SUMMARY REPORT
Trust Board :DRAFT
November 2014
Subject
Quarterly update on acute hospital standards for people with Learning
Disabilities
Prepared by
Associate Director of Nursing/Nurse Consultant Older People and Team Leader
Learning Disabilities Liaison team
Approved by
Director of Nursing & Midwifery
Presented by
Associate Director of Nursing/Nurse Consultant Older People and Team Leader
Learning Disabilities Liaison team
Purpose
This report provides evidence of compliance towards National Standards for
care of people with Learning Disabilities in acute hospitals and the recently
published Joint Health & Social Care Self Assessment Framework. It also
outlines the recommendations for acute hospital, from a recent Confidential
Inquiry into premature deaths of people with Learning Disabilities and
proposes a new format for the Learning Disabilities Action/Improvement plan
Decision
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Approval
Information
Assurance
Corporate Objectives
Quality Care
Inspired People
Healthy Organisation
Innovate & Collaborate
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Executive Summary
People with Learning Disabilities have an equal right to healthcare. It is important, therefore,
that the Trust has services, staff and support which enable people with Learning Disabilities to
use our services. The Trust needs to ensure that our healthcare services provide a high
standard of care and treatment to people with Learning Disabilities – which meet national
requirements and standards. Care and treatment of individuals must take into consideration
and make reasonable adjustments where necessary, for their complex needs and disabilities.
Progress continues to be made towards the national standards, as laid out in the Monitor
framework and Care Quality Commission and in the recently published Joint Health & Social
Care Self Assessment Framework; the Trust continues to provide high quality care to people
with Learning Disabilities
The focus of the Learning Disabilities Liaison team is to work with clinical teams across the
hospital, community settings and primary care to facilitate and promote high quality of care to
people with Learning Disabilities, as they access Trust services.
A recent Confidential Inquiry into the premature deaths of people with Learning Disabilities sets
out a range of recommendations for improvement in health services for this group of patients.
The Learning Disabilities Liaison team has now undertaken a self-assessment against the
recommendations and has published a new/revised Learning Disabilities Trust Improvement
plan - which has incorporated the Joint health & social care framework. This combined and
revised action plan will be reported, via the Patient Experience Committee at the next regular
Trust Board report and regularly monitored at the LD Health Subgroup.
Quality Impact Assessment
This report provides assurance of compliance with CQC standards - Outcomes 1, 4, and 7.
The Trust has a legal duty to ensure equality of service provision and to meet requirements from the
Equality Act (2010).
Financial Impact Assessment
No direct impact
Key Recommendations
The Trust Board is asked to:
1. Review the Trust’s continued position and satisfy itself that the Trust is able to declare
continuing compliance towards the Monitor Compliance framework
2. Note the progress of compliance against the self-assessment of the Confidential Inquiry particularly those relevant to acute hospital services as set out in the PHNT LD Improvement
plan 2014/15.
Next Steps
The Trust Board will continue to receive reports on progress towards the national standards for
people with Learning Disabilities (quarterly).
Action/Improvement plan based on the recommendations from the Confidential Inquiry continues to
be Implemented in 2014/15 and progress monitored by LDL Team leader and reported to HASG,
Patient Experience Group and reported to the Trust Board at next quarterly report
DETAILED REPORT
Trust Board
November 14
Subject
Quarterly update on acute hospital standards for people with Learning
Disabilities
Prepared by
Associate Director of Nursing/Nurse Consultant Older People
Approved by
Director of Nursing & Midwifery
Presented by
Associate Director of Nursing
Purpose
People with Learning Disabilities have an equal right to healthcare. It is important, therefore,
that the Trust has services, staff and support which enable people with Learning Disabilities
to use our services. This report details the work undertaken to review the working of the
Learning Disabilities Liaison team, the scope of practice for this team and to improve how
people with Learning Disabilities are supported as they use Trust services.
The Trust Board is required to review compliance with the national Monitor framework for
standards of care for people with Learning Disabilities –
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Mechanisms to ‘flag’ patients with a learning disability
Protocols to ensure reasonable adjustments to pathways of care
Readily available and comprehensive information for people with a learning disability
Protocols ensuring support for family carers
Training for all staff
Protocols to encourage representation of people with a learning disability and their
family carers
Regular audits in place, with findings reported in public
This report provides detail of the work towards compliance against this framework and other
national standards
Background
People with learning disabilities often have specific health needs, in addition to the general
health needs which the rest of the population face throughout life. However, for various
reasons, they often struggle to access the same level of healthcare services – both in terms
of primary and secondary care.
