2019

Action Taken (AI summary) The care home has implemented a Resident of the Day procedure for care file updates, reviews of care plans, and a diary record for tracking residents' dental care; staff have also attended CCG training on dental hygiene for vulnerable residents.

Action Taken (AI summary) The Trust has implemented several changes, including inviting relevant healthcare professionals to CPA meetings, entering all patients' weight and height into the Malnutrition Universal Screening Tool (MUST), and ensuring patients with long-term nutritional needs remain open to the dietician. These improvements are incorporated into the physical health strategy.

Action Taken (AI summary) The Council reviewed the accident site and, although not considered contributory factors, ordered the recovery of road markings and replacement of defective hazard marker posts. The council also removed hawthorn bushes contributing to reduced visibility.

Action Taken (AI summary) The Trust has already implemented measures like case discussion groups and reflective practice groups run by psychotherapists. They also have MDT handovers every morning and provide more access to psychological therapies. The ward also considers the admission of EUPD patients carefully.

Action Taken (AI summary) Police CCTV operators will now scan for water safety equipment as part of the initial response where someone has entered the water. Sussex Police will be supporting the summer 'Keeping safe campaign' which includes water safety advice, highlighting the dangers of entering the sea when under the influence of drink/drugs or in adverse weather conditions.

Action Taken (AI summary) Wiltshire Police states that staff briefings have been sent out reminding 999 call handlers to use the three-way call process when needed. They also state that further revisions of the relevant Force procedure on managing calls have now taken place.

Action Taken (AI summary) The Trust's suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. The Trust is strengthening its clinical and service leadership to ensure have the necessary breadth of skills and resource to lead safe and effective services.

Action Taken (AI summary) The Trust conducted a review of outpatient CTPA studies, created a central register for radiographer training across multiple sites, and reviews staff training during annual appraisals.

Action Taken (AI summary) The Trust has drafted a standard operating procedure for handovers, added an SBAR tool to the Paediatric proforma, developed a tool to safely exclude brain injury in intoxicated patients, and created a training tool with the South West Ambulance Service on "Confirmation Bias".

Action Taken (AI summary) Birmingham and Solihull Mental Health NHS Trust has developed a dedicated crisis email address for Home Treatment Teams with dedicated support to manage the system. They have also increased the capacity of the out of hours service by putting a senior clinician (Band 7) on duty each evening and have increased the capacity of their Home Treatment Teams and are now ‘over-recruited’ to medical positions.

Action Taken (AI summary) HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record. Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all patient-facing staff.

Action Taken (AI summary) The Trust revised its Transfer of Patients Policy, ratified on May 7th, and delivered "Transferring the Critically Ill Patient" training including a decision to not transfer patients on Hi Flo airvo2 without battery backup. They also redesigned transfer stickers using an SBAR format.

Action Taken (AI summary) HC-One implemented an action plan at Bakers Court to address the concerns highlighted. Multi-factorial Falls Risk Assessments will inform the development and implementation of a daily plan of care.