Care plan failures
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
33 items
1 source
8 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
R5 - Named person for care plans
Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant MDT and sign off the final decision. (And see Recommendation 99 (R99) below.)
Matched on
terms: care, plan
Inquiry recommendation
83match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: care, plan
Inquiry recommendation
83match
LAMI-64 - Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Matched on
terms: care, plan
Inquiry recommendation
82match
R12 - Person-centred care plans with family involvement
Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans should be shared with the service user themselves (where appropriate) and families, who should be able to challenge...
Matched on
terms: care, plan
Inquiry recommendation
82match
COVID-M3.9 - Standardised Advance Care Planning
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients' wishes and preferences for future care and treatment in order to...
Matched on
terms: care, plan
Inquiry recommendation
82match
R18 - Care planning system
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Matched on
terms: care, plan
Inquiry recommendation
78match
R15 - Independent care plan reviews
Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be regular independent reviews overseen by the Public Health Agency (PHA) to assess any deviation from best practice, both...
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(37) - Prepare and periodically review leaving care plans for all looked after children
A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for further support.
Matched on
terms: care, plan
Inquiry recommendation
78match
WATE-(34) - Designate social worker responsible for care plan implementation and child supervision
An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Matched on
terms: care, plan
Inquiry recommendation
73match
R16 - Missed care incident reporting
If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
Matched on
terms: care, plan
Inquiry recommendation
66match
WATE-(31) - Require comprehensive child needs assessment before admission to care
Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Matched on
terms: care
Inquiry recommendation
65match
R6 - Named person approval for transfers
The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to the Trust in which they are cared for. This approval must be recorded in the healthcare notes.
Matched on
terms: care, plan
Inquiry recommendation
65match
WATE-(12) - Safeguard field social worker's responsibilities for placement supervision and care planning
Any arrangements made for the provision of residential care or fostering services should expressly safeguard the field social worker's continuing responsibilities for supervision of the placement and care planning.
Matched on
terms: care, plan
Inquiry recommendation
60match
R24 - TVN instructions recorded
Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
Matched on
terms: care, plan
Inquiry recommendation
60match
6 - Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and...
Matched on
terms: care, plan
Inquiry recommendation
57match
WATE-(38) - Extend local authority duty to provide parental-level support for care leavers
The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so as to ensure that placing authorities provide the level of support to be expected of good parents, including...
Matched on
terms: care
Inquiry recommendation
53match
WATE-(36) - Provide facilities and encourage acquisition of independent living skills in care settings
The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.
Matched on
terms: care
Inquiry recommendation
52match
R30 - Fluid balance monitoring
Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
Matched on
terms: care
Inquiry recommendation
48match
R22 - Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Matched on
terms: care
Inquiry recommendation
48match
WATE-(35) - Ensure foster carers receive continuing support and access to specialist services
Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Matched on
terms: care
Inquiry recommendation
48match
WATE-(45) - Require social worker assessment and inter-departmental consultation before residential school placement
Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of the child's needs and family situation is needed as well as an educational assessment; and (b) in the...
Matched on
terms: plan
Inquiry recommendation
45match
WATE-(32) - Follow emergency child admissions with comprehensive assessment within prescribed period
All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Matched on
classifier match
Inquiry recommendation
44match
R39 - DNAR decision awareness
Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Matched on
terms: care
Inquiry recommendation
39match
F236 - Identification of who is responsible for the patient
Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.
Matched on
terms: care
Inquiry recommendation
39match
7 - Audit maternity and paediatric services
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be in place by September 2015.
Matched on
terms: care
Inquiry recommendation
36match
R27 - Positional change records
Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Matched on
classifier match
Inquiry recommendation
36match
R26 - Wound documentation
Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
Matched on
classifier match
Inquiry recommendation
36match
WATE-(39) - Require fostering services to monitor, analyse, and report placement breakdowns periodically
Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director of Social Services.
Matched on
classifier match
Inquiry recommendation
34match
IBI-9d - Haemophilia Centre Resources
The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they involve patients in their discussions.
Matched on
terms: care
Inquiry recommendation
32match
WATE-(40) - Develop key indicators to monitor compliance with safeguards for looked after children
Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review requirements; and (d) rota visits by elected members.
Matched on
classifier match
Inquiry recommendation
27match
R28 - Nutritional screening
Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Matched on
classifier match
Inquiry recommendation
22match
IBI-10a(iv) - Thalassaemia Society Support
Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Matched on
classifier match
Inquiry recommendation
18match
IBI-2c - Community Support Events
There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
Matched on
classifier match