BOARD OF DIRECTORS PAPER COVER SHEET Meeting date: 31 January 2007 Agenda item: 9.4 Title: PARLIAMENT & HEALTH SERVICE OMBUDSMAN RECOMMENDATIONS RE: PATIENT COMPLAINT Purpose: To update the Board on the completed Action Plan following an Ombudsman investigation Summary: A complaint was made in 2002 by the son of a patient who had sustained a number of falls whilst an inpatient in the RD&E resulting in a fractured hip. The complainant was dissatisfied with the response from the RD&E and subsequently requested an Independent Review. The request was not accepted. Remaining dissatisfied the complainant referred the case to the Parliament and Health Service Ombudsman in 2004. Following a 3 month investigation the Ombudsman upheld the complaint and made a number of recommendations which the RD&E accepted. A Trust wide steering group has developed and monitored the delivery of an action plan to ensure all the recommendations were implemented. This has now been completed and this paper is intended to update the Board. Recommendation: To acknowledge implementation of the Ombudsman s recommendations Prepared & presented by: Marie-Noelle Orzel, Director of Nursing & Service Improvement This report covers: (Please tick relevant box below) Healthcare Standards (CORE C1b, Monitor please specify which standard) C14c Healthcare Standards (DEV T Finance please specify which standard) Service Development Strategy Performance Management Local Delivery Plan Business Planning Assurance Framework Complaints x Other (Please specify) Note: This paper/ policy has been assessed for any equality, diversity or human rights implications.
BOARD UPDATED OF TRUST IMPLEMENTATION OF PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN S FINDINGS AND RECOMMENDATIONS 1) BACKGROUND In May 2002, an inpatient at the Royal Devon & Exeter NHS Foundation Trust (RD&E) had a number of falls whilst on Tavy ward, one of which resulted in the patient sustaining a fractured hip. Her son complained to the Trust but was dissatisfied with the response and requested an independent review. The request was refused. The patient s son remained dissatisfied and therefore referred the case to the Parliamentary and Health Service Ombudsman. The Trust was contacted by the Ombudsman in August 2004 who conducted a thorough investigation. The final report and recommendations were received by the RD&E in June 2005 which the Trust accepted. The recommendations identified a number of issues that related specifically to the elderly care unit but also had implications for practices Trust wide. Marie-Noelle Orzel, Director of Nursing & Service Improvement, worked with specific teams to develop an action plan to take forward the recommendations. The action plan was submitted to the Parliamentary and Health Service Ombudsman in September 2005 when the details of the actions were presented to Parliament through the Select Committee. Implementation of the key recommendations was managed through the establishment of a Trust wide falls steering group and delivery of the action plan co-ordinated by the service development team. The action plan acted as a catalyst for a number of developments, all of which have resulted in an improvement of patient care, especially the care of the older patient. Consequently, what could have been viewed as a negative incident has brought about a variety of positive changes. 2) SUMMARY OF KEY ACTIONS Appendix 1 outlines the detailed action plan that was developed based on the Ombudsman s recommendations. In summary the Trust has addressed the following key recommendations: The Trust should consider the introduction of visual aids in the form of symbols to indicate the status of patients at risk of falling on the wards. Yellow and black triangular magnetic signs have been produced that have a symbol of a figure falling backwards, similar to the slippery surface warning cones. The signs can be displayed (with the patient s permission) on lockers or bed heads. This has helped to highlight and identify patients who are at a high risk of falling. This initiative has been supported with the development of a comprehensive Falls Policy that was introduced in October 2005. The policy gives staff a practical framework to more effectively manage patients who are at risk of falling and includes:
