Independent investigation into the care and treatment of Mr N and Mr G

The commissioners of services and CNWL Trust response Brent Borough Director Jan-20 CNWL audits NICE standards yearly as part of the National Clinical Audit of Psychosis (NCAP). There is now a Trust wide steering group lead by the Medical Director for implementation should ensure that the care and treatment The EIP Audit Report for 2020/21 showed that the Trust was marked as “top performing” for Timely access. Areas of Dialog + and local groups to monitor local implementation. There will be an automatic of people with psychosis is delivered to meet The Trust’s Early Intervention in Psychosis (EIP) service will participate in auditing of NICE standards as identified for further improvement in Brent were; prompt in the clinical record to ensure Dialog + is completed. the expectations of NICE guidance CG178 in part of the National Clinical Audit of Psychosis (NCAP) • physical health assessment and interventions and Brent community teams. • outcome measures including use of Dialog, an outcomes tool. Monthly physical health performance monitoring has shown consistent sustained The Trust will review care pathways in line with NICE guidance. improvement over time. Other areas did not require action. A Clinical Lead with allocated sessional time chairs a monthly trust wide development Care pathways have been reviewed in line with NICE guidance. An Early Intervention Service clinical lead has been meeting to discuss and agree implementation of Early Intervention Service processes and appointed in the Trust to lead on the early intervention model. systems to ensure consistency and conformity to the NICE guidance. Early Intervention Service teams have received family intervention training. Staff are also encouraged to complete Before 2020 oversight on this service by Commissioners was through the Integrated Cognitive Behavioural Training (CBT) training. Governance Committee (IGC) and the Clinical Quality Review Group (CQRG). Moving into a Single Operating Model compliance was initially through the monthly Brent Three members of staff have been added to the team using funding from the Long Term Plan, creating increased Quartet Executive and Delivery Governance but this is now through the Integrated Care assessment and care coordination capacity and improved oversight and leadership, therefore supporting delivery of the Partnership Board. Early Intervention in Psychosis Referral To Treatment (RTT) Further monitoring through the Integrated Care System(ICS) is in place is via the System requirements. Oversight Meetings which are held every quarter with the Trust. NWL CCG Response Assistant Director of MHLDA, Head •These actions were completed in November 2019 with •The proposal that informed the redesign of the service on NICE guidance for all major Mental Health conditions and Before 2020 oversight on this service was through the Integrated Governance Committee of MHLDA, Consultant Clinical additional psychology investment. confirmation of additional investment is available was signed off by the Brent Executive Board in Sep 2019. (IGC) and the Clinical Quality Review Group (CQRG). a) Initial services provided psychological therapies but these were inadequate in terms of both Psychologist, Clinical Director for •The revised offer is for on average of 12 sessions per • Psychological interventions is now the first line core treatment option. Moving into a Single Operating Model compliance was initially through the monthly Brent capacity and NICE compliant. As a result we reviewed the skills mix, capacity and capability of the Brent Mental Health Services, Brent client. •The analyses of service user feedback in relation to mental health care also contained recommendations regarding Quartet Executive and Delivery Governance but this is now through the Integrated Care commissioned psychological therapies with a view to aligning this provision with NICE recommended Mental Health Services Borough •Given the complexity of the presentations, the new improved access to psychological therapy as did the Mental Health Five Year Forward View which emphasised the need Partnership Board. guidance for psychological interventions as a first line core treatment option. Director specifications recognise that most of the individuals in this to increase access to psychological therapies both within and beyond IAPT. •The Integrated Partnership Board meets monthly and has a specific mental health and group will need at least 16-20 sessions therefore this • This is reflected in the specifications. Our response acknowledged that many people with severe mental health well-being Executive Group reporting to the board. Since this incident, there has been significant investment in mental health services as a result of the redesigned offer has the flexibility of both short term and conditions faced long waits for psychological therapy. •This group has responsibility for monitoring service outcomes, and service user feedback NHS Long-term plan and Mental Health Investment standards. This investment will continue to grow longer term support. To address this we: and works to address any identified gaps and barriers to ensure that the service continues to improve services. •The length of treatment is also in line with the NICE •increased access to psychological therapies for people to include for those individuals with psychosis, bipolar disorder to meet the needs of the service users. recommendations for psychosis. This action has been and personality disorder. • Membership includes local partners from the NHS Mental Health Trust, Local Authority, complete based on identified needs of - flexibility for CCG, Voluntary Sector, Carers reps and service user reps. We: further session which is now routine with the additional • There is representation from acute mental health, primary care, community services, a) redesigned this service to be NICE compliant b) Increased access routes to psychological therapies investment in psychological therapies. There is on-going substance misuse, accommodation and employment. within and beyond IAPT. systematic reviews to ensure that this is meeting the needs • There are systematic reviews on access and demand to include mental health, c) Worked with CNWL and other commissioned services to ensure that patients have full access to of this cohort of service users substance misuse, treatment and support for service users with ADHD psychological therapies in line with best practice guidance. d) Started treatments in early intervention in psychosis services within 2 weeks of referral. e) Offered cognitive behavioural therapy for psychosis (CBTp) which can be started during an acute phase and thereafter can be continued into the community.

