Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003)

The Trust should consider the gaps and issues for debate in the internal inquiry report identified (above) in this review to establish whether they have been addressed since the internal inquiry and, where they have not, ensure that appropriate action is put in place.

The Trust should consider adding a column to its format for action plans to record evidence of completed actions. Further improvements are needed to the format to ensure that action plans are effective monitoring tools to enable the recording and continuous review of actions until they are signed off, with evidence of completion recorded.

The Trust should review its arrangements for managing health and safety systems and consider appointing a qualified Health and Safety manager to strengthen its overall structure for risk management.

The Trust should review its arrangements for managing security, including designating a local security management specialist (LSMS).

It is essential that the re-provision of the PICU on the Springfield Hospital site is commissioned and completed as soon as possible.

The Trust should audit and review response times from its Estates Department to requests for repairs in areas where patients may be at high risk.

Pending the completion of the new purpose-built PICU consideration should be given the need for short-term improvements to the present ward environment, for example through the use of colours in the décor and of light and space. (The King’s Fund "Enhancing the Healing Environment" programme and the NHS Estates "Art of Good Health" series offer some useful advice.)

Now the appointment of a substantive consultant psychiatrist to share the clinical leadership of John Meyer Ward with the ward manager has been confirmed. Further development of the ward team should now be undertaken using an appropriate tool, for example the "Creating Capable Teams" tool kit developed by the Sainsbury Centre for Mental Health and the National Institute for Mental Health in England (NIME).

The Trust should ensure that regular clinical supervision is a priority and that staff appraisal for all staff is consistent across all locations and services, regularly monitored and audited.

The nursing skill mix including the use of agency staff for inpatient wards as well as the PICUs should be regularly reviewed in line with evidence-based practice and service developments.

The Trust should review as soon as possible its strategy and action plan for equality. (See also Recommendation 14 below).

The opportunity should be taken to refine the John Meyer Ward Operational Policy, building on the good work to date, in preparation for the move to the new purpose-built PICU.

The John Meyer Ward team should continue efforts to improve services in light of the patient experience survey findings. Particular emphasis is needed to find ways of improving the range of activities for patients, particularly at evenings and weekends.

Building on the evidence from the work on "The Experience of Adult Inpatient Care", the Trust should explore further the reasons for the variances in levels of satisfaction with the service between people defining themselves as black or black British and their white or Asian / Asian British counterparts. The outcomes of this further work could help to address the reasons for dissatisfaction and inform the Trust's Equality Strategy. (See also Recommendation 11 above)

The Trust should consider urgently the resources devoted to and structure of the clinical audit team to offer career progression and to improve retention of staff.

The Trust should examine all its policies and procedures to ensure that they are up to date, and establish a process for monitoring and the regular auditing of their implementation. Where reviews of policies and procedures are overdue or necessary they should be completed as soon as possible. A system should be put in place to ensure that a regularly updated portfolio of Trust policies and procedures is readily accessible for all services, wards and teams. Consideration should be given to a standardised format for all policies and procedures whether Trust-wide or local with a front sheet providing information on the policy number, author, date of publication and review date.

In addition to the current review of the Trust's CPA Policy, a review of CPA practice in the Trust should be undertaken and completed as a high priority to: identify areas for further improvement and consistency; develop an action plan; make improvements and ensure implementation is monitored. Particular attention should be paid to the seamless continuation of CPA and engagement of care coordinators when patients are admitted to hospital or transferred between inpatient wards.

The Trust should consider appointing a trust-wide CPA coordinator to continue the drive to improve CPA practice and compliance across the trust. This officer should be of suitable seniority.

The Trust should continue to introduce and evaluate zoning pilots for risk-assessment with a view to expanding zoning across the Trust.

Work should be commissioned to embed zoning into the Trust's CPA policy and procedures.

Implementation of zoning on John Meyer Ward and elsewhere should develop as a team process. It should be developed on John Meyer Ward as an action research project and be subjected to evaluation, perhaps as part of the Trust's Practice Development Programme.