Pennine Acute Hositals NHS Trust
NHS / Health Body
Action Taken
Pennine Acute Hospitals NHS Trust has been undertaking a review of current documentation and monthly audits of nursing metrics on Ward T7, and implemented measures trust-wide. They are also reviewing and ratifying nursing documents to implement a more rigorous governance process. (AI summary)
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Dear Hashmi, Re: Inquest into the death of Joyce Hartford am responding to recent Regulation 28 report to prevent future deaths, served to the Trust on 15" July 2015. You raised the following matters of concern with the Trust: During the course of the inquest hearing it became apparent that the nursing tools (in particular; the 'Purpose T) assessments, records; associated documentation and nursing discharge summary were incomplete andlor inaccurate. Whilst was told that the to its credit; had been conducting audits since the Summer of 2014 in order to improve nurse record keeping; Mrs Hartford died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards. As this was not the first case over which had presided that involved concerns arising record keeping that fell below expectation (over and above the aforementioned) considered that was under an obligation to this to your attention. Continued_ Chairman, Mr John Jesky Chief Executive , Dr Gillian Fairfield The Mrs Mrs the Trust; from bring
Pridein Quady- Resonsile The Pennine Acute Hospitals NHS} Pennine comou SMN NHS Trust Following the receipt of the Regulation 28 would wish to advise you of the following actions both within Ward T7 where Mrs Hartford was admitted and across the Trust: Action taken within Ward T7 We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited the nursing metrics which includes the quality of record keeping: Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts;as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are performed competently this includes completion of documentation such as District Nurse referrals; SKIN bundles (for tissue viability) and Rounding Tools (involves staff predetermined questions to ask patients on a regular basis about care needg and includes checks on the patient environment ) There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant memberoof staff at the time of the audit These include accurate and timely completion of risk assessments, use of appropriate care plans and reassessments_ SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue team. For early detection and management of pressure ulcers the use of scenario training on the completion of the PurposeT tool is now in place. The introduction of an air flow mattress store on the unit now ensures that patients who have suffered a fractured neck of femur are admitted to the Unit A&E directly onto a 'presioco' mattress. Since February 2015,the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating' nursing documentation within medical records This was addressed and results improved to 92% in June, 95% in and 93% in August Communication and dissemination 0f actions and lessons learnt is made through a of methods including: newsletters, safety huddles, handover sheets, and resource and training boards and when indicated on a one to one basis am pleased to advise that since 4th 2015, Ward T7 has not reported avoidable any hospital acquired pressure ulcers. Continued, Chairman, Mr John Jesky Chief Executive Dr Gillian Fairfield [+r using being nursing using timely Viability from May the July variety May
Pridein Quality-Cnven Responshe The Pennine Acute Hospitals NHS Pennine Compassuonate NHS Trust Trust wide initiatives We would wish to assure you that we are aware of need to continue to improve the quality of documentation within the organisation and the following initiatives are underway: Over the past 18 months Nursing Metrics have been introduced, part of which involves audit of the quality of nursing documentation in the case notes Over the last 12 months we have also reviewed the process of developing, reviewing and ratifying nursing documents to implement a more rigorous governanc proceesn through our Nursing Documentation Group and the Nursing and Midwifery Board SThis project is ongoing: The Nursing Documentation Group has widened its remit to cover Allied Health Professionals and Maternity documentation. main objective is to align documentation control and development processes across specialities With the support of the Chief we have now secured support of a team from the Trust Development Agency to help improve record keeping and a Trust wide documentation standardisation project is underway The Trust has also commenced the implementation of the 'EVOLVE' system Which will introduce electronic records across the Trust; This will be piloted later this year and is projected to start on 17h November and run for 4 Weeks with a Trust wide rollout projected to take 4 months starting in January 2016. The Project brief is to replace all clinical documentation with electronic forms hosted within the Evolve electronic case note system_ This will help mandate the completion of patient assessments_ The first phase of forms to be piloted on two wards at NMGH will on nursing assessment documents, associated care plans and referrals and will include nutritional assessments, falls and bed rails risk assessments_ dementia screening and the pressure ulcer care plan. The Trust is also introducing Ward Accreditation, a new project which will help us to monitor safe practice by measuring the quality of nursing care delivered by ward teams Aslpait of this project we will be checking and monitoring the quality of record keeping including patient assessments. Could please extend my sincere condolences to Mrs Hartford's family. If there is any further information that you require please do not hesitate to contact me_