The Trust will put a system in place to ensure quality and timeliness standards are maintained. Brent Borough Director Jan-20 The Trust standard is that discharge notifications are sent within 24 hours of discharge from inpatient wards. A new Pharmacists closely monitored the rollout of the new discharge notification form ensuring There is now an automatic 24-hour discharge notification that goes to GPs which provides medication, diagnosis and that GPs received the necessary information related to medication changes at discharge. brief notification. This was initially monitored by matrons and pharmacists. It is now automatically monitored through Discharge notifications continue to be monitored through Tableau reports for timeliness tableau. with any identified issues escalated through local Care Quality Meetings. Following implementation of the system for GP notification, the Trust sought feedback from GPs who confirmed Before 2020 oversight on this service by Commissioners was through the Integrated satisfaction with the process and that they were receiving information in a timely way. Governance Committee (IGC) and the Clinical Quality Review Group (CQRG). Moving into a Single Operating Model compliance was initially through the monthly Brent Quartet Executive and Delivery Governance but this is now through the Integrated Care Partnership Board. Further monitoring through the Integrated Care System(ICS) is in place is via the System Oversight Meetings which are held every quarter with the Trust.

The Trust will continue to monitor CPA reviews ensuring that the system for reminders to complete Brent Borough Director Jan-20 There is regular communication to team leaders & care coordinators on upcoming CPA reviews and their deadlines. This These are monitored through clinical quality and performance meetings. them is robust and that exceptions are reviewed and mitigating actions put in place. includes a full yearly list as well as monthly reminders and status reports utilising a RAG system. CPA timeliness is a Key Performance Indicator (KPI) that is monitored monthly and The Trust has signed up to Triangle of Care In line with the new national community mental health framework the Trust is currently transitioning from CPA and will Tableau reports show dates from the clinical records system, SystmOne, for timeliness. be embedding Dialog+ across services in 2022. Training is being rolled out to staff in community teams over the next This is also reviewed in Team, Borough and trust-wide meetings. few months with a view to launch the tool in regular practice in May 2022. This metric is reviewed at the monthly performance meetings in the boroughs with Since the incident, the Trust has introduced a new clinical records system, SystmOne, linked to tableau reporting. exception reports required when targets are missed in the team. CNWL has signed up to Triangle of Care - a national scheme to ensure carers are appropriately involved in a persons Before 2020 oversight on this service by Commissioners was through the Integrated care. This means we are embedding the following 6 key standards in our services Governance Committee (IGC) and the Clinical Quality Review Group (CQRG). 1.(cid:9)Carers should be identified at first contact with services or as soon as possible thereafter Moving into a Single Operating Model compliance was initially through the monthly Brent 2. Staff should be trained in carer awareness & engagement – 47 staff from Brent have been trained in the first months Quartet Executive and Delivery Governance but this is now through the Integrated Care of implementation Partnership Board. 3.(cid:9)Policies should be in place around confidentiality and information sharing with carers. Further monitoring through the Integrated Care System(ICS) is in place is via the System 4.(cid:9)Carers Champions should be in place in all teams. Oversight Meetings which are held every quarter with the Trust. 5. Carers should be “introduced” to the service and provided with a range of information. 6.(cid:9)Carers should be signposted to or offered a range of carer support services

