COAEE Plan for Nightingale

Context
Background
Songbird is a long term and short breaks service for adults with learning disabilities and physical
disabilities. The young adults may also display some milder challenging behaviours.

There is a mixed staff team in terms of ages, ethnicities. They are also mixed in their career
experiences, time in care, and length of service at Songbird.

In the last 2 years there has only been one reported meds error in 2018/19 and none in 19/20 until
September when a serious error occurred. As a result 2 staff were dismissed and another resigned.
There has been retraining, new competency checks, additional checks put in place and workshops in
team meetings. None of this has been effective and errors have continued to occur.

Overall the following areas for improvement have been identified:

1. Increase staff knowledge

2. Improve paperwork and process
3. Increase staff ownership and accountability
4. Increase the level of auditing and challenge

Most Important Focus

It is felt that the poor paperwork and process is most likely to lead to a further error and
therefore this should be the initial focus of intervention.

What resources are available to help develop this?

1. The staff team
2. Staff from other services with expertise
3. Local Authority QA
4. Pharmacy
5. NICE/RPS Guidance

What other resources are needed?

1. Someone to support the process of change
2. A plan
3. Time
4. A space that is neutral to work on this

What is most important to use time and effort on when looking at the
focus area?
The staff teams views on and ownership of the paperwork and process

Objective
We want to engage the team in developing a new set of medication
processes and paperwork that conform to legal guidance but also work for them.

Actions
Who What How When
 Discuss the plan with manager
Discuss the plan with the team
Arrange 2 dates to get the team
together
Book a venue for the meeting
Facilitate the workshop days
Remove the old paperwork and
replace with the new
The staff will produce the rest of the plan as we go as they should decide the route that is right for
them. They will plan how they want the workshop days to run, any activities they think would help
etc.
Call her then email the plan 14/02/20
How would they like the days to 26/02/20
work?
Assess rota, other training etc. 01/03/20
Arrange for FSW/agency/ staff
from other services to support
young people
05/03/20
Day 1: A number of team building By end of
exercises. Staff will deconstruct March
the medication paperwork
Discuss what works what doesn’t,
what can be changed, what can’t
and why.
Day 2: Re-create the paperwork
and process by the end of the day
By
01/04/20

Evidence
Indications the work is going as planned
 Staff agree that this is a good way forward
 Staff attend the workshop days
 Staff engage in the workshop days
 Staff plan how they want to progress following the workshops
 Staff follow the plan they have made

What might make the objective more specific?

 Meeting with staff to discuss the plan and how they would like it to go forward

What evidence will emerge while working towards the objective?

 More positive culture around medication
 Better practice around administering medication
 Staffs true level of knowledge

What evidence will we see when we reach our objective?

 Neat and accurate MAR charts that meet requirements
 Simpler process which staff understand and follow
 Less errors
 Appropriate reporting when errors do occur
 Staff team who feel safe in challenging each other appropriately

What evidence do we not want to see?

 Disengagement of staff
 Poorer practice
 Continued failure to follow process
Evaluation
The process will be evaluated by the staff team via a reflective workshop in a team meeting. This will
be to discuss how they found the process of creating the paperwork, how it made them feel, what
worked well and what they felt could have been improved or changed. They should also reflect on
how they feel the new system is working and why they feel it is or is not. The reflection should take
place around a month after the workshops and introduction of the new process to allow time for the
process to settle in.

The final process and paperwork produced will be evaluated by the QA officer completing a full audit
on the paperwork to establish that it meets requirements, that it is being utilised correctly by all
staff, that it is being audited regularly and action is being taken where issues are highlighted. This
will take place 1 month after it is introduced and again 3 months after introduction. The reason for
doing this twice is to ensure that the process remains embedded.

Both evaluations will be communicated via written report to senior management.