Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011. South West Acute Hospital Learning Disability (LD) review.

Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011 Title of Report: Status: Board Sponsor: Author: Appendices South West Acute Hospital Learning Disability (LD) review. For information Francesca Thompson, Director of Nursing Francesca Thompson, Director of Nursing Appendix I Extraction of South West SHA report Page 6-16 for the RUH NHS Trust. Appendix II South West Acute Hospital Peer Learning Disabilities Review and benchmarked position. 1. Purpose of Report (Including link to objectives) To inform the Board on the South West Acute Hospital LD review and the RUH benchmarked position. 2. Summary of Key Issues for Discussion The RUH benchmarked 7 th out of 18 Acute Trusts. The submitted action plan has prioritised the key areas namely: easy information read; communications; training and carers needs. 3. Recommendations (Note, Approve, Discuss etc) To discuss the report findings and note that the action plan has been submitted to the SHA within the deadline. The action plan has been approved by Management Board and will be monitored via the patient experience group and the Access to Acute group which is community wide. 4. Essential standards of quality and safety (CQC) that apply Outcome 1: A - K Outcome 2: A E, H Outcome 4: A G, K- M, W Outcome 5: A- C; Outcome 7: A, B, D, F, G, J - L Outcome 10: A, F 5. Legal / Regulatory Implications (NHSLA / ALE etc) Single Equalities Scheme legislation. 6. Risks, threats or opportunities None identified. Agenda Item: 10 Page 1 of 18

7. Resources Implications (financial / staffing) The RUH have invested in a Sister in Quality Improvement for Mental Health and LD. Her role is to work within the Quality Improvement Team and be an expert resource for front line staff. 8. Equality and Diversity This work is clearly focussed upon increasing health equality for people with a LD and identified as a priority for the South West Region. 9. Communication There needs to be a focussed communication on awareness of people with LD. The information available on the RUH website needs to be strengthened. 10. References to previous reports Patient Experience Quarterly Reports contains a regular update on our work with patients with a LD. 11. Freedom of Information Public. Agenda Item: 10 Page 2 of 18

1. INTRODUCTION The NHS South West, in partnership with local commissioners, has facilitated a series of peer reviews to identify acute hospitals ability to meet the needs of people with learning disabilities. This report outlines the process and findings of the review which took place with the Royal United Hospital Bath NHS Trust on 20 October 2010. 1.1 National and local drivers A range of findings from various enquiries and reports have all identified significant failings by NHS and Social Care agencies in meeting the health needs of people with a learning disability (LD), including premature and avoidable deaths. Key reports identifying the health inequalities experienced by people with a learning disability and their families have included: Death by Indifference Report published by MENCAP in 2007; Independent inquiry undertaken by Sir Jonathan Michael, Healthcare for All published in 2008; Findings of the Joint Ombudsman Report Six Lives published in 2009; Equal Access- Department of Health, 2009 Action by the NHS to address the findings of the Sir Jonathan Michael Inquiry, Healthcare for All, prompted by the Mencap report Death by Indifference was highlighted within Valuing People Now: a new three year strategy for people with a learning disability, published in 2009. As a result of the identified health inequalities, NHS South West prioritised a range of Strategic Ambitions to improve healthcare throughout 2008/2009 to 2010/2011, which have included ambitions to improve health care for people with a learning disability (LD). During this time, the South West Strategic Health Authority have facilitated the implementation of a comprehensive self assessment and performance framework related to healthcare for people with a learning disability both in 2008/2009 and 2009/2010 across all NHS South West. Although there continues to be more work to do, good progress has been made within the ambitions to improve primary care services such as registration with GPs and the completion of annual health checks. In addition a strong network of clinicians and Learning Disability Partnership Board health sub group representatives has been established across the South West. This has led to positive developments in sharing good practice and identifying common themes for further development. An example of this has been the development of a web site to enable mainstream clinicians to access Easy Read health information to provide to patients. This is available at http://www.apictureofhealth.southwest.nhs.uk Agenda Item: 10 Page 3 of 18

