff newsletter to include the most up to date waiting times for appointments, and will include a Mental Health focus session over the next month during regular training for GPs. A protected education time in January will also focus on triaging, including clinical considerations and the triage process and protocols.

Action Taken (AI summary) Herefordshire Council has made changes to the structure, processes, and practice within the service, including robust processes and proactive work with partners. A system for identifying process failure is now in place, covering supervision of officers, management oversight of the CRM system, and weekly reviews of each case. A programme of case auditing is also being developed.

Action Taken (AI summary) The Trust has introduced a senior nurse care review in the ED, developed and piloted a local competency package for pressure area care (starting with the Frailty service), refreshed Tissue Viability link nurse roles with additional training, and holds a weekly Pressure Ulcer panel to discuss incidents of pressure damage.

Action Taken (AI summary) Wye Valley NHS Trust utilizes clinical streaming in the ED. The Trust detailed changes being made to the Serious Incident (SI) process, which are designed around learning lessons from unfortunate events and not apportioning blame.

Action Taken (AI summary) Hertfordshire County Council fixed faulty lights on the pedestrian refuge on Digswell Hill after a report in January 2022, and have checked them every 20 days since. The site is now included in the asset inventory for regular inspections and maintenance.

Action Taken (AI summary) Birmingham Women and Childrens NHS Trust has ensured that national guidance such as that the best practice guidance on Homecare medicines, issued in 2011 and known as ‘the Hackett Report’ has been put into practice. It has implemented a system in which Parenteral Nutrition (PN) prescriptions are completed in accordance with existing standards and a second check of PN prescriptions is carried out by a qualified healthcare professional. The Trust has developed and implemented a standard operating procedure for both the medical and surgical divisions to ensure patients with medical conditions overseen by another hospital have a named consultant at their local hospital and that the specialist department of the overseen hospital is consulted. They have also improved information held on patients with open access to the children's ward, developed a proforma for details of health professionals involved in patient care, and implemented the "situational awareness for everyone programme".

Action Taken (AI summary) • The use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld, has been relaunched and clarified to all pertinent staff. • All speciality specific thromboprophylaxis guidelines are being reviewed.