Pressure Points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes'
|
|
- Joanna Christal Pierce
- 5 years ago
- Views:
Transcription
1 Pressure Points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes' Jill Manthorpe & Stephen
2 Dramatic images Cruel care home owner and nurse who left elderly and vulnerable people in their care in agony with bedsores (Mail Online 2013).
3 Serious Case Reviews to Safeguarding Adult Reviews (local) Safeguarding Adults Board must arrange for there to be a review of any case in which (a) an adult in the SAB s area with needs for care and support (whether or not the local authority was meeting any of those needs) was, or the SAB suspects that the adult was, experiencing abuse or neglect, and (b) the adult dies or there is reasonable cause for concern about how the SAB, a member of it or some other person involved in the adult s case acted. (see Care Act 2014 & Guidance)
4 This presentation Covers a set of Serious Case Reviews of incidents in care homes where pressure ulcers were discussed Briefly describes pressure ulcers Explains why a pressure ulcer is not inevitably a matter that should be reported to Adult Safeguarding Analyses what the Reviews found
5 Pressure ulcers Pressure ulcers also known as pressure sores, decubitus ulcers or bedsores Painful and distressing yet, in many circumstances, preventable or treatable Approx. 700,000 people in the UK are affected annually, - 20% of long-term care residents are at risk.
6 What s a pressure ulcer? A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (European Pressure Ulcer Advisory Panel 2009). UK grades pressure ulcers 1-4 (4 = most severe) NICE (2014) recommends using a validated scale to assess ulcer risk and support their clinical judgement, eg Braden scale, Waterlow score, or Norton risk assessment scale
7 Change under Care Act The simple fact that an adult at risk has a pressure ulcer even a serious one is not in itself a reason to suspect abuse or neglect. (SCIE 2015).
8 What SCRs found: Pressure ulcers amid poor care quality This SCR found poor training and inadequate multi-agency responses to tissue viability concerns. It recommended that selffunders must receive appropriate support from social work staff and other professionals, including contract monitoring staff. It led to a Council review of care homes and suspension of funding until acceptable standards were operating. (Bedford Borough & Central Bedfordshire Safeguarding Adults Board 2009a) (BBCB).
9 Mr S multiple PU (died post infection) The coroner described the nursing care received as woefully inadequate and death was for want of care by those charged with it. SCR recommended that Policy and procedures for tissue viability should be reviewed. (BBCB 2009b)
10 The failing home Amidst a catalogue of problems, a high incidence of pressure sores was noted by the SCR (2 deaths). Actions of visiting professionals criticised, eg Community Nursing Service; Adult Community Services; GPs (9); police; ambulance service; local Partnership Trust; and the inspectorate failing to recognise problems: All failed to be eyes and ears for safeguarding. Pressure ulcers were not proved to be the cause of death, but provided cause for concern about institutional neglect
11 Orchid View (2014) This investigation focused on a similar range of poor practices as those in previous investigations with residents with pressure sores, poor quality dressings, low staffing levels, staff sleeping at night and rudeness towards residents (p45). And relatives often notice: Mr D had been in Orchid View for some 2 weeks for respite when he was taken to hospital, and he died shortly afterwards. Both his wife and their friend expressed their concerns that a pressure sore had developed while he was at the home.
12 But some people ARRIVE with pressure ulcers Adult B - SCR Nottingham 2011 Main recommendation = single robust assessment process and better cooperation between health and social care, with the view that an overall care coordinator could have improved the assessment process and reduced the risks for Adult B. Staff completing tissue viability care plans were recommended to follow best practice guidelines.
13 & some homes find it hard to cope In BL staff were not competent to correctly assess risks, identify controls or carry out evaluations (re major needs). Risk assessments did not cover areas eg moving and handling or sufficient details around pressure care. Systems for audit, monitoring and compliance of risk assessments were not evident.
14 Support for/within homes Some failings in multiagency working as well as problems with individual practices. Other themes include not adhering to NICE guidance and delays in response. Relatives may have concerns that pressure ulcers were not being managed appropriately.
15 Conclusion 1 High risks of pressure ulcers among care home residents thus making problems in care quality particularly serious for residents. Problems in prevention and treatment are not solely attributable to care home staff but to the extent to which they are supported by NHS professionals, and the wider problems of the sector which make communication, information sharing, accountability and resource provision difficult.
