Stockport NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has implemented twice-daily triage by a senior dietitian, prioritising patients, and is updating its enteral feeding policy with specific guidelines for administration. (AI summary)
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Dear Ms. Costello, I am writing further to the inquest of Lesley Mawby, which concluded on the 21 May 2021, and the Regulation 28: Report to Prevent Future Deaths and the matter of concern as follows: It is a matter of concern that there are residua! staffing shortages in the Dietetic team leading to delays in assessments on weekdays and meaning weekend cover cannot be provided. · I am grateful to you for providing me with the opportunity to respond to your concerns. I asked the Divisional Director of the Divison of Integrated Care to provide me with the information requested which I trust is satisfactory to you. Over the past 3 years the Dietetic Service has seen a significant increase in dem,ind on the service and staffing establishment has not been enhanced in line with this need. The increase in demand and requirement to increase staffing establishment has been recognised and actions are in place to address this issue, .as outlined below. Twice daily triage There is twice daily triage by a senior dietitian. All referrals for new patients are triaged by the Dietitians and. prioritised according to the dietetic referral triaging criteria, The 'Inpatient ward referral triage criteria' (Appendix A}, details the target times for reviewing referred patients in line with priority category. However, the Dietitians review all referrals in full and use clinical judgement to review a patient sooner if necessary. 7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients operates in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C .. The subsequent Your Health. Our Priority.
dietetic review would then tailor the regime if necessary, but the regimes set in the guidance ensure that adequate nutrition would be received. Improved process A new streamlined process has been implemented, where staff add the referrals to a . spreadsheet with 'assessment due date' documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a 'review date' documented and reason for review. The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian. Business Case developed Therapies Staffing A risk assessment in respect to the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee. A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required. Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BOA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the . roles and responsibilities of non-registered staff being examined. · Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:
• The staffing establishment for community and acute nutrition and dietetic teams have been combined to work flexibly across both services.
• The specialist acute caseloads have been combined and will be prioritised accordingly across the service.
• Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner.
• Recruitment is underway to fill the current vacancies and these are being advertised both internally and externally. Interviews will be held in July 2021.
• A gap analysis has been completed and current gap in skillset identified. Training of substantive staff is to be arranged. Incident reporting The Dietetic Service has recognised that it is not always able to meet the target times to review patients that it sets itself due to the increase in demand. Incidents are reported via the Trust's incident reporting system (Datix), when patients are not reviewed within the timeframe specified at triage. The incidents are reviewed weekly at the Incident Review Page 2
Group, chaired by the Deputy Director of Quality Governance. The actions detailed above aim to reduce the risk of incidents occurring. We hope that the above addresses your concerns and assures you that the Trust has taken this matter of highest importance and put adequate actions in place. Please do not hesitate to contact me if you require any further information.
dietetic review would then tailor the regime if necessary, but the regimes set in the guidance ensure that adequate nutrition would be received. Improved process A new streamlined process has been implemented, where staff add the referrals to a . spreadsheet with 'assessment due date' documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a 'review date' documented and reason for review. The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian. Business Case developed Therapies Staffing A risk assessment in respect to the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee. A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required. Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BOA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the . roles and responsibilities of non-registered staff being examined. · Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:
• The staffing establishment for community and acute nutrition and dietetic teams have been combined to work flexibly across both services.
• The specialist acute caseloads have been combined and will be prioritised accordingly across the service.
• Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner.
• Recruitment is underway to fill the current vacancies and these are being advertised both internally and externally. Interviews will be held in July 2021.
• A gap analysis has been completed and current gap in skillset identified. Training of substantive staff is to be arranged. Incident reporting The Dietetic Service has recognised that it is not always able to meet the target times to review patients that it sets itself due to the increase in demand. Incidents are reported via the Trust's incident reporting system (Datix), when patients are not reviewed within the timeframe specified at triage. The incidents are reviewed weekly at the Incident Review Page 2
Group, chaired by the Deputy Director of Quality Governance. The actions detailed above aim to reduce the risk of incidents occurring. We hope that the above addresses your concerns and assures you that the Trust has taken this matter of highest importance and put adequate actions in place. Please do not hesitate to contact me if you require any further information.