2020

Action Taken (AI summary) Kent County Council has installed 'clearway' signs and implemented a temporary traffic regulation order prohibiting parking on the section of dual carriageway. A permanent traffic regulation order with permanent posts and signage will replace the temporary order.

Action Taken (AI summary) Blackpool Teaching Hospitals addressed concerns about bed lever fitting at Thornton House by clarifying that Occupational Therapists, now correctly trained, will prescribe and fit them after a full assessment. The intermediate care team and LCC were informed of updated processes at a meeting on December 2, 2020, and the Trust shared findings with senior Allied Health Professionals across the Lancashire and South Cumbria Integrated Care System. Lancashire County Council updated their 'Bed Rail and Bed Lever Policy and Procedure' to clarify the escalation process for concerns, effective January 8, 2021, with a further review planned for April 2021. They also rectified a miscommunication regarding bed lever usage at Thornton House, agreeing with Blackpool Teaching Hospitals that bed levers can be used when appropriate and fitted only by trained Occupational Therapy staff. Mobility 2000 Ltd has carried out further training with staff on fitting bed levers and straps, and will now supply a hard copy of the manufacturer's instructions with every bed lever.

Action Taken (AI summary) The Queen Elizabeth Hospital Kings Lynn provided a medical records audit across the Trust's wards. They also have updated falls risk assessments and management plans to include contacting Mental Health Liaison. A review of the QEH guidelines for those on Fresnuis is underway and due by the end of February 2021.

Action Taken (AI summary) The Trust updated falls risk assessments to consider mental health, including a direct reference to contacting Mental Health Liaison. They have also informed nursing staff of these changes and shared learning from the case with the Mental Health Strategy Implementation Group.

Action Taken (AI summary) The Trust has implemented several actions to improve the safe use of IV contrast in CT scans, including communicating a new IV Contrast protocol, emphasizing the importance of personalized evaluations for patients with eGFR less than 30, recording radiologist authorization decisions, providing specific training for radiographers and admin staff, and creating a new radiology request form to incorporate safeguards for patients with abnormal renal function.

Action Taken (AI summary) The respiratory team developed a Standard Operating Procedure to ensure all investigation results are reviewed promptly. The trust Divisional Director for Imaging has reviewed the processes and has improved the system, which is now formally incorporated within the trust Standard Operating Procedure.

Action Taken (AI summary) SBARD is integrated into the patient handover used by the wards at every handover, with a template document used. EObs has been introduced. The Recognise and Response Team (RRT) has been expanded to provide their services 24/7 and teaches SBARD on all new staff inductions.

Action Taken (AI summary) The Corporate Client Team now makes direct contact with all newly referred clients. Guidance has been put in place for the CCT on actions to take if a client is experiencing an immediate crisis. An appointment with a consultant psychiatrist is now booked to take place in the same week as the therapy assessment, and therapists have been given guidance on the advice that they should give to any newly referred clients who they feel are higher risk.

Action Taken (AI summary) The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries and a senior doctor checks the documentation. Pennine Care NHS Foundation Trust has issued all new trainees with laptops, and documentation review is now incorporated in trainees’ weekly supervision.

Action Taken (AI summary) The Trust undertook a Serious Incident Investigation and developed an action plan. Risk assessments are completed and include contingency plans, and guidance is available for staff on leave arrangements. The learning has been shared with medical staff, Senior Nurse Managers, and at the Eastern Locality Learning from Experience meeting and the Adult Directorate Governance Board meeting.

Action Taken (AI summary) The Trust has developed a protocol for handover from Spire Fylde Coast Hospital to the Emergency Department and then ophthalmology and has reminded ED staff that variable doses of medication should be written on the PRN section of the chart. Morphine elixir has been treated as a restricted drug since November 2018, with all doses recorded in the restricted drugs register.