16 Conclusions 2 SCRs and SARs are likely to be more common following the Care Act are care homes ready in case? But main lessons learned from SCRs/SARs around pressure ulcers relate to internal safeguards and external supports
17 Key resource
18 Acknowledgement & disclaimer We acknowledge funding from the NIHR Policy Research Programme. The views expressed here are those of the authors and not the NIHR.
Appendix Five Decision Pathway Pressure Ulcers and safeguarding Adults (A3 format)
Appendix Five Decision Pathway Pressure Ulcers and safeguarding Adults (A3 format) Pressure ulcer is observed. Concern is raised that a person has significant skin damage. Category / Grade 3 and 4 or Multiple
More informationAppendix 5. Safeguarding Adults and Pressure Ulcer Protocol: Deciding whether to refer to the Safeguarding Adults Procedures
Appendix 5 Safeguarding Adults and Pressure Ulcer Protocol: Deciding whether to refer to the Safeguarding Adults Procedures Safeguarding Adults and Pressure Ulcer Protocol: Deciding whether to refer to
More informationPressure Ulcers ecourse
Pressure Ulcers ecourse Module 1: Introduction Handout College of Licensed Practical Nurses of Alberta (Canada) CLPNA.com and StudywithCLPNA.com CLPNA Pressure Ulcers ecourse Module 1: Introduction Page
More informationAdult Practice Review Report
Adult Practice Review Report North Wales Safeguarding Adults Board (NWSAB) Concise Adult Practice Review Re: APR2/2016/Conwy 1. Brief outline of circumstances resulting in the Review 1.1 Patient A died
More informationPressure ulcers: revised definition and measurement. Summary and recommendations
Pressure ulcers: revised definition and measurement Summary and recommendations June 2018 We support providers to give patients safe, high quality, compassionate care within local health systems that are
More informationSafeguarding Children Annual Report April March 2016
Safeguarding Children Annual Report April 2015 - March 2016 Report Author: Andrea Anniwell, Interim Named Nurse for Safeguarding Children Date: April 2016 1 CONTENTS SECTION PAGE 1 Introduction 3 2 Overview
More informationThe West Sussex Safeguarding Children Board s Response to SCR O Serious Case Review
The West Sussex Safeguarding Children Board s Response to SCR O Serious Case Review Introduction by independent Chair This tragic case centred on a concealed pregnancy and the subsequent death of a new
More informationPressure Ulcers (pressure sores)
Pressure Ulcers (pressure sores) How to reduce the risk of acquiring pressure sores in hospital Other formats If you need this information in another format such as audio tape or computer disk, Braille,
More informationDate of publication:june Date of inspection visit:18 March 2014
Jubilee House Quality Report Medina Road, Portsmouth PO63NH Tel: 02392324034 Date of publication:june 2014 www.solent.nhs.uk Date of inspection visit:18 March 2014 This report describes our judgement of
More informationStrengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU)
Strengthen Patient Care by Reducing Hospital Acquired Pressure Ulcers (HAPU) Nihar Bhatia Head Quality Assurance & Fortis Operating System and Prateem Tamboli, Facility Director, Fortis Escorts Hospital
More informationPressure Ulcers The BHTA guide to prevention and cash releasing savings
Pressure Ulcers The BHTA guide to prevention and cash releasing savings Pressure Ulcers: The BHTA guide to prevention and cash releasing savings In the UK, around 400,000 individuals develop a new Pressure
More informationPRESSURE ULCER PREVENTION SIMPLIFIED
10 PRESSURE ULCER PREVENTION SIMPLIFIED This simplified leaflet is intended to give you information about pressure ulcer and aid your clinical practice PRESSURE ULCER PREVENTION SIMPLIFIED Pressure ulcer
More informationENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report
