Norfolk

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.

Action Taken (AI summary) The Queen Elizabeth Hospital has implemented clear guidance for doctors on investigating patients admitted after pacemaker insertion and implemented a system for cardiac technicians to directly contact clinical teams about abnormal results. The hospital is moving to an electronic reporting system and cardiology consultants are routinely present on site on weekends.

Action Taken (AI summary) Norfolk County Council has taken action regarding the individual worker involved and the Adult Social Services Quality Assurance Team is developing a Best Practice factsheet to formalise local custom and practice regarding contacting people referred to the Service.

Action Taken (AI summary) Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users after incidents, and making referrals.

Action Taken (AI summary) The nursing home asserts it already meets required standards for equipment maintenance and staff training. They are implementing weekly wheelchair checks and providing staff with updated guidelines, including a wheelchair safety checklist to be used each time a resident uses a wheelchair.

Action Taken (AI summary) Roundwell Medical Centre has implemented several immediate actions regarding patients on addictive medications including assigning a single GP where possible, detailing clinical plans, adding read codes for easy identification, and a six-month medication review. They will design a bespoke "Addictive Medication Review" template within 3 months and include patients on weekly medication in risk profiling.

Action Taken (AI summary) St Stephens Gate has reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. They are arranging laminated copies of the NICE Traffic Light guidance to be present on desks in all nurses' consulting rooms and have discussed the outcomes of this case at practice clinical meetings and reviewed policies and procedures accordingly.