++ Director of Nursing & Quality The Ipswich Hospital Heath Road ...

++Compliance InspectorCQC EastCitygate,GallowgateNewcastle Upon TyneNE1 4PADirector of Nursing & QualityThe Ipswich HospitalHeath RoadIpswichSuffolkIP4 5PDTel: 01473 703507Fax: 01473 703866Siobhan.Jordan@ipswichhospital.nhs.uk22nd June 2011I am pleased to be able to provide you with updated compliance plans containing assurance ofongoing improvements related to compliance against the Health and Social Care Act 2008(Regulated Activities) Regulations 2009 with specific reference to the identified regulation:Our Reference: SJRegulation 9 - Care and welfare of people who use services (Patient slips trips and falls & developedpressure ulcers)If you require any further information, please do not hesitate to let me know and I will be pleased toassist.Yours sincerelySiobhan JordanDirector of Nursing & QualityCc Lynne Wigens, Director of Patient Safety & Clinical Quality, NHS Suffolk1

Compliance Plan for compliance with CQC Outcome 4/Regulation 9 - Falls PreventionGreen - completed Amber – partially completed/in progress Red – deadline breachedRef Issue Proposed Action1 SIRI incidents relating tofalls identify trainingrequirements2 Not all staff recognisepatients at risk of falls3 RCA to be undertaken onall fallsSet up process to ensure thatany ward/dept where SIRIoccurs receive intensivetraining within 2 weeks ofincidentTraining programme to bereviewed to recognisetriggers implement 7 SimpleSteps (7SS)Datix risk reportingmanagement systemResponsibleLeadPatientExperienceNurseFalls GroupPatientExperienceNursePatientExperienceNurse & RiskManagementCoordinatorProposedcompletion dateActualCompletiondateComments17/11/10 17/11/10 Training provided within 2weeks17/11/10 17/11/10 Scenario based learning (e.g.from incidents)Specific HCA and RN scenariolearning sessionsFalls S/D planned annually17/04/11 updated10/05/11CompletedPreliminary programmedeveloped on Datix systemReview and adjustment to bemade following feedback.Update:17 th March 11Adjustments to be completedby 17 th April 11 to enable fullimplementationUpdate 10/05/11All patient falls areinvestigated using RCAthrough DATIXWEB. This ismandatory and enables 100%compliance with RCA.2

Ref Issue Proposed Action4 Review of falls policy toincorporate seven simplesteps and clear guidanceon who is at risk of falls5 Nurses recruited to alladult wards or CentralBank Services (CBS) shouldreceive intensive supportand training.Policy review and updateOngoing clinical placementtraining, relating to the 7SSprevention programme.Participation in HCA trainingprogrammeResponsibleLeadFalls PreventionGroupPatientExperienceNurseProposedcompletion dateActualCompletiondateComments31/12/10 01/12/10 Ratified by Patient SafetyGroup 01/12/10Update:17 th March 11Further update to policycurrently underway in light ofrevised training programmeand NPSA alert re Head InjuryManagement05/01/1105/01/11New RN’s employedundertake falls trainingUpdate:17 th March 11All clinical staff will receivefalls prevention andmanagement training withinthe Moving & HandlingTraining.05/04/11Update 17 May 11Training Fall Awareness andPrevention Training for staffas part of Mandatory Moving& Handling 1 hour dedicatedsession (including DVD, fallsrisk assessment, care planningand management)Senior ClinicalPractice05/01/1105/12/10Mandated element ofcorporate HCA training3

Ref Issue Proposed Action6 Clarification of fallsawareness training7 Need to explore othermethods of delivery offalls prevention training.8 Insufficient Low HeightBeds availableStaff should receive fallsawareness within movingand handling trainingExplore the Feasibility of anE learning packageSubmit business case toInvestment ScrutinyCommittee.ResponsibleLeadProposedcompletion dateActualCompletiondateCommentsFacilitatorprogramme commencedMETs Group 14/02/11 17/03/11 Moving and Handlingprovision of falls awarenessunder reviewFalls PreventionGroup (Reportsto PatientSafety Group)AssociateDirector Nursing(Quality &Compliance)28/02/11Updated01/04/1105/04/11 Update:17 th March 11Falls prevention andmanagement DVD complete.Will be launched for use inApril 11 within new training.For review in 3 months ofimplementationUpdate:5 th April 11New method of deliveringtraining in place28/02/11 28/02/11 Business Case submitted31/01/11. 50% of all EPBs tobe purchased will be lowheight beds.Outcome awaited.Update:17 th March 11Full review of all businesscases to the InvestmentScrutiny Committee complete– requires formal ratificationby Trust BoardUpdate: 15 th MayBusiness case approval forpurchase of 100 additional4

