Tees Esk & Wear Valley NHS Foundation Trust
NHS / Health Body
Action Taken
Tees, Esk and Wear Valleys NHS Foundation Trust has implemented weekly Fundamental Standards Group meetings, added Section 17 leave to the Trust wide preceptorship package, and arranged a task and finish meeting to develop a more frequent auditing process. They have also provided staff with leave folder templates and contact cards, and continue to audit clinical records to assess compliance with Section 17 leave procedures. (AI summary)
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Chief Executive:
Chair: 1 Office of the Chief Executive West Park Hospital Edward Pease Way Darlington County Durham DL2 2TS
11th October 2024
Private and Confidential HM Assistant Coroner Mr Simon Connolly By email:
Inquest into the death of Matthew Gale
I am writing to you in response to the Report to Prevent Future Deaths (PFD), served on the Trust on 16 August 2024, in relation to compliance audit data relating to Section 17 leave. Our Chief Nurse has been working with the Care Group Directors of Nursing, Medical Directors and Directors of Therapy to ensure that the Trust have consistent oversight of daily performance and the improvement trajectory around Section 17 leave, which is reported to the Board of Directors.
As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:
- The weekly Fundamental Standards Group for all inpatient staff have amended its agenda to focus purely on quality assurance audit results to enable audit results to be discussed, with agreed actions identified for matrons and managers.
- Section 17 leave and communication with families/carers around the responsibilities of the accompanying role has been added to the Trust wide preceptorship package, which is required to be undertaken by every registered nurse who joins the Trust.
- The Trust continue to work with families to focus on the importance of carers, families and loved ones and their involvement in care.
- In June 2024 a task and finish meeting was arranged to discuss the May audit results to develop a more frequent auditing process at ward level to monitor compliance with Section 17 leave requirements, develop a training package for all staff and to review the Section 17 leave policy. Since the development of this task and finish meeting, the Trust have done a significant amount of work to improve Section 17 leave compliance.
The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been
Chief Executive:
Chair: 2 amended and now includes sections to identify the name of the accompanying person and they now have to sign to confirm that they are aware of the leave conditions prior to each period of leave.
The changes to the Section 17 leave policy has been discussed at Quality Board, which included a representative from the Integrated Care Board, NHS England and the Care Quality Commission, who all approved of the changes.
The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.
The ADONs have all been provided with a checklist to complete which requires them to confirm that the updated Section 17 leave policies have been shared with all relevant staff that they have responsibility for and that this has been included as a topic at multi-disciplinary team meetings, for a period of 2 weeks, to raise awareness of the changes in policy in addition to the requirements of staff to attend the Section 17 training.
In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders is a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.
The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.
We hope that the above demonstrates that the Trust are continuously working to improve processes around Section 17 leave and will continue to monitor this closely to ensure the changes are embedded.
Chair: 1 Office of the Chief Executive West Park Hospital Edward Pease Way Darlington County Durham DL2 2TS
11th October 2024
Private and Confidential HM Assistant Coroner Mr Simon Connolly By email:
Inquest into the death of Matthew Gale
I am writing to you in response to the Report to Prevent Future Deaths (PFD), served on the Trust on 16 August 2024, in relation to compliance audit data relating to Section 17 leave. Our Chief Nurse has been working with the Care Group Directors of Nursing, Medical Directors and Directors of Therapy to ensure that the Trust have consistent oversight of daily performance and the improvement trajectory around Section 17 leave, which is reported to the Board of Directors.
As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:
- The weekly Fundamental Standards Group for all inpatient staff have amended its agenda to focus purely on quality assurance audit results to enable audit results to be discussed, with agreed actions identified for matrons and managers.
- Section 17 leave and communication with families/carers around the responsibilities of the accompanying role has been added to the Trust wide preceptorship package, which is required to be undertaken by every registered nurse who joins the Trust.
- The Trust continue to work with families to focus on the importance of carers, families and loved ones and their involvement in care.
- In June 2024 a task and finish meeting was arranged to discuss the May audit results to develop a more frequent auditing process at ward level to monitor compliance with Section 17 leave requirements, develop a training package for all staff and to review the Section 17 leave policy. Since the development of this task and finish meeting, the Trust have done a significant amount of work to improve Section 17 leave compliance.
The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been
Chief Executive:
Chair: 2 amended and now includes sections to identify the name of the accompanying person and they now have to sign to confirm that they are aware of the leave conditions prior to each period of leave.
The changes to the Section 17 leave policy has been discussed at Quality Board, which included a representative from the Integrated Care Board, NHS England and the Care Quality Commission, who all approved of the changes.
The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.
The ADONs have all been provided with a checklist to complete which requires them to confirm that the updated Section 17 leave policies have been shared with all relevant staff that they have responsibility for and that this has been included as a topic at multi-disciplinary team meetings, for a period of 2 weeks, to raise awareness of the changes in policy in addition to the requirements of staff to attend the Section 17 training.
In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders is a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.
The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.
We hope that the above demonstrates that the Trust are continuously working to improve processes around Section 17 leave and will continue to monitor this closely to ensure the changes are embedded.