A further common theme identified has been in relation to acute hospital services. Within NHS South West there is also an active network of clinicians who support and lead best practice in acute services nationally and regionally. However, indications are that best practice is not consistently implemented within all acute hospitals. As a result of this common theme being identified, the South West Strategic Health Authority has facilitated commissioners across NHS South West to undertake this Acute Services Peer Review. 2. REVIEW The aim of the NHS South West peer review of acute hospitals is to make a significant impact on the speed, consistency and effectiveness in order to improve the outcomes experienced by patients with a learning disability and their families. The purpose of the review is to coordinate a consistent self assessment process across all 18 acute hospitals within NHS South West in order to: Establish a transparent baseline of current practice for each acute hospital; Identify best practice that can be shared; Identify areas for action between local hospitals and commissioners. The review process has confirmed the vital importance of: Engaging with people who use the service and carer representative organisations such as Health Champs, Carers UK, Carers Inclusion; in determining priorities and the need to continue to listen to these individuals as well as staff; Delivering improvement, in a coordinated way, by strong partnership working across the NHS, Mencap, Local Authorities and service user/carer groups, Local Involvement Networks and other third sector organisations. 2.1 Overview of the RUH Review on 20 October 2010 The review team worked to a series of standards used for all acute trusts in the South West to measure performance in the following areas: Reasonable adjustment made by the organisation to accommodate patients with a LD, e.g. special arrangements to give an anaesthetic to patients who are very frightened. Systems for flagging LD patients and availability of information on their needs. Use of the hospital specialist LD liaison nurse role. Availability of Easy Read (pictorial) patient information. Transition arrangements from child to adult services. Carer support and active involvement with care. Partnership working with community teams. Discharge arrangements Agenda Item: 10 Page 4 of 18

Training records to support staff working with people with a LD. Policy and process regarding: Safeguarding; Mental Capacity Act; Deprivation of Liberty. Board level awareness and commitment to the needs of people with a LD. Heather Devey, Practice Development nurse, organised the arrangements for the 20 October. There was excellent Board representation during the morning session, with Project Search students invited for lunch to talk with the team about their experience of the RUH. The Director of Nursing and Executive Lead for LD was sent the following message the day after the review including the comments: The review team particularly commented on how welcoming all the staff were and how open and honest they had been; there was a real sense that everyone was committed and willing to learn and improve. The Head of Patient Experience (HoPE) has been leading RUH developments for people with a LD through partnership with community LD teams and through the Access to Acute (A2A) Group. There is an existing Action Plan for people with a LD, which is monitored through the Patient Experience Group. The HoPE was able to submit over 80 items of evidence for the Review Evidence File. 2.2 Key findings The fey findings can be seen at Appendix I as extracted from the South West SHA report. The RUH NHS Trust was benchmarked 7 th overall out of 18 Acute Trusts. The SHA remarked upon a notable difference in performance for those Acute Trusts with designated Learning Disability nurses (marked in navy blue in Appendix II). 3. CONCLUSION The RUH NHS Trust conducted a self assessment of care of patients with learning disabilities. In the main our self assessment was deemed to be an accurate and honest reflection. Our performance has been notable due to a lack of a designated learning disability nurse and therefore our recent appointment of a Sister in Quality Improvement for Mental Health and Learning Disabilities will most certainly further strengthen this important aspect of care. The review and action plan has been submitted to the SHA within the deadline following approval by the Management Board. The action plan focuses upon the key areas for improvement namely patient information; communications; training and carers needs and will be monitored through the Patient Experience Group and Access to Acute Care which is community wide. Agenda Item: 10 Page 5 of 18

4. RECOMMENDATION For Trust Board to continue their endorsement of the Mencap Getting it Right Charter: Agenda Item: 10 Page 6 of 18