ENCLOSURE: J Date of Trust Board 29 February 2012 Title of Report Purpose of Report Abstract Pressure Ulcer Clinical Improvement Programme This paper provides a progress report on our work in support of
More informationMERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY
MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY Date of Meeting: 29 th September 2016 Agenda No: 6.7 Attachment: 11 Title of Document: Safeguarding Adults Quarter 1 Report (April June 2016) Report Author:
More informationsample Pressure Sores Prevention & Awareness Copyright Notice This booklet remains the intellectual property of Redcrier Publications L td
First name: Surname: Company: Date: Pressure Sores Prevention & Awareness Please complete the above, in the blocks provided, as clearly as possible. Completing the details in full will ensure that your
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationSAFEGUARDING ADULTS AT RISK IN LONDON
SAFEGUARDING ADULTS AT RISK IN LONDON - A STOCKTAKE REPORT TO SUPPORT THE SAFEGUARDING ADULT SUMMIT STEPHAN BRUSCH NHS England [London Region] TABLE OF CONTENTS Forward Introduction Executive Summary Learning
More informationSafeguarding Vulnerable Adults Annual Report
Safeguarding Vulnerable Adults Annual Report 2014-2015 Author: Margaret Jolley, Head of Adult Safegaurding & Vulnerable Adults 1 Contents Executive Summary 3 Introduction 3 Responsibilities 3 Reporting
More informationVision 3. The Strategy 6. Contracts 12. Governance and Reporting 12. Conclusion 14. BCCG 2020 Strategy 15
Bedfordshire Clinical Commissioning Group Quality Strategy 2014-2016 Contents SECTION 1: Vision 3 1.1 Vision for Quality 3 1.2 What is Quality? 3 1.3 The NHS Outcomes Framework 3 1.4 Other National Drivers
More informationSafeguarding Adults. Annual Report
APPENDIX I Safeguarding Adults Annual Report 2009 2010 Authors Neil Boyland Sue Leathers 1. Definition All persons have the right to live their lives free from violence and abuse. This right is underpinned
More informationInformation For Patients
Information For Patients Pressure Ulcers (A test to examine the arteries that supply blood to the heart) Liverpool Heart and Chest Hospital NHS Foundation Trust Thomas Drive Liverpool Merseyside L14 3PE
More informationPrevention and Management of Pressure Ulcers
EWMA Educational Development Programme Curriculum Development Project Education Module: Prevention and Management of Pressure Ulcers Latest revision: October 2015 ABOUT THE EWMA EDUCATIONAL DEVELOPMENT
More informationOrchid View. Serious Case Review June 2014
Orchid View Serious Case Review June 2014 Orchid View Serious Case Review June 2014 1 Contents Acknowledgements 3 Executive Summary 4 Findings and recomendations 6 1. Introduction 17 Orchid View 17 Southern
More informationHow to Prevent Pressure Ulcers. Advice for Patients and Carers
How to Prevent Pressure Ulcers Advice for Patients and Carers This booklet contains the best advice currently available to help people avoid getting a pressure ulcer. It is for people who are at risk
More informationSafeguarding Adults Reviews Protocol
Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adults Reviews Protocol July 2016 SAR Process July 2014 (revised July 2016) Page 1 Contents 1. Introduction 2. Criteria
More informationThe implications of the Francis Report for Adult Safeguarding. Jill Manthorpe
The implications of the Francis Report for Adult Safeguarding Jill Manthorpe What would this assignment look like in 2050? Write a letter to Nurse Ratchet from One Flew over the Cuckoo s Nest highlighting
More informationStaffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adult Reviews (SAR) Protocol
Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adult Reviews (SAR) Protocol SAR Process July 2014 (revised August 2017) Page 1 Contents 1. Introduction 2. Criteria 3.
