NTW(C)18 Group Nurse Director Safer Care

Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Tissue Viability Policy NTW(C)18 Group Nurse Director Safer Care Kevin Chapman Tissue Viability Modern Matron Business Delivery Group Date ratified November 2016 Implementation date November 2016 Date of full implementation November 2016 Review Date November 2019 Version Number V04.2 Review and Amendment Log Version Type of change Date V04 Review Nov 16 Description of change Updated sections; 1, 3, 4, 5, 7, 10-12, 16. V04.1 Update Sept 17 Update due to clinical transition V04.2 Update Sept 17 Inclusion of TV-PGN-05 This policy supersedes Reference Number Title NTW(C)18 V04 Tissue Viability Policy

NTW (C) 18 Tissue Viability Policy Section Contents Page No: 1 Introduction 1 2 Trust Statement 1 3 Tissue Viability Structure 2 4 Duties and responsibilities 3 5 Access to Tissue Viability Services 6 6 Training and Education 7 7 Identification of Stakeholders 8 8 Definition of Terms 8 9 Equality and Diversity 9 10 Implementation 8 11 Monitoring compliance 8 12 Standard/Key Performance Indicators 9 13 Fair Blame 10 14 Fraud and Corruption 10 15 Associated documentation 10 16 References 10 Standard Appendices attached to policy Appendix A Equality and Diversity Form 11 Appendix B Communication and Training Checklist & Needs Analysis 14 Appendix C Audit and Monitoring Tool 16 Appendix D Policy Notification Record Sheet - click here

NTW (C) 18 Practice Guidance Note documentation listed separate to policy PGN No: Description Version / Issue Issue Date Review Date TV-PGN-01 Access to Tissue Viability V01 Apr 15 Apr 18 Appendix 1 Contact Information Issue 1 Apr 15 Apr 18 Appendix 2 Tissue Viability Referral Form 1 Apr 15 Apr 18 TV-PGN-02 Pressure Ulcer Care V02 Issue 1 Nov 16 Nov 19 Appendix 1 Appendix 2 Guidance for completing Braden Scale on RiO The European Pressure Ulcer Advisory Panel classification system Issue 1 Nov 16 Nov 19 Issue 1 Nov 16 Nov 19 Appendix 3 Repositioning Chart Issue 1 Dec 13 Dec 16 TV-PGN-03 Aseptic Non Touch Technique V01 Jan 16 Jan 19 TV-PGN-04 Wound Care Assessment V01 Jul 16 Jul 19 Appendix 1 Wound Assessment, Intervention and Evaluation of Care Plan Issue 1 Jul 16 Jul 19 Appendix 2 Key for Wound Re-assessment Issue 1 Jul 16 Jul 19 TV-PGN-05 Entonox Clinical use during wound management by the Tissue Viability Nurses V01 Issue 1 Sep 17 Sep 20

Background The Tissue Viability Nursing Service is available to offer support and advice to Patients, their relatives and carers, health care professionals and the Trust. In support of this policy a set of Practice Guidance Notes (PGN s) have been developed to support the implementation, treatment, monitoring and management of evidence based interventions Collaboration remains of high importance to strengthen continuity and ultimately quality of patient care. The Tissue Viability Practice guidance notes are to be utilised across the Trust and should offer a structured approach to patient care and assist practitioners in the clinical decision-making process. Clinical decisions made by the practitioner should also take into account the individual circumstances of the patient, the clinical setting of the interventions, where possible patient preferences, available resources, local knowledge, risk management and more recent developments or research within tissue viability. NTW(C)18 Tissue Viability V04.2 Sep 17

