Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 67
Action
Share safeguarding escalation learning with relevant staff so similar incidents automatically trigger Trust safeguarding-team escalation and local-authority follow-up.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Establish a dedicated telephone number and contact time for discussing hospital discharges.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Offer additional pressure-ulcer care training to care organisations where required.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Embed the practice changes in operational procedures for all community teams.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Continue collaborative safeguarding work with system partners to embed improvements in partnership working, discharge planning and holistic, personalised care.
Stated by Central London Community Healthcare NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Embed the practice changes in operational procedures for all community teams by 31 March 2023.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Share discharge communications and care plans with all providers involved in patients’ care.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Offer additional pressure-ulcer prevention training to care organisations where required.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Contribute to developing the NCL tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Stated by University College London Hospitals NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Stated by University College London Hospitals NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Train registered nurses to add discharge-relevant nursing notes to Epic discharge summaries; training is complete for senior ward nurses.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Discuss potential interview conflicts of interest with the Local Authority to identify the appropriate interviewing lead.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Contact adult social care to request care-plan updates when additional needs are identified during initial visits or risk assessments.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Identify potential conflicts of interest when interviewing the organisation’s care staff.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Ensure robust and timely communication with all agencies involved in care arrangements.
Stated by Kapital Care (UK) Limited Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Obtain the relevant discharge notification form before starting hospital-discharge care packages.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Provide refresher pressure-ulcer management training where appropriate.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review organisation-wide training needs for all employed care staff.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source
Action
Review policies and procedures addressing the identified safeguarding and care concerns.
Stated by Kapital Care (UK) Limited Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Review mandatory pressure-ulcer management training requirements for care staff.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Review organisational recording and documentation practices.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source
Action
Continue working with partner agencies to build on current improvements and incorporate learning from the Safeguarding Adults Review.
Stated by Westminster City Council Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Stated by Westminster City Council Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Continue embedding discharge and coordinated-care improvements and reviewing practice with whole-person care central to changes.
Stated by Westminster City Council Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Stated by Westminster City Council Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Work with Kapital Care to support improvements in care practice, documentation, escalation and communication.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Review safeguarding-enquiry recommendations for lessons and improvements across relevant organisations.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Stated by University College London Hospitals NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Review and improve local processes and staff education to prevent poor patient outcomes and support safe, holistic discharge and community care.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Contribute to development of the North Central London tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Communicate to staff the referral-screening process requiring completion of skin and nursing sections before referrals reach community partners.
Stated by University College London Hospitals NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Stated by University College London Hospitals NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Request additional pressure-ulcer management and repositioning training from CNWL Academy.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review care-staff training needs across the organisation.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source
Action
Continue improving procedures by identifying gaps and incorporating further preventative measures.
Stated by Kapital Care (UK) Limited Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Contact adult social care to request care-plan updates when additional needs are identified.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Identify potential conflicts of interest when interviewing care staff and discuss appropriate interview leadership with the Local Authority.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Request relevant assessments, care information and emergency contact details from involved professionals.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review mandatory pressure-ulcer management training requirements for care staff.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review hospital discharge information and discharge letters to identify care-delivery needs.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Contact district nurses whenever they are involved in an adult’s care arrangements.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Review all policies and procedures following safeguarding and coroner findings.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source See 64 more actions
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to consider documented pressure-ulcer risk when issuing care instructions
Wider context from the report “5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions . She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
” Is this part of a recurring concern? Yes — Inadequate management of pressure ulcers .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to adequately investigate safeguarding explanations and evidence
Wider context from the report “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to implement system, training and partnership changes after safeguarding investigation
Wider context from the report “8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months . The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place .
Apparently, no lessons have been learnt.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to involve district nursing team in discharge planning
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting , it is much more likely that this measure would have been considered.
” Is this part of a recurring concern? Yes — Unreliable hospital discharge processes .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report “3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction .
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice.
Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report “4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to establish daily skin-integrity monitoring responsibility
Wider context from the report “2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share safeguarding escalation learning with relevant staff so similar incidents automatically trigger Trust safeguarding-team escalation and local-authority follow-up.
Verbatim wording from the response “• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated telephone number and contact time for discussing hospital discharges.
Verbatim wording from the response “• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer additional pressure-ulcer care training to care organisations where required.
Verbatim wording from the response “• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the practice changes in operational procedures for all community teams.
Verbatim wording from the response “In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
Verbatim wording from the response “• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training.
Verbatim wording from the response “• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
Verbatim wording from the response “• We have enhanced lines of communication between our teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborative safeguarding work with system partners to embed improvements in partnership working, discharge planning and holistic, personalised care.
Verbatim wording from the response “We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.
Verbatim wording from the response “• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the practice changes in operational procedures for all community teams by 31 March 2023.