Various national reports and inquiries have identified the need for health providers to ensure
specific actions and services are in place to appropriately support people with Learning
Disabilities and their carers who use services. The most recent one being: A Confidential
Inquiry into premature deaths of people with a learning disability.
The Confidential Inquiry has made a number of recommendations (18 in total) which they
feel will help improve the healthcare of people with a learning disability and reduce the
number of premature deaths.
We reported at the March 2014 board meeting that a self-assessment against the relevant
recommendations (11 out of the original 18) had been undertaken by the LDL Team. In the
main we assessed ourselves as being 75% compliant (GREEN) with only two
recommendations in Amber and two in which we had a low score on (Red). An update on
progress in relation to these scores now shows more green scores 9 out of 11, with the
remaining 2 reds now being Amber (See Annex 1) and we are confident of achieving 100%
scores in most of the recommendations within the set timeframes. This process has and will
continue to involve members of DUG, the Health Sub group of the local Learning Disabilities
(partnership) Board and Patient Experience group. They were given the opportunity to
highlight the areas they want prioritising in the oncoming year. Please note highlighted
Actions on the Improvement plan.
National Standards for People with Learning Disabilities in Hospital
Progress has been made towards the PHNT LD improvement plan 2014/15 and national
standards as laid out in the Monitor framework and Care Quality Commission and is reported
in Annex 1. The Trust continues to provide high quality care to people with Learning
Disabilities. Some examples of this are as follows:
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The LD awareness E-learning module and will be trialled with the day case
department staff in the next few months. The feedback will be used to make any
changes prior to it becoming mandatory for all staff.
Derriford Users Group (DUG) continues to have regular meetings that focus on
different aspects of Derriford Hospital. The most recent input was to review the
patient’s journey through day case department. A photograph Journey poster has
been produced and will be displayed in the department and it is there for
everyone. The next planned task will be mystery shopping around toilet facilities
at Derriford Hospital.
A reasonable adjustments risk assessment tool is now used for all LD in patients.
Specific LDL team core care plan is being used and a copy in easy read will be
available in the patients bed file for all LD in-patients.
LD Discharge Plan document in easy read is now available to be used for people
with LD, as appropriate, when they are discharged from hospital.
LD Liaison Team has continued to use the meridian essence of care patient
questionnaire and a short report of audit of essence of care has been produced.
There were still some issues in regards to questions impacting on reliability of the
results. The questions have recently been reviewed and will improve the reliability
of the overall results in future reports.
The Team has worked with RAPA software developers and we will receive alerts
in regards to out patient’s appointments for people with a LD at Derriford hospital.
It has been reported from our IPMs system that approx. 3294 appointments were
made for people with a LD at Derriford hospital from Jan 2012 March 2013. With
the new staffing additions to the team (admin and Band 3 post) we are now in a
position to develop a pathway on how we respond/meet the needs of people with
LD attending outpatient appointments.
We have worked with IT to start a data base of basic information on patients with
LD attending Derriford hospital (See Annex 2) . This information is very useful, for
example its shows Fal ward as one of the most used wards by people with a LD.
This has guided us in looking at the patient’s journey in this area and choosing
this area for trial of our LD awareness e-learning package.
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An excellent example for reasonable adjustments made by the Derriford Hospital
is the development of the LD GA clinic. This clinic is to be held once a month at
Freedom Unit. The purpose of the clinic is to allow people who would not normally
cooperate with vital investigative procedures the opportunity to be asleep (have a
General Anaesthetic (GA)) to have them done. The clinic is managed and
supported by the LDL team with full support from the theatre team and allows us
to plan for complex and challenging patients.
Following the Team leaders presentation at this years (March 2014) Confidential
Inquiry one year on conference on how we use RAPA to identify patients with LD
we have been asked to submit this piece of good practice as a short summary
and has been recently published in the Department of Health’s Confidential
inquiry progress report.
New improved documentation around assessing a person’s mental capacity and
best interest decisions has been developed by the LDL team and is currently
being trialled for LD patients across the Trust. We plan to evaluate the pilot of
Mental Capacity/Best Interest record - to clarify if this makes Serious Medical
Decisions clearer and easier to manage for those who lack capacity.