1 Introduction 1.1 In response to understandable public and professional concerns about the Identification, treatment, management and monitoring of Tissue Viability issues especially those related to pressure ulceration in the United Kingdom (UK), the provision of a robust Tissue Viability service to the Trusts patient group is now regarded as a high priority area for the National Health Service (NHS). 1.2. This importance has been reinforced by the introduction of key performance targets for NHS to identify and reduce the incidences of avoidable harm as a direct result of pressure damage. This is reflected in The Commissioning for Quality and Innovation (CQUIN) and Quality, Innovation, Productivity and Prevention (QIPP) performance targets and the introduction of the safety thermometer and is further reinforced by Standard 6 of Essence of Care 2010 Benchmarks for the prevention and management of pressure ulcers. (DH, 2010) 1.3. All NHS organisations must also be prepared to respond to incidents that may have serious long term healthcare implications for their patient group. Requirements for this are set out in NICE guidelines 179 and subsequent Quality Standard 89. 1.4. Mental Health Trusts are not immune from such incidents and indeed in some instance issues relating to Tissue Viability and pressure care may be compounded by the underlying co morbidities of the patient group. It is therefore essential that they work closely with Trust departments and other organisations in preventing and where necessary responding to incidents. 2 Trust Statement 2.1 The (the Trust/NTW) are committed to the prevention of and effective management of Tissue Viability and pressure care throughout the organisation. 2.2 In order to achieve this, the Trust will put in place a clinical and managerial infrastructure to support the prevention and effective management of Tissue Viability that accords with national and local guidance and conforms to current best practice in the area. 2.3 The Trust will ensure that this infrastructure is supported by the resources required to meet these objectives. 2.4 The Trust recognises that Tissue Viability cannot be delivered without the involvement and commitment of all staff, regardless of role. Therefore all staff will accept personal responsibility for delivering effective Tissue Viability/pressure care supported by policy, practice guidance notes, adequate specialist knowledge, equipment, resources and training where appropriate. 1

3 The Trust Tissue Viability Structure NTW Director of Infection Prevention and Control NTW Tissue Viability Modern Matron IPC Modern Matrons (Triage/Facilitative Role Out of hours, TVN sickness / holidays) Memorandum of Understanding or Service level Agreements South Tyneside Foundation Trust Northumbria Healthcare NHS Foundation Trust Newcastle upon Tyne Hospitals NHS Foundation Trust Trust wide Link Practitioner Network Trust wide Physical Health Link Network 3.1 The Trust's Tissue Viability structure will comprise the following components - The Chief Executive of the Trust (CEO) The Executive Director of Nursing and Operations and Chief Operating Officer of NTW (DoN) The Board of The Director of Infection Prevention and Control (DIPC) - Line manager for TVN The Trust wide lead for Tissue Viability 3.2 Within the Trust the Tissue Viability function will be represented on the following committees and groups - 2

The Trust wide Quality and Performance Committee Each Groups Quality and Performance Committees The Trust wide Clinical Risk Management/Patient Safety Committee The Trust wide Health and Safety Committee Each Group s Business Meeting North East Region Tissue Viability Specialist group where all Trusts benchmark their performance against key performance indicators and where best practice is shared and lessons learnt Other groups as appropriate 3.3 The designate Managerial lead for Tissue Viability will be facilitated by the Director of Infection Prevention and Control (DIPC) who will monitor and manage the performance and delivery of Tissue Viability services across the Trust and report key performance data to the Board of Directors. 3.4 The Trust's provision of Tissue Viability structure may be supported by Memorandum s of Understanding or Service Level Agreements with the following agencies Acute hospital Trusts - Specialist support and advice outside of the clinical skills of the trust lead provider Acute hospital Trusts - For additional holiday/sickness cover (Max 2 weeks) 3.4.1 These arrangements are reported in the annual report of the Tissue Viability Lead which is presented to the Board of Directors 4 Duties and Responsibilities 4.1 The Chief Executive is responsible for ensuring that an appropriate and adequate infrastructure exists to support the provision of Tissue Viability services throughout the organisation. 4.2 The Executive Director of Nursing and Chief Operating Officer of NTW Ensure that all Medical and Nursing staff are aware of this policy and other policies and guidance which relate to this policy Ensure that adequate training is given to allow medical and nursing staff to implement this policy safely Executive Director of Nursing and Chief Operating Officer briefs the Board of Directors on all aspects of Tissue Viability and the performance of the Trust in relation to national standards and targets 4.3 The Director of Infection Prevention and Control (DIPC) will assume the following roles and responsibilities: 3

