South Yorkshire East

Action Planned (AI summary) The hospital trust is implementing a falls ward accreditation program to improve quality of care proactively, and is providing training to staff. The accreditation will be monitored by the falls prevention practitioner.

Action Planned (AI summary) Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status.

Action Planned (AI summary) The Trust is re-launching the "Stop the Clot" campaign to ensure VTE prophylaxis is appropriately undertaken and in a timely manner. There is a quality improvement project on the medical assessment unit to ensure greater compliance with the medical VTE risk assessment form.

Action Planned (AI summary) The Trust intends to improve communications by introducing a process whereby Clinical Hub staff within EOC are able to make direct radio contact with police on scene; the Trust is discussing implementation with police forces. A review of current processes and communications between agencies is within the scope of the Sheffield Crisis Care Concordat.

Action Planned (AI summary) Warning signs will be installed to warn of potential slippery road conditions by the end of September 2017.

Action Planned (AI summary) Allied Healthcare acknowledges the concerns and will perform a review of practices/policies/procedures relating to the use of slide sheets and update the Senior Coroner. They confirm that all of Allied Healthcare's training documents are currently being reviewed every two years or sooner, if guidelines change. RDASH held a meeting with District Nurses and their Line Managers to discuss the report. Training on pain management in patients with dementia and cognitive impairment is ongoing and will incorporate learning from the Regulation 28 report.

Action Planned (AI summary) The trust intends to address the need for increased capacity to conduct basic out-of-hours patient reviews and is considering options to expand out-of-hours community provision as part of its service transformation process.

Action Planned (AI summary) An action plan is in place to ensure correct management of oral paracetamol for adult patients of extremely low body weight, including updating the drug chart, developing information for staff, and providing additional training. An audit of documentation of weights recorded in relevant nursing records and charts and on prescription charts will be undertaken.

Action Planned (AI summary) The Trust will reiterate the importance of recording all relevant data on the IAPT system through internal communications. The Trust is also part of a national 'Sign up to Safety' movement and is relaunching its campaign to reduce suicides.

Action Planned (AI summary) Doncaster Borough Council intends to reduce the speed limit on a stretch of the A630 to 40mph, complemented by additional signage and road markings; this is subject to statutory processes and is anticipated to be implemented by early summer 2016 at the latest.

Action Planned (AI summary) Policy changes have been made so that only a manager grade can close an ACCT, and ACCTs cannot be closed unless the case review comprises at least two people and all actions on the CAREMAP have been completed; HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved. NHS England is reviewing templates for first night screening and risk assessment as part of the deployment of a new Health & Justice Information System, with rollout expected from July 2016 to July 2017.

Action Planned (AI summary) The Leeds Teaching Hospitals NHS Trust has re-circulated the pathway document, updated in October 2014, which highlights the need for completion of the referral form as fully and accurately as possible; the team has altered the MDT reply forms to state that responsibility for patient care remains with the referring team until the patient has been seen in Leeds. The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are collaboratively revising inter-provider transfer of care processes for cancer patients in West Yorkshire and expect to embed the revised processes by the end of February 2016; the Trust will embed the revised processes and ensure junior medical staff completing MDT pro formas remain well supported by the end of February 2016.