Recommendation
The Trust must ensure that a process is in place that indicates that family members have been offered the opportunity to see a copy of the report, indicating when this has been completed.
View response
1. Complete 31/01/2020
2. Complete 31/01/2020
3. Duty of Candour audit has been completed and actions include further training to staff, improved documentation on Datix, updated patient information in the form of a leaflet and in root cause analysis templates, a dedicated web page for patients and staff, feedback to families. feedback to patients and families following review of investigation by commissioners and work relating to patient feedback on Duty of Candour and root cause analysis experiences.
4. Registered for this event however due to COVID all peer review work relating to the accreditation scheme has been paused therefore this action has not progressed.
Recommendation
The Trust must ensure that the process of managing conditionally or absolutely discharged patients in community mental health teams is set out in the relevant policy/ies.
View response
1. Complete. Transfer of Discharge of Care of KMPT Patients Policy Outreach and Section 4.3 sets out the requirements for Forensic Service oversight of conditionally discharged patients under the management of locality CMHTs.
2. Complete. The Forensic Outreach and Liaison Service Operational policy sets out the processes of managing patients in secure units transition into the community, ongoing supervision and process for involvement of forensic services in Risk Reduction work with the CMHT locality teams.
3. Complete. The Joint Operating Model Policy with Kent County Council sets out arrangements for joint supervision of conditionally discharged restricted patients. It is premature at this stage to measure the full impact of this joint arrangement. This will be monitored on an ongoing basis through the Serious Incident process and feedback provided to teams as necessary.
Recommendation
The Trust must ensure that when new processes are introduced, they are clearly described in relevant policies or procedures and adhered to.
View response
1. Complete - Where a Policy procedure is created that affects a policy (e.g. a procedural flowchart appended to a policy is changing) updates are included in the main policy and ratified through the relevant governance structures. Policy/Procedure author(s) amend the documents in a timely way (e.g. if there is a change in legislation or a guidance). The Policy Manager monitors the policies to ensure they are within date and that reviews are completed as indicated in policy Trust Secretariat quality checks that the relevant matters have been complied with before it can be placed before the ratifying committee. Compliance and adherence to relevant policies are monitored as set out in the policy monitoring section which may include auditing or reporting in the performance and activity reports. .
Recommendation
NHS England Specialised Commissioning Team must consider and review the evidence they are using as assurance that recommendations have been addressed.
View response
Other recommendations did not relate to KMPT.
Recommendation
NHS England (South) should consider overseeing all recommendations made for NHS England by any independent reports.
View response
Other recommendations did not relate to KMPT.
Recommendation
NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when a serious incident is also being investigated as a serious criminal offence.
View response
Other recommendations did not relate to KMPT.
Recommendation
The Trust must ensure that all relevant key lines of enquiry are identified and addressed in internal investigation reports (for example in this case, safeguarding issues in relation to Mr S’s older relations).
View response
1. Document Terms of Reference agreed in Trust-wide Patient Safety Incident and Mortality Review Panel. Complete 04/03/2020
2. Terms of Reference added to Datix Complete 04/03/2020.
3. A new RCA template is now in use since April.
Recommendation
The Trust and their commissioners should work together to ensure that any issues regarding the quality of investigation reports are addressed in a final draft report prior to the report being shared with families.
View response
1-3 Complete and indicated on templates in use -20/01/2020. As a result of the new centralised investigation team, positive verbal feedback has been received from the CCG regarding improved root cause analysis report quality. .
Recommendation
The relevant department within NHS England must work with the CCGs to facilitate a co-ordinated approach by them that ensures standards are met for all serious incident investigations and associated action plans.
View response
Other recommendations did not relate to KMPT.
Recommendation
The Trust must assure themselves and their commissioners that the provision of six-monthly reviews to patients in receipt of clozapine is embedded in every-day practice.
View response
1. Completed - June 2020.
2. The process has been piloted, reviewed and embedded. The first round of checks to include Clozapine is due to commence on 14/09/20. Robust standards have been agreed in conjunction with the Chief Pharmacist and the Head of Nursing for CRCG.
04/11/2020
Clinical quality manager has confirmed that all 10 CMHTs have now had a CliQ check with the Clozapine standards being checked against. Action to remain open for a further period of three months to enable compliance to be measured.
Recommendation
The Trust must assure themselves and their commissioners that the arrangements for managing the risks of conditionally or absolutely discharged patients is appropriate, and embedded in every-day practice.
View response
1. Complete. Forensic Operational Outreach Liaison Service (FOLs) has been developed and is now fully operational, which is dedicated to managing all patients discharged to Kent. FOLS CMHT Link Database and attendance at risk forums provide the safety measure to ensure that forensic patients are discussed and overseen; this is a joint responsibility between FOLS and CMHTs to raise any changes with their forensic patients.
2. Complete. Monthly locality risk forums take place jointly between the CMHT locality and a member of FOLS. There have been no STEIS cases relating to this theme which indicates that this process is working and making a difference. There have not been any incidents highlighting any transitions or joint working between these teams or from patients under these services. FOLS has been subject to QIA and only closed recently and there have not been SIs to note.
3. Complete. Each community mental health team locality team has a dedicated named link mental health practitioner from FOLS.
Recommendation
The Trust must undertake further work with Swale Community Mental Health Team to ensure that crisis and contingency plans are in place and fully completed for all patients.
View response
1. Complete and occurs every two months.
2. Full review completed 02/03/2020 and fed back to Head of service on 04/03/2020. The quality of crisis and contingency plans are reviewed on an ongoing basis as part of the care groups rolling CliQ check process. The performance is sometimes impacted on by staffing gaps however this remains under constant review by the managers who work to ensure temporary staffing whilst recruitment is under way. A further CliQ check is being undertaken on 14/09/20 to test the compliance and effectiveness of the actions taken.
Recommendation
The Trust must ensure that this audit and future related audits undertaken are accompanied by a clear narrative indicating the audit findings and any follow up action required.
View response
1. Complete. The CliQ standard operating procedure is in place and guides quality leads. A review of the quality of these action plans is completed periodically by Care Group leadership teams.