To approve the appointment of the Tissue Viability Modern Matron DIPC is responsible for the strategic and operational management of the Trust Tissue Viability Lead To formally review, on at least an annual basis, the arrangements for Tissue Viability within the Trust To formally receive and review the Annual Report of the Tissue Viability Lead and communicate their findings directly to the Board To receive and review regular reports on any Tissue Viability/Pressure care incidents occurring within the Trust To monitor any budget/financial expenditure to ensure effective use of available resources and financial prudence 4.4 The responsibilities of the Planned, Urgent and Specialist Care Groups will be: To lead the implementation across the Trust of Tissue Viability and Pressure care measures, which incorporates best practice and evidence based research To support the Tissue Viability lead in working towards the implementation of standards and strategies as defined by the Department of Health and where necessary developing action plans for implementation with the organisation To promote communication and engagement with staff at all levels of the organisation in respect of best practice in the prevention, management and monitoring of Tissue Viability and pressure care To support the provision of the trust-wide link practitioner network to ensure ward based continuity of wound/pressure care 4.5 The roles and responsibilities of the Tissue Viability Modern Matron (Or Nominated Deputy) will be to Oversee local control of Tissue viability policies and associated Practice Guidance notes and monitor their implementation Have the authority to challenge inappropriate clinical practice Assess the impact of all existing and new policies and plans and make recommendations for change, where indicated Be an integral member of the organisation s clinical governance and patient safety teams and structures Provide appropriate and up-to-date clinical advice on Tissue Viability matters to staff, within the constraints of available resources and time Promote Tissue Viability throughout the Trust by working with Groups as part of the integrated governance system and supporting clinical staff of all grades Assessing the need for, and provide an ongoing programme education and training to staff 4

Undertake routine monitoring and surveillance of incidents relating to Tissue Viability and pressure care across the Trust Undertake routine and occasional audits in accordance with the annual audit programme as identified in annual work plan key performance indicators Work proactively with other agencies to identify best practice and understand lessons learnt relating to tissue viability and pressure care Advise the DIPC and Board of Directors on the current state of Tissue Viability in the Trust Report any breaches of policy/guidance or failure of adherence to standards to appropriate Groups Cooperate fully in and where appropriate lead on the investigation, management and analysis of incidents relating to Tissue viability and pressure care The Trust will ensure that there is access to a properly supported and trained Tissue Viability lead The provision of Tissue Viability advice will be provided either by staff directly employed by this Trust, by means of a Memorandum of Understanding with another Trust or by a combination of the two methods. These arrangements will be formally reviewed and agreed at least annually by the Board of Directors The Tissue Viability lead will be supported with appropriate secretarial and clerical support, secure office and storage space, access to IT services (including email, intranet and internet access), specialised equipment and other general resources as required to perform its functions The Tissue Viability lead will have access to educational, training and development opportunities sufficient to ensure that they remain up to date and informed about current issues and can fulfil the ongoing educational requirements of their professional bodies The Infection Prevention and Control Modern Matrons will support the TVN during periods of annual leave/sickness by triaging staff enquiries and issues relating to Tissue Viability and where necessary and appropriate facilitating access to support, advice or treatment via existing Memorandum of Understanding 4.6 The roles and responsibilities of the manager of a patient area (any area where service users normally and routinely attend for assessment, investigations or treatment, including wards, day units, community units, physical treatment centres etc.) will be to Ensure that standards relating to the identification and management of tissue viability related issues and pressure care are implemented in the patient area Ensure that all staff working in the patient area (including bank, locum and other temporary staff, and including non-clinical as well as clinical staff) are aware of their personal responsibility to identify and manage 5