More informationReduce the Pressure Assess the Risk. Ian Bickerton International Manager Posture and Pressure Care Product Specialist
Reduce the Pressure Assess the Risk Ian Bickerton International Manager Posture and Pressure Care Product Specialist INVACARE UK & MSS Manufacturing facility Pencoed, near Cardiff, Wales Estimate
More informationOrchid View. One year on
Orchid View One year on 2 This report incorporates the comments and views of the relatives at the Orchid View workshop held on 26 June 2015. 3 Contents 01 Foreword 02 Introduction 03 Actions taken to achieve
More informationSafeguarding Children & Young People
Safeguarding Children & Young People Author: Responsibility: Helena Hughes, Designated Nurse Dr Wendy Kuriyan, Designated Doctor Dr Abdullah Khan, Named GP All Staff Effective Date: January 2014 Review
More informationShaping the future CQC s strategy for 2016 to 2021
Shaping the future CQC s strategy for 2016 to 2021 CQC is the independent regulator of health and adult social care in England. We make sure health and social care services provide people with safe, effective,
More informationOur next phase of regulation A more targeted, responsive and collaborative approach
Consultation Our next phase of regulation A more targeted, responsive and collaborative approach Cross-sector and NHS trusts December 2016 Contents Foreword...3 Introduction...4 1. Regulating new models
More informationPRESSURE ULCERS: PREVENTION USING RISK ASSESSMENT
PRESSURE ULCERS: PREVENTION USING RISK ASSESSMENT Some patients will be more at risk than others of developing pressure damage. Using a pressure ulcer risk assessment tool will help identify those at risk
More informationEnsuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS
Ensuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS April 2017 Contents Page 1. Purpose 2 2. Key Functions 2 3. Governance and Administrative
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationCLINICALRESEARCH & DEVELOPMENT
CLINICALRESEARCH & DEVELOPMENT Improving policy and practice in the prevention of pressure ulcers Ayello, E.A. (3) Predicting pressure ulcer sore risk. National Association of Directors of Nursing Administration
More informationDRAFT ADULT SAFEGUARDING POLICY
DRAFT ADULT SAFEGUARDING POLICY Version 2.0 Status Comments from discussion at Quality, Safety and Clinical Risk Committee meeting on 21 November incorporated Author Jude Channon Senior Responsible Officer
More informationIndependent investigation into the death of Mr Jan Gillett a prisoner at HMP Norwich on 14 December 2016
Independent investigation into the death of Mr Jan Gillett a prisoner at HMP Norwich on 14 December 2016 Crown copyright 2015 This publication is licensed under the terms of the Open Government Licence
More informationSafeguarding Adults Annual Report
Safeguarding Adults Annual Report 2017-2018 Trust Board Item: 17 Date: 11 th July 2018 Purpose of the Report: Enclosure: M The purpose of this annual report is to inform members of the Trust Board of the
More informationTRUST BOARD 22 December Nursing, Quality & Patient Experience Directorate. TISSUE VIABILITY Update and Ambition
TRUST BOARD 22 December 26 Nursing, Quality & Patient Experience Directorate TISSUE VIABILITY Update and Ambition Executive Summary The aim of the Tissue Viability Service is to provide specialist assessment
More informationSAFEGUARDING ADULTS STRATEGY
SAFEGUARDING ADULTS STRATEGY Originator: Corporate Nursing Date Approved: May 2009 Approved by: Safeguarding Committee Date for Review: May 2011 Contents Page 1. Introduction 3 1.1 Vision 3 1.2 Scope 3
More informationLEARNING FROM SARS: A REPORT FOR THE LONDON SAFEGUARDING ADULTS BOARD
LEARNING FROM SARS: A REPORT FOR THE LONDON SAFEGUARDING ADULTS BOARD SUZY BRAYE AND MICHAEL PRESTON-SHOOT 18 th July 2017 Contents Executive summary... 2 1. Introduction... 8 2. Methodology... 9 3. The
More informationDraft Commissioning Intentions
The future for Luton s primary care services Draft Commissioning Intentions 2013-14 The NHS will have less money to spend over the next three years. Overall, it has to make 20 billion of efficiency savings
More informationPressure Injuries. Care for Patients in All Settings
Pressure Injuries Care for Patients in All Settings Summary This quality standard focuses on care for people who have developed or are at risk of developing a pressure injury. The scope of the standard
More informationPressure Ulcer Prevention
Information for patients This leaflet can be made available in other formats including large print, CD and Braille and in languages other than English, upon request. This leaflet has been adapted from
More informationSafeguarding Adults Policy
