Independent investigation into the care and treatment of Mr T

a) To address this the Trust’s Management of Serious Incidents Policy was updated in September 2015 and details that, ‘The Risk and Patient Safety Manager will act as the contact point within the Trust for any independent investigation and will co-ordinate any requests for documentation or interviews with members of staff. The Head of Governance and Assurance oversees their work. Completed September 2015 Reports on SIs and learning are shared with commissioners and the Board. Trust Board and Clinical Quality Review Meeting b) As part of each start-up meeting NHS Patient Safety Lead November 2017 A checklist is already in use. NHS England sends this checklist to NHS England(London) have information ready for start up meetings. NHS England(London) Independent Investigation Review Group

Operational changes have been incorporated Associate Director for Completed March 2015 & There is Strategic Bed Management Group that review and Executive Management Group and Trust’s bed management system into the policy. Section 14 of the current Bed the Acute Division updated January 2017 monitor the bed management system and how well it is the Board should be incorporated into the management policy describes the process and performing. This group provides updates to the Executive policy responsibilities for those that have been Management Group and the Board. referred for a bed and are on the pending list. This process is now robust and well embedded and those on the pending list are regularly reviewed by the bed management team and the list is circulated to key managers and clinicians across the Trust.

In relation to the recommendation that all Associate Director for Completed March 2015 & There is Strategic Bed Management Group that review and Updates from the Strategic Bed London Mental Health Trust’s actively the Acute Division updated January 2017 monitor the bed management system and how well it is Management Group presented to monitoring their ability to provide beds - the performing. the Executive Management Group Trust’s Bed Management Policy section 9 and the Board. details the ‘whole system approach’ to bed management. This includes: details of the weekly and monthly bed management meetings; systems to ensure that an up to date bed state is known and communicated, and referrals are logged; and the bed management escalation process in the event that delays have been identified in locating a bed. A Compact (Pan London multi-agency Chair of Mental Health August 2018 The Compact was presented to the Cavendish Square Group on Quality & Clinical Governance agreement) between London’s mental health Transformation Board 10th March 2017. committee, NHS England(London) and acute Trusts, Local Authorities, CCGs, NHS NHS England Commissioning operations group England, NHS Improvement, London Commissioning operations group (NHS England) will monitor Ambulance Service and Police Services has Minutes of Commissioning Operations Group (NHS England). adherence and report to Mental been developed. This includes a regional Health Transformation Board and escalation process if no bed has been identified CCG Chief Officers within 6 hours from the decision to admit. It requires incident investigation of any 12 hour delays. This sets out minimum expectation of bed management to minimise risk of patients waiting to be admitted. The CCGs and Trusts are working together to implement this.

a) The Trust reviewed its Management of Director of Nursing Completed September 2015 Reports on SIs and learning are shared with commissioners and Trust Board and Clinical Quality Serious Incidents Policy in June 2015 to include the Board. Review Meeting the arrangements for the approval process of serious incident investigation reports. Serious Incident Group in place. Reports are reviewed at the Serious Incident Group and Signed off by the Medical Director and/or the Director of Nursing. The Reports are then signed off by commissioners. Where possible and when it is appropriate, investigators and Clinical Experts for Serious Incidents are now selected from the division that they work within so that there is more specialist knowledge in place. The Risk and Patient Safety Manager supports the investigator to gather and review evidence. b) A further review of the Serious Incident Director of Nursing July 2017 The report from this review will be shared with commissioners Clinical Quality Review Meeting process is being undertaken to further to provide assurance strengthen the process. Part of this review will Head of look at developing the investigation capability Governance and Quality at the Trust and competency and capability of Assurance investigators.

a) This is a central action in the Care Quality Medical Director Completed 2016 Audit reports and crisis plans. Clinical Quality Review Meeting and Recovery Division should Commission (CQC) MUST_DO & SHOULD_ Do Director of Nursing Trust Board meetings will monitor implement measures to provide Action plan. Evidence of communications to staff about the policy and access progress against CQC actions. assurance that risk assessments - Up to date guidance / policy around Care Clinical Director of the to the policy. meet the necessary quality Plans and Risk Assessment Recovery and standards. In particular, all risk - Robust governance systems in place to Rehabilitation Division Audit of evidence of the implementation of the Clinical Risk assessments should flag known monitor quality as well as quantity Assessment and Management Policy. relapse signs and proven risk - An assurance process with clear lines of Associate Director for management strategies accountability for performance. the Recovery and Training rates monitored at Rehabilitation Division Risk assessment training continues to be delivered. This includes divisional performance meetings. Assessment; lining to care plan, triggers for reviewing risk and (643 members of staff have updating on EPR. undertaken this training as of April The training is for all clinical staff who will be undertaking 2017) clinical risk assessment