Verbatim wording from the response “In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
Verbatim wording from the response “• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share discharge communications and care plans with all providers involved in patients’ care.
Verbatim wording from the response “• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.
Verbatim wording from the response “• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer additional pressure-ulcer prevention training to care organisations where required.
Verbatim wording from the response “• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to developing the NCL tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Verbatim wording from the response “• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Verbatim wording from the response “• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Verbatim wording from the response “• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train registered nurses to add discharge-relevant nursing notes to Epic discharge summaries; training is complete for senior ward nurses.
Verbatim wording from the response “• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Verbatim wording from the response “• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Verbatim wording from the response “• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss potential interview conflicts of interest with the Local Authority to identify the appropriate interviewing lead.
Verbatim wording from the response “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact adult social care to request care-plan updates when additional needs are identified during initial visits or risk assessments.
Verbatim wording from the response “• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify potential conflicts of interest when interviewing the organisation’s care staff.
Verbatim wording from the response “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure robust and timely communication with all agencies involved in care arrangements.
Verbatim wording from the response “• Kapital care is ensuring robust and timely communication is undertaken with all agencies.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain the relevant discharge notification form before starting hospital-discharge care packages.
Verbatim wording from the response “• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
Verbatim wording from the response “• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide refresher pressure-ulcer management training where appropriate.
Verbatim wording from the response “• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
Verbatim wording from the response “• Kapital Care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review organisation-wide training needs for all employed care staff.
Verbatim wording from the response “• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review policies and procedures addressing the identified safeguarding and care concerns.
Verbatim wording from the response “Kapital Care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review mandatory pressure-ulcer management training requirements for care staff.
Verbatim wording from the response “• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review organisational recording and documentation practices.
Verbatim wording from the response “• Review of recording and documentation within the organisation.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with partner agencies to build on current improvements and incorporate learning from the Safeguarding Adults Review.
Verbatim wording from the response “The local authority will continue working with partner agencies to build on the current improvements, which will be further informed by the outcome of the current Safeguarding Adults Review process.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Verbatim wording from the response “• Standard operating procedures are being updated to reflect the outcomes of the workshops. This includes:
◦ a training package for newly qualified social workers entering the service and for experienced social workers as part of their yearly appraisal and continuous professional development. The training package focuses on identifying care needs associated with pressure care, manual handling and equipment, medication, risk management plans and the co-ordination role of a social worker.
◦ an improved tool for discharge including a template checklist to ensure all key areas are addressed.
◦ key escalation points and links with community providers including District Nurses.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue embedding discharge and coordinated-care improvements and reviewing practice with whole-person care central to changes.
Verbatim wording from the response “The authority is addressing the multiple actions required to improve hospital discharge and delivery of co-ordinated care. All future actions and learning arising from Professor Shannon’s death will be implemented with whole person care central to any changes. We are absolutely committed to maintaining and embedding those improvements already implemented, prioritising implementation of those in progress and consistently reviewing our practice.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Verbatim wording from the response “• To support an all-agency approach to discharge planning, social workers now use a checklist to ensure that all aspects of the care plan have been actioned prior to discharge, e.g., equipment delivery, district nurse involvement, care agency fully briefed. This is to minimise the risk of there being any gaps in the discharge process across all agencies.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.
Verbatim wording from the response “• The Safeguarding Service has revised its practice so that when reviewing cases in professional supervision, it will explore whether delegated or direct conversations should take place, factoring in whether there are conflicts of interest in individual agencies being asked to conduct parts of the safeguarding enquiry.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Verbatim wording from the response “• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Kapital Care to support improvements in care practice, documentation, escalation and communication.
Verbatim wording from the response “• The local authority has worked with Kapital Care to support improvements in their practice, as detailed in Kapital Care’s response regarding their training, documentation, escalation to use if there is an issue, improved communication with District Nurses and others involved in a person’s care.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review safeguarding-enquiry recommendations for lessons and improvements across relevant organisations.
Verbatim wording from the response “• The London Multi-Agency Safeguarding Adults Policy requires all individual organisations to review the recommendations identified in the Section 42 Safeguarding Enquiry investigation report for any lessons to be learned. This has now taken place, but the delay is acknowledged and is a learning that will be addressed by all partners.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Verbatim wording from the response “• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient’s notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Verbatim wording from the response “• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Verbatim wording from the response “• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve local processes and staff education to prevent poor patient outcomes and support safe, holistic discharge and community care.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to development of the North Central London tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Verbatim wording from the response “• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate to staff the referral-screening process requiring completion of skin and nursing sections before referrals reach community partners.
Verbatim wording from the response “• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will further be communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request additional pressure-ulcer management and repositioning training from CNWL Academy.
Verbatim wording from the response “• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care-staff training needs across the organisation.
Verbatim wording from the response “• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue improving procedures by identifying gaps and incorporating further preventative measures.
