Kent and Medway

Action Taken (AI summary) The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments for evidence of carer involvement was also carried out and reported to the Leadership Forum.

Action Taken (AI summary) The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.

Action Taken (AI summary) HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS is compiling a learning bulletin for all staff on their intranet by the end of September.

Action Taken (AI summary) East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland on June 30, 2015, instructing staff to record medical issues in the wing observation book and the Local Security Strategy has been amended to reflect this procedure.

Action Taken (AI summary) Mayday Healthcare has implemented measures including monthly SMS reminders to staff, consultant training, client feedback forms, quarterly letters to staff, and updated yearly training program in regards to documentation, escalation, administration of medication and compassion.

Action Taken (AI summary) Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.

Action Taken (AI summary) Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve documentation and monitor through clinical audit. The training available to staff for holistic assessment and care planning has been revised and is being rolled out.

Action Taken (AI summary) Lifestyle Care booked dysphagia training for staff in February and March 2014 and a Nutrition and Hydration course in March 2014. They received confirmation from SALT that they will now be charging £125 per session and sessions can be booked from the end of March.