APPENDIX I South West SHA Learning Disabilities Peer Review Report 2. Key findings of the review 2.1 Context The Royal United Hospital Bath NHS Trust provides acute treatment and care for a catchment population of around 500,000 people in Bath, and the surrounding towns and villages in North East Somerset and Western Wiltshire. The Trust occupies a 52-acre site about 1½ miles from Bath city centre and became a National Health Service Trust in 1992. The Trust provides 687 beds and a comprehensive range of acute services including medicine and surgery, services for women and children, accident and emergency services, and diagnostic and clinical support services. The Trust employs around 4,800 staff, some of whom also provide outpatient, diagnostic and some day case surgery services at local community hospitals in Bath and North East Somerset, Somerset and Wiltshire. This fulfils part of the Trust aim to provide high quality care to people in their local communities. The hospital provides healthcare to the population served by three primary care trusts: NHS Bath & North East Somerset; NHS Wiltshire; NHS Somerset. In NHS Bath & North East Somerset: There is an estimated population of 3643 people with a learning disability of whom 815 are known to statutory services; 47% of people known to services have received a health check; General Practitioners are recognising people with a learning disability at a rate of 4.2 per thousand which compares with a regional average of 4.9 and a national average of 4.2. In NHS Wiltshire: There is an estimated population of 9078 people with a learning disability of whom 2048 are known to statutory services; 71% of people known to services have received a health check; Agenda Item: 10 Page 7 of 18

General Practitioners are recognising people with a learning disability at a rate of 4.2 per thousand which compares with a regional average of 4.9 and a national average of 4.2 In NHS Somerset: There is an estimated population of 10374 people with a learning disability of whom 2303 are known to statutory services; 19% of people known to services have received a health check; General Practitioners are recognising people with a learning disability at a rate of 4.6 per thousand which compares with a regional average of 4.9 and a national average of 4.2 Source: 2009/10 data published by South West Public Health Observatory The headings below are based around the seven sections of the self assessment tool which has been used as a framework for the gathering of information and evidence. 2.2 Information for people with a learning disability and family carers Strengths Patients with a learning disability are identified at the pre-operative assessment stage and pre- operative assessment nurses provide individual patient assessment and tailor patient admission in accordance with patient and carer needs. It is identified at this stage if the person is known to the Community Team or Bath People First. There is also an emergency referral process for patients with a learning disability and two examples were given where someone came into the Emergency Department who had been flagged, and had got their passport quickly. The Community Learning Disability Team felt this had worked well. The Trust Communications Department or Patient Advice and Liaison Service could assist any department or individual clinician in the production of or adaptation of Easy Read documents. The Review Team found some positive examples of accessible information in the following areas: A Patient Advice and Liaison Service and Complaints leaflet in Easy Read format; In Occupational Therapy, there is an information leaflet in hard copy that is issued to all patients about what they can expect from their service and who to contact if they wish to raise a compliment or complaint. The Review Team felt confident that patients with a learning disability would know how to complain by using this process providing they are able to follow symbols and Easy Read literature; Accessible medicines information is made available on an individual basis and the first action by the Medicines Advice Pharmacist would be to access the Picture of Health website. Agenda Item: 10 Page 8 of 18

Areas for improvement Pre-admission booklet Through the Access to Acute Group, known as A2A, the Community Learning Disability Nurses work is underway to produce a pre-admission booklet for patients with a learning disability. The Trust Head of Patient Experience has been leading this initiative working with the Head of Communication, Sister from the Emergency Department and a Community Nurse from Wiltshire who specialises in working with people with a learning disability. The booklet is in the early stages of production and is likely to be divided into planned admission, emergency admission, outpatient and discharge with appropriate images, text and spaces for the reader to write own notes etc. The Review Team suggest that this work should be prioritised to ensure the pre-admission booklet being developed is in an accessible format and easily available to people with a learning disability Easy read leaflets A range of Easy Read leaflets should be available on key aspects of services and treatments in the hospital and it is suggested that current leaflets are put into Easy Read versions. A photo-symbols library is a resource that would greatly assist the production of leaflets, booklets, posters etc. Website There is no Easy Read information for people with a learning disability on the website and this is a resource which could be developed with downloadable information etc. It is understood that the Trust will be looking at this as part of their action plan following this review. Health Information Group The Head of Communication is in the process of setting up a Health Information Group, which will be able to influence Trust wide use of Easy Read patient information. Complaints and Comments The Communications Department has been working with the Patient Advice and Liaison Service and Complaints Team to produce Easy Read versions of the complaints / concerns literature. An Easy Read version is available on the public website. However the Review Team found this extremely difficult to access. There is also no obvious mechanism whereby patients can give feedback or comments directly on the website. Agenda Item: 10 Page 9 of 18

