This project review has found that there has been an overall improvement in the quality and delivery of pressure ulcer prevention care. The levels of harm have reduced and teams are starting to identify acts or omissions in care through their reflections.
6.2 The incidences of pressure ulcers have increased overall in 2018/2019, however this is likely due to a change in the reporting and categorising process. It is difficult to assess if the total number of pressure ulcers have increased as a result of other reasons until we can identify the full impact of the recent process changes.
6.3 Staff have had to adjust to a number of changes over the last year, including new terminology for pressure ulcers, changes in reporting processes and documentation changes whilst delivering pressure prevention care. Given that all teams are under immense pressure in the present climate, the developments seen in numbers of holistic assessments, care planning and general improvements in practice are encouraging and a positive achievement.
6.4 However there are still improvements to be made in the quality of the assessments, ensuring they are accurate and up to date, and in the quality of care plans. Teams continue to need support with the reflective discussion tools to ensure all aspects of care are detailed and reviewed.
6.5 Actions have been highlighted and recommendations made for teams to improve over the next six months to develop staff performance, quality of assessments and pressure prevention care for patients. These actions have been formatted to the Quality Improvement Plan spreadsheet used by teams to monitor service improvements. These will be discussed at Divisional Patient Safety Meetings, disseminated to all teams and progress reviewed by the Clinical Governance Team.
Full details available in the QI pressure ulcer project review paper