The Christie NHS FT Annual Report & Accounts 2019-20

The Christie NHS Foundation Trust Annual Report & Accounts 2019-20

below the with 29 category 2 pressure ulcers and no category 3 & 4 pressure ulcers that developed after admission An Executive Nursing Panel (new format introduced January 2020 – Friday FoCUS) is undertaken to review all category 2 pressure ulcers and above.. NHSI guidance advises that NHS Trust’s should no longer use the definition of avoidable or unavoidable. This has therefore not been included in this report. Themes arising from RCA investigations have been identified as: • Inaccurate calculation of pressure ulcer risk factors. • Inconsistent practice in the reassessment of risk on change of condition and change of care setting • Inconsistent practice when conducting a head to toe skin infection • Inconsistent practice when initiating a repositioning regime for patients at risk of pressure ulcers • Inconsistent practice in the use of pressure relieving mattress pump or other pressure redistribution equipment

Pressure ulcers developing after admission (cumulative) (Grade 2+, Deep Tissue Injuries, Unstageable)

35

30

25

20

15

10

5

0

Apr

May Jun Jul

Aug Sep Oct

Nov Dec Jan Feb Mar

2018/19 Total 2019/20 Total

1 4

4 8 5

10 11

13 13 10

17 15 13

18 17 15

21 18 18

22 20 20

23 21 23

25 24 25

26 28 28

29 29 30

19/20 Reduction Trajectory 3

8

Patient Falls We aimed to maintain the 2018/19 outturn of no more than 22 falls with harm. There have been 36 inpatient falls with minor harm in 2019/20. The chart below demonstrates that we have exceeded the threshold by 14 cases. All cases are reviewed by the ward teams and discussed at a mutli-professional learning event twice a month. All recorded falls are graded as minor and therefore minimal harm has occurred to all patients

89