Aneurin Bevan University Health Board
NHS / Health Body
Action Taken
Aneurin Bevan University Health Board is reintroducing training on falls risk assessment and prevention, reviewing the falls risk assessment process, and developing an action plan to capture and monitor actions, and is exploring learning from the use of sensors in care homes. (AI summary)
View full response
Dear Ms Saunders Re: Aneurin Bevan University Health Board response to Regulation 28 Report received following the inquest touching on the death of Mary Doreen White I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Mary Doreen White. As requested, the information presented below is intended to describe the action taken / being taken to mitigate the risk of future deaths. The Health Board fully accepts that protecting in-patients from falls and the related harm is the responsibility of the entire multidisciplinary team. This is extensively supported by the evidence base and national guidance, which the Health Board both endorses and works to incorporate in its approach to protecting patients whilst in hospital. Matter of Concern 1– Staffing As you state, despite taking all reasonable steps to secure the required nurse staffing levels, Bargoed Ward had a deficit in their staffing numbers when Mrs White fell. Additional staffing was secured however there remained a shortfall of 1 HCSW. The Health Boards expectation is that on occasions where the required staffing levels cannot be met, this deficit is to Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board Pencadlys, Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffôn: 01633 436700 Tel No: 01633 436700 E-bost: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
be reported using the RL Datix reporting system and the appropriate escalation to the senior nursing team should occur. The risks associated with staff shortages are then reviewed by the senior nursing team, and actions taken to minimise harm. This includes; prioritising duties for that shift, reviewing staffing across the site and reviewing the needs of patients and deploying staff appropriately. Patients identified as enhanced observation requiring 1:1 supervision should be prioritised when allocating staff to ensure appropriate observation and patient care. The Health Board has a ratified escalation framework which clearly articulates the process to follow in incidents whereby there are staffing deficits that despite best efforts have not been rectified. This framework describes everyone’s responsibility in maintaining appropriate and safe nurse staffing levels and sets out clear actions if there is a deviation from what is required. Additionally, daily site meetings occur to review nurse staffing levels, consider any deficits, manage and identify any potential risks and escalate any requirements to the Resource Bank. Bargoed ward comes under the remit of section 25B of Nurse Staffing Levels (Wales) Act 2016 (NSLWA). In line with the requirements of the Act, an in- depth bi-annual review is undertaken to determine acuity, dependency and nurse staffing requirements. Quality indicators aligned to the NSLWA are considered during the re-calculation, one of which is falls. The bi-annual review involves the full engagement and contribution of the Assistant Divisional Nurse, Senior Nurse, Ward Sister, finance and workforce to ensure the ward establishment is appropriate to meet the needs of the patients. In addition, the quality patient safety (QPS) team monitor the numbers of falls across the Health Board and review any themes and learning. Recruitment and retention have been challenging, especially during Covid. The Health Board has recently promoted local recruitment events at all enhanced Local General Hospitals (eLGH), including Ysbyty Ystrad Fawr, (YYF) which were successful in recruiting to and above the healthcare support worker establishment. It is envisaged that the successful applicants will be in post by the end of April 2023. Furthermore, the Health Board are introducing the Safecare Programme on all wards under section 25B of the NSLWA. Safecare is a national programme currently being rolled out across all Health Boards in Wales. It matches staffing levels to patient acuity, providing control and assurance from bedside to board. It is designed to increase patient safety while maintaining efficiency and enables informed decisions to be taken at various levels of management. Additionally, the Safecare system allows ward staff to complete a register of staff in attendance shift by shift as well as undertaking an assessment of patient acuity twice a day. Nursing teams are able to make professional judgements on whether or not the staffing levels are appropriate to meet the needs of the patients and raise red flags to record identified risks. The system provides the senior nursing teams with instant access to ward level 2
