14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.
15. We have set out below the actions the Trust has taken in response to the issues it identified. We asked our adviser whether the actions taken by the Trust would be likely to prevent a similar failing from reoccurring. We also asked whether there was evidence to show the action had been taken, and whether there was sufficient monitoring to ensure the improvement is maintained. We have included their observations below.
16. Ms M’s complaint to the Trust included concerns there was no clear policy or training for staff in dealing with dementia patients.
17. The Trust acknowledged failings in the care provided to Mrs L. It said staff working in its frailty wards and in same day emergency care had undergone training relating to dementia awareness. This training was also being encouraged across all clinical areas. The Trust also provided a ‘mobile dementia tour’ for staff to help improve practice.
18. The Trust has also put in place dementia specific training, sepsis and safeguarding training. The Speech and Language Therapy team are providing training specific to feeding difficulties. The Trust is putting in place ongoing training to reinforce the importance of individualised care.
19. The dementia lead is responsible for ensuring staff attend essential to role dementia awareness training. The Trust made the essential to role dementia awareness training mandatory, and by March 2025, reported 96.5% compliance with training.
20. Our advisor told us these actions address the issue of training. They have said it should be recognised that organising and implementing training takes time. It also takes time to roll training out to staff whilst still ensuring the ongoing provision of 24/7 care. Essentially, staff training has to be staggered to allow staff to attend.
21. Ms M also complained staff did not have a full picture of individual dementia patient’s needs and there was a failure of systems and processes.
22. The Trust has purchased dementia friendly cups and plates and implemented dementia symbols (forget-me-nots) in frailty handovers. It also improved signage on doors and in corridors to help guide patients with cognitive impairments.
23. The Trust also explained it was recruiting a dementia lead to improve the care provision for patients with dementia and their carers. Patients who are admitted with dementia or challenging behaviour are identified on the clinical system and can then be reviewed by the Dementia Lead.
24. The dementia lead is responsible for auditing improvements. Our advisor told us this should be sufficient to ensure improvements are maintained
25. Ms M complained again after Mrs L was admitted to the Trust. This complaint raised similar issues. She referred to her previous complaint and explained she had seen no evidence of improvements since she first complained to the Trust
26. The Trust response notes it implemented a 24/7 outreach service for staff to escalate any concerns about patients. The Trust was working to expand this to obtain information about a patient’s condition directly from them or family members daily, which is currently being implemented.
27. Our adviser has noted here that work is still ongoing here. All the actions and improvements referred to by the Trust recognise and adhere to the NMC Code, which says nurses should work with people to ensure they deliver care effectively and should maintain the knowledge and skills they need for safe and effective practice.
28. Our Principles of Good Administration say organisations should do what they say they will do. This means if an organisation commits to doing something they should keep to it. Our Principles for Remedy say putting things right may include changes to procedures or staff training to ensure the poor service is not repeated.
29. We have not seen any indication to suggest the Trust has not implemented the actions it promised to. The information we have seen shows the Trust identified failings in the care it had provided to Mrs L, and it acknowledged and apologised for these. This appears to be in line with our Principles of Good Administration.
30. We can see the Trust has implemented improvements following Ms M’s complaints, and it is continuing to put these in place. We are satisfied the actions the Trust has set out are sufficient to prevent something similar from happening again This appears to be in line with our Principles of Good Administration, as it has put in place service improvements to ensure the poor service is not repeated.
31. We understand witnessing concerning events so soon after her complaint to the Trust was upsetting for Ms M and has caused her real concern.
32. Systemic changes cannot always be made immediately as it takes time to put training and new systems in place. We know this does not change Ms M’s experience but hope she understands the Trust is taking the appropriate action to implement improvements.
33. We thank Ms M for bringing her concerns to us. We hope our statement reassures her that the Trust has made improvements since she complained about the care her mother received from the Trust, and that these improvements should be maintained.