Independent investigation into the care and treatment of Mr I

To update both our Adult and Child Safeguarding procedures to this effect. Updated procedures signed off by the Executive Director of Services To launch classroom based Safeguarding and Boundaries training. E-learning package in place and staff completion records (mandatory course for all new starters) To recommission safeguarding e-learning which is up to date with the latest Care Act 2014 legislation. Changes to our client monitoring systems and reviewed procedures signed off by the Executive Director of Services Head of Learning and Development January 2016 To carry out a comprehensive review of our Support Planning and Client Risk Management policies and procedures and recording processes. Head of Business Excellence (policies and procedures) and Head of Information (recording processes) April 2016

To carry out a Fact Finding report within 4 weeks of a client death. If this raised concerns a comprehensive Best Practice Review to be carried out by a manager who is not connected to the service. Fact Finding Reports and Best Practice Reviews Completed Completed To update the Best Practice Review policy and procedure to emphasis the sharing of learning with relevant partner agencies. Updated procedure signed off by the Executive Director of Strategy and Policy. Head of Business Excellence December 2015

In line with the new requirements for access to waiting targets the EIS team will review their team operational policy to include Zoning procedures. To be discussed within local team meetings. An away day will also be held where clarification on zoning procedures will be discussed and agreed with all staff members. Implementation plan to include communications strategy with partner agencies. Minutes of Team Meetings. Away day minutes. Copy of revised Team Operational Policy. Briefing papers to be developed Audit of staff understanding and implementation. EIS Team Manager April 2016

Where there is multi-agency involvement, CNWL care co-ordinators involve and inform partners of the shared care plan (under CPA) including Housing. This was addressed in the CNWL recommendations 9, 10, 11. This is underpinned by achieving information sharing as per the Pan-London Information Sharing Agreement (ISA). CNWL signed pan-London ISA. Divisional Director January 2016 Information sharing and escalation will be added as a standing agenda item to Team Meeting and included within the Team Operational Policy. Minutes of Team Meetings. EIS Team Manager February 2016 The Trust will develop a briefing sheet covering frequently asked questions and include examples. This will be available on Trustnet. Briefing sheets. EIS Team Manager July 2016

NHSE to share report with The Health and Wellbeing Board to support any improvements in system integration and transformation. To be presented after publication. Minutes and agreed actions from The Health and Wellbeing Board on taking this forward. Director of Nursing North West London. Jan 2016

All clinical policies will have a section on monitoring compliance and effectiveness. All new policies follow a prescribed template that includes this section. Review of the Clinical Policies list. Quality Assurance Manager Completed The Trust-wide Annual Clinical Audit Plan will include key policies to be audited e.g. risk assessment and care planning. The Annual Clinical Audit Plan with the regular update reports to the Care Quality Group including results on audits on risk assessment and care planning. Quality Assurance Manager April 2016 Documentation of contract review meetings. Quality Assurance Manager June 2016 Compliance with key policies will be monitored by bi-annual reporting to the Quality and Performance Committee. Clinical Audit report which is presented to the Operations Board and the Quality and Performance Committee. Quality Assurance Manager Bi-annual Raw data including patient number will be sent to team managers in order for them to act on any non-compliant cases and verify the data. Email trail showing communication with team managers. Quality Assurance Manager Quarterly The verified data will be monitored by the Divisional Boards. Minutes of Divisional Directors meetings from the Divisional Board

To review all relevant procedures to ensure the regularity of welfare checks is made explicit, including how it should be recorded and how it relates to the Missing Person procedure if a client is not seen for a period of time. Updated procedures signed off by the Executive Director of Services. Head of Business Excellence January 2016

Transfer protocol between NWDAS & SWDAS to updated to incorporate findings of MT draft report. Meeting with NWDAS to agree transfer protocol. Transfer protocol to be shared with staff team. Senior Operations Manager Fortnight Meeting held with NWDAS and update to protocol agreed for both services. Deputy Operations Manager 1 Month Task delegated to Access Team Leader who ensured protocol dissemination as highlighted in bullet pointed actions. Protocol stored on shared drive. Protocol discussed at team meeting. Protocol distributed to entire staff team via email. Deputy Operations Manager 6 Weeks Transfer protocol reviewed and amended slightly to augment robust wording. Both Tri-borough and Turning Point Information Sharing Protocols distributed amongst staff team. Tri-borough and Turning Point Information Sharing Protocols reviewed through CPD at team meeting and discuss in 1-2-1 supervision. Operations Manager 3 Months Transfer protocol to be reviewed, ensure all measures implemented and transfers Audited. Review Information sharing Protocols knowledge amongst staff team. Senior Operations Manager 6 Months