Signage There was concern about the lack of signage around the hospital especially for toilets and no use of photos or other symbols within the signage was observed. Signage in some areas would be particularly confusing for someone with a learning disability. It is understood that this is being addressed in the next few months as part of a Trust wide improvement plan for signage and information. 2.3 Reasonable adjustments and service delivery Strengths The review identified some good examples of reasonable adjustments including the following; Admission Patients with a learning disability are identified at the preoperative assessment stage as outlined in Information section above. Discharge There was a very positive example provided of discharge in the Day Surgery Unit which the Review Team found most impressive. This showed early discharge planning and early discharge of a patient, where there was no risk to the patient, but where early discharge was identified as reducing stress on the individual. There is also a relatively new system set up that involves Wiltshire and Bath and North East Somerset Adult Community Health and Social Care services. This is a Discharge and Therapeutic Evaluation Service Project which commenced in August 2010 with the aim to improve discharge and a Project Brief was provided in the evidence folder. Discharge planning for complex cases happens on admission and, in conjunction with the Discharge Team; a date for discharge is set. This is seen as a very positive initiative. At the moment it is being trialled in the Minor Accident Unit but it is likely to expand. The Occupational Therapists aim to involve the Community Learning Disability Teams in discharge planning if the patient is already known to them. Training The Trust state that Learning Disability Training is in place and a training schedule was provided. See it My Way Living with a Learning Disability is a training session open to all Trust staff which was held in September 2010 and will be used again. Service users reported how involved they had been with this training event and staff reported the effectiveness and impact this had had. Deaf awareness training has been received by over 200 staff. There is a sign translate service available which is utilised for such training events. Agenda Item: 10 Page 10 of 18

Carers If carers are required to provide additional support, they are paid for by the Primary Care Trust and a process is in place for this. Car parking is free for carers and there is a carer book on the wards to communicate with them about services and support available. There was an example given of a carer being accommodated while her husband had an appointment and an example of carers being accommodated during a prolonged admission. Recent improvements have been seen by staff with many more adjustments being made than have been previously. Areas for improvement Electronic flagging There is no electronic flagging in place and the current system is not able to accommodate the introduction of flagging systems. This system is being replaced by a Millennium system in summer 2011 and it is anticipated that that flagging of people with a learning disability will then take place. At present, non -elective patients with a learning disability are not always known about and therefore reasonable adjustments may not be put in place. The Bath People First card 1, showing specific requirements of a person on a credit card sized card is a lone initiative and has not been fully adopted by the Trust but is an example of good practice. Hospital Passport A Passport exists, but there is patchy use of this across the Trust and patients are not being consistently encouraged to bring it in from the community; work on joining up with the community service to ensure consistency with this is needed. Nutrition/hydration The Review Team found variable staff awareness of the system in use for identifying vulnerable patients who require help with feeding, (the red jugs and red tray system), across the Trust, There was evidence that Carer s are asked about food choices but not always the person with a learning disblity themselves. There are no picture menus or Easy Read safe swallow guidelines and this has been recognised by the Trust as an area for improvement. Acute Trust Learning Disability Liaison Nurse There is no Acute Trust Learning Disability Liaison Nurse in post and some staff indicated a need for this during the review. Plans are under development for the Trust to employ a Agenda Item: 10 Page 11 of 18