data and a site wide view of staffing status, highlighting areas of concern to enable effective and evidence-based decision making regarding the appropriate deployment of nursing staff to support patient safety. Matter of Concern 2 – Environment In YYF the ward configurations are L shaped and split by pods which are able to accommodate 8 patients in single rooms, staff are usually allocated to a pod. There are computers and notes available in all pods to ensure that staff can remain in their designated areas whilst completing their nursing duties. The single room environment can be challenging when multiple patients require an enhanced level of care. There is a requirement for staff to carefully consider how individual patients needs can be met and formulate a care plan outlining frequency of observation and level of care required. If a patient is assessed as requiring enhanced observation with 1:1 supervision, then staffing plans must reflect this. Additionally, if patients require cohorting level of observation this can be met by using a cohorting approach to meet care needs. Where one to one supervision or cohort nursing is assessed as being required the medical wards at YYF utilise the end pod. The ‘end pod’, has 8 beds with the smallest footprint. These areas tend to be the quietest areas within the ward layout and is therefore effective in reducing over stimulation due to constant noise and ward activity. Bargoed Ward ensures patients requiring enhanced care are nursed in this area. All current core staff on Bargoed Ward have undertaken training on the Multi-Disciplinary Falls Risk Assessment via virtual classroom sessions and there has also been on site training. Matter of Concern 3- Use of Day Rooms All wards have a day room area for patients, these are utilised to support the use of meaningful activities. Since the reduction in Covid 19 cases this area is often used during daytime hours to support the cohorting of patients who require a higher level of supervision. However, there are instances during extreme demand when the dayroom is unable to be used. All wards on the YYF site have an activities box, supplied by the Patient Centred Care team, access to interactive devices and projectors screens have just been introduced. Volunteers have also restarted, therefore facilitating activities and providing companionship to our patients has been reintroduced. Matter of Concern 4- Use of sensors Sensors have the function to alert staff if a patient is attempting to stand or get out of their bed. This will alert staff, who may not be in the immediate 3
area, that a patient is at risk of falls as they are attempting to mobilise. Bargoed Ward does have some movement sensors in place for patients, for whom they have assessed as suitable and appropriate. Following discussion with the Assistant Director of Therapies and Health Science, work has been undertaken nationally as to the effectiveness of sensors in falls management. Information suggests that for the majority the use of sensors may not be as effective as initially thought. This remains under discussion by the ‘National Inpatients Falls Network’. As a Health Board we need to collectively explore learning from the use of sensors in the Care Homes setting and how this may translate into the secondary care environment. There is also work ongoing at a national level with Health and Safety, it is recognised that we need to understand the national picture in adopting best practice and national learning. To further support our response an action plan will be developed to capture and monitor actions and will be shared at Falls and Bone Health Group by the clinical team. I trust that this information addresses the concerns raised in your report, however, please do not hesitate to contact me should you require any further information.
be reported using the RL Datix reporting system and the appropriate escalation to the senior nursing team should occur. The risks associated with staff shortages are then reviewed by the senior nursing team, and actions taken to minimise harm. This includes; prioritising duties for that shift, reviewing staffing across the site and reviewing the needs of patients and deploying staff appropriately. Patients identified as enhanced observation requiring 1:1 supervision should be prioritised when allocating staff to ensure appropriate observation and patient care. The Health Board has a ratified escalation framework which clearly articulates the process to follow in incidents whereby there are staffing deficits that despite best efforts have not been rectified. This framework describes everyone’s responsibility in maintaining appropriate and safe nurse staffing levels and sets out clear actions if there is a deviation from what is required. Additionally, daily site meetings occur to review nurse staffing levels, consider any deficits, manage and identify any potential risks and escalate any requirements to the Resource Bank. Bargoed ward comes under the remit of section 25B of Nurse Staffing Levels (Wales) Act 2016 (NSLWA). In line with the requirements of the Act, an in- depth bi-annual review is undertaken to determine acuity, dependency and nurse staffing requirements. Quality indicators aligned to the NSLWA are considered during the re-calculation, one of which is falls. The bi-annual review involves the full engagement and contribution of the Assistant Divisional Nurse, Senior Nurse, Ward Sister, finance and workforce to ensure the ward establishment is appropriate to meet the needs of the patients. In addition, the quality patient safety (QPS) team monitor the numbers of falls across the Health Board and review any themes and learning. Recruitment and retention have been challenging, especially during Covid. The Health Board has recently promoted local recruitment events at all enhanced Local General Hospitals (eLGH), including Ysbyty Ystrad Fawr, (YYF) which were successful in recruiting to and above the healthcare support worker establishment. It is envisaged that the successful applicants will be in post by the end of April 2023. Furthermore, the Health Board are introducing the Safecare Programme on all wards under section 25B of the NSLWA. Safecare is a national programme currently being rolled out across all Health Boards in Wales. It matches staffing levels to patient acuity, providing control and assurance from bedside to board. It is designed to increase patient safety while maintaining efficiency and enables informed decisions to be taken at various levels of management. Additionally, the Safecare system allows ward staff to complete a register of staff in attendance shift by shift as well as undertaking an assessment of patient acuity twice a day. Nursing teams are able to make professional judgements on whether or not the staffing levels are appropriate to meet the needs of the patients and raise red flags to record identified risks. The system provides the senior nursing teams with instant access to ward level 2
data and a site wide view of staffing status, highlighting areas of concern to enable effective and evidence-based decision making regarding the appropriate deployment of nursing staff to support patient safety. Matter of Concern 2 – Environment In YYF the ward configurations are L shaped and split by pods which are able to accommodate 8 patients in single rooms, staff are usually allocated to a pod. There are computers and notes available in all pods to ensure that staff can remain in their designated areas whilst completing their nursing duties. The single room environment can be challenging when multiple patients require an enhanced level of care. There is a requirement for staff to carefully consider how individual patients needs can be met and formulate a care plan outlining frequency of observation and level of care required. If a patient is assessed as requiring enhanced observation with 1:1 supervision, then staffing plans must reflect this. Additionally, if patients require cohorting level of observation this can be met by using a cohorting approach to meet care needs. Where one to one supervision or cohort nursing is assessed as being required the medical wards at YYF utilise the end pod. The ‘end pod’, has 8 beds with the smallest footprint. These areas tend to be the quietest areas within the ward layout and is therefore effective in reducing over stimulation due to constant noise and ward activity. Bargoed Ward ensures patients requiring enhanced care are nursed in this area. All current core staff on Bargoed Ward have undertaken training on the Multi-Disciplinary Falls Risk Assessment via virtual classroom sessions and there has also been on site training. Matter of Concern 3- Use of Day Rooms All wards have a day room area for patients, these are utilised to support the use of meaningful activities. Since the reduction in Covid 19 cases this area is often used during daytime hours to support the cohorting of patients who require a higher level of supervision. However, there are instances during extreme demand when the dayroom is unable to be used. All wards on the YYF site have an activities box, supplied by the Patient Centred Care team, access to interactive devices and projectors screens have just been introduced. Volunteers have also restarted, therefore facilitating activities and providing companionship to our patients has been reintroduced. Matter of Concern 4- Use of sensors Sensors have the function to alert staff if a patient is attempting to stand or get out of their bed. This will alert staff, who may not be in the immediate 3
area, that a patient is at risk of falls as they are attempting to mobilise. Bargoed Ward does have some movement sensors in place for patients, for whom they have assessed as suitable and appropriate. Following discussion with the Assistant Director of Therapies and Health Science, work has been undertaken nationally as to the effectiveness of sensors in falls management. Information suggests that for the majority the use of sensors may not be as effective as initially thought. This remains under discussion by the ‘National Inpatients Falls Network’. As a Health Board we need to collectively explore learning from the use of sensors in the Care Homes setting and how this may translate into the secondary care environment. There is also work ongoing at a national level with Health and Safety, it is recognised that we need to understand the national picture in adopting best practice and national learning. To further support our response an action plan will be developed to capture and monitor actions and will be shared at Falls and Bone Health Group by the clinical team. I trust that this information addresses the concerns raised in your report, however, please do not hesitate to contact me should you require any further information.