Safeguarding Adults Policy Ratified Status Quality and Patient Safety Committee V2 Issued November 2015 Approved By Consultation Equality Impact Assessment Quality and Patient Safety Committee Safeguarding
More informationReducing Avoidable Heel Pressure Ulcers through education/active monitoring
Reducing Avoidable Heel Pressure Ulcers through education/active monitoring United Lincolnshire Hospitals NHS Trust Mark Collier, Lead Nurse - Tissue Viability United Lincolnshire Hospitals NHS Trust mark.collier@ulh.nhs.uk
More informationHome Care: potential and paradox a case study of England
Home Care: potential and paradox a case study of England Jill Manthorpe Professor of Social Work @scwru PART 1: POLICY AND CONTEXT Home care mostly local government commissioned but not provided Assessment
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationImplementing bulk prescribing for care home patients
Bulletin 66 May 2014 Community Interest Company Implementing bulk prescribing for care home patients There are many patients in care homes taking medicines when required (prn), and this inevitably presents
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support The Open and Honest Care: Driving Improvement organisations to become more transparent
More informationSafeguarding Adults Board Business Plan
Safeguarding Adults Board Business Plan 2014-16 Objectives 1 Improve the standards of care to support the dignity and quality of life of vulnerable people in receipt of health and social care, including
More informationSafeguarding Adults & Mental Capacity Act (2005) Annual Report 2016/17
Safeguarding Adults & Mental Capacity Act (2005) Annual Report 2016/17 Author: Candy Gallinagh Designated Nurse for Safeguarding Adults Supported by: Soline Jerram, Director of Clinical Quality & Patient
More informationQuality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement
Quality Accounts: Corroborative Statements from Commissioning Groups Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The primary
More informationCWHHE CCG Collaborative Safeguarding Annual Report December 2016
CWHHE CCG Collaborative Safeguarding Annual Report 2015-16 23 December 2016 Written and compiled by: Assistant Director for Safeguarding Contributions from the Designated Nurses for; Central London CCG
More informationPractice Guidance: Large Scale Investigations
Practice Guidance: Large Scale Investigations Version: Version 1: April 2014 Ratified by: Leeds Safeguarding Adults Board Date ratified: April 2014 Author/Originator of title Safeguarding Policy, Protocols
More informationUNDERSTANDING THE NEW CRIMINAL OFFENCES CREATED BY THE MENTAL CAPACITY ACT 2005
UNDERSTANDING THE NEW CRIMINAL OFFENCES CREATED BY THE MENTAL CAPACITY ACT 2005 Jill Manthorpe & Kritika Samsi Social Care Workforce Research Unit King s College London Mental Capacity Act 2005 Aims to
More informationWe are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.
Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Brambles Care Home Birchfield Road, Redditch, B97 4LX Tel: 01527555800
More informationBOARD OF DIRECTORS. Quality. n/a. For information and assurance
BOARD OF DIRECTORS Meeting Date and Part: 30 September 2016 Part 1 Subject: Section on agenda: Supplementary Reading (included in the Reading Pack): Officer with overall responsibility: Author(s) of papers:
More informationNHS Isle of Wight Clinical Commissioning Group: Governing Body
NHS Isle of Wight Clinical Commissioning Group: Governing Body Date of Meeting: 21 March 2013 Agenda Item: 7.1 Paper number: GB13/027 RESPONSE TO THE FRANCIS REPORT Sponsor: Dr John Partridge, Clinical
More informationSkills Passport. Keep this Skills Passport in your Personal & Professional Development File (PPDF)
Skills Passport - NURSING BSc (Hons) / M Nurs in Nursing Studies / Registered Nurse Skills Passport Student s Name: Cohort: Guidance Tutor Group: Keep this Skills Passport in your Personal & Professional
More informationStockport All Agency Safeguarding Adult Review (SAR) Protocol
Stockport All Agency Safeguarding Adult Review (SAR) Protocol Operational from the 1 st May 2015 Introduction The Care Act Statutory Guidance sets out the procedures that Stockport Safeguarding Adults
More informationCHILD DEATH OVERVIEW PANEL. East Sussex and Brighton & Hove Fourth Annual Report to
CHILD DEATH OVERVIEW PANEL East Sussex and Brighton & Hove Fourth Annual Report 01-04-12 to 31-03-13 1. The Child Death Overview Panel (CDOP) is the inter-agency forum that meets regularly to review the
More informationCompetency Statement: Pressure Ulcer Management Competency Indicators 1 st Level
Competency Statement: Pressure Ulcer Management 1 st Level 2 nd Level 3 rd level 4 th level. Risk Assessment a) Explain the principles of prevention. b) Discuss the importance of skin assessments on admission.