a falls risk assessment tool falls care pathway falls care plan As a result of piloting the policy, beds that have the ability to be lowered to just above floor level have been trialled for patients who are at high risk of falling. The RD&E now have 5 of these ultra low beds that are predominantly used in elderly care areas. These beds have made a huge improvement to the dignity and privacy of such patients who previously may have been nursed on a mattress on the floor in order to manage their safety. Profile of Essence of Care to be raised on elderly care wards The profile of Essence of Care (EoC) has been raised Trust wide by the leadership of the Director of Nursing & Service Improvement. The Senior Matron for Older People acts as the EoC lead for the Trust and is supported in the implementation of the standards by the senior matrons and matrons. A matron in orthopaedics has acted as a champion and facilitator for staff and has developed a user friendly EoC model and documentation to enable staff to produce action plans in response to specific issues. These have helped to motivate staff in making EoC part of the culture of care. EoC action plans are also used as evidence for the achievement of Healthcare Standards within the quarterly reporting framework. NSF4 Guidelines- to provide elderly people with specialist attention whilst in hospital care A successful bid to the Department of Health secured funding to appoint 2 older person s nurses for a 2-year period which led to the Age Matters project. The aim of this project has been to raise awareness of older people s needs across the Trust. The project has now ended but the work continues through the efforts of an Age Matters link nurse group led by the Senior Matron for Older People. The role of the link nurse is to act as a champion for older people in their respective wards and departments, advocating best practice and acting as experts in the care of older people. The group meets monthly to share ideas and guest speakers are invited to talk on topics related to older people, which to date have included hearing loss, care of hearing aids, legal issues (such as enduring power of attorney) and managing acute confusion. Planned topics include continence management, medicines management in older people, diabetes and depression. A representative form Age Concern is due to attend next month s meeting to talk about the organisation s work. All trust staff are welcome to attend these sessions as a learning opportunity. Consider the introduction of multi-professional integrated records. An elderly care ward (Kenn) and the acute stroke unit (Clyst) were selected to pilot an adult generic care pathway which is designed as a multi professional record. Following the success of this project it has now been agreed to implement this multi-professional documentation throughout the Trust.
In addition, the Liverpool Care Pathway (LCP), which again uses a multiprofessional care record for the care of patients who are dying, has been in use for over a year now on all the elderly care wards. The use of this pathway has greatly improved communication between staff and carers of dying patients and has enabled carers to be more actively involved as a partner with staff in the care of their loved one. Following the introduction of the LCP, the Senior Matron has noticed a considerable decrease in the number of complaints (which were already few in number) regarding palliative care on the elderly care wards. This initiative is also in the process of being rolled out trust wide. 3) CONCLUSION All the recommendations outlined in the Ombudsman report have been implemented successfully across the Trust. This has had a positive impact and improved care for a large number of patients. The original complaint arose as a result of a patient falling whilst in our care. All falls are reported and monitored via the Trust incident reporting process and the number of falls monitored regularly by the directorates and the Governance Committee. Whilst this was a challenging experience for the staff involved, the Trust has used the opportunity to review and improve the wider care of the older patient. M-N Orzel Director of Nursing & Service Improvement 17 January 2007
ACTION PLAN IN RESPONSE TO OMBUDSMAN RECOMMENDATIONS FOR PREVENTION OF FALLS No. Recommendation Action Who by Progress to date Timescale 33 a) Risk Assessment a. Evaluation and critical appraisal of the evidence base To further improve the prevention and management of falls, the Trust should consider the introduction of hip protectors and fall protection monitors. 1. To consider the Introduction of fall protection monitors and hip protectors. Matron- Older People does not support the use of hip protectors & monitors in acute settings. 2. Develop Trust Falls Policy (to include guidance on the use of bed rails). Trust Falls Group b. Falls Policy has been developed via the Trust Falls Management Group. This has incorporated the Trust bed rails policy policy in place April 2006 33 b) The Trust should consider the introduction of visual aids in the form of symbols to indicate the status of patients at risk of falling on wards. Consider the introduction of appropriate visual aids and symbols. Matron - Older People c. Work ongoing within Trust and local health care community to integrate with Devon Falls Strategy a. Work with photo graphics, Estates dept & falls steering grouping in progress to develop patient alert signs to identify patients at risk on wards. b. Small test of change planned to assess impact. Signs now supplied to all wards and displayed on patient bed heads or lockers.
33 c) Environment and Staffing Levels Review of skill mix on elderly care wards, taking into account the dependency needs of patients. Use Ward Audit results and AfC to review current skill mix for all elderly care wards. Director of Nursing & SI, Lead Nurse for Medicine and Matron, Older People 1. Increased numbers of staff in comparison to 2004 2. Skill mix & staffing levels reviewed regularly in response to activity, workload, workforce issues and changes in practice & service delivery.. 33 d) Where bank staff are employed, a system should be in place to keep them up to date with policies and procedures. 35 a) Care Planning The Trust to review nursing model used for care planning. Ensure that staff understand the importance of assessing, planning, delivering and evaluating a quality standard of care. Written record care to be maintained with patient s clinical notes. 1. Review current process 2. Consider implementation of more effective processes as appropriate. 1. Elderly care to review nursing model used for care planning. Senior Nurse, Nurse Bank Dir of N&S Director of Nursing to discuss with Senior Nurse re: system for training & updating in policies & procedures a. Nursing model reviewed Activities of Daily Living model still appropriate but has been expanded & adapted to meet acute medical needs of patient group now cared for on unit. Operational Policy for bank Staff developed and implemented Sep 2006 Falls Care plan now in place where appropriate as per falls policy. 2. A care plan to be in place so that all staff can be aware when a patient intermittently b. Adult Pre-operative Assessment Care Plans that are multi-professional have.
35 b) The Director of Nursing & SI to raise the profile of Essence of Care on elderly care wards. Toolkit available by CNO. 35 c) NSF4 guidelines The Trust must ensure that the member of ward staff, who will be the link nurse responsible to the Matron, is fully supported in carrying out this role starved of fluid and food in preparation for surgery. Report on actions taken to date re: Essence of Care within the Trust. Aim to provide elderly people with specialist attention whilst in hospital care Director of Nursing & SI Matron been piloted in surgery and will be used Trust wide. Senior Matron for Older People is also Essence of Care (EoC) Lead for the Trust and chairs Trust EoC steering group. Number of resources now in place to help ward & departmental staff to implement EoC benchmarking Majority of wards now involved in EoC with action plans in place 2 x Older Person s Nurses have been appointed, using Department of Health funding (2004-06) to support nurses in the delivery of improved care for older patients within the Trust. They have set up an education programme to enable older people link nurses to spread good practice on the wards. A Trust wide survey of staff s knowledge of older people s Ongoing as EoC is embedded as part of Trust Governance framework. EoC action plans now provide part of evidence for Healthcare standards. Project finished June 2006. Age Matters link nurse group established to spread and champion good practice across wards
38 a) Communication The Trust has a responsibility to ensure that all members of staff communicate any variance in patient s care to a member of family whenever possible. 1. Multi Disciplinary Team (MDT) (nurses, doctors and therapists) to communicate with each other about the patients. Matron, Older People & MDT team health care needs will be used to inform and development an ongoing education programme regarding health of older people in the Trust. a. Daily meetings now held (Mon- Fri) with nurses & therapists to update each other on patient care plans (which are kept with the patients at the end of the bed). b. Family/carers are actively encouraged to contribute to care planning as partners in care. and Departments. This includes monthly education of link nurses c. Weekly MDT meetings are held to discuss patient s care, progress and treatment goals If appropriate, carers are invited to this meeting. d. Variance in a patient s condition is now communicated to family /carer as soon as possible and preferably face to
face contact is made. 2. Review current incident reporting process Governance Manager e. Incident forms will be modified to include a section to document if relatives/carer has been informed about the incident Record Keeping Records need to be more regular and coordinated. A registered nurse needs to countersign entries. Entries should be clear with counter signature DoN & SI to ensure Matrons make all staff aware of updating themselves on the NMC Guidelines for Records and Record Keeping Director of Nursing & SI / Matrons f. Ward nurses now have patient information on computer printouts which can be updated as needed a. Trust wide annual audit of record keeping & documentation is in place. Results fed back to practitioners through the current management system. b. More overt presence of Matrons in clinical area to provide direct leadership and supervision. c. Elderly care wards are planning to benchmark using EoC record keeping benchmark. Ongoing Senior Matrons and matrons now in post in all areas. October 06
Consider introduction of multi-professional / integrated records The Trust to review its practice of interdisciplinary communication and recordkeeping for a more coordinated approach. a. Single Assessment Process (SAP) Steering group in recognition of the need to reflect SAP philosophy (sharing information & avoiding duplication regarding patient s care). April 2006 b. Development of Integrated Care Pathways is linked to this Adult generic care pathway trialled on elderly care ward & stroke unit Oct 06. To be implemented Trust wide