Pridein Quady- Resonsile The Pennine Acute Hospitals NHS} Pennine comou SMN NHS Trust Following the receipt of the Regulation 28 would wish to advise you of the following actions both within Ward T7 where Mrs Hartford was admitted and across the Trust: Action taken within Ward T7 We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited the nursing metrics which includes the quality of record keeping: Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts;as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are performed competently this includes completion of documentation such as District Nurse referrals; SKIN bundles (for tissue viability) and Rounding Tools (involves staff predetermined questions to ask patients on a regular basis about care needg and includes checks on the patient environment ) There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant memberoof staff at the time of the audit These include accurate and timely completion of risk assessments, use of appropriate care plans and reassessments_ SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue team. For early detection and management of pressure ulcers the use of scenario training on the completion of the PurposeT tool is now in place. The introduction of an air flow mattress store on the unit now ensures that patients who have suffered a fractured neck of femur are admitted to the Unit A&E directly onto a 'presioco' mattress. Since February 2015,the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating' nursing documentation within medical records This was addressed and results improved to 92% in June, 95% in and 93% in August Communication and dissemination 0f actions and lessons learnt is made through a of methods including: newsletters, safety huddles, handover sheets, and resource and training boards and when indicated on a one to one basis am pleased to advise that since 4th 2015, Ward T7 has not reported avoidable any hospital acquired pressure ulcers. Continued, Chairman, Mr John Jesky Chief Executive Dr Gillian Fairfield [+r using being nursing using timely Viability from May the July variety May
Pridein Quality-Cnven Responshe The Pennine Acute Hospitals NHS Pennine Compassuonate NHS Trust Trust wide initiatives We would wish to assure you that we are aware of need to continue to improve the quality of documentation within the organisation and the following initiatives are underway: Over the past 18 months Nursing Metrics have been introduced, part of which involves audit of the quality of nursing documentation in the case notes Over the last 12 months we have also reviewed the process of developing, reviewing and ratifying nursing documents to implement a more rigorous governanc proceesn through our Nursing Documentation Group and the Nursing and Midwifery Board SThis project is ongoing: The Nursing Documentation Group has widened its remit to cover Allied Health Professionals and Maternity documentation. main objective is to align documentation control and development processes across specialities With the support of the Chief we have now secured support of a team from the Trust Development Agency to help improve record keeping and a Trust wide documentation standardisation project is underway The Trust has also commenced the implementation of the 'EVOLVE' system Which will introduce electronic records across the Trust; This will be piloted later this year and is projected to start on 17h November and run for 4 Weeks with a Trust wide rollout projected to take 4 months starting in January 2016. The Project brief is to replace all clinical documentation with electronic forms hosted within the Evolve electronic case note system_ This will help mandate the completion of patient assessments_ The first phase of forms to be piloted on two wards at NMGH will on nursing assessment documents, associated care plans and referrals and will include nutritional assessments, falls and bed rails risk assessments_ dementia screening and the pressure ulcer care plan. The Trust is also introducing Ward Accreditation, a new project which will help us to monitor safe practice by measuring the quality of nursing care delivered by ward teams Aslpait of this project we will be checking and monitoring the quality of record keeping including patient assessments. Could please extend my sincere condolences to Mrs Hartford's family. If there is any further information that you require please do not hesitate to contact me_