More informationTrust Board meeting: Wednesday 8 th May2013 TB
Trust Board meeting: Wednesday 8 th May2013 Title Pressure Ulcer Prevention Report Status History A paper for information N/A Board Lead(s) Mrs Elaine Strachan-Hall, Chief Nurse Key purpose Strategy Assurance
More informationGuidance on End of Life Care-Updated July 2014
Guidance on End of Life Care-Updated July 2014 INTRODUCTION Definition of End of Life Care: End of Life care helps all those with advanced, progressive, incurable illness to live as well as possible until
More informationCARERS WELCOME PACK COMMUNITY MENTAL HEALTH DIVISION
CARERS WELCOME PACK COMMUNITY MENTAL HEALTH DIVISION Contents WELCOME CARE, TREATMENT AND SUPPORT FOR SERVICE USERS CARER S SUPPORT NATIONAL AND LOCAL CARERS SERVICES CARING IN A CRISIS INFORMATION SHARING
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support The Open and Honest Care: Driving Improvement organisations to become more transparent
More informationh. HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST LEARNING FROM DEATHS POLICY. Broad Recommendations / Summary
201 2017.473h. HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST LEARNING FROM DEATHS POLICY Broad Recommendations / Summary In-hospital death occurs. Patient 18 years of age or above. Yes Child Death Review
More informationIncident & Serious Incident Policy/Procedure
Incident & Serious Incident Policy/Procedure 1 SUMMARY This policy and procedure details the approved requirements for the identification, notification, investigation, action planning/ implementation,
More informationUse and views of the Mental Capacity Act 2005
Use and views of the Mental Capacity Act 2005 Kritika Samsi, Jill Manthorpe Social Care Workforce Research Unit King s College London Programme of Research Mental Capacity Act Introduction to : Evidence-based
More informationSafeguarding Adults Protocol
Safeguarding Adults Protocol Pressure Ulcers and the interface with a Safeguarding Enquiry 1 1 Under Section 42 of the Care Act 2014 October 2017 Contents 1. Introduction 2 2. Aim 4 3. Scope 5 4. Impact
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationPOLICY FOR PREVENTION, MANAGEMENT AND REPORTING OF PRESSURE UILCERS
POLICY FOR PREVENTION, MANAGEMENT AND REPORTING OF PRESSURE UILCERS Guideline Reference: 1692 Version: 2.3 Status: Adopted Type: Clinical Policy Guideline applies to (Staff Group) All West Suffolk Hospital
More informationTissue Viability Service
Oxford Health NHS Foundation Trust Tissue Viability Service Tissue Viability Service Tissue Viability Service What is the Tissue Viability Service? The Tissue Viability Service is nurse led and provides
More informationREPORT TO MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY
REPORT TO MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY Date of Meeting: 26 November 2015 Agenda No: 6.2 Attachment: 06 Title of Document: Adult Safeguarding Annual Report 2014/15 Purpose of Report:
More informationTop 12 Courses for Newcross Nurses and HCAs BETTER PEOPLE BETTER TRAINED
Top 12 Courses for Newcross Nurses and HCAs BETTER PEOPLE BETTER TRAINED Top 12 Courses for Newcross Nurses and HCAs Contents Venepuncture Syringe Drivers Catheterisation Medication Training Wound Care
More informationIndependent Investigation Action Plan for Mr L STEIS Ref No: 2014/7319. Report published: NHE to complete
Independent Investigation Action Plan for Mr L STEIS Ref No: 2014/7319 Statement from Oxleas NHS Foundation Trust The Trust would like to offer sincere condolenses to the family and friends of Mr Parsons.
More informationThe Development and Benefits of 10 Year s-experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust
Pressure Ulcer Incidence: The Development and Benefits of 10 Year s-experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust Introduction In settings without any systematic, on-going
More informationThe Journey towards zero avoidable pressure ulcers
The Journey towards zero avoidable pressure ulcers Annette Bartley RGN MSc MPH Quality Improvement Consultant Health Foundation/Institute for Healthcare Improvement Quality Improvement Fellow Understanding
More informationBirmingham Safeguarding Adults Board. Executive Summary
Birmingham Safeguarding Adults Board A Serious Case Review in Respect of A2 Executive Summary Steve Harris, Chair of Serious Case Review Panel Jane Lawson, Report Author 16 th August 2012 1 Birmingham
More informationNHS WIRRAL SAFEGUARDING CHILDREN ANNUAL REPORT
NHS WIRRAL SAFEGUARDING CHILDREN ANNUAL REPORT 1 st APRIL 2011 31 st MARCH 2012 BACKGROUND All NHS bodies have a statutory duty to make arrangements to safeguard and promote the welfare of children under
More informationCare Quality Commission (CQC) Inspection Briefing