Ref Issue Proposed Action9 To investigate use ofassistive technologies -patient leaving alarm matsTo investigate use ofanother supplier ofassistive technologies -patient leaving alarm mats• Identify suppliers• Plan Trial• Audit trial• Evaluate trialFurther evaluation of newproduct• Identify additionalsuppliers• Plan Trial• Audit trial• Evaluate trialResponsibleLeadFalls PreventionGroup (Reportsto PatientSafety Group)Proposedcompletion date31/03/11May 2011ActualCompletiondate17/02/11May 2011Commentselectric profiling bedsUpdate:17 th March 11Review 5 types of equipmentSelect suitability for acutehospital settingTrial commenced on 25/10/103 complex care wardsEvaluate 25/01/11 andproduce report then rollout toother areas where there arepatients at higher risk of falls.Update: 17 th March 1115/05/11We have evaluatedthe initial trial – in view of anumber of limitations of theproduct we will trial anotherproduct within 2 complex carewards from 8 th April 11.Update 17 May 11The trial has been completedfeedback is positive; a reportwill go to the June FallsPrevention Group, forrecommended action.Update 17 th JuneSecond type trialled April –May 2011 staff found easierto use and more reliable,purchase costs to bedetermined5

Ref Issue Proposed Action10 Trust wide review of allassessmentdocumentation in light ofcomplexity and multipletypes and sources noted.Review of method ofdocumentation of care inrelation to falls assessmentand management withinTrust-wide nursingdocumentation reviewResponsibleLeadAssociateDirector ofNursing (QualityandCompliance)Proposedcompletion date01/06/11Extended:20/07/11ActualCompletiondateCommentsTrust-wide documentationreview undertaken. Keymandatory assessmentsincluding falls assessment toolto be included in admissionbooklet for every patient.Update: 4 th April 11Draft shown to Sue Verow,CQC local assessor whoprovided feedback which isbeing incorporated into latestdraft.Update 25 th MayPilot successful onSaxmundham Ward. Formalfeedback obtained andcomments & suggestionsincorporated.Update 15 th JuneDraft finalised and approved.Now being printed andtraining sessions scheduled.Details of revisionsVersion 1 Jan 2011 Development of Compliance Plan Catherine MorganVersion 2 Feb 2011 Update with actions Catherine MorganVersion 3 March 2011 Updates included within compliance plan Linda CollinsVersion 4 April 2011 Updates included within compliance plan Cath Gorman6

Version 5 May 2011 Updates included within compliance plan Cath GormanVersion 6 June 2011 Updates included within compliance plan Cath Gorman7

Compliance Plan for compliance with CQC Outcome 4/Regulation 9 - Pressure Ulcer PreventionGreen - completed Amber – partially completed/in progress Red – deadline breachedRef Issue Proposed Action Responsible Lead1 Braden (pressure ulcerassessment) tool requiringreview and update.2 Poor standard of pressureulcer care planning3 Poor standard ofdocumentation:• repositioning of patient• evidence of assessmentof skin integrity onadmissionModification and reviewof Braden tool to include• diabetes as riskfactor• Skin integrity chart• pressure relievingequipment requestsand actionsTo develop and pilotpressure areaprevention andmanagement care planReview of method ofdocumentation of carein relation to pressurearea care within Trustwidenursingdocumentation review.Tissue Viability LeadNurseTissue Viability LeadNurseAssociate Director ofNursing (Quality andCompliance)ProposedcompletiondateActualCompletiondateComments31/08/2010 31/08/10 Diabetes as risk factorimportant in relation todiabetic heel ulcers.Skin integrity – particularly onadmissionEquipment informationneeded, particularly type used,equipment requested withtime/date, when equipmentarrived on ward time/date, andother preventative actionstaken)31/10/2010 31/10/10 Pressure ulcer care plansdeveloped for grades 1, 2, 3 &4. In use and compliance beingJune 2011Extended:20/07/11monitored.Trust-wide documentationreview undertaken. Pressureulcer assessment tool to beincluded in admission bookletfor every patient.Update 21 st MarchDraft version awaiting minorchanges and will be piloted onSaxmundham ward8

Ref Issue Proposed Action Responsible Lead4 Insufficient pressurerelieving equipmentavailable5 Insufficient pressurerelieving equipmentavailable6 Insufficient pressurerelieving equipmentavailable.7 Insufficient pressurerelieving equipmentavailable.Trust-wide review ofdelays in obtainingpressure relievingequipment.Immediate purchase of75 repose mattressesand cushionsAdditional weekenddecontaminationrequired for dynamicmattressesIntroduction of 8 highspecification mattresseson trialAssociate DirectorNursing (Risk andPatient Safety)Associate DirectorNursing (Risk andPatient Safety)Head of InfectionPrevention & ControlTissue Viability LeadNurseProposedcompletiondateActualCompletiondateCommentsUpdate 25 th MayPilot successful onSaxmundham Ward. Formalfeedback obtained andcomments & suggestionsincorporated.Update 15 th JuneDraft finalised and approved.Now being printed and trainingsessions scheduled.01/12/2010 01/12/10 Outcome of review reported toPatient Safety Group 01/12/10minutes point 30/10.14/12/10 14/12/1021/12/10 21/12/10 Additional cleaning to be put inplace as required on BankHoliday weekends for dynamicmattresses.Activity monitored andreported (with actions taken)by Head of IPC to ADoN’s.21/12/10 21/12/10 KCI mattresses introduced9