Verbatim wording from the response “We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact adult social care to request care-plan updates when additional needs are identified.
Verbatim wording from the response “• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify potential conflicts of interest when interviewing care staff and discuss appropriate interview leadership with the Local Authority.
Verbatim wording from the response “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request relevant assessments, care information and emergency contact details from involved professionals.
Verbatim wording from the response “• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review mandatory pressure-ulcer management training requirements for care staff.
Verbatim wording from the response “• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review hospital discharge information and discharge letters to identify care-delivery needs.
Verbatim wording from the response “• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact district nurses whenever they are involved in an adult’s care arrangements.
Verbatim wording from the response “• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all policies and procedures following safeguarding and coroner findings.
Verbatim wording from the response “Kapital Care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority should determine which person or agency is most appropriate to lead interviews where Kapital Care has a potential conflict of interest.
Verbatim wording from the response “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.” Source location Response from Kapital Care
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 37 1 Share communications and care plans with all providers involved at discharge.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 2 Hold monthly review meetings with University College Hospital NHS Trust and partners to improve partnership working.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 3 Share the learning with all providers of Community Nursing Services.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 4 Work with the Safeguarding Adults Executive Board to embed safe-discharge improvements across the system.
Stated by Central London Community Healthcare NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source 5 Review completed actions at scheduled Divisional Quality forums and provide assurance to the Patient Safety Risk group.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 6 Review completed actions through Divisional Quality forums and provide assurance to the Patient Safety Risk group.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 7 Establish monthly partnership review meetings with University College Hospital NHS Trust and partners.
Stated by Central London Community Healthcare NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 8 Work with the Safeguarding Adults Executive Board to embed safe-discharge changes and provide system assurance.
Stated by Central London Community Healthcare NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source 9 Share learning with all providers of community nursing services.
Stated by Central London Community Healthcare NHS Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 10 Roll out discharge-summary nursing-note training to specified wards across all hospital sites linked with community and social-care partners.
Stated by University College London Hospitals NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 11 Complete robust handovers with previous care providers.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 12 Request additional pressure-ulcer management and repositioning training from CNWL Academy for care staff with identified needs.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 13 Review care plans whenever care concerns are raised or identified.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 14 Report concerns affecting care delivery immediately to adult social care to secure a solution.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 15 Continue improving procedures, identify further gaps and incorporate additional preventative measures to protect adults’ dignity.
Stated by Kapital Care (UK) Limited Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source 16 Facilitate joint visits with adult social care or other relevant professionals when concerns are identified.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 17 Escalate concerns and issues immediately to the Local Authority.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 18 Request relevant assessments, care information and emergency contact details from professionals involved in an adult’s care.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 19 Meet commissioners and safeguarding leads to identify and address required improvements.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 20 Record pressure-area concerns on body maps and report identified concerns to relevant professionals.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 21 Ensure social workers are core members of multidisciplinary hospital discharge planning meetings.
Stated by Westminster City Council Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 22 Monitor Kapital Care’s delivery of agreed actions through quarterly contract-management reviews.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 23 Enhance commissioned-service contract specifications to focus on person-centred care.
Stated by Westminster City Council Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 24 Facilitate social care hospital practice workshops to improve discharge coordination and communication with care agencies.
Stated by Westminster City Council Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 25 Roll out Epic discharge-summary nursing-note training to specified wards across all hospital sites and evaluate and report it quarterly.
Stated by University College London Hospitals NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 26 Train senior ward nurses to add discharge and continuity-of-care nursing notes to Epic discharge summaries.
Stated by University College London Hospitals NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 27 Meet commissioners and safeguarding leads to identify and address required improvements.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 28 Review organisational recording and documentation.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source 29 Record pressure-area concerns on body maps and report identified concerns to relevant professionals.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 30 Report concerns affecting care delivery immediately to adult social care.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 31 Review care plans when concerns are raised or identified.
Stated by Kapital Care (UK) Limited Status unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022. View source 32 Obtain the relevant discharge notification form before commencing hospital-discharge care packages.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 33 Maintain and regularly review the implemented actions and identified learning.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 34 Complete robust handovers with previous care providers.
Stated by Kapital Care (UK) Limited Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source 35 Ensure robust and timely communication with all agencies involved in care arrangements.
Stated by Kapital Care (UK) Limited Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source 36 Facilitate joint visits with adult social care or other relevant professionals when concerns arise.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source 37 Escalate concerns and issues immediately to the Local Authority.
Stated by Kapital Care (UK) Limited Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share communications and care plans with all providers involved at discharge.
Verbatim wording from the response “• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly review meetings with University College Hospital NHS Trust and partners to improve partnership working.
Verbatim wording from the response “• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the learning with all providers of Community Nursing Services.