pressure care and issues relating to tissue viability. In particular this involves o o o Being familiar with, and adhering to specific policy and practice guidance Participating in training (where appropriate) Reporting all Tissue Viability/pressure ulcer incidents in a timely manner and in-line with Trust reporting procedures Ensure that service users and visitors have access to advice and support as needed on issues relating to tissue viability, wound care and pressure care Ensure that all routine and occasional audits relating to Tissue Viability/pressure care are completed accurately and returned in a timely manner Report any breaches of policy/guidance or failure of adherence to standards to the Clinical Nurse Managers and Tissue Viability team Cooperate fully in the investigation, management and analysis of episodes of avoidable harm, including root cause analysis and after action reviews 4.7 All Trust staff - (clinical and non-clinical, including locum and agency staff) have a personal responsibility to ensure that the risk of pressure damage to service users, minimised by ensuring that they Are familiar with, and adhere to, current Trust policy and guidance That the Trust s policy, NTW(C)18 - Tissue Viability policy, includes relevant practice guidance notes (i.e. pressure ulcer management) Participate in relevant education and training as pertinent to their grade, job role and professional responsibilities 5 Access to Tissue Viability Advice Staff wishing to refer clients to Tissue Viability should refer to practice guidance note attached to this policy, TV-PGN-01 for information and referral forms. The DIPC will ensure that appropriate Trust Policy (this document), and Practice Guidance Notes (PGN s) giving practical advice on general Tissue Viability precautions and procedures is developed, reviewed and maintained Practice Guidance Notes form part of the Trust s Tissue Viability policy, and it is expected that staff will follow the guidance contained within them unless there is a compelling reason to deviate from it. Such reasons should be documented whenever the circumstance occurs and notified to the Tissue Viability team so that modifications to future editions can be made if necessary 6

The DIPC/Tissue Viability team will publish and distribute current arrangements for accessing advice relating to Tissue viability as a Practice Guidance Note. The Guidance Note will incorporate the arrangements for contacting the lead and contingencies in the event of out of hours, sickness or holiday enquiries Because of the rapidly changing nature of advice relating to Tissue Viability, amendments and additions to the Practice Guidance Notes will be made as and when necessary at the discretion of the Tissue Viability lead. Any significant changes will be reported to the Trust wide Safer Care Group and physical health and well-being group 6 Training and Education Tissue Viability and topics associated with it (Pressure care, wound care, pressure relieving equipment, compression therapy etc) will be provided: Training to staff across NTW will be facilitated by the Trust team for Tissue Viability, where necessary and appropriate they will involve external specialists to assist this process To nominated Tissue Viability link practitioner staff, initially a two day induction training followed by regular updates provided by the Tissue Viability team or appropriate external provider On an ad-hoc basis to specific clinical staff depending on the topic and complexity of the subject and specific client issues A training package is to be developed and delivered Trust wide once agreed. This to include access to relevant E-learning resources where agreed as appropriate and validated. A variety of formats will be developed, which may including face-to-face sessions, E-learning and patient information leaflets etc Additional training will be offered for staff wishing to develop greater skills and knowledge in Tissue Viability, or in response to an identified need Records of training will be held centrally for the purpose of audit and within departments for the purposes of local monitoring and appraisal/ personal development plans 7 Identification of Stakeholders North Locality Care Group Central Locality Care Group South Locality Care Group Corporate Decision Team Business Delivery Group Safer Care Group 7

Communications, Finance, IM&T Commissioning and Quality Assurance Workforce and Organisational Development NTW Solutions Local Negotiating Committee Medical Directorate Staff Side Internal Audit 8 Definition of Terms used CEO Chief Executive of NTW Trust CQUIN The Commissioning for Quality and Innovation DoN Executive Director of Nursing and Chief Operating Officer of NTW Trust DH Department of Health DIPC Director of Infection Prevention & Control IT Information Technology NTW Northumberland Tyne and Wear NHS Foundation Trust PGN Practice Guidance Note QIPP Quality, Innovation, Productivity and Prevention 9 Equality and Diversity Assessment 9.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 10 Implementation 10.1 Taking into consideration all the implications associated with this policy, it is considered that a target date of November 2016 is achievable for the contents to be embedded within the organisation. 11 Monitoring Compliance 11.1 Surveillance and Monitoring of Incidents The Trust will monitor the incidence, prevalence and patterns of avoidable harm occurring through the following means 8

