2022

Action Taken (AI summary) Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. Central London Community Healthcare NHS Trust has enhanced communication with University College Hospital NHS Trust by setting up a specific phone number and time for discussing hospital discharges, and set up monthly review meetings. Learning from the incident has been shared with staff, and safeguarding concerns will automatically trigger an internal escalation to the safeguarding team. They have also strengthened discharge planning processes. The Trust enhanced communication lines, set up monthly review meetings with the hospital, shared learning with staff to escalate safeguarding concerns, and strengthened discharge planning processes. Progress will be reviewed at divisional quality forums, and changes will be embedded in operational procedures by March 31, 2023. Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. Westminster City Council has worked with partner agencies to review integrated discharge, and multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care. The Trust reviewed and improved local processes and education for staff, strengthened collaboration with community partners, and formed a monthly partnership to review progress, share learning, and collaborate on improvements to enhance the quality and safety of hospital discharge processes and care outside of the hospital. UCLH has reviewed and improved local processes and education for staff to prevent further poor outcomes for patients. Pressure ulcer training for therapists has commenced, with completion planned by the end of June 2023 and they have agreed to meet monthly as a newly formed partnership to review progress against the actions, share learning and collaborate on improvements.

Action Taken (AI summary) HFT has made improvements to service provision at Valley View, commissioning an independent review and working with stakeholders. They have increased staffing levels, provided training on specific health conditions, implemented a new digital care planning system, and enhanced the Quality Assurance Framework.

Action Taken (AI summary) North East London Foundation Trust has taken several actions, including updating training for nursing staff on care planning and observation, improving processes for auditing emergency equipment, and installing a new SAS Alarm system in clinical areas.

Action Taken (AI summary) Runwood Homes has implemented changes including a new pre-admission form, staff training on individualised care plans, improved medication management protocols, and monthly care plan audits by the senior team.

Action Taken (AI summary) Mirus Wales has taken action by removing key storage from unlocked locations and reinforcing medication policies and training.

Action Taken (AI summary) The MPS will include more specific wording in the MPS Police Driver and Vehicle Policy – Vehicle and Equipment SOP in relation to the use of warning equipment around vulnerable road users and pedestrians, and will undertake a review of the Policy.