Norfolk

Action Taken (AI summary) The Trust has implemented a new recruitment system (TRAC), engaged a partner organization to promote career opportunities through social media, and has action plans for 'hotspot' areas.

Action Taken (AI summary) Kings Lynn and Eastgate Residential Care Homes engaged a fire consultant to observe fire drills, amended the pre-assessment form to include questions on distress caused by fire alarms, and revised the PEEP form. They have also amended the Group's Fire Drill Procedure and implemented relevant training.

Action Taken (AI summary) Following the incident, the Waveney River Centre no longer hires its pool for swimming parties. Staff formal safety training courses such as IOSH have been arranged.

Action Taken (AI summary) The Queen Elizabeth Hospital King's Lynn NHS Trust has given a copy of the Regulation 28 notice to each nurse on Windsor ward, shared the RCA with senior nurses in A&E, launched a falls campaign, provided training on falls assessment, piloted a new bed rails assessment document, and set up a falls intranet site. It has also devised a training programme for Registered Nurses on the undertaking and interpretation of neurological observations and updated mandatory training days.

Action Taken (AI summary) Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone call to rearrange an appointment instead of sending a letter. The clinical team leader monitors cases that have an appointment pending on a daily basis.

Action Taken (AI summary) The company has ceased the practice of personnel entering grain bins for cleaning. They have also booked IOSH Directing Safely and Managing Safely courses for staff.

Action Taken (AI summary) A memorandum was sent to all Home Managers regarding timely meals, choking risk assessments, and SALT referrals. The Senior Manager Monthly Report was amended to monitor Homes' adherence to the memorandum.

Action Taken (AI summary) Norfolk County Council changed its social care support arrangements to wards at Hellesdon Hospital in May 2015, establishing a dedicated Hospital Discharge Social Care Team and other measures to ensure care packages are arranged and followed up.

Action Taken (AI summary) The Trust updated its Observation and Engagement of Service Users policy and communicated changes to staff. Additional height bars were added to a railing on the disabled access ramp and the Trust has decided to enclose the ramp, with work scheduled for completion by the end of March 2016. The Trusts have worked together to develop a process for ensuring that patients under the care of mental health services who require acute care have a clear pathway which includes agreed communication channels between clinicians. A flow-diagram has been developed and is being used. The hospital has worked with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway to ensure inpatients from the local mental health facility can access care and treatment in the Emergency Department in a timely manner. A written pathway and flow diagram has been developed for staff.

Action Taken (AI summary) Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need for disciplinary action for breaches, greater written documentation, and are undertaking measures on a continual improvement basis.

Action Taken (AI summary) Norwich Practices Health Centre will have a standing agenda item called 'Patients of Concern' at their weekly clinical meeting, and have agreed to have a 'Patients of Significant Concern' register with immediate effect. A reflective discussion with the Designated Nurse for Safeguarding Children took place.

Action Taken (AI summary) HMP Wayland published a Governor's Order clarifying the recording of medical issues occurring overnight and amended the Local Security Strategy to support this. They also introduced a new radio system with more radios for healthcare staff. HMP Wayland has issued a Governor's Order instructing staff to record medical issues during the night in the wing observation book and amended the Local Security Strategy to reflect this procedure. A new radio system has been introduced at HMP Wayland and all healthcare staff are now routinely issued with radios.

Action Taken (AI summary) Norfolk County Council has stopped sending letters to individuals about whom concerns have been raised, and staff have been instructed to make face-to-face contact when telephone contact is not possible. Staff have also been reminded to record all steps taken to make contact, assess risk, and escalate cases to senior staff if contact is not made within two days.