o Routine reporting of incidents according to local policy and process o Reporting of serious and untoward incidents according to local policy and process o Routine collection of data by the Tissue Viability team using nationally recognised tools such as the safety thermometer, pressure ulcer data collection tool etc. This information will be fed back to appropriate Committees and groups through routine SAFEGUARD reports, the Serious Incidents reporting mechanism, and the Annual Report 11.2 Audit and Assurance Framework 11.2.1 The implementation of Tissue Viability arrangements and practice guidance notes will be audited through the following processes The Tissue Viability team will undertake occasional audits as part of the annual audit programme as identified in the annual work programme. 11.2.2 Assurance on the state of Tissue Viability in the Trust will be delivered by the following routes:- Through a range of Trust wide and local governance groups pertinent to the topics covered. I.e. Physical health group, patient safety, medical devices group The Tissue Viability team will produce and monitor an annual work and audit programme Quality and Performance Groups within clinical Groups (In-patient and Specialist) will receive routine reports on incidents and issues relating to Tissue Viability and in particular pressure ulcers. This may include analysis of incidents, training figures and compliance with policies and practice guidance notes as identified through other audits The Tissue Viability team will produce and disseminate as appropriate an annual report and occasional additional reports at the request of specialist groups or in response to incidents 11.2.3 The Annual Report will also include the annual work plan for the forthcoming year, together with progress achieved against previous work plans 11.2.4 Improvements to care following the implementation of this guideline are subject to regular feedback and audit. Audit will follow the National Institute for Care Excellence, Clinical Guidelines 7 and 29. 12 Standard/Key Performance Indicators 12.1 The service user care plan will document the Category/Stage of pressure ulcer 9

12.2 A pressure ulcer of Category 2 or above will be documented as a clinical incident and reported via the Trusts electronic reporting systems. (See NTW(O)05 Incident Policy) Local Authority safeguard reporting should take place in line with local policy using their designated documentation. 12.3 Service users admitted with pressure ulcers will have these assessed within the parameters of national guidance or agreed local protocol. 12.4 Service users with pressure ulcers or who have been assessed as being at risk will receive appropriate pressure relieving support surface or strategies. 12.5 Service users with Category 1-2 pressure ulcers will receive high specification foam mattresses/cushions, and will have a documented repositioning programme; exceptions to this will be recorded with rationale. 12.6 Service users with Category 3-4 pressure ulcers will have alternating overlay or sophisticated low pressure support as a minimum and closely observed; exceptions to this will be recorded with rationale. 12.7 Pressure ulcers will be treated with modern wound dressings which are documented in the service user s care plan. 12.8 Service users and carers should receive information about pressure ulcers in a range of formats to suit their needs. 13 Fair Blame 13.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 14 Fraud and Corruption 14.1 In accordance with the Trust s policy NTW(O)23 Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance. 15 Associated documentation Part of NTW(C)18 Tissue Viability Policy, practice guidance notes o TV-PGN-01 Access to Tissue Viability Advice o TV-PGN-02 Pressure Ulcer Care o TV-PGN-03 Aseptic Non-Touch Technique [ANTT] o TV-PGN-04 Wound Assessment NTW(O)01 Development and Management of Procedural Documents 16 References 10

1 Cullum N, Deeks J, Sheldon TA, Song F and Fletcher AW (2002) Beds, Mattresses and Cushions for Pressure Sore Prevention and Treatment. The Cochrane Library http://gateway1.ovid.com/ovidweb.cgi 2 Department of Health (2001) The Essence of Care HMSO. London 3 National Institute for Clinical Excellence (2014) Pressure Ulcers: Prevention and management.cg179 National Institute for Clinical Excellence, London. https://www.nice.org.uk/guidance/cg179 4 Roycroft-Malone J, and McInnes E. (2000) Pressure Ulcer Risk Assessment and Prevention. Technical Report. RCN, London. http://www.rcn.org.uk/professional/clinical_downloads/pressure_ulcer_risk _assess_1.pdf 5 Dixon J, Cranny G, Iglesias C, Nelson E, Hawkins K, Phillips A, Torgerson D, Mason S and Cullum N (2006) Radomised controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial, British Medical Journal, Vol. 332. 1413-1415. 6 Fader M, Bain D and Cottenden A (2003) Pads and Pressure: an investigation into the effects of absorbent incontinent pads on pressure management mattresses. Poster presentation. Tampere 2003. 7 European Pressure Ulcer Advisory Panel (1998). Pressure Ulcer Treatment Guidelines. [online] [1 st June 2007]. http://www.epuap.org/gltreatment.html 8 Wong V.K and Stotts N.A (2003). Physiology and Prevention of Heel Ulcers: The state of science. Journal Wound Ostomy Continence Nursing 30(4): 191-198. Department of Health (2010) Essence of Care: Benchmarks for the prevention and management of pressure ulcers. [Online] Accessed 27/09/16 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2166 99/dh_119979.pdf National Institute for Health and clinical Excellence (2015) Quality Standard 89, [Online] accessed 27/09/16. https://www.nice.org.uk/guidance/qs89 11

