The recommendations w ere collated into individual projects based upon themes, and using our quality improvement methodology to enable a consistent and sustained approach to the achievement of these objectives. Each project has a designated executive, a senior responsible officer (SRO) and may have a small project team appointed. We are using the quality improvement plan as a dynamic document; w ith additional topics added over the year, as w e identified areas that required further improvement. The quality improvement plan is monitored monthly through the clinical quality improvement group that reports into the trust compliance group and onto the Quality and Safety Committee. 2020 The CQC undertook an unannounced w inter assurance visit to the urgent and emergency care department on 3 February 2020. Their report w as published in April 2020 and rated the service Re quires Im provement with tw o areas receiving a regulation notice: The trust must ensure sufficient provision of out of hours endoscopy service to minimise risk of treatment delay to patients w ho require to access the service The trust must ensure detailed up to date records are kept in relation to provision of care and treatment and it is reflective of each patient’s full clinical pathw ay and include actions taken in response to individual risks The trust implemented a quality improvement plan to address recommendations raised and strengthen the leadership team w ith the service areas. 2021 The CQC conducted an unannounced inspection of the emergency and urgent care department on 14 February 2021. Their report w as published on 27 April 2021, giving the department a rating of inadequate and the trust received a section 29A w arning notice. The concerns identified by the CQC from their inspection w ere: Risk assessments w ere not being completed for all patients w ithin the emergency department Not assured that patients presenting w ith acute mental health illness w ere receiving timely assessments There w as a lack of adherence to infection, prevention and control procedures The process for the provision of the out of hours endoscopy service for patients presenting w ith acute upper gastrointestinal bleeding w as not embedded Immediate actions w ere implemented follow ing receipt of the w arning notice, w ith further actions underw ay. We have undertaken a review of these findings across the trust, for all core services to ensure the learning is shared w idely and improves services across the w hole trust. We are confident that the actions undertaken and planned in the coming w eeks will ensure w e continue to improve the safety of patients in our emergency department.
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