Care Quality Commission

“The Trust has moved the handbook of medical emergencies, which includes guidance on the management of hyponatraemia, to the Trust intranet, which can be more easily accessed by staff. (See Recommendation 4 of the Action Plan). This was completed in August 2018.”

“the Trust will be ensuring that adherence to the policy for the Management of the Acutely Ii! Patient is monitored at the divisional Morbidity and Mortality meetings.”

“Recommendation 5 of the Action Plan sets out that; 'Desmopressin should be notified as a high risk drug that should not be discontinued without specialist advice.' The specialist providing the advice to discontinue the drug will ensure that there is a plan in place to reintroduce the drug at an appropriate time. This action has been implemented by the Medicines Management Committee with input from the pharmacy department.”

“The updated guidance on the management of hyponatraemia will set out the importance of ensuring that patients with hyponatraemia have regular monitoring of their fluid balance charts.”

“The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the r”

“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”

“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”

“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”

“Allreferrals for suspected DVT are recorded by the Administrative Team at the practice and followed up 48 hours later to ensure the results have been received”

“We propose to respond to each of them in turn for ease of reference.”

“The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence therapy prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter”

“We aim to have completed our review by the end of 2017 and will consider the need for publication of any additional safety advice at this time in conjunction with our medicine colleagues.”

“PAGB and its member companies recognise that clear information needs to be made available to warn of the risk of increased flammability of clothing and bedding which has been in contact with paraffin-containing emollients.”

“The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and”

“The Trust is committed to learning from serious incidents and has made changes to its systems to minimise the risk of a similar incident recurring in the future, including change of PEG policy, and the introduction of a PEG pathway checklist.”

“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”

“I have reviewed practice within the team in relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to [name redacted] - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC)”