Appendix A Equality and Diversity Impact Assessment Screening Tool Names of Individuals involved in Date of Initial Review Date Service Area / Review Screening Directorate Chris Rowlands 2019 Trust wide Policy or Service to be Assessed Is this a new or Existing NTW(C)18 Tissue Viability - V04.1 existing Policy or Service? Describe the aims, objectives or purposes of the Policy or Service Are there any associated objectives of the Policy or Service? If so what are they? The viability of body tissue is essential if the patient is to avoid additional pain, infection and possible mortality from the effects of ulcers and wounds. Those patients who do develop ulcers or have chronic wounds potentially increase these levels of risk to them and pose a risk of litigation to the Trust. This policy seeks to minimise the occurrence of ulcers and wounds and to dictate the effective monitoring, management and treatment of such occurrences for service users of the Trust. Does the policy unlawfully discriminate against equality target groups? Does the policy promote equality of opportunity for equality target groups? Does the policy or service promote good relations between different groups within the community, based on mutual understanding and respect? No the policy recognises the potential for a negative differential impact linked to the following intrinsic risk factors: Reduced mobility or immobility Sensory impairment Acute illness (including cognitive health needs) Level of consciousness Sex, extremes of age, communication needs Vascular disease Severe chronic or terminal illness Previous history of pressure damage Malnutrition and dehydration Therefore there is potential for a negative impact for the following strands. Age, Disability, Race, Religion/Faith. The policy recognises that a diversity of needs should be met. The policy requires staff to be mindful of equality and diversity issues - staff will ask patient s if there are any issues in relation to age, gender, ethnicity and culture, religion, disabilities, sexual orientation that they would like to be considered. 12

Equality and Diversity Impact Assessment Screening Tool Which equality target groups of the population do you think will be affected by this policy or function? Equality Target Group (code in bold type) Black and Minority Ethnic People (including gypsy/travellers, refugees and asylum seekers) BME Women and Men WM What positive and negative impacts do you think there may be for each equality target group(s)? There maybe some negative differential impacts in relation to race or ethnicity (Including cultural beliefs and norms) in delivering services within diverse communities regarding the wound care products used as they may not be acceptable if they include animal products. Need to ensure that catering provides culturally sensitive options that are supportive to meeting the nutritional requirements for tissue viability. Requirement for gender sensitivity. Issue of transgender needs to be considered. People in Religious/Faith groups RF As for BME population Disabled People DP Older People OP Need to provide information about tissue viability in an accessible format. Clear need to monitor patients at greater risk such as those presenting with diabetes. As for Disability Children C Communication issues Young People YP Communication issues Lesbian Gay Bisexual and Transgender People LGBT People involved in the criminal justice system CJS Staff S NA NA NA Any other group(s) AOG 13

Equality and Diversity Impact Assessment Screening Tool Screening Tool Checklist : Summary Sheet Positive Impacts (Note the code of groups affected) Negative Impacts (Note the code of groups affected) See comments above Additional Information and Evidence Required Recommendations Issues raised suggest that a full impact assessment would be useful to give consideration to the communication issues raised and to establish effective links with other identified policy/function areas. From the outcome of the Screening, have negative impacts been identified for race or other equality groups? Yes No If yes, has a Full Impact Assessment been recommended? If not, why not? Yes The production of guidance notes will form the focus of a full impact assessment. Once compiled, these notes will be provided to a cross-section of service users in a consultation meeting. Manager s signature: Chris Rowlands Date November 2016 14

