Herefordshire review

Deliver a learning event to the teams involved in this episode of care delivery. This will provide staff with the learning from this review and give education on the actions.

Provide a Trust wide briefing on this case, detailing the observations, learning and recommendations from this individual management report. This will be communicated and Team managers will be directed to discuss in Team meetings.

SBARD training will be delivered to the teams involved in this case and will also be made available to other Trust services in Herefordshire.

Conduct an audit of carers assessments completion and review dates will be completed for the Herefordshire Memory Assessment Service and Older Person Services.

Conduct an audit of completion of care plans, risk assessments and crisis contingency plans for the Herefordshire Memory Assessment Service and Older Person Services.

Development work on better liaison and promotion of careers support services linked with wider Trust work in this area. This will include the development and communication of strategies to be used when reasonable support is being refused.

Review the Herefordshire Memory Assessment and Older Person Services sharing of information with clinicians, patients and carers, including the practice of copying or addressing letters to patients. This will also consider the sharing of information regarding medication and care planning.

Provide clear guidance to ensure that patients and carers are offered and consistently reminded of a clear single point of contact at whatever level they are engaged, and that appropriate supporting information is given regarding planned interventions and indications for contacting services before crisis.

Provide clear guidance on the process for ascertaining that a carers assessment has been requested, and undertaken or refused, should be reviewed, including its documentation and reference to actions in RIO.

Meet with Wye Valley Trust nursing lead to discuss methods for improving communication between services in light of the learning from this IMR.

All cross boundary Nursing cases to be discussed at Clinical supervision to ensure that there is a plan to try and gain access to information.

When Care Notes Electronic records are introduced, separate records should be created for carers who are in receipt if direct interventions from Trust services with links to the patient’s records so that other services within the Trust can have access to carer records. Separate interventions for a carer would be visible and in the case of Admiral Nurses, the involvement of the service would be clear to all who view the record.(the Admiral Nurse would still need to maintain their WANDA records)

Where Admiral Nursing Service are seeing carers, key points of information and concern should be actively shared with other members of the care team e.g. GP and Psychiatrist etc via telephone, email or letter as appropriate with professionals and agencies involved in the care and support of the family.

West Mercia and Warwickshire Police Firearms Licencing Departments to consider the feasibility of implementing the wording of the Recommendation 6 of Durham DHR re Adults A-F (February 2013) and report back to the Hereford Community Safety Partnership within 3 months.

Map of Medicine needs to include the car pathway for domestic abuse

The care pathway needs to be reviewed to assess whether it is fit for purpose for all age groups, amended as necessary and published on adult focused web

The CCG to include a link to the document managing pain in dementia in their next GP newsletter

Trust to look at ways of ensuring that information leaflets for carers of patients with a diagnosis of dementia is given to all carers, in order that they are aware of how to access help if required.

Trust to look at developing a carer’s self-assessment tool that could be completed by carers of patients with dementia, in order to identify those carers who are finding it difficult to cope.