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Content ArticleThis joint project with East Berkshire CCG was highlighted within the AKI Programme within Oxford Patient Safety Collaborative. Fewer residents are suffering urinary tract infections (UTIs) following the introduction of a hydration programme in care homes. UTIs are closely associated with dehydration. This project was designed to encourage residents to drink more fluids with the aim that this would lead to fewer UTIs requiring medication or hospital admission. This approach involved introducing structured drinks rounds seven times a day, designed and delivered by care home staff. The initial focus was in four care homes which had higher than average UTI admission to hospital rates.
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Content ArticleThis short blog provides a ‘glimpse of brilliance’ video on donning and doffing of PPE – this includes some reflections on experience of a care home manager in Salford. This information is sourced from Safer Salford.
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Content ArticleRESTORE2 TM is a physical deterioration and escalation tool for care/nursing homes. It is designed to support homes and health professionals to: recognise when a resident may be deteriorating or at risk of physical deterioration act appropriately according to the resident’s care plan to protect and manage the resident obtain a complete set of physical observations to inform escalation and conversations with health professionals speak with the most appropriate health professional in a timely way to get the right support provide a concise escalation history to health professionals to support their professional decision making. Here you can find all the official resources to accompany the initiative.
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Coronavirus: 'I didn't want her dying on her own'
Patient Safety Learning posted an article in Blogs
Siobhan Brammeld is a care worker at Massereene Manor care home in County Antrim and leads the social care team. She has sat with several residents as they passed away having contracted COVID-19. In this interview with BBC News NI she says she was convinced some residents had "died before their time". "I feel as though I am on autopilot - it never leaves my head. Sometimes I worry that I could have done more," she said. "These are sad times, scary times too," she added. Siobhan told BBC News that staff felt not enough was done to prepare them for the pandemic and that workers like her were left to the side. "I feel we were left on our own. We as workers were forgotten about as well as the wee residents," she said. "At the start of all this I just wanted to scream at somebody - could someone please come and help these wee residents? I just didn't want them to die before their time." "I watched what was happening in other countries and you knew it was coming, but there didn't seem to be an awful lot happening to prepare us." -
Content ArticleIn this interview, Cheryl Crocker, AHSN Network Patient Safety Director, tells us more about her role and why she is passionate about care homes.
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Content ArticleMedicines errors in care homes are unacceptably high. A key study found that residents taking 7 or more medicines had a 79% chance of being a victim of a medicines error (Alldred et all 2009). In his article, published by Care Right Now, Steve Turner discusses the benefits and challenges of electronic MAR charts and best practice in medicine record keeping.
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Content ArticleIn his blog, Steve Turner, Head of Medicines and Prescribing at Medicine Gov, talks about how to manage medicines in care homes and implement quality standards. This blog is designed to provide information for care homes and for those choosing a care home.
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Content ArticleMarginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. This review from Cheraghi-Sohi et al. in the International Journal for Equity in Health highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments.
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Content Article
Why malnutrition matters in care homes? (October 2019)
Claire Cox posted an article in Community care
In this short video, Professor Martin Green explains why good nutrition in care homes is essential. He explains that screening patients before they come to the care home is a 'must do' rather than a 'nice to have'. This video was made for the National Nutrition awareness week in 2019.- Posted
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Content ArticleI-Hydrate was a collaborative research project, which used service improvement methodology, and was undertaken at two privately operated North West London care homes in partnership with care home staff, residents and their carers and families. I-Hydrate aimed to optimise the hydration of residents in nursing homes, improve the quality and safety of care and decrease dehydration and the morbidity associated with it.
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Malnutrition Task Force case study: Lyn's story
Claire Cox posted an article in Community care
Follow Lyns story, an animation highlighting the challenge of malnutrition in later life. The Malnutrition Task Force (MTF) are united to combat preventable and avoidable malnutrition and dehydration among older people in the UK. Established in 2012, they believe that good nutrition and hydration is fundamental to delivering dignified care, and enabling older people to live fulfilling and independent lives. Tackling malnutrition is everybody’s business. The MTF works with partners across sectors and settings to raise awareness of undernutrition in later life and its causes, provide information and guidance, and spread best practice and innovation to improve the lives of older people in the UK. -
Content ArticleVenous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or its part can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE. With an estimated incidence rate of 1-2 per 1,000 of the population, VTE is a significant cause of mortality and disability in England with thousands of deaths directly attributed to it each year. One in twenty people will have VTE during their lifetime and more than half of those events are associated with prior hospitalisation. At least two thirds of cases of hospital-associated thrombosis are preventable through VTE risk assessment and the administration of appropriate thromboprophylaxis.
