Improvement Action Plan Declaration It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that the actions are measurable, timely and will deliver sustained improvement. Actions should be implemented across the NHS board, and not just at the hospital inspected. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above. A representative from Patient/Public Involvement within the NHS should be involved in developing the improvement action plan. NHS board Chair NHS board Chief Executive Signature: Signature: Full Name: Full Name: Date: Date: Ref. Action Planned Timescale to meet action Responsibility for taking action Progress Date Completed Requirements Screening and Initial Assessment 1. NHS Grampian must ensure that all older people who are admitted to hospital are accurately assessed within the national standard recommended timescales. This includes nutritional screening and assessment, falls assessments, moving and handling assessments and pressure ulcer risk assessment. Produced by: NHS Grampian Page: Page 1 of 9 Review Date: 16 weeks following inspection 1
There must be evidence of reassessment, where required. 1.1 NHS Grampian response: The Care Assurance and Reflection Tool (CART) is used across all adult acute inpatient areas and this includes the monitoring of documentation relevant to the monthly topic. Each inpatient area completes five each month and if themes are identified, quality improvement methodology utilised to achieve sustainable improvement. The Senior Charge Nurses can choose to complete additional sections if they identify any issues. A Short Life Working Group will be established to review the validity of documents used by NHSG relating to differing timescales for screening and assessments (in line with patient safety and reducing variation). The aim is to create a consistent holistic approach to screening across all acute adult inpatient areas. Working with the Professional Practice, Workforce & Education Chief Nurse and the Grampian Nutritional Care Group, a programme of education will be created in order to raise awareness of current national assessment and screening standards to ensure practice is undertaken effectively The CART will be reviewed for the need of an additional page to audit the accurate completion of all documents listed above. This would be completed for the 5 CARTs per month to either provide assurance or direct improvements required. 30/06/2019 30/06/2019 Produced by: NHS Grampian Page: Page 2 of 9 Review Date: 16 weeks following inspection 2
Learning from the report will be shared at a NHSG Acute Shared Learning Event in order to highlight the findings of the report to the multidisciplinary teams. NHS Grampian must ensure that do not attempt 2 cardiopulmonary resuscitation (DNACPR) certificates are fully and accurately completed. This is to comply with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy- Decision Making and Communication (2016). 2.1 NHS Grampian response: Safety and quality medical leads have been appointed in NHSG and one of their roles will be to present a Quality Improvement action plans for certain items. A quality improvement action plan will be developed for DNACPR with subsequent consultation and agreement with medical management team at a Divisional Clinical Director/Unit Clinical Director meeting. 30/04/19 Deputy Medical Director for Acute Sector/ Divisional Clinical Director Medicine The agreed action plan will be implemented and regular audits will be completed in order to assess improvement. Person- centred care planning 3 NHS Grampian must ensure that for patients assessed as not having capacity to make decisions, the principles of the Adults with Incapacity (Scotland) Act 2000 are applied. This includes ensuring full and accurate completion of AWI certificates. This is to comply with the Adults with Incapacity (AWI) (Scotland) Act 2000 part 5- Medical Treatment and Produced by: NHS Grampian Page: Page 3 of 9 Review Date: 16 weeks following inspection 3
Research; and Care of Older People in Hospital Standards (2015) criteria 3.4 and 3.5. 3.1 NHS Grampian response: Safety and quality medical leads have been appointed in NHSG and one of their roles will be to present a Quality Improvement action plans for certain items. A quality improvement action plan will be developed for the accurate completion of AWI certificates with subsequent consultation and agreement with medical management team at a Divisional Clinical Director/Unit Clinical Director meeting. The agreed action plan will be implemented and regular audits will be completed in order to assess improvement. 4 NHS Grampian must ensure that patients have personcentred care plans in place for all identified care needs. These should be regularly evaluated and updated to reflect changes in the patient s condition or needs. The care plans should also reflect that patients are involved in care and treatment decisions. This is to comply with The Code: Professional Standards of Practise and Behaviour for Nurses and Midwives (Nursing Council, 2015); Care of Older People in Hospital Standards (2015) criteria 1.1, 1.4, and 11.2a; and Food, Fluid and Nutritional Care Standards (2014) criterion 2.9a. NHS Grampian response: Following the successful rollout of the patient admission assessment record (PAAR), the next focus for document development is a daily patient centred care plan that focuses on what the patient needs today. 30/04/19 Deputy Medical Director for Acute Sector/ Divisional Clinical Director/Unit Clinical Director Medicine Produced by: NHS Grampian Page: Page 4 of 9 Review Date: 16 weeks following inspection 4