We plan to Collect and respond data in relation to LD DNA’s for 2 or more
appointments missed.
Report Mortality review summary/themes have been presented to the
Safeguarding Steering Group.
LDL team to work specifically with Cancer Lead nurse and Cancer Nurse
Specialists to ensure people with LD are accessing screening, investigations and
treatments in a timely manner; develop Easy Read information for these service
areas.
Conclusion and recommendations
Good progress towards standards of care in hospital for people with Learning Disabilities is
demonstrated in relation to the trust being confident in being compliant with MONITOR’s risk
assessment framework.
The recently published Confidential Inquiry has given us a good opportunity to review the
progress towards improving standards of care for people with Learning Disabilities. Within
the following 3 months from the last report progress continues to be made in regards to the
LD PHNT Improvement Plan and is reflected in the improved scoring of ambers to green and
reds to ambers.
The Trust Board is asked to:
1. Review the Trust’s continued position and is satisfied that the Trust is able to declare
continuing compliance towards the Monitor Compliance framework.
2. Note the progress made in the LD PHNT Improvement Plan 2014/15.
Learning
PHNT
Learning
Disabilities
Disabilities
National
Improvement
Standards Action
Plan plan
Framework
Requirement/Measure
Rating
Annex 1
Actions
Standards with on-going actions to maintain compliance
Monitor (2)
Does the NHS Trust provide readily
available and comprehensible
information to patients with learning
disabilities about the following
criteria?: treatment
options/complaints/procedures/appoi
ntments.
(1-4)
PHT = 3
This action will now
Recommendation 2
Peer
Review
1.5
Clear,
accessible
and
timely
information about medication and
specific treatments and procedures is
available to people with learning
disability and carers.
(1-3)
PHT - 2
Continue to develop with LD Link nurses for
specific treatments.
Involvement of LD Liaison team in decisions
re LCP for people with LD. Link forum held on
6/10/14.
This action will now be met under
Recommendation 2
Monitor (2)
Does the NHS Trust have protocols in
place to encourage representation of
people with learning disabilities and
their family carers
(1-4)
PHT = 4
Derriford User Group (DUG) involved in local
LD Board, Health Sub-group.
DUG involved in local LD events and in
regular feedback to the Liaison team
Representation of DUG now extended to
Cornwall and New Devon. LD representative
from DUG to attend next PEC meeting.
Review on Quarterly basis
Ongoing action
Monitor (2)
Does the NHS Trust have protocols in
place to regularly audit its practices
for patients with learning disabilities
and to demonstrate the findings in
routine public reports?
(1-4)
PHT = 4
Regular use of Essence of Care audits via
(Meridian).
Mortality Reviews undertaken of people with
LD who have died in hospital Report
completed and presented to SGA board. Key
findings to be presented to HASG.
Review on Quarterly basis
Ongoing action
Peer
Review
2.2
Patients with learning disability and
their carers receive appropriate
information about nutrition and
hydration during admission.
(1-3)
PHT - 3
Serco have developed Easy Read information
re menus - these have been reviewed by
DUG.
DUG have worked with Serco to give
feedback on menus from people with LD
This action will now be met under
Recommendation 2
Peer
Review
6.2
Recording of and learning from other
incidents involving people with
learning
disability,
including
complaints /Patient advice and
Liaison Service feedback etc.
(1-3)
PHT - 3
Datix flag in place to identify incidents for
people with LD.
Incidents reviewed and
reported through Safeguarding Steering
Group.
Review on Quarterly basis
On-going action
Peer
Review
7.1
Patient safety issues are identified
proactively and patients receive a
high standard of fundamental care.
(1-3)
PHT - 3
Meridian Essence of Care filter in use – to be
reviewed for all LD patients; Complaints for
people with LD highlighted and reviewed by
LD team. This action will now be met under
Recommendation 2
be
met
under
Recomme
ndation
Requirement/Measure
Rating
Actions
New Standards from CI with New Actions for Trust LD Improvement Plan
Recommen
dation 1
Clear identification of people with
learning disabilities on the NHS
central registration system in all
healthcare record systems.
Recommen
dation 2
Reasonable adjustments required by,
and provided to, individuals, to be
audited annually and examples of
best practice to be shared across
agencies and organisations.
75%
Green
2.3 Meridian questionnaire to include standard
Questions in relation to this. 2.4 Develop tool
and evaluation process to measure staff
culture in regards to people with LD after
completing LD awareness training. 2.5
Continue to develop area specific easy read
information with Link staff and DUG.