Care Quality Commission (CQC) Inspection Briefing The CQC exists to make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective,
More informationSFHCHS4 Undertake tissue viability risk assessment for individuals
Undertake tissue viability risk assessment for individuals Overview This standard covers undertaking risk assessment in relation to pressure area care and the risk of skin breakdown. This assessment will
More informationA Prudent Approach to Health: Prudent Health Principles
A Prudent Approach to Health: Prudent Health Principles 1. Summary The following paper sets out the Bevan Commission s final advice on the Prudent Health Principles to the Minister for Health and Social
More informationThis paper provides an update on the the recent national SPSP conference the programme of work for Tissue Viability Acute Adult Care SPSP
Greater Glasgow and Clyde NHS Board Board Meeting December 2016 Board Paper No. 16/81 Scottish Patient Safety Programme Update 1. Background The Scottish Patient Safety Programme (SPSP) is one of the family
More informationSAFEGUARDING ADULTS COMMISSIONING POLICY
SAFEGUARDING ADULTS COMMISSIONING POLICY Director Responsible: Responsible person Target Audience: Name of Responsible Committee Nursing Matt O Connor Safeguarding Adults Lead All NHSBA staff and contractors
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent and consistent in publishing safety, experience
More informationSocial care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1
Managing medicines in care homes Social care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
More informationSafeguarding Adults and Pressure Ulcer Protocol DECIDING WHETHER TO REFER TO SAFEGUARDING ADULTS
Safeguarding Adults and Pressure Ulcer Protocol DECIDING WHETHER TO REFER TO SAFEGUARDING ADULTS Contents page Page number Introduction 3 Aim of the Protocol 3 Purpose of the Protocol 3-6 How to use the
More informationA concern means any complaint, claim or reported patient safety incident.
PUTTING THINGS RIGHT ANNUAL REPORT -2017 Introduction The Putting Things Right Annual Report provides information on the progress and performance of Powys Teaching Local Health Board (hereafter, the health
More informationSafeguarding Strategy
1 Safeguarding Strategy 2017-2020 2 Contents Section Page No. 1 1.1 1.2 2.0 2.1 Introduction Legal Framework for Safeguarding What does Safeguarding cover? Our Duties Statutory Compliance for Safeguarding
More informationWound Care and. February Lymphoedema Service
Wound Care and February 2016 Lymphoedema Service Contents Introduction... 2 About the service... 2 Service provision... 2 Advice, education and training... 4 Service locations and hours of operation...
More informationThe state of health care and adult social care in England 2015/16 Care Quality Commission 13 October 2016
The state of health care and adult social care in England 2015/16 Care Quality Commission 13 October 2016 The annual State of Care report, out today (Thursday 13 October) reports excellent examples of
More informationSafeguarding Children Annual Report
Safeguarding Children Annual Report Reporting period April (2014) End March (2015) Julie Adesanya Designated Nurse Safeguarding Children/Children in Care Diana Jellinek Designated Doctor Safeguarding Children/
More informationMortality Report Learning from Deaths. Quarter
Mortality Report Learning from Deaths Quarter 3 2017 Introduction In December 2016 the CQC report Learning, Candour and accountability: A review of the way NHS Trusts review and investigate the deaths
More informationSafeguarding Annual Assurance Self-assessment Tool. Sheffield Health and Social Care NHS Foundation Trust
Safeguarding Annual Assurance Self-assessment Tool Sheffield Health and Social Care Foundation Trust Introduction - About this Self-assessment This self-assessment is an assessment of your own internal
More informationJuly- December Training Programme. Dumfries DG1 3SJ. Venue: Dumfries Enterprise Park, Tinwald Downs Road,
Training Programme July- December 2018 Venue: Dumfries Enterprise Park, Tinwald Downs Road, Dumfries DG1 3SJ 01387 249111 www.caretrain.co.uk info@caretrain.co.uk Moving and Handling Courses Moving and
More informationInformation on How to Prevent Pressure Ulcers ( Bedsores ) for Patients, Relatives and Carers in Hospital and in the Community
Information on How to Prevent Pressure Ulcers ( Bedsores ) for Patients, Relatives and Carers in Hospital and in the Community Tissue Viability Team Community & Therapy Services This leaflet has been designed
More informationHOSPITAL DISCHARGE FOLLOW UP REPORT: NOVEMBER 2016
HOSPITAL DISCHARGE FOLLOW UP REPORT: NOVEMBER 2016 Following on from the Healthwatch Special Inquiry into hospital discharge which took place during July and August 2014 and the subsequent Healthwatch
More information