An independent investigation into the care and treatment of mental health service users (F and Maureen) in County Durham: Published 6 September 2017

There are clear processes and procedures in place on MHSOP wards which ensure that findings from patients’ assessments are clearly linked to planned care. a)5 wards are piloting a refreshed Frailty CLiP (including falls). Full roll out is planned by the end of December 2017. b)The Behaviours that Challenge CLiP is being implemented on all MHSOP wards c)Improved MDT Care Planning in the electronic record is being developed with IT support. d) Dietitian colleagues to deliver training in use of SANSI tool (to replace MUST) across all wards – when the tool is ACD D&D 1 incorporated into PARIS e) Specialty department specific harm support minimisation training e-learning module will be available to ward to ward staff. TARGET DATE FOR COMPLETION a)31st December 2017 b)31st December 2017 c)Progress is dependent on IT work schedule d)Progress is dependent on IT work schedule e)Progress is dependent on training department PROGRESS July 2017 Pilot in progress July 2017 Principles agreed Training records Training records

There are clear processes and procedures in place on MHSOP wards which ensure that findings from patients’ assessments (in relation to aggression) are clearly linked to planned care. a)Since the index incident, the Behaviours that Challenge CLiP has been reviewed and updated to include new National guidance and updated NICE guidance. b)The revised CLiP includes the development of a Behaviour Support Plan – Ward Managers are tasked with ensuring that these are developed where necessary TARGET DATE FOR COMPLETION a)Complete b)28th February 2018 PROGRESS Complete MHSOP findings from the Trust-wide Clinical audit

MHSOP can demonstrate adherence to the Supportive Engagement and Observations Procedure a)SBARD highlighting the recording requirements from the procedure to be circulated through MHSOP b) SBARD to include instructions regarding the need to give a rationale for rare circumstances where the procedure cannot be followed. c) QuAGs have considered the use of zonal observation as per the procedure TARGET DATE FOR COMPLETION a)30th September 2017 b)30th September 2017 c)31st October 2017 PROGRESS Modern matrons to randomly spot-check recording records of patients requiring Supportive engagement and provide reports to SDG in December 2017 and June 2018

All polices are updated according to Policy guidelines As part of the policy and procedure review process the Policy Lead is responsible for undertaking review of the evidence base which includes NICE Guidance where relevant. This process is documented within the Governance of Policies and Procedures Policy document CORP-0001-v5: The Executive Management Team has delegated authority from the Trust Board to ratify all Trust policies and procedures. Minor amendments have been made to this policy following the homicide review recommendations to further strengthen stipulated Policy Lead responsibilities in relation to updating the evidence base of relevant policies and procedures. TARGET DATE FOR COMPLETION Complete PROGRESS Complete

MHSOP can demonstrate that clear communication regarding incident reporting has been shared with ward staff a)SBARD to be written and circulated within MHSOP b) review of recorded incidents, trends including low reporting is a function of QuAGs c) ward report-outs include discussion of incidents that have occurred and confirm reporting has taken place TARGET DATE FOR COMPLETION a)30th September 2017 b)31st December 2017 c)31st December 2017 PROGRESS SDG minutes QuAG minutes QuAG minutes, and QuAG reports to LMGB and SDG Modern matron spot-checks of daily report-outs

We can provide evidence that the CLiP is implemented on all MHSOP wards. a)continue the roll-out of the CLiP b) audit compliance with the requirements of the CLiP TARGET DATE FOR COMPLETION a)31st December 2017 b)28th February 2018 PROGRESS SDG and QuAG minutes Audit report

MHSOP can demonstrate clear risk assessments which are linked to care plans a) Narrative summary of risks has been introduced with an MHSOP specific crib sheet b) MHSOP harm minimisation training will incorporate medical history and the requirement to develop linked care plans c) the Care Planning development workstream is exploring electronic ways to link risks identified to care planning TARGET DATE FOR COMPLETION a)Complete b)Progress is dependent on training department support c)Progress is dependent on IT work schedule PROGRESS Complete Safety Summary Compilation - Specialty Crib MHSOP.pdf Training content & ACD D&D training records Notes from the Nurse working group / reports from PARIS development team