specialist learning disability nurse. The Head of Patient Experience takes a formal lead for people with a learning disability or mental health. She previously worked as an Occupational Therapist in a Community Team for People with a Learning Disability and is extensively involved in improving the experience and care of patients with a learning disability. She has worked closely with a carer of a daughter with a learning disability over several years on Trust wide issues and this carer is part of the Patient Experience Group. NHS Bath and North East Somerset Speech Therapists have responsibility for patients with a learning disability and both the Wiltshire and Bath and North East Somerset Community Learning Disability Teams provide in- reach service for patients with a learning disability. There are nominated leads in different areas within the Trust who have a particular interest in learning disability issues and have volunteered to take on a champion role. This is on an ad hoc basis and there is no systematic approach to this with arrange of different types/grades of staff and no consistent way of ensuring that they would know about a new patient with a learning disability. Carers spoken to said they would have liked a Liaison Nurse/Specialist Nurse to support them but acknowledged that there is a Community Nurse being used for this role on a trial basis. This is an area for review and improvement. The Community Learning Disability Team suggested that a dedicated nurse is important to ensure representation at discharge meetings etc. The development nurse from the Royal National Hospital for Rheumatic Diseases has led on a lot of the changes in good practice from her experience of working with people with head injury; however she is only in post until end March 2011 and plans for sustainability will needed. Single Equality Scheme Although the Single Equality Scheme does mention learning disability patients, there is no action plan in place which is currently being developed. Training A Mental Health Nurse from the Royal National Hospital for Rheumatic Diseases NHS Foundation Trust is delivering some training on a six month trial basis and although Safeguarding Training was seen to be very good as outlined in Section Four, specific learning disability awareness training and communication training was less so. The Community Learning Disability Team is delivering half hour sessions to ward staff but this is very early days. Only 97 staff out of 4,500 staff have been trained and staff with whom the Review Team spoke to had not received communication training. Agenda Item: 10 Page 12 of 18

See it My Way is a way of increasing insight and awareness into learning disability with staff, people with learning disability and carers in attendance as described in the Strengths section above but did not appear to have been targeted at all staff. It is suggested that a more formalised training plan needs to be developed with a link to other training and education including Communication Training and other aspects of improving practice for people with learning disabilities. 2.4 Involvement of people with a learning disability and their carers Strengths One case study in particular illustrated good involvement where a person with a learning disability was involved in every step of the patient pathway including preparation. People with a learning disability and carers were invited to talk to the Review Team both at the Royal United Hospital Bath NHS Trust Review and the Royal National Hospital for Rheumatic Diseases NHS Foundation Trust Review. A Patient Experience Group meets monthly. It has been inclusive of carers and a patient with a learning disability since 2007. This offers a chance for patients to talk about their experience and was seen as good practice by the Review Team. A Privacy and Dignity audit has taken place and Privacy and Dignity Patient Experience data was provided for the Review Team as well as results of the National inpatient survey. Involvement initiatives are carried out by the by the Head of Patient Experience who produces Quarterly Patient Experience Reports. The Review Team recommend that the excellent work carried out in involvement and engagement should be documented and formalised to capture what takes place. One example included honorary contracts in place with paid carers. The carer, who the Review Team met, wanted it noted that every single time they had had contact with the Trust, the staff spoke directly to the person with a learning disability first which they thought was excellent and as it should be. Areas for improvement Hospital Passport Staff have to be reminded to look at the Hospital Passport and there is no specific area in the patient folders for staff to look for key information that is obvious and can be easily found. Patient feedback There is a Patient Experience Tracker, which is a hand held device given to patients to feedback their experience on a small number of questions such as: Was the ward clean, were people friendly? Although this was seen as good practice it is designed for people with full capacity and has not been adapted for people with a learning disability. This is something that the Trust are invited to explore further in order to receive feedback from people with a learning disability. Agenda Item: 10 Page 13 of 18

Carers There was evidence that carers are offered food, drink, a bed and free parking; however there was a mixed experience of this, some good, some not good by carers. There were some situations where they thought there was possibly too heavy a reliance on carers. Although not yet ratified, the Review Team thought that the Carer Policy has the balance right and this may help with this issue but needs ratifying and implementing as soon as possible. 2.5 Capacity, Consent, Safeguarding and the Law Strengths The Review Team were impressed by the understanding, the cooperation, and the amount of staff who had attended Safeguarding Training. Examples of consent, capacity and access to the Independent Mental Capacity Advocacy Service were given and it was clear that they are being appropriately used which was very positive. Ward staff and surgeons appeared aware and well prepared for safeguarding and mental capacity issues. There is core skills training provided for two or three days and much work has taken place on improving safeguarding. There was some good evidence provided on legal advice and Easy Read information. The Review Team identified a very good protocol for Do not Resuscitate Orders and Best Interest decisions, to be signed off by families and carers; this was seen as a robust process and good practice which is embedded across the Trust. Partnership working evident and there are joint training sessions on Mental Capacity Act with Adult Social Care. There is bi-annual reminder leaflet about Deprivation of Liberty Safeguards, Mental Capacity Act and Safeguarding and there are three Safeguarding Leads. There is no out of hour service for safeguarding but the Trust makes use of the Adult Social Care duty desk with a clear process to follow. The Independent Mental Capacity Advocacy Service is provided by Bath MIND and a service has also been agreed with Bath MIND to provide advocacy services for patients without capacity who may be involved in research. Areas for improvement Training There is a training role for a pilot period of six months. The post holder from the Royal National Hospital for Rheumatic Diseases NHS Foundation Trust carries out most of the training and it is not clear what arrangements will be in place when this post comes to an end. Agenda Item: 10 Page 14 of 18

