Clinical Governance

P_CIG_20 Safe and Secure Handling of Medicines

 

This policy aims to offer practical advice and outline steps that must be taken to ensure medicines are handled safely and securely within all care environments and services and by directly employed staff.

The policy is underpinned by key legislation, for example, the Medicines Act, the Misuse of Drugs Act and associated regulations, the Health and Safety at Work Act, the Control of Substances Hazardous to Health Regulations and the regulations relating to the disposal of hazardous and other controlled wastes.

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P_CIG_19 Choices Policy

Lincolnshire Community Health Services (LCHS) strives to provide high quality care to patients in their own home. When patients needs require them to be cared for in an alternate environment such as a community hospital or a short term community care (transitional) bed (assessment and treatment, transitional care, reablement or rehabilitation), LCHS teams manage this change but continue to aim for their patients to return to care provided in their own home as soon as possible. When ready for discharge (This means assessed by LCHS as safe and ready to be moved on from their present place of care) services remain committed to the principle of Home First which recognises the importance of discharge into patients own homes where this can be done safely.

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P_CIG_17 Clinical Audit Policy and Procedures 2016-2019

The purposes of this policy and procedures are to set out a framework for the conduct of clinical audit within the Trust, and to maintain and support a culture of best practice in the management and delivery of clinical audit within the Trust.

 

The Trust acknowledges the significance of clinical audit as a quality improvement process and as an important mechanism for providing assurance in relation to the provision of safe and effective patient care. The Trust is therefore committed to delivering effective clinical audit in all the clinical services it provides. This document provides a framework to support the following throughout the Trust:

 

 

 

 

 

  • the conduct of clinical audit

  • the promotion of a culture of learning and continuous service improvement that delivers demonstrable improvements in patient care and contributes to meeting the Trust’s corporate objectives

 

 

 

 

 

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G_CIG_01 PALS SOP

 

The Standard Operating Procedures (SOPs) is a working document which sets out the core functions and procedures of the PALS service. The service is designed to be flexible so changes and improvements can be incorporated to reflect the requirements of patients, carers and relatives.

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P_CIG_16 Open and Honest Care (including Duty of Candour) Policy

The Open and Honest Care (incorporating Duty of Candour) Policy has been developed in line with the National Patient Safety Agency (NPSA) guidance, "Saying Sorry When Things Go Wrong". The "Duty of Candour" places a legal duty on all NHS provider bodies registered with the Care Quality Commission, to inform and apologise to patients if there have been mistakes in their care that have led to significant harm. The Open and Honest Care (incorporating Duty of Candour) Policy provides a framework for all staff within Lincolnshire Community Health Service NHS Trust, to ensure the appropriate management and review of organisation wide risks and the embedding of lessons learnt, to prevent mistakes happening again.

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P_CIG_15 Policy for the Management of Medication Errors

This policy details the immediate, medium and long term actions to be taken following the discovery of a Medication Error to ensure patient safety and to support staff. 

 This document sets out the organisation's policy on the management of medication errors. It aims to: 

  • Strengthen the organisation's just and fair blame culture in response to adverse healthcare events 
  •       Facilitate organisational learning through the findings of thorough and careful
  •       investigation at local level 
  •       Provide a framework for practitioners to improve practice 
  •       Ensure appropriate actions are taken by managers and applied consistently across the organisation

The organisation encourages a sensitive response to medication errors through a comprehensive assessment taking full account of the context and circumstances surrounding the incident.

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P_CIG_14 Controlled Drugs Policy

The purpose of this policy is to provide guidance on all aspects of controlled drug management in primary care services within Lincolnshire Clinical Commissioning Groups and Lincolnshire Community Health Services (LCHS). This version of the policy (version eight) replaces version seven issued in February 2012. This policy incorporates all the legislative changes published by the Department of Health up to the end of December 2013. It also recommends areas of good practice to strengthen the governance arrangements for controlled drugs. The policy has been developed in line with Department of Health guidelines to enable the appropriate management of controlled drugs in primary care services within Lincolnshire Clinical Commissioning Groups and Lincolnshire Community Health Services.

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P_CIG_13 Development and Control of Patient Group Directions (PGDs)

The purpose of this policy is to set out a generic framework for a co-ordinated approach to the development and control of PGDs in use in Lincolnshire Community Health Services (LCHS) Trust. The policy contains a standard template for all Trust PGDs. Using the framework and template should ensure that PGDs comply with the legislation and are reviewed and updated as required. 

The preferred way for patients to receive medicines is for a trained health care professional to prescribe for individual patients on a one-to-one basis. An alternative to a prescription for an individual patient is for a prescriber to give a documented Patient Specific Direction (PSD), which instructs another health care professional to supply or administer a medicine to a specified patient.

A Patient Group Direction (PGD) is a written instruction for the sale, supply and/ or administration of named medicines in an identified clinical situation. It applies to groups of patients who may not be individually identified before presenting for treatment. A PGD is not a form of prescribing.

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P_CIG_11 School Nursing Service Local SOP for the Safe and Secure Handling of Medicines

The purpose of this guidance is to implement a co-ordinated and standardised approach to operational and clinical management of all practices in Lincolnshire School Nursing Services involving medicines and their use.

This SOP aims to offer practical advice and outline steps that must be taken to provide safe prescribing, administration, handling, storage, custody and issue of medicinal products in the School Nursing Service.

Careful medicines management reduces potential risk or errors which could impact negatively on patients or practitioners

This SOP aims to ensure that medicines are handled safely and securely within all care environments and services provided by School Nurses and by directly employed staff.

This SOP considers the processes associated with the safe use of medicines and includes;

  • The physical handling of medicines
  • Storage and supply of medicines
  • Use of prescribing
  • Ordering

 

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P_CIG_08 Complaints

Following the introduction of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, from 1 April 2009, a single two-stage approach to complaints handling has been introduced to provide a service user-focused service. This approach gives greater flexibility to organisations in how they handle and respond to complaints and encourages a culture that seeks and uses people's experience of care to improve quality, as detailed within Making Experiences Count Reform of the Health and Social Care Complaints Arrangements. The NHS Constitution makes clear what people expect when they complain. The combined health and social care regulator, the Care Quality Commission (CQC), requires registered Providers of services to investigate complaints effectively and learn lessons from them.

It is the aim of this policy,

  • To ensure that a full, open and honest response is provided to all complainants, whether made orally, in writing or electronically.
  • To ensure all complaints are investigated thoroughly, impartially and appropriately.
  • To ensure all staff are supported through the process of a complaint investigation.
  • To ensure that lessons learned are shared across the organisation in order to rectify mistakes and to improve the quality of services for the future.

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