(S) December 2013 (C) January 2014

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1 Action Identified Lead Timeframe Evaluation RAG Rating 1. Training 1.1 Complete a TNA in relation to all community and Hospital staff. The TNA will outline different methods and levels of training for ALL staff involved in delivering patient care (This will include training to support dressings December 2013 The TNA is currently being developed and will be agreed at the January 2014 meeting. An interim evaluation of training undertaken across the divisions to date outlining % and equipment choice). 1.2 Work with Learning and Development to ensure robust reporting processes are in place to measure completion of training in line with the developed TNA. 1.3 Review Manual Handling training across the organisation. 1.4 Review training and processes in place to support Bariatric patients accessing services across the Trust. Carol Le Blanc Learning and Development Karen Woodward, Manual Handling Lead Karen Woodward, Manual Handling Lead (S) January 2014 (S) February 2014 (C) March 2014 of staff has been completed. Meetings have been undertaken with the Nurse Consultant and Learning and development to identify the processes needed. No Update for December this work will commence in January 2014 No Update for December this work will commence in February 2014 Beverley Tabernacle, Deputy

2 2. Risk Assessment Process 2.1 Review the current Risk assessment processes across Hospital and Community Services. 2.2 Implementation of standardised documentation across all areas of the organisation (Body Maps, Waterlow, nutrition assessment, turning clocks) 2.3 Review processes for the risk assessment of pressure reliving equipment across the hospital and community. Ruth Hodgkinson, Community Equipment Lead A new process of risk identification is currently being tested in the District Nursing service. Evaluation of this will be presented at the January 2014 meeting The TV Team have reviewed and standardised the current documentation and developed and implemented a new turning clock and turning guidance for all areas. This is supported in the community by new guidance for care workers in relation to turning. Meeting have been undertaken with Talley the provider for Hospital equipment. A review undertaken of community equipment will be discussed at the January 2014 meeting Beverley Tabernacle, Deputy

3 3. Delivering Care 3.1 Review the processes in place for assessing and supporting the needs of the patient with continence issues (This will include a review of product selection) 3.2 Review the current link nurse structure ensuring that processes are fit for purpose in relation to supporting and updating this group of staff. 3.3 Implementation of the Better Care Together boards so staff are aware of their performance in relation to preventing pressure ulcers. 3.4 Review escalation processes in relation to pressure ulcers ensuring clear lines of responsibility and accountability are outlined. Professional Leads/ Clinical Managers Work has commenced to look at the continence assessment and product selection process for patients. Attend all in one products have been removed from use from all wards and departments The review of the link nurse structure has been commenced Trust Board agreed the go ahead for the Better Care Together Boards at the November Board Clear escalation processes have been put in place for district nursing teams and safety huddles are currently being tested led by the Team Managers 4. Equipment 4.1 Review the current Beverley Tabernacle, Deputy

4 budgets in relation to the rental of special mattresses across the organisation. 4.2 Review the current budget in relation to the provision and decision making process for prescribing dressings review the wound care formulary. 4.5 Set up regular monitoring meetings with TALLEY to ensure that scrutiny of the rental process is in place. 5. Harm Free Care Panels 5.1 Develop TOR for the HFC Panels 5.2 Develop reporting processes to ensure that themes are captured and reported through the PUP steering group and actioned. (C) December 2013 Ongoing. Increased scrutiny of the rental process. For November 2013 this has resulted in a 10000K reduction in spend Ongoing Ongoing Complete Under Development 5.3 Develop data reporting systems for the PUP group in Pat Graham Patient Safety Manager Under Development Beverley Tabernacle, Deputy

5 order to capture improvements in outcomes. Janet Heaton, Information Services Beverley Tabernacle, Deputy

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