Recommen
dation 4
A named healthcare coordinator to be
allocated to people with complex or
multiple health needs, or two or more
long-term conditions
75%
Green
4.2 GP's need to be involved with agreeing
ESP's.
Recommen
dation 5
Patient-held health records to be
introduced and given to all patients
with learning disabilities who have
multiple health conditions
75%
Green
5.2.ESP to be taken to transitions meeting for
consideration of use and how to implement
this.
Recommen
dation 7
Team
priority
People with learning disabilities to
have
access
to
the
same
investigations and treatments as
anyone else, but acknowledging and
accommodating that they may need
to be delivered differently to achieve
the same outcome?
50%
Amber
7.2 LDL team to meet with Cancer Link Nurse
and have a look at what easy read is available
and
what
needs
to
be
readily
available/displayed. 7.3 Appointments for
cancer patients are now being addressed via
outpatients being on RAPA system and a
specific easy read follow up appointment letter
has
been
agreed
but
now
needs
implementing.
Recomme
ndation 9
Adults with learning disabilities to be
considered a high risk group for
deaths from respiratory problems.
50%
Amber
9.1 LDL team to put a reminder 'Did you have
a flu vaccination' with an onward referral to
GP if needed. 9.2 LDL liaison team to confirm
with lead therapists pathways for involving
community therapist for LD patients.
Recomme
ndation 10
Mental Capacity Act advice to be
easily available 24 hours a day.
100%
Green
No Actions
Recommen
dation 11
Team
priority
The definition of Serious Medical
Treatment and what this means in
practice to be clarified.
75%
Green
11.1 LD MCA form to go through document
approval process and be included in the
Policy and Procedure in relation to this.
Recommen
dation 12
Mental Capacity Act training and
regular updates to be mandatory for
staff involved in the delivery of health
or social care.
75%
Green
12.1 learning development to give assurance
around training in regards to MCA for other
staff.
Recomme
ndation 13
Do Not Attempt Cardiopulmonary
Resuscitation Guidelines (DNRCPR)
to be more clearly defined and
standardised across England.
100%
Green
No further actions
Recomme
ndation 17
Systems in place to ensure that local
learning disability mortality data is
analysed and published on population
75%
Green
14.1 To aim to complete a multi-disciplinary
review (this will depend on agreement from
senior
management
and
CCG/LA
75%
Green
1.1 Need to add new Devon catchment area
DES lists to the IPMS and RAPA 1.2 ED use a
system called HAS our LD list needs adding to
this system.
profiles and Joint Strategic Needs
Assessments
Key: Green 75% or above
Amber 50%
Red 25% or below.
commissioners) for at least one case once a
year for lesson learnt purposes and share via
LOG.
Annex 2: Data for LD Patients - 1st December 2013 to May 31st 2014
How many Hospital Admissions
for the LD population?
Top 3 wards admitted to with
average length of stay? (not to
include MAU or SAU)
Excludes Day-case Admissions
as average length of stay
required
Average Length of all stay’s ?
% of Readmissions within 1
month ?
Numbers of RIP ‘s ?
LD Population
308
General Population
55,130
Clinical Decision Unit, Zone A,
Level 6 – 0.77 days
Central Delivery Suite (Adults),
Zone D, Level 4 – 1.82 days
Fal Ward, Zone B, Level 4 – 2.33
days
Whitehorse Assessment Unit –
1.10 days
Argyll Ward (Adults), Zone D,
Level 7 – 4.57 days
5.53 days
12.99 %
Fal Ward, Zone B, Level 4 – 3.20
days
4.53 days
5.58 %
7
803
Data Information for Out Patient Appointments:
Number of outpatient
appointments for the LD
population?
Number of DNA’s for the LD
population?
1260
166,938
81
10,093
Data Information on LD Datix’s (July to Sept 2014):
No. of Datix
17
Dealt with at Ward
Level:
13
Further Investigations
Needed:
2
SGA Referral made:
2 (community
concerns)
Overnight Ward transfers for patients with a LD May to September 2014:
No of Bed Moves
No of appropriate bed moves
i.e. MAU, CDU
No of other bed moves
20
17
3 (all three were from ICU and
at the time deemed
appropriate)
(Information on Urgent Dols requests made for patients with a LD to be included in future reports).