Appendix B Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc. Please identify the risks if training does not occur Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning Existing Policy To make healthcare staff aware of the issues involved in patients with tissue viability problems in order to avoid suffering, harm, infection and mortality. NICE clinical guideline standards. CQUIN targets Safety thermometer EPUAP guidelines Nominated Tissue Viability link practitioners will be offered initial 2 day inductions as they represent direct link between TVN and wards. All other Nursing, medical and AHP staff working with clients vulnerable to pressure damage or wounds will have the chance to attend open sessions Nominated Tissue Viability link practitioners will be offered initial 2 day inductions as they represent direct link between TVN and wards. All other Nursing, medical and AHP staff working with clients vulnerable to pressure damage or wounds will have the chance to attend open sessions Management cascade Tissue Viability Lead to offer specific departmental training as need indicates. Link practitioner cascade TVN led Awareness sessions Training and education in pressure ulcer risk assessment and prevention Open sessions + departmental specific Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. Ward and Associate Directors. 15

Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training Inpatient services - Qualified Nursing Unqualified Nursing Medical AHP Tissue Viability Link practitioners Awareness of: The Policy NICE / EPUAP Guideline on pressure ulcer assessment and prevention Recognition of risk factors that lead to pressure ulcers Initiation and maintenance of preventative measures Assessment of pressure ulcers, their grading and their treatment/on-going care Specific 2 day induction training, followed by regular bi-monthly updates and training. 3 yearly On-going Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact:- 0191 245 6770 (internal 56770) 16

Statement Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. NTW(C)18 Tissue Viability Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Frequency/Method/Person Responsible Where results and any associated action plan will be reported to implemented and monitored; (this will usually be via the relevant governance group). 1. The individual s care plan contains a classification/ grade of pressure ulcer, which should be accessible to all members of the multidisciplinary team As clinically indicated/named Nurse/Ward Team Issues related to client care will be documented in Rio or associated Trust approved documents. Relevant incidents will be reported via appropriate Group,(Urgent, Planned, Specialist), patient safety group, physical health group. 2. A pressure ulcer identified as Category 2 or above is documented as a clinical incident and reported according to trust policy via the web-based reporting system/safeguard alert As clinically indicated, via safeguard/named Nurse/ward Team/TVN Notified Issues related to client care will be documented in RiO or associated Trust approved documents. Relevant incidents will be reported via appropriate Group,(Urgent, Planned, Specialist), patient safety group, physical health group 3. Individuals with pressure ulcers have their ulcers assessed initially (within 6 hours) and assessment is ongoing according to NICE guideline criteria As per policy and as clinically indicated, using EPUAP guidelines, qualified nurse or ward doctor TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) 4. Individuals with pressure ulcers have access to appropriate pressure relieving support surfaces or strategies throughout a 24 hour period Needs clinically risk assessed as indicated, monitored by ward staff and equipment ordered via TVN TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) 17

Continued. NTW(C)18 Tissue Viability Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Frequency/Method/Person Responsible Where results and any associated action plan will be reported to implemented and monitored; (this will usually be via the relevant governance group). 5. Individuals with Category 1 2 pressure ulcers have high specification foam mattress/cushion and very closely observed for deteriorations. Individuals have a documented repositioning regime As Clinically indicated, implementing repositioning chart by ward team members TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) 6. Individuals with Category 3 4 pressure ulcers have alternating overlay or sophisticated low pressure support as a minimum and closely observed. this is documented in the care plan As clinically indicated, ordered via TVN, monitored via ward nursing team members TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) 7. Individuals with pressure ulcers have their ulcers dressed with modern wound dressings, which are documented in the care plan. As clinically indicated, after review by TVN or appropriately trained individual TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) 8. Carers and patients have been informed about pressure ulcers and should be directly questioned about their satisfaction with, and the adequacy of, the information provided. This should be documented in the patient s notes. As clinically indicated, using appropriate methods (Phone, letter, face to face) by appropriate member of the clinical team taking account of confidentiality issues, where appropriate involving TVN specialist. TVN will report quarterly on incidents, events and omissions to relevant Group, (Urgent, Planned, Specialist) The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 18