2.6 Leadership and management Strengths The Review Team observed significant senior commitment to the learning disability agenda during the review visit. There is a non-executive champion and the Executive lead is the Director of Nursing. She has responsibility for learning disability issues and represents the Trust on the Learning Disability Partnership Board. Other members of this Board were also present on the day of the review. The MENCAP Charter has been endorsed by the Trust Board and there is a strong commitment to Project Search- see next section for full details. The Review Team saw this as making a real difference to changing attitudes and culture within the organisation. Partnership working is clearly important to the Trust. The Head of Patient Experience has strong links with the Community Learning Disability Teams; Project Search and People First and increasingly include the Patient Advice and Liaison Service and Complaints staff. These relationships will continue to develop. The Head of Patient Experience has also developed a partnership with local Black Minority Ethnic groups and carer groups and is a member of Bath and North East Somerset Local Involvement Network. The Trust is an integral member of the community, particularly in terms of adult safeguarding and has a presence on subgroups of the Local Adult Safeguarding Board. There is a Patient Experience Group which reports to the Trust Board on a quarterly basis, is chaired by the non executive lead champion and also has a carer representative who has daughter with a learning disability. No patients have yet been to the Board but the Project Search has been discussed there. The Project Search initiative is something that has been implemented within the Trust and demonstrates a high level commitment to the Learning Disability Agenda from Trust Leadership. This was seen as a very positive and an excellent example of good practice. By employing young people with a learning disability in the Trust this has had a major effect on the culture. Staff can see that these young people can work and become part of the organisation, so it removes some of the suspicion, fear, myths and stigma. It was highlighted that the best way to get the learning across is to employ people with a learning disability in the organisation and is an alternative approach to ensuring integration. The different types of jobs people with a learning disability are employed in include: making denture moulds, working in the restaurant and working in the pharmacy. One person was able to carry out his work with a robot arm and all of this demonstrated the range of potential and the big impact providing someone with a job could have. Areas for improvement Learning Disability Strategy. Despite many positive developments there is currently no Learning Disability Strategy in place which the Review Team suggest would draw all the activities together into a Agenda Item: 10 Page 15 of 18

coherent plan. Having this would demonstrate the Trusts commitment to the agenda and would support staff in seeing a vision for the future of services for people with a learning disability. Partnership working The Review Team found a lot of reliance on the Community Learning Disability Team which is commissioned to provide work on an in-reach basis to the hospital. Both organisations need to work in partnership to ensure this arrangement works effectively. There were mixed reports about communication by the hospital to the Community Learning Disability Team and vice versa meaning that communication relating to a patient with learning disability being admitted was at times compromised. Nominated learning disability leads/ward champions There are currently no nominated leads or ward champions for learning disability across the Trust although some staff expressed an interest in this following the See it My Way event. This is an area that could be developed and learning from other areas may be useful here. 2.7 Organisational learning Strengths The Review Team saw evidence of good systems in place to record serious incidents and near misses. The DATEX system links evidence and documents risk. There is a good culture for learning across the Trust with an openness and honesty in the case histories presented. As a result of learning there is a referral process for people with a learning disability admitted to the Trust and an action plan for the care of people with a learning disability dated April 2010. Mortality reviews take place by carrying out six monthly random reviews on 50 patients. The Trust is also part of the Independent Confidential Enquiry and the first review meeting on a death of a person with a learning disability has just taken place. There have been four deaths of people with a learning disability this year within the Bath and North East Somerset area to date; as part of the Confidential Enquiry process and local investigations work is underway to identify themes relating to these; however early indications are that they were individual, and in two cases expected, events. The Patient Experience Group influences future developments and learning; the A2A group is an example of this. The action plan is discussed at the Patient Experience Group on a bi-monthly basis and any other issues or suggestions for improvement are fed into minutes and quarterly Board reports. Areas for improvement Learning from patient feedback Agenda Item: 10 Page 16 of 18