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Report to Prevent Future Deaths: Regulation 28 – Eileen Pollard
Claire Cox posted an article in Coroner reports
The Coroners and Justice Act 2009 allows a coroner to issue a Regulation 28 report to an individual, organisations, local authorities or government departments and their agencies where the coroner believes that action should be taken to prevent further deaths. Eileen Pollard died of a myocardial infarction. This coroners report was due to concerns raised by the patient numerous times around the call bell either not being near the patient or not working.- Posted
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Content ArticleBetween 25-30 April 2020, three nurses working at Waitakere Hospital, New Zealand tested positive for coronavirus (COVID-19). In the week prior to testing positive, the nurses had been working on a ward caring for a group of elderly patients with COVID-19. The patients were from an aged residential care (ARC) facility in West Auckland.
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Content ArticleNadia Whittome, an MP, went back to work in social care when the pandemic struck but was dismissed when she spoke out about the lack of personal protective equipment (PPE) faced by workers on the frontline. She recounts her experience in a blog to the Guardian.
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Content ArticleA blog in the Guardian from an anonymous care worker about the unfair treatment of care home workers, the lack of personal protective equipment available, the fear of speaking up, and the stress and anxiety the pandemic is causing.
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Content ArticleThe Health and Social Care Select Committee is currently holding an Inquiry into Delivering Core NHS and Care Services during the Pandemic and Beyond. It’s stated aim is to ‘give focus to these upcoming strategic challenges, and give those working in the NHS and care sectors an opportunity to set out what help they will need from Government in meeting them’[1]. In its call for evidence the Inquiry has specifically identified ‘meeting the needs of rapidly discharged hospital patients with a higher level of complexity’ as one of the issues it will cover [2]. This is a joint submission (see attachment) to the Inquiry by Patient Safety Learning and CECOPS which is focused on this specific issue.
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Content ArticleThis report, from the International Long Term Care Policy Network, provides examples of the policy and practice measures that have been adopted internationally to prevent COVID-19 infections in care homes and to mitigate their impact. This is a 'live' document that will be updated regularly and expanded as more information becomes available.
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- Older People (over 65)
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Adult social care statistics: the potential for change
Patient Safety Learning posted an article in Blogs
The lack of funding in social care doesn’t only mean that services are unable to meet demand – there is also under-investment in data and analytics. Laura Schlepper explains why social care data matters and what would help to increase its potential. -
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Coronavirus (COVID-19): reuse of medicines in a care home or hospice
Claire Cox posted an article in Guidance
Standard operating procedure on how to run a safe and effective medicines reuse scheme in a care home or hospice during the coronavirus outbreak. -
Content Article
COVID-19: How to work safely in care homes
PatientSafetyLearning Team posted an article in Guidance
Government guidance for those working in care homes providing information on how to work safely during this period of sustained transmission of COVID-19.- Posted
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Content ArticleThis is the written transcript and the video recording of the Health and Social Care Committee meeting that took place on Friday 17 April on the topic of: Management of the Coronavirus Outbreak. Witness(es): Dr Alison Pittard, Dean, Faculty of Intensive Care Medicine; Dame Donna Kinnair, Chief Executive and General Secretary, Royal College of Nursing; Professor Anthony Costello, Professor, UCL Institute for Global Health Witness(es): Matt Hancock, Secretary of State, Department for Health and Social Care; Jonathan Van-Tam, Deputy Chief Medical Officer for England, Department for Health and Social Care
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Content ArticleYou must notify the Care Quality Commission (CQC) of the death of a person using your service if either of the following has happened: the person died while a regulated activity was being provided their death may have been a result of the regulated activity or how it was provided. You must report the death without delay. CQC has provided the notification form to complete along with guidelines.
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Content ArticleBBC Radio 4's You and Yours programme discusses the impact of coronavirus on social care and asks listeners if they feel their relatives in care are being properly protected? One listener, Amanda, speaks about the recent loss of her father who had Alzheimer's Disease. Following a fall and a hospital admission, he contracted the virus. A second caller, Bill, talks about the challenges and risks associated with needing care and support at home as a disabled man. Follow the link below to hear the full programme. This feature aired on 14 April 2020.
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Content Article
Dementia and COVID-19: Four big problems, three solutions
Anonymous posted an article in Blogs
Day 1, Dad goes into a care home so Mum can have respite care. Day 5, the care home provider announces a lockdown is in place. Day 12, Dad develops a raging temperature. Day 13, he develops a persistent cough, and they try to evict him back home to Mum. Here’s our story...