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Main Issues identified-
1.neighbor was not allowed to travel with mavis, this would have contributed to her feeling insecure and unsafe.
2.staff did not explain fully what was happening and instead assumed lack of capacity and understanding.
3.consent was not gained, as staff assumed she was unable to give consent, they instead spoke over her.
4.procedures and Mavis's care were not explained to her it was assumed she understood.
5.Mavis was caused considerable pain and struck out at staff unintentionally coming into contact with staff. she was then anxious that she has hit someone.

was this a quality experience?
no. The needs of Mavis were not considered, nor was holistic care provided by staff to help Mavis feel as comfortable as possible.

Could anything be done to improve this?
1.communication.
2.contact Bill to find out his ETA, with a view to waiting or him to arrive.
3.explain to Mavis what is happening

Did Mavis have a voice?
no, Mavis was spoken over and assumed to understand what she was being told. After striking out at a member of staff which may have been because she felt she needed to protect herself, she was labeled instantly with 'Dementia'.

What could be done to give Mavis a voice?
1.explain what is happening.
2.check understanding with Mavis
3.ask her about what happened or what Bill does to open communication and make her feel more comfortable.
4. ask if she would like to wait for Bill
5.ask what she would like to do.

Hollie Roe

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1.Lack in communication, respect, safety and dignity.

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1.Lack in communication, respect, safety and dignity.

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no one explain what is hapening and gain consent from her.
2. It is not a quality experience; she did not feel safe or comfortable about the process; the service was not efficient.
3.4.5. effective communication; reassuarance; built the trust and safe enviaronment.
S.K.

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We found that one of the main Issues was communication. We felt that there was a lack of reassurance, it states that Mavis was scared & worried & without anyone accompanying her to the hospital she could have had some reassurance to ease her. Possibly get in contact with Bill and have him in the phone to ease her mood.
- An X-ray comes in to conversation but Mavis is unsure as to what one of those is, unfortunately Bil is not there to ask the questions. Staff could have explained then and there why the X-ray was needed. The staff communicate to one another about what should or shouldn’t be done and Mavis is very unclear about her pathway of care and it isn’t made clear to her.

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Was this a quality experience for Mavis?

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Was this a quality experience for Mavis?

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It was not a quality experience due to the fact that Mavis was continually scared, worried and in pain. She was alone without Bill and after being told that she was married to Bill, noone escalated this to contact him to let him know what had happened. The staff did not meet Mavis’ needs nor was holistic care shown.

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Could anything be done to improve this for Mavis & Did Mavis have a voice?

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Could anything be done to improve this for Mavis & Did Mavis have a voice?

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- A phone call to Bill will have impacted massively, he could have been her voice for her needs and worries.
- the staff could have gone through her personal likes and dislikes to understand her personal needs & wants.
- staff could have been mire informative about her pathway of care.

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What frameworks could help?Managers and clinical professionals are likelyto face the following kind of scenario:“Many different people and processes haveto be involved if change is to be effective.What frameworks can help me to identify thekey areas for my attention?”Since its earliest days, the NHS has beencharacterised by almost constant structuralchange. Change of this kind has resolvedsome problems, at some times, but has leftmany other deep-seated problems untouched.There is increasing recognition that people –individuals, teams and workforces – offer thekey to lasting change in the health service.Many will be concerned, therefore, to knowmore about working with others to create anadaptable workforce of the kind described inthe NHS Plan (DOH, 2000) – well led and fitfor practice and purpose. Here we cover twoof the more widely used ‘packages’ thatchange management consultants, amongothers, have used to develop integratedchange programmes.

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What frameworks could help?Managers and clinical professionals are likelyto face the following kind of scenario:“Many different people and processes haveto be involved if change is to be effective.What frameworks can help me to identify thekey areas for my attention?”Since its earliest days, the NHS has beencharacterised by almost constant structuralchange. Change of this kind has resolvedsome problems, at some times, but has leftmany other deep-seated problems untouched.There is increasing recognition that people –individuals, teams and workforces – offer thekey to lasting change in the health service.Many will be concerned, therefore, to knowmore about working with others to create anadaptable workforce of the kind described inthe NHS Plan (DOH, 2000) – well led and fitfor practice and purpose. Here we cover twoof the more widely used ‘packages’ thatchange management consultants, amongothers, have used to develop integratedchange programmes.

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In Mavis sonoria, could used fish bone diagram to recognise actual problems she has had during her patients gerny. But it does not give the answer to the prblems. Therefore,   

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In Mavis sonoria, could used fish bone diagram to recognise actual problems she has had during her patients gerny. But it does not give the answer to the prblems. Therefore,   

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SKL.

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We discussed the idea of the spaghetti diagram laying out Mavis’ journey upto this point. With every detail laid out we could identify where & what problems occurred.

The main areas for alteration could be the an improvement in the communication with Mavis. There was a lack of involvement between Mavis & the staff involving her care. If there Bill was communicated with also this may have eased Mavis’ experience with him knowing and being by her side ev this step of the way