Leicester City and South Leicestershire

Action Planned (AI summary) The Trust has drafted a three-year mental health strategy, expected to be finalised by October 2018. They are strengthening training for staff caring for people who self-harm, anticipated to take 6 months to implement, and will send a communication to all staff reminding them of the escalation process in the interim. The Trust has given all trainees on the relevant rota in Adult Mental Health and Learning Disabilities service remote access to clinical systems. An induction for central duty rota doctors was held on 3.08.18 and will be video recorded for future use, and the central duty rota on call guide was updated in July 2018.

Action Planned (AI summary) The CAA will continue to drive forward the plan to ensure operators are `electronically conspicuous' which will help to reduce the incidence of such events. The MAC programme works closely and collaboratively with the UK Airprox Board, UK Flight Safety Committee, Military Aviation Authority and industry stakeholders to understand and assess risk and identify effective and collaborative mitigations.

Action Planned (AI summary) The practice will liaise with care homes to get written confirmation when a patient changes GP, including consent and next of kin notification; future projects will include better advertisement; communication arriving at the old practice will be forwarded to the new practice; and a written policy will be created for changing patient care when a patient resides in a care home. The practice will improve advertisement of changes with posters, require written signed documentation of conversations with patient or next of kin, and forward communication received by the donor practice to the receiving practice for six weeks. In the future, project plans must outline roles and responsibilities, communications must be dated and documented, there must be a system for forwarding communications regarding patients, carehomes should have systems for tracking information shared with GP practices, and ELR CCG will require providers to keep a record of information received and discussed with residents.

Action Planned (AI summary) BSAC is rewriting its core Diver Training Programme to include a skills sheet for instructors to sign off individual skills. BSAC will also produce a guidance document on weightbelt removal and remind instructors of the importance of teaching this skill. Dulwich BSAC 102 will develop a means of recording partial training completion. They will also seek clarification from BSAC regarding sequencing of lessons and guidance on DSMB use.

Action Planned (AI summary) HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The prison is also working with EMAS to ensure effective Joint working and consistency of approach in all the prisons, with a joint emergency response protocol expected by 31 July 2016. East Midlands Ambulance Service (EMAS) has formed a senior regional group to address issues relating to secure environments, such as prisons and secure mental health units. They also plan a meeting with secure environment teams to address access issues, ambulance activation protocols, and partnership working principles.

Action Planned (AI summary) The company will be submitting an application to the MHRA to update the labelling of several E45 products to include guidance on potential flammability. The warning to be added to the product labelling is: "If using large quantities, regularly change clothing, bedding or dressings impregnated with the product and keep away from fire as may pose a fire hazard". CFOA has circulated the report to Chief Fire Officers/Chief Executives and other practitioners in the fire and rescue services and Chief Fire Officers/Chief Executives will ensure that the information and details contained within your report are shared with the appropriate staff. The MHRA included an article in Drug Safety Update on paraffin-based skin emollients and fire risk, reminding healthcare professionals to advise patients on the risks and to change clothing and bedding regularly. NHS Improvement have informed the editors of the BNF that the risk also applies to less concentrated aqueous based paraffin containing products, and the BNF will in future include a revised warning that will inform healthcare professionals of the risk applying to all paraffin containing products. NHS Improvement will communicate this risk to the Medication Safety Officers (MSOs) network so the risk can be appropriately communicated and addressed within their organisations. NHS Improvement have also asked the Care Quality Commission, the Royal College of Nursing, and networks within the care home sector to communicate the risk via suitable newsletter and bulletin articles.

Action Planned (AI summary) Sainsbury's is awaiting a response from the HSE regarding lift design, installation, and signage standards and will then take appropriate action at the Glen Road store and other similar stores. The HSE will raise the incident as a concern at a European forum for lifts in 2016 and with the relevant BSi committee, for consideration in future revision of the Lifts Directive.

Action Planned (AI summary) The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and consider other workforce diversity options if there are no applicants again.

Action Planned (AI summary) Adult Social Care will send letters to individuals waiting for assessments from an Adult Mental Health Team, explaining Adult Social Care's role and how to contact the team if the situation changes; case records across Adult Mental Health have been reminded of the importance of feeding back to the whole multi-disciplinary team and to carers, not solely the Registered Medical Officer. The LPT will review and update its DNA policy by March 2016; CMHTs are undergoing service redesign to remove internal barriers between the Outpatients Service and the wider CMHT, including a pathfinder project in North West Leicestershire CMHT to look at a multi-disciplinary team held caseload model with the aim to roll this out across all CMHTs by April next year.

Action Planned (AI summary) Leicestershire County Council proposes to place give way road markings on Bonehams lane and "Slow" markings on Ullesthorpe Road to advise drivers of the presence of a junction with a view to encouraging them to reduce their speed.