Trust Response Brent Borough Director Jan-20 Since the incident, there is currently a new CNWL Dual Diagnosis worker assigned to Brent 1 day a week to support NICE guidelines are assessed thought the yearly National Clinical Audit of Psychosis The Trust will demonstrate implementation of the guidance in the Brent Early Intervention Service. those who have been referred. (NCAP). Since the incident, the mental health charity Rethink Mental Illness has been commissioned to work with patients who Before 2020 oversight on this service by Commissioners was through the Integrated have substance misuse related issues but do not meet threshold for traditional substance misuse services. These are Governance Committee (IGC) and the Clinical Quality Review Group (CQRG). outreach workers and work proactively to engage these service users. Rethink workers are based in the community Moving into a Single Operating Model compliance was initially through the monthly Brent mental health teams. Quartet Executive and Delivery Governance but this is now through the Integrated Care Partnership Board. We have recently launched the Rapid Engagement and Support Team (REST) team at Park Royal which is a team Further monitoring through the Integrated Care System(ICS) is in place is via the System working to support inpatients with dual diagnosis and upskill our inpatient staff in supporting service users with Oversight Meetings which are held every quarter with the Trust. complex mental health needs and substance misuse. In addition, training programme that was implemented at the time of this review included recommendations from the NICE 2016 Coexisting severe mental illness and substance misuse: community health and social care services guidance, including Substance Misuse Interventions. Standards from the guidance are also picked up in Serious Mental Illness (SMI) physical health work. NWL CCG Response NWL Assistant Director of MHLDA, •This newly designed service was signed off by the Brent •The new Peer Support Service for mental health and substance misuse was signed off by the Brent Quartet in February The redesign of the Mental Health and Substance misuse Peer Support project was Head of MHLDA, NWL Clinical Lead Quartet in February 2021 and implementation started on 2021 with implementation from 1st April 2021 and provides increased peer support: navigators (PSNs), aligned to the agreed and signed off by the Brent Quartet Executive and Delivery Governance. We had in place an assertive system wide community service provided through generic peer support for Mental Health Services, NHS the 1st April 2021. Transformed Brent locality hubs to support, encourage and inspire individuals, delivering personalised, recovery- As we moved to a Single Operating Model this is now overseen by the Integrated Care that worked to a strengths model, recognising and building on service user’s strengths and abilities Brent CCG Clinical Lead for Mental •There is monthly monitoring of this service both in terms focused programmes of 1-1 intervention and community navigation to support sustainable mental health self- Partnership Board which meets monthly. and using creative models as well as involvement in their local communities to facilitate more social Health, Brent Mental Health Services of qualitative ad quantitative measures. management. inclusion. Borough Director •Systematic monitoring is on-going with a full service •The service provides purposeful pre- and post-discharge support to patients in Park Royal Centre for Mental Health review planned for the end of the first year led by and other acute settings, delivered by PSNs working alongside CNWL’s Community Access Service team and *EACH Since this incident, there has been significant investment in mental health services as a result of the Healthwatch - March 2022. support workers. NHS Long-term plan and Mental Health Investment standards. This investment will continue to grow •The outcome from the review will inform any desired •This is a comprehensive, approachable programme which also offers confidence-building volunteering opportunities to improve services. changes including any remodelling and respecifying based and activities aligned to Brent’s existing Social Prescribing service to ensure that there is co-ordinated, effective cross- on identified needs and service users and carers referrals into and out of local services. Substance misuse outreach and support is provided by Substance Misuse We reviewed this provision to: experiences Outreach Workers (SMOWs) integrated into Brent's Mental Health Service. a) Identify at risk groups of individuals with mental illness and substance misuse locally •The SMOWs work with existing substance misuse organisations, primary and secondary care teams, Adult Services and b) design outreach support with skill sets that to support people who struggle with substance misuse local VCS around referrals, screening, assessment, psychosocial interventions, recovery planning and community c) respecified this provision to be more responsive and provide personalised management plans and navigation for this cohort of individuals. activities to support the reduction of harmful substance use behaviours •The service also provides an engaging mental health wellbeing and recovery group-based programme incorporating d) included advocacy support to connect service users with other services to help them manage their opportunities for creative expression and healthy living alongside peer discussions and techniques for, e.g. managing dependencies. anxiety, mindfulness, cultivating confidence and using motivational interviewing and coaching techniques to support e) included crisis intervention, emotional, practical and psycho-social support service users to self-identify strengths and aspirations. Emotional and psycho-social support is provided through active f) included support to services users to develop social skills listening and solution-focused approaches to work through individual needs and aspirations. g) included behaviour management support to maximise social inclusion and help individuals with *EACH is the Ethnic Alcohol Counselling service in Hounslow. coexisting severe mental illness and substance misuse integrate in their communities and to engage with relevant statutory and voluntary services

