Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

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9.2.4 Outbreaks and Incidents• There were no outbreaks in this quarter.• There was one MRSA new isolate in this period.Board of Directors Meeting, 29 March 2012Agenda Item 7• The RCA into the Clostridium difficile case in October 2011 has been completedand reviewed The source of C.difficile was unknown, as there were no othercases identified during the time of the person’s stay. However, the RCA processidentified a number of leaning points for the service, regarding recording andacting on increased episodes of faecal incontinence. Although there was noevidence that cross infection had taken place, the need to improve hand hygienemonitoring and address some compliance issues was included in the action planto ensure infection risks are minimised. Education on these issues has beendelivered by the IPCT.9.2.5 Exeter Prison (Healthcare Areas)The refurbishment work at HMP Exeter is almost complete; primary care will becompliant with environmental standards under Outcome 8 on completion of thiswork.Weekend cleaning of the primary care areas at HMP Exeter continues to beundertaken by nursing staff, NHS Devon has agreed to follow up progress of thePrison service business case to resolve this.Action plans are in place at HMP Channing’s Wood and Dartmoor to rectify recentcleaning deficits there.Cleanliness audit scores have now been received from all 3 prisons. The in-patient unit will be known as a supported living unit from the 1 st April.Devon Partnership Trust will de-register this site with the CQC and althoughhealthcare staff will continue to have a role, responsibility for this unit will transferto the prison.9.2.6 PEAG actions and outcomes Mattress audit. This is planned by the IPCT and undertaken collaboratively withthe link practitioners.Cleanliness Validation audits. Some scores are lower than the 91% target,although this may reflect only one room on the day of audit. Therefore to provideaccurate information and assurance to the Trust, It was proposed that PEAG reevaluatehow monitoring is reported with a view to inclusion of the routinemonitoring undertaken by housekeeping staff and the use of a stretch target.The Hotel Services Manager is continuing to work to ensure that there is regularin-house monitoring on the Langdon site. This is unresolved currently.New bins have been ordered for all adult areas to ensure compliance with thesafety notice concerning removal of plastic bags.New beds have been ordered to negate the potential ligature risk associated withthe main type in use.Page 48 of 156
10 Eliminating Mixed Sex AccommodationBoard of Directors Meeting, 29 March 2012Agenda Item 710.1 The NHS Operating Framework requires all providers of NHS funded care to re-confirmwhether they are compliant with the national definition ‘to eliminate mixed sexaccommodation except where it is in the overall best interests of the patient, or reflectstheir patient choice’. Those organisations that either do not make a declaration ordeclare they are not compliant will face penalties. Trust Boards must refresh theirdeclarations no later than 1 April 2012 and must ensure that they are clearly visible ontheir website.10.2 The compliance declaration should be accompanied by a commitment to audit dataquality and to publish the results. The purpose of the audit is to ensure that allepisodes of unjustified mixing are captured and reported, and that mixing is onlyclassified as “justified” if it is genuinely in the patient’s overall best interests. Noreportable breaches have occurred since the Trust first declared its compliance inMarch 2011; therefore no audit has been necessary10.3 A matrix for determining clinically justified breaches has been agreed with NHS Devonas the lead commissioner and reporting arrangements are in place through themonthly contract quality review meetings.Declaration of complianceDevon Partnership NHS Trust is pleased to confirm that we are compliant withthe Government’s requirement to eliminate mixed-sex accommodation, exceptwhen it is in the patient’s overall best interest, or reflects their personal choice.We have the necessary facilities, resources and culture to ensure that patientswho are admitted to our hospitals will only share the room where they sleep withmembers of the same sex, and same-sex toilets and bathrooms will be close totheir bed area. Sharing with members of the opposite sex will only happen whenclinically necessary such as where people need the highest level of one to onenursing support and observation for short periods of time (for example in a highdependency or ‘extra care’ area in an acute inpatient ward).If our care should fall short of the required standard, we will report it. We will alsoset up an audit mechanism to make sure that we do not misclassify any of ourreports. We will publish the results of that audit as part of our ‘quality of care andpatient experience’ report in September 2012.11 Recommendation to the Board of DirectorsThe Board is asked to receive the report and note its contents and to approve thestatement of compliance with eliminating mixed sex accommodation requirements asset out above.Alison MooresDirector of Nursing and Practice12 th March 2012Appendix 1: Quality, safety and effectiveness performance indicators 2012/13Appendix 2: PCA quality assuranceAppendix 3: 2012/13 CQUIN targetsPage 49 of 156
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