Verbatim wording from the response “Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Safeguarding Adults Executive Board to embed safe-discharge improvements across the system.
Verbatim wording from the response “• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review completed actions at scheduled Divisional Quality forums and provide assurance to the Patient Safety Risk group.
Verbatim wording from the response “Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February 2023 and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review completed actions through Divisional Quality forums and provide assurance to the Patient Safety Risk group.
Verbatim wording from the response “Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish monthly partnership review meetings with University College Hospital NHS Trust and partners.
Verbatim wording from the response “• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Safeguarding Adults Executive Board to embed safe-discharge changes and provide system assurance.
Verbatim wording from the response “• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning with all providers of community nursing services.
Verbatim wording from the response “Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.” Source location Response from Central London Community Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out discharge-summary nursing-note training to specified wards across all hospital sites linked with community and social-care partners.
Verbatim wording from the response “• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete robust handovers with previous care providers.
Verbatim wording from the response “• A robust handover is completed with any previous care provider.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request additional pressure-ulcer management and repositioning training from CNWL Academy for care staff with identified needs.
Verbatim wording from the response “• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care plans whenever care concerns are raised or identified.
Verbatim wording from the response “• Review the care plan when any concerns are raised/identified.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report concerns affecting care delivery immediately to adult social care to secure a solution.
Verbatim wording from the response “• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue improving procedures, identify further gaps and incorporate additional preventative measures to protect adults’ dignity.
Verbatim wording from the response “We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate joint visits with adult social care or other relevant professionals when concerns are identified.
Verbatim wording from the response “• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate concerns and issues immediately to the Local Authority.
Verbatim wording from the response “• Kapital Care will immediately escalate any concerns or issues to the Local Authority.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request relevant assessments, care information and emergency contact details from professionals involved in an adult’s care.
Verbatim wording from the response “• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet commissioners and safeguarding leads to identify and address required improvements.
Verbatim wording from the response “• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record pressure-area concerns on body maps and report identified concerns to relevant professionals.
Verbatim wording from the response “• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.” Source location Response from Kapital Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure social workers are core members of multidisciplinary hospital discharge planning meetings.
Verbatim wording from the response “The authority is committed to supporting an integrated hospital discharge process and will ensure social workers are core members of hospital multi-disciplinary discharge planning meetings.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Kapital Care’s delivery of agreed actions through quarterly contract-management reviews.
Verbatim wording from the response “• Local authority contract managers have been meeting regularly with Kapital Care and will continue to monitor delivery of their agreed actions quarterly.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance commissioned-service contract specifications to focus on person-centred care.
Verbatim wording from the response “• The local authority’s contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate social care hospital practice workshops to improve discharge coordination and communication with care agencies.
Verbatim wording from the response “• Since December 2022 the local authority has arranged and facilitated three social care hospital practice workshops with the staff teams to raise awareness and improve practice. The workshops focused on the key points raised by the coroner at the end of the Inquest with regards to the social workers’ understanding of their role in both co-ordinating the care for discharge and information that is shared and communicated with care agencies.” Source location Response from City of Westminster
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Epic discharge-summary nursing-note training to specified wards across all hospital sites and evaluate and report it quarterly.
Verbatim wording from the response “• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train senior ward nurses to add discharge and continuity-of-care nursing notes to Epic discharge summaries.
Verbatim wording from the response “• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet commissioners and safeguarding leads to identify and address required improvements.
Verbatim wording from the response “• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review organisational recording and documentation.
Verbatim wording from the response “• Review of recording and documentation within the organisation.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record pressure-area concerns on body maps and report identified concerns to relevant professionals.
Verbatim wording from the response “• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report concerns affecting care delivery immediately to adult social care.
Verbatim wording from the response “• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care plans when concerns are raised or identified.
Verbatim wording from the response “• Review the care plan when any concerns are raised/identified.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain the relevant discharge notification form before commencing hospital-discharge care packages.
Verbatim wording from the response “• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and regularly review the implemented actions and identified learning.
Verbatim wording from the response “• Kapital care will ensure the implemented actions and identified learning as detailed within this report are maintained and reviewed regularly. These actions will ensure close partnership working with all agencies involved in an individual care arrangement.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete robust handovers with previous care providers.
Verbatim wording from the response “• A robust handover is completed with any previous care provider.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure robust and timely communication with all agencies involved in care arrangements.
Verbatim wording from the response “• Kapital care is ensuring robust and timely communication is undertaken with all agencies.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate joint visits with adult social care or other relevant professionals when concerns arise.
Verbatim wording from the response “• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.” Source location Response from Kapital Care (UK) Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate concerns and issues immediately to the Local Authority.
Verbatim wording from the response “• Kapital Care will immediately escalate any concerns or issues to the Local Authority.” Source location Response from Kapital Care (UK) Limited
Open published response
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