The Trust will update the risk assessment policy and train staff in community teams on its application. Brent Borough Director Jan-20 The Trust has developed training and this is delivered face to face or virtually. The Risk Assessment policy was updated The Operational Board reviewed arrangements for effective risk assessment and and a quick reference guide developed and communicated trust wide. management. The Trust continues to support effective clinical risk assessment. The Risk Assessment Dashboard was developed to The Early Intervention Service (EIS) currently monitors risk assessment/dashboards simplify the existing processes and was launched on the clinical records system, SystmOne, in September 2020 in weekly and discuss in multidisciplinary team meetings. conjunction with revised guidance and an e-learning package. The Trust-wide face to face virtual training has been delivered twice a month during the past 12 months and is Before 2020 oversight on this service by Commissioners was through the Integrated advertised in the Trust weekly bulletin. Governance Committee (IGC) and the Clinical Quality Review Group (CQRG). Risk assessment training was delivered to the Brent team. The Early Intervention Service (EIS) also added training on risk Moving into a Single Operating Model compliance was initially through the monthly Brent assessments as part of the EIS development plan. Quartet Executive and Delivery Governance but this is now through the Integrated Care Partnership Board. Further monitoring through the Integrated Care System(ICS) is in place is via the System Oversight Meetings which are held every quarter with the Trust.

There was a limited service in place and as a result, we worked with ADHD providers to redesign our NWL Assistant Director of MHLDA, •On-going from April 2020 - interrupted by the pandemic This service redesign is included in the 2021 Contract and Service Development Improvement Plan (SDIP) and on-going The Integrated Care Partnership Board has oversight of this provision which meets ADHD pathway and ensure that referrals into the service are directly from GPs and local Clinicians. The Head of MHLDA, NWL Clinical Lead and resumed in February 2021. work to embed this within our primary and secondary care offer for individuals who require ADHD diagnosis and on- monthly. newly designed service now provides rapid diagnosis and treatment for all ADHD referrals, including: for Mental Health Services, NHS going support. Patient access on referral to electronic rating scales to support diagnosis; Brent CCG Clinical Lead for Mental Diagnosis Health, Brent Mental Health Services Prescription and titration Borough Director Assessment of on-going needs for specialised online support services if preferred or indicated as more suitable; Liaison with local secondary and primary care mental health services; Shared care agreements with referring GPs for on-going care. Provision of expert support to primary care practitioners so that individuals with ADHD can be managed in primary care, rather than being referred to local secondary care mental health services; We increased the capacity and confidence of primary care practitioners in recognising and managing ADHD; Support and advise patients to enable them to take ownership of their treatment; and Support integrated care. East Berkshire Clinical lead for MH (CCG & BHFT) This has been implement throughout 2021/22 The service redesign was undertaken by clinical leads for the CCG and BHFT and was discussed and approved at many The service will be monitored through regular contact with BHFT and in particular East Have a diagnostic pathway into Berkshire Healthcare Foundation Trust which includes prescription different committee's including the Clinical Interface Committee. Berkshire Service Forum and titration. New updated shared care prescribing arrangements with GPs. This is a primary care based Locally Commissioned Service where once titrated by secondary care primary care will manage patient's prescribing and monitoring with fast track access back to secondary care. Complex patients retained by secondary but prescribing by primary care. Primary Care will not take patient back from external providers unless shared care protocols are adhered to. Work underway with secondary care to ensure we have improved capacity and managed waits for assessments. 6 week post diagnostic course available - understanding ADHD

The Trust will ensure there is a mechanism for assessing and recording capacity to consent. Brent Borough Director Jan-20 Staff training has been aligned to the standardised way of recording capacity to consent. The induction training for The Trust's Mental Health Act Law Group is chaired by a Non Executive Director and Doctors includes capacity to consent to treatment, and includes how to complete a comprehensive capacity assessment oversees the application of the Mental Health Act as well as the Mental Capacity Act. in regards to treatment. Clinical records are regularly audited and trust wide Mental Capacity Act Tableau reports The Mental Capacity Act E-learning module forms part of the Trust’s mandatory training programme for frontline staff. are generated and reviewed. Since the incident, the Trust has changed clinical record systems (from Jade to SystmOne) with a standardised way of Senior staff have ability to run SystmOne reports that would identify gaps. recording capacity assessments now in use. Responsible Clinicians review admission clerking in to ensure approved clinicians There are newly developed capacity assessment forms and best interest strategy meeting templates for staff to use and responsible for the treatment of detained patients are aware of the requirement to complete where appropriate. document capacity and consent to treatment and outcomes of reviews. Capacity and consent to treatment is part of the multidisciplinary template on SystmOne. Mental Capacity and Best Interest Assessments are recorded in patient notes and on relevant templates on SystmOne. The Trust has a lead for the Mental Capacity Act.