Work is ongoing to develop the care plan document and an implementation plan is in place that will commence in April 2019. The rollout will be similar to the PAAR with ongoing support for clinical areas. 30/04/19 for roll out across NHSG for 31/08/20 Food, fluid and nutrition 5 NHS Grampian must ensure that food record and fluid balance charts are commenced and accurately completed for patients who require them. This includes the recording of oral nutritional supplements. Appropriate action must be taken in relation to intake or output as required. This is to comply with Food, Fluid and Nutritional Care Standards (2014) Criterion 4.1(g). Working with the Professional Practice, Workforce & Education Chief Nurse and the Grampian Nutritional Care Group, a programme of education will be created in order to raise awareness of the current standards for the accurate completion of food record and fluid balance charts to ensure documentation is completed accurately. Learning from the report will be shared at a NHSG Acute Shared Learning Event in order to highlight the findings of the report to the multidisciplinary teams. A new Nutritional Support record has been developed and has been trialled in a number of areas in the Acute sector. This has shown early signs of improvement. Roll out for the organisation will be complete by April 2019. 30/06/2019 30/04/2019 Produced by: NHS Grampian Page: Page 5 of 9 Review Date: 16 weeks following inspection 5
6 NHS Grampian must ensure that staff can deliver safe and effective falls prevention and management. This includes ensuring that a person- centred falls care plan is fully completed. This is to comply with Care of Older People in Hospital Standards (2015) criteria 11.4 and 11.5. NHS Grampian response: There has been a significant improvement in the assessment of falls risk for patients and subsequent falls reassessments where required. Falls As part of CART, falls documentation will continue to be reviewed with appropriate feedback to point of care teams to increase compliance. All patients who have a fall in hospital have the completed paperwork checked by a Nurse Manager or a Chief Midwife with feedback provided back to the team on the quality. A multi-professional team will review all falls with harm that have occurred over the past three months to identify any themes and any areas for improvement Ongoing Ongoing Produced by: NHS Grampian Page: Page 6 of 9 Review Date: 16 weeks following inspection 6
7 NHS Grampian must ensure that the SSKIN bundles are consistently and accurately completed to ensure that the frequency of repositioning is indicated and the results of skin inspection are documented. This is to comply with Best Practise Statement for the Prevention and Management of Pressure Ulcers (2009) Section 5. NHS Grampian response: This work is fully supported by the Tissue Viability Team across all inpatient areas. Pressure Area Care NHSG is working on introducing a new document, SSKIN. This has been adapted from NHS Greater Glasgow and Clyde documentation. The SSKIN document is currently being used in conjunction with the Waterlow document in identified clinical areas. From March 2019 the plan is to transfer from Waterlow Document to the SSKIN document in a phased manner if all testing goes as planned. Patients will have the SSKIN document applied on initial admission assessment and evidenced in the self-care section of the PAAR. 8 NHS Grampian must ensure that wound assessment charts are in place for those patients with a known pressure ulcer or break in skin integrity to support Produced by: NHS Grampian Page: Page 7 of 9 Review Date: 16 weeks following inspection 7
safe and effective care delivery. This must include recording the grade of any pressure ulcers and a clear plan of management. This is to comply with Best Practise Statement for the Prevention and Management of Pressure Ulcers(2009), Section 4; and The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (2015), sections 8.2, 10.2 and 10.4. NHS Grampian response: This work is fully supported by the Tissue Viability Team across all inpatient areas. NHSG is working on introducing a new document, SSKIN. This has been adapted from NHS Greater Glasgow and Clyde documentation. During the implementation process of the new SSKIN daily risk assessment tool there will be opportunities to ensure the wound assessment and measurements are correctly documented. Tissue Viability team will provide ongoing education and support of the SSKIN bundle and the change to new bespoke care planning. This is to ensure that staff are completing the wound assessment charts as part of wound management. This change will be discussed at a number of meetings: NHSG Nursing & Midwifery Quality of Care and Standards Council (November 2019). Senior Nurse Leadership Team (March 2019) Acute Nurse Manager Meeting (March 2019) Produced by: NHS Grampian Page: Page 8 of 9 Review Date: 16 weeks following inspection 8
Acute Senior Charge Nurse Council(March 2019) Produced by: NHS Grampian Page: Page 9 of 9 Review Date: 16 weeks following inspection 9