The Patient Experience Tracker is produced nationally by Dr Foster. The Patient Advice and Liaison Service report monthly to the relevant Boards and commissioners and the information is acted upon. However the option of Easy Read or pictures/symbols has not yet been taken up by the Trust so the current tool is not accessible to people with a learning disability. This has the potential to be developed to ensure learning from feedback from people with a learning disability. 2.8 Fundamental Care Strengths The Trust is fully engaged in the NHS South West Quality and Safety Improvement Programme which addresses the fundamental aspects of care to include pressure ulcers, falls, multidisciplinary team rounds, the deteriorating patient, medicines management and pre - operative care. The Review Team found the Trust to be making excellent progress on this. Safety briefings take place on every shift change and issues about any patient are discussed using the whiteboard three times per day. The Trust has an Essence of Carer clinical audit programme and audits one aspect every two months Other examples included: Access to Acute Group which monitors an action plan on improving admissions and links closely with the Patient Experience Group; Multi disciplinary meeting for discharge to ensure safeguarding and co-ordination and this highlighted the significant role of Community Matrons in supporting learning disability discharges; Positive palliative care example for both hospital and on discharge. There is a comprehensive pack of admission and inpatient documentation that ensures all aspects of fundamental care are appropriately assessed and evaluated with documents around risk assessment, mobility, malnutrition and the red/amber/green traffic lights which are shown on the care plans. Areas for improvement The Trust identifies the need to audit care plans for people with a learning disability which the Review Team agree would be very useful tool in assuring continuous improvement. 2.9 Feedback from people who use services and carers The Review Team met some carers during the review day and heard about some mixed experiences. Some were very positive and spoke of the fact that the person with a learning disability is always addressed first and treated with dignity and respect. However there is a danger sometimes that carers may be over relied upon and it is hoped that the Carer Policy, which is waiting to be ratified, may help with this. The Review Team also met with some people working on Project SEARCH. These are not patients but work in the hospital in a range of different roles and departments and spoke highly of their position. Agenda Item: 10 Page 17 of 18

2.10 Areas of innovative/best practice identified During the review process areas of innovative or best practice in the Royal United Hospital Bath NHS Trust have been identified by the Review Team are: Honorary contracts with paid carers as described in section 2.4; Discharge and Therapeutic Evaluation Service Project which has been very successful and is hoped will be rolled across the Trust. This is a multidisciplinary team dedicated to patients being admitted at the front door. Staff review information provided on admission such as assessment information and what requirements are needed for discharge- see Section 2.4 Protocol for Do not Resuscitate Orders and Best Interest decisions, signed off by families and carers- see Section 2.5 Project Search was seen as a very positive and an excellent example of good practice. By employing young people with a learning disability in the Trust this has had a major effect on the culture of the organisation see Section 2.6 2.11 Conclusion The Royal United Hospital Bath NHS Trust has many positive developments in place that demonstrate a growing awareness of the needs of people with a learning disability. There is a good culture for learning across the Trust with a demonstrable openness and honesty in their approach. There are many good examples of reasonable adjustments being made to meet individual needs. The Project Search was seen as very positive and an excellent example of good practice. There are systems in place to record serious incidents and near misses and some excellent work being carried out in involvement and engagement. Key areas for improvement included: Ensuring the Patient Experience Tracker is easily accessible for people with a learning disability by using pictures and symbols; Development of a Learning Disability Strategy; A more formalised training plan to link with other training and education which includes Communication Training and other aspects of improving practice for people with learning disabilities. Ensuring that carers are not over relied upon, listening to their needs and implementing the new Cares Policy; Completion of the pre-admission booklet; Improved signage throughout the hospital Agenda Item: 10 Page 18 of 18