Action Plan. Requirements Action Planned Timescale Responsible Person

Transcription

1 Action Plan Service Name: Spire Murrayfield (Edinburgh) Service number: Service Provider: Spire Healthcare Ltd Address: 122 Corstorphine Road, Edinburgh EH12 6UD Inspector: Winifred McLure Date Inspection Concluded: 11 th May Requirements Action Planned Timescale Responsible Person Quality Statement 0.2 Requirements The provider must: 1 make it clear on all public facing documentation that Healthcare Improvement Scotland are the regulator for independent healthcare services in Scotland and can accept complaints at any time. This should also include our full name, address, telephone number and address on documentation and website Business Development Manager to review leaflet and make amends in line with guidance issued by HIS. 21 Jerrot Sawden Produced by: Susan Higgins Page:1 of 5 Review Date:

2 Quality Statement 3.2 Requirements The provider must: 2 ensure that all staff carrying out regulated work are enrolled in the Protecting Vulnerable Groups (PVG) Scheme Quality and Compliance Manager to ensure all remaining Consultants are enrolled in the PVG scheme 21 Norma O Hare Recommendations Action Planned Timescale Responsible Person Quality Statement 0.3 Recommendations We recommend a ensure that consent to share information is recorded Information held about you) Business Development Manager to liaise with Head Office and legal team to review corporate patient registration form to reflect consent to share information with all key parties. Jerrot Sawden Quality Statement 1.4 Recommendations We recommend that the service should: b make sure staff have medicines training and competencies updates in line with their policy Pharmacy Manager to formalise medicines management training for all clinical staff. Review of all medicine management competencies and ensure Produced by: Susan Higgins Page:2 of 5 Review Date: Lynda Robertson/ Flower

3 20.1 Medicines Management updates are completed Quality Statement 1.5 c make sure that patient care records are completed consistently in line with the hospitals policy 14.5 Information held about you) To review the process for ensuring timely insertion of the clinic letter into the medical record prior to patient admission. To continue to actively encourage use of the single patient record for all consultants. To ensure care pathway contains single point of record in relation to VTE risk assessment and prophylactic management. Flower / Sandra Bladon Quality Statement 2.4 d improve the storage of items in the theatre department 13.1 Prevention of infection) To review current storage provision within the theatre environment and forward plan for additional storage capacity. Ken Hay / Alison Green e carry out a risk assessment to Risk assessment to be carried out by Theatre Alison Green / Rob Produced by: Susan Higgins Page:3 of 5 Review Date:

4 identify any risks associated with a shared theatre preparation rooms 13.2 Prevention of infection) Manager in conjunction with Lead Engineer to identify any potential risks and actions required in having a shared theatre prep room Kidd Quality Statement 3.2 f ensure the staff handbook for nurses and healthcare workers are kept up to date workers 10.7-Staff) Quality Statement 4.3 Review current induction handbook and ensure all changes of personnel and information is updated and reviewed regularly Flower / Ward Sisters Quality Statement 4.3 g carry out regular staff surveys 12.3-Clinical effectiveness) To carry out a local staff engagement survey in the interim period while the corporate survey is being reviewed. Alison Green / Jerrot Sawden Name Alison Green Designation Head of Clinical Services Produced by: Susan Higgins Page:4 of 5 Review Date: Signature Date

5 13 / 06 / In signing this form, you are confirming that you have the authority to complete it on behalf of the service provider. Produced by: Susan Higgins Page:5 of 5 Review Date: