Independent investigation into the care and treatment of DO

In 2011, following the formation of clinical academic groups (CAG’s), an assessment and treatment team was established in Croydon for people with mood, anxiety and personality disorders. The service had two distinct functions: to act as a GP front facing assessment service and; provide medium to long term case management for people moderate to severe need. By 2013 it became apparent that these two functions needed splitting to demand and capacity. Two assessment and two treatment service were created to cover east and west Croydon within existing funding. In April 2013 a small assessment team was established and the former assessment and treatment primary focused on providing medium to long term treatment to people experiencing non-psychotic disorders. The assessment team and treatment services were subject to review in 2014 and Trust secured c. £2m investment from Croydon CCG for these two services. The services were redesigned 2015 to create one Borough wide assessment and liaison services and two treatment services. The assessment and liaison service were designed with the recognition that it required two full time consultant psychiatrist’s and a greater number of senior practitioners to ensure that people referred received a high-quality assessment and a rapid formulation of peoples’ needs. After assessment the service offers 12 week stabilisation by providing an array of biological, psychological and social treatments. The majority of people are discharged back to primary care at the end of the 12 weeks and some people will go on to have longer support in either the treatment, psychosis service and/or crisis services. The two treatment teams consist of a fulltime consultant and a visiting clinical multidisciplinary team consisting of nurses, occupational therapist, psychological therapists and social workers. In the majority of cases, the team provides 6 to 18 months treatment, which includes psychological therapies that are provided from within the team. A small number will receive indefinite care and treatment. Whilst developing the assessment and liaison team model, the Trust, in partnership with Croydon Council, developed a reablement service, which supports people to engage in meaningful occupation. The team consists of occupation therapists and support workers. The person using the service are often transitioned from the assessment service to receive support before being fully discharge back to the care of their GP. Finally, in 2015 other investment was provided to the home treatment service to have the capacity to provide robust crisis interventions to avoid admission to hospital or step-down people from hospital sooner. The Trust routinely undertakes Best Practice visits which look at leadership engagement and quality indicators. A Best Practice visit can be triggered if there are concerns about a team e.g. through patient feedback, complaints or incidents. The Trust has a Complaints, Patient Advice and Liaison Service, Quality Alert process and Patient Experience surveys (PEDIC) which allow direct feedback on the quality of services. The Trust has a Freedom to Speak Up Guardian in post with champions across the Trust and sites. This promotes openness and allows notification to the Board of any safety concerns. The Trust’s Whistleblowing policy also allows staff to raise concerns and identify concerns. The Commissioners have oversight of these areas through the Core Contract Meeting and Clinical Quality Review Group. Since August 2015 the Trust’s Chief Operating Officer has run monthly performance and contracts monitoring meetings. The meetings review data from all teams within the Trust ensure performance standards are met. Where a team is not meeting the performance standards they are put into ‘recovery’, resulting in an increase in support, oversight and plan to address areas of concern. The Trust works with SLaM Partners who support the Trust with Quality Improvement and Team Development. For teams put into recovery SLaM Partners can work with teams to support improvement and sustain change. From Autumn 2017 the Director of Nursing has run Quality Compliance meetings which ensure quality standards are met in Trust services. The Chief Operating Officer and Director of Nursing triangulate data on services to identify if there are any areas presenting a risk to the organisation. The Trust runs Quality Walkarounds involving members of the Executive team clinical teams. Teams are able to escalate any quality and safety issues impacting on the delivery of care and services, directly to a Board member. The Board member will then ensure any changes required take place. In 2018 the Trust underwent a reorganisation to a Borough model, which has removed layers of management between the Board and Ward improving oversight and escalation. The Chief Operating Officer, Service Directors and Contracts and Performance Management Team negotiate all contracts to provide teams with the adequate finances to ensure that teams can provide care to the required evidence based standard. The Quality Improvemetn Team have recently launched the Community I Care initiative. The aim is for people who access SLaM community services to receive the highest quality care in the right place at the right time from a service that is sustainably run. Work has begun to define the scope of the work which will incorporate patient safety and quality standards for community teams. The Trust is currently developing the community Quality, Effectiveness & Safety trigger Tool (QuESTT). The tool provides an early warning indicator to detect potential deterioration in the quality of care which will enable proactive action prior to any deterioration occurring. The pilot of Community QuESTT started earlier in 2018 with older adults. Following this there was a redesign of the system and the testing is planned for October to December 2018 with the final roll out across all community teams from January 2019.

The Trust provides training on investigations through the Practical Guide to Structured Investigations training. This is a full day’s training which provides investigators with the techniques and skills to investigate a complaint or serious incident. The training covers the importance of openness, family and carer involvement and the formal obligations of proactive communication arising from the Duty of Candour / national complaints legislation. Complaint investigators are provided with additional support through local governance complaints and serious incident leads, line management and the central complaints team. Each complaint investigation is reviewed and signed off by senior staff before it leaves the organisation to ensure that it is Open and Transparent; and that that the concerns outlined are addressed in full of actions to address these in place. This is also underpinned by Trust polices -The Complaints policy and Investigations policy both refer to the Trust's Duty of Candour / Being Open policy. Learning and development from complaints are underpinned by the Complaints Policy, Learning Lessons policy and Investigations policy. Further assurance that complaints drive improvements are through the quarterly Lessons Learned report and complaints report which share learning throughout the Trust and individual learning lessons events. Services complete in depth reviews on the themes from complaints to identify further learning and improvements. The Trust’s Director of Nursing holds Quality Compliance meetings with each directorate to ensure that complaints are investigated and responded to appropriately. E&D prompt Directorate Training leads to include training resulting from lessons learned in their annual training plan, some areas have included this as a standing item on their Workforce Development committees. Individual complaint investigations are reviewed and signed off by senior staff in the organisation to ensure learning has been identified and actions are outlined. Learning and actions from each complaint is recorded on the Trust’s complaints system which allows thematic review and ensures that where a need for improvement is identified, these are made. The Trust completes regular audits on Duty of Candour to ensure compliance with the standards, learning identified from these audits is shared across the Trust. These are reported externally to commissioners, centrally to the Quality Committee and locally to Directorate Governance Executives. The MP members enquiry template response will be amended to ensure MPs are asked to share the response with their constituent and to signpost back to SLaM if there are any outstanding issues of concern. Complete 2018.

Each core trainee (junior doctor) has a requirement to report any complaints made against them to their supervisor as part of the training requirements. The Trust records the roles of professionals involved in any complaint using the complaints system. All SLaM core trainees have an educational contract which includes the importance of supervision. Supervisors of core trainees are required to have a training portfolio including the use of supervision. Any complaints should be discussed with the supervisor in their clinical supervision. Core trainees receive an induction presentation on complaints and incident handling and the reporting systems. To support core trainees in appropriately signposting complainants – leaflets and posters are a core requirement of each clinical area. Information is also publicly available on the Trust external website. A protocol regarding supervising the trainee through the complaints process in parallel with the Trusts’ complaints investigation policy is being developed. This will involve the trainee meeting with the clinical supervisor in the first instance and being supported by their educational supervisor and training programme director with the involvement of the director of postgraduate medical education where necessary. The protocol will cover the need to consider the complaint as an opportunity for the supervisor to review the trainee’s work load and performance, organise joint meetings with patient and/or carers if that is considered useful and transfer of patient care from the named junior doctor to a different clinician where necessary. An audit to be carried out for all complaints that have involved a trainee psychiatrist over the past year, identify the main themes and issues and develop guidance to clinical supervisors about how to respond to formal and informal complaints regarding trainees. October 2018. Development of a protocol to support supervisors of junior doctors through the complaints process. The protocol will be completed with an implementation plan. December 2018. An audit will be completed 6 months post implementation of the protocol to assess if the standards have been met with an action plan put in place to address this if not. June 2019.

For all comprehensive incident investigations an executive chaired strategy meeting is held at the start to commission the investigation and at the end, to sign off the investigation. During these meetings contact with families and carers is discussed and with plans for contact agreed. Consideration is given to any support needs families and carers may need to enable them to participate in the investigation. A senior member of the Trust will be assigned to make the initial contact with the person affected with follow up contact from the investigation team. Contact with families and carers underpinned by the Policy for Being Open and Duty of Candour and the Policy for the Investigation of incidents, complaints and claims. These policies outline the requirements for contact with families including consideration of the needs of those affected e.g. assistance to participate in the investigation, ongoing support and follow up following the incident. Meetings with families and carers are held at a convenient location for those affected. Training is provided to investigators through the Practical Guide to Structured Investigation training which includes meetings with families. Appraisal and evaluation of investigations is undertaken internally and externally to the Trust. From Autumn 2017 the Trust Serious Incident Review Group, chaired by the executive Director of Nursing, has reviewed each serious incident investigation. The group scrutinises reports to ensure Duty of Candour has been met and that the views of family members have been considered. Reports are shared family members as part of the review process to ensure their feedback is included as part of the evaluation process. Families and carers and given the opportunity to meet with the Trust to review investigations and are able to provide feedback in a way that is convenient to them. The Trust is rolling out a series of lessons learned events with Directorates and will include a vignette on interactions with family members. The first will take place during the October Leadership event. December 2018.

The Trust has an established Supervision Policy which has been revised twice since this incident. The first revision was in 2014, where all existing policies were brought together into one document and a requirement was made for all clinical staff to receive supervision at least once a month for an hour. This was audited in a Supervision Audit to check that supervision was happening by CAG and discipline. In 2018 the second revision was completed with a plan for dissemination and implementation. The Trust monitors compliance with supervision through the appraisal system stored in the Education and Development LEAP system. It is a core requirement for 10-12 supervision sessions to take place over each year. The Trust’s appraisal system requires both appraiser and appraisee to confirm that supervision has taken place. Individual staff supervision records are kept locally and “ensure clinical practice reflects the delivery of service user care”. The Trust is currently working to move to electronic recording of supervision using the Education and Development LEAP system. This will include a template to record supervision and the option of uploading supervision records. The Trust is undertaking an audit to assess compliance with the Trust’s Supervision Policy and the quality of the supervision staff experience. This will consist of direct contact with all staff via a survey and further review through the LEAP data. December 2018 for staff survey and March 2019 for compliance audit.

The Trust has run a one-day CPA training in the past, as non-mandatory the course was stopped due to low numbers attending. The Trust has reviewed the need for training and does not believe that a one-day course is required. The revised CPA policy was ratified in May 2017, with publicity through the June policy bulletin. The policy is available on the Trust intranet. The policy can be accessed by any staff member on the policies page of the intranet and a quick guide for its use is the "Policy on a Page" document. Education and Training department were notified of the policy update so it could be in corporate in any training that referred ton CPA. Nursing forms a major part of the Trust’s workforce. In May 2018 the Trust finalised core competencies and job descriptions for Band 2-6 nursing staff. Competencies for Band 5-6 nurses which includes specific assessment of a nurse’s understanding and competence in relation to CPA which are aligned to job descriptions. CPA training – The Trust will review the current requirement for training that directly supports the ethos of the CPA at the next meeting of the Trustwide Education and Development Committee in October 2018. Each clinical team holds regular multi-disciplinary team meetings where patient’s care is reviewed. Individual supervision is used to review caseloads of workers and care plans. The Trust’s Chief Operating Officer reviews data on compliance with CPA through the monthly performance and contracts meetings. In November 2017: 93.2% of people on CPA had a formal 12-month review, November 17: 91% of people on CPA had a formal risk assessment, Health intelligence indicates a total of 21% of our patients on CPA, a 6% increase from 15% when the policy was done in 2015. The Trust is currently working on the development of the new community care plan and risk assessment audit tool using Quality Improvement methodology. Functionality will include “pull through” of risk assessment information to develop the care plan in collaboration with the service user. The next phase is to streamline the suite of CPA yearly review documentation, to ensure that it is service user friendly and to incorporate a comprehensive review process. The Trust will review a 10% of records for compliance. December 2018. An audit will be undertaken in the Croydon Assessment and Liaison Team to review a sample of records against the standards for CPA to ensure these have been correctly applied and adhered to. Learning from this audit will be shared through the Serious Incident Review Group and Croydon Performance, Operations and Quality meeting. December 2018. The Trust reviewed the risk assessment tools available to staff in January 2017 with the creation of a single risk assessment tool for adult mental health. Aligned to this improvement were made to the electronic system of monitoring compliance with risk assessment standards. Dashboards for completion are available to all teams and managers. An electronic audit tool to look at the quality of the completed documentation has been developed. Prior to this information was locally held and completed. This allows the Trust to ensure that risk assessments are completed and appropriately address the identified risks. The Director of Nursing reviews the audit results as part of the monthly quality compliance meetings with monthly reviews in each Directorate Governance Executives meeting. Completed in 2017. The Trust has an established Supervision Policy which requires all clinical staff to receive supervision at least once a month for an hour. Clinical supervisors have access to a two-day training course is available to all clinical staff who are band 5 and above. This supports quality supervision to be provided to staff. The Trust is due to undertake an audit as outlined in recommendation 2 which will incorporate action 3.2c). December 2018 (staff survey) and March 2019 (compliance audit). The Trust audit of supervision ( outlined in recommendation 2 above) will seek staff opinion on whether supervision has led to them being able to do their job more effectively. This provides some evaluation of the quality of care being delivered. The Trust will review adherence to this recommendation by July 2019 which will allow 2 audits to have taken place. July 2019.

Since 2012, Croydon CCG have introduced the Joint Impact Assessment Panel (JIAP), whose overarching remit is to provide a reliable and consistent approach for assessing the current and future impact across quality, equality and Privacy, prior to procurement or re-procurement of any new service; in addition to ensuring Patient and Public engagement. No additional actions identified to meet recommendation. Not applicable.

The Operational Policy for the Croydon Assessment and Liaison Team was updated in 2018 to ensure this met the needs of all service users. The assurance processes for individual operational protocols sit with the management structures of each Directorate. The Croydon Directorate Performance and Quality Meeting has oversight of these policies. Actions completed to address recommendation. Complete - May 2018.

Each core trainee (junior doctor) has a requirement to report any complaints made against them to their supervisor as part of the training requirements. The Trust records the roles of professionals involved in any complaint using the complaints system. All SLaM core trainees have an educational contract which includes the importance of supervision. Supervisors of core trainees are required to have a training portfolio including the use of supervision. Any complaints should be discussed with the supervisor in their clinical supervision. Core trainees receive an induction presentation on complaints and incident handling and the reporting systems. To support core trainees in appropriately signposting complainants – leaflets and posters are a core requirement of each clinical area. Information is also publicly available on the Trust external website. A protocol regarding supervising the trainee through the complaints process in parallel with the Trusts’ complaints investigation policy is being developed. This will involve the trainee meeting with the clinical supervisor in the first instance and being supported by their educational supervisor and training programme director with the involvement of the director of postgraduate medical education where necessary. The protocol will cover the need to consider the complaint as an opportunity for the supervisor to review the trainee’s work load and performance, organise joint meetings with patient and/or carers if that is considered useful and transfer of patient care from the named junior doctor to a different clinician where necessary. An audit to be carried out for all complaints that have involved a trainee psychiatrist over the past year, identify the main themes and issues and develop guidance to clinical supervisors about how to respond to formal and informal complaints regarding trainees. October 2018. Development of a protocol to support supervisors of junior doctors through the complaints process. The protocol will be completed with an implementation plan. December 2018. An audit will be completed 6 months post implementation of the protocol to assess if the standards have been met with an action plan put in place to address this if not. June 2019.

The Trust’s Home Treatment Teams now accepts referrals from out of area mental health services e.g. CMHTs or psychiatric liaison teams. The Acute Referral Centre (ARC) receives referrals and triages them. If a community team received a discharge notification from an out of area A&E with a recommendation for referral to a Home Treatment Team this would be passed to the ARC. A survey including 2 team leaders from each Directorate will be undertaken to ensure that they appropriately direct HTT referrals to the correct area. December 2018.

The Trust allocated a suicide prevention lead to who oversees the current training programme and links with local authority public health suicide reduction leads. The Trust has an established a one-day face to face training programme for suicide and self-harm awareness which ran until November 2017. This was a non-mandatory training accessible for all staff. The course is currently under review to ensure it meets the requirements of the recommendation. The programme has been co-designed and delivered by an experienced nurse and a service user. The Trust redesigned the Risk Assessment Tool in January 2017 which ensures that Trust patients in adult mental health services receive a single comprehensive risk assessment. The risk assessment contains prompts for the assessor to identify risk factors in self-harm and suicide including engagement and hopelessness. The assessment flags the SHIELD risk assessment which provides a score that can be used to explore the nature of thoughts and feelings experienced which can inform care planning including risk management plans. The risk assessment tool automatically pulls together individual risk events The Recovery and Support plan is used in community teams, the plan is focussed on the individual recovery, support and crisis care for the patient for their symptoms, including suicide and self-harm. The suicide prevention lead will review the current provision of suicide and self-harm awareness training in conjunction with the Education and training department tutors to ensure the training recommences and is publicised to relevant clinicians. An analysis of training needs for suicide and self-harm will be carried out through the Trust-wide Education and Development Committee in October 2018. In June 2018 the Trust will review audit the efficacy of the training programme.