Ref Issue Proposed Action Responsible Lead8 Insufficient pressurerelieving equipmentavailable.9 Insufficient pressurerelieving equipmentavailable.10 Insufficient Electric ProfilingBedsPurchase of 51 highspecification foammattressesPurchase of highspecification foammattresses for use in allTrust bedsPurchase 51 ElectricProfiling Beds andimmediate introductionof 5 EPB’sAssociate DirectorNursing (Quality &Compliance)Senior Moving &Handling AdvisorTissue Viability LeadNurseAssociate DirectorNursing (Quality &Compliance)ProposedcompletiondateActualCompletiondateComments28/02/11 31/03/11 Bed stock specificationreviewed to ensure correct sizeof mattresses purchased toensure compliance withentrapment regulations.51 orderedUpdate 31 st MarchMattresses delivered and inuse on 31 st March28/02/11 31/03/2011 Current bed stock specificationreview currently underway toensure correct size ofmattresses purchased toensure compliance withentrapment regulationsUpdate 31 st MarchBed stock review complete,mattress sizes identified forvarious types on beds in use28/02/11 08/02/11 Order placed 08/02/11 for 51Electric Profiling Beds (EPBs).An interim 20 EPB’s to bedelivered 11/02/115 EPB’s to be placed into theAcute Respiratory Care UnitUpdate 31 st March51 EPB’s delivered and in use10

Ref Issue Proposed Action Responsible Lead11 Insufficient Electric ProfilingBeds12 Lack of standardisedapproach to pressure ulcerpreventionSubmit business case toInvestment ScrutinyCommittee.Development of apressure ulcer trustpolicyAssociate DirectorNursing (Quality &Compliance)Tissue Viability LeadNurseProposedcompletiondate28/02/11Trust Board28/04/11ActualCompletion Commentsdate15.06/11 Business Case submitted31/01/11.Outcome awaited.Update 21 st MarchOutcome of all bids to ISC forapproval at Trust Board on28/4/11Update 15 th June100 additional EPB’s ordered02/03/2011 02/03/11 Policy is currently in draftformat and has beendistributed for consultation.Update 31 st MarchApproved at Patient Safetygroup 09/02/11 and forratification at HealthcareGovernance Committee02/03/11.13 Not all applicable nursingstaff have received trainingon pressure ulcerpreventionFormalise delivery oftraining programmesand report oncomplianceTissue Viability LeadNurse20/02/11 20/02/11 TV link programme updatedand available to all nursingstaff. HCA “Skin Matters”programme updated.Training delivered and status ofcompliance to be reported inmonthly Trust-wide pressureulcer report, reported byward/dept and business unit.This is to include the Central11

Ref Issue Proposed Action Responsible LeadProposedcompletiondateActualCompletiondateCommentsStaff Bank nurses.Aim to ensure that allnurses have receivedtissue viability trainingwithin a 3 year period.Tissue Viability LeadNurse2 training sessions a month tobe delivered, accommodating30 nurses at each session.Update 21 st MarchTraining data presented to theNMB monthly to enablemonitoring and challenge.14 Not all applicable nursingstaff have received trainingon pressure ulcerprevention.Performancemanagement of reducedcompliance of trainingDirector of Nursing &Quality / AssociateDirectors of Nursing28/02/11Completiondate extendedto ensureongoing action01/06/1128/02/11 Any areas that have notreleased staff for training willbe identified and addressed atbusiness unit performancemeetings (monthly). This is toinclude the Central Staff Bank.Update 21 st MarchTraining data reviewed (perbusiness unit) and whererequired this is raised atperformance meetings15 A need for patientinformation to assist patientinvolvement in care forpressure ulcer preventionDevelop patient leafletTissue Viability LeadNurse01/04/2011 01/04/2011 Update 1 st April 11Source and develop effectivepatient literature.Leaflet developed andcurrently being piloted on12

Ref Issue Proposed Action Responsible LeadProposedcompletiondateActualCompletiondateCommentsLavenham Ward. Feedbackfrom staff and patients beingsought.16 Insufficient pressurerelieving equipmentavailable.Bid to Charitable FundsCommittee to purchaseadditional pressurerelieving equipmentAssociate DirectorNursing (Quality &Compliance)05/03/11 05/03/11 Bid submitted and approved topurchase 150 underlays and 51power boxes for use withinspecification foam mattressesUpdate 15 th JuneOrder placedDetails of revisionsVersion 1 Jan 2011 Development of Compliance Plan Catherine MorganVersion 2 Feb 2011 Update with actions Catherine MorganVersion 3 April 2011 Update with actions and addition of compliance 16 Catherine MorganVersion 4 May 2011 Updates included within compliance plan Cath GormanVersion 5 June 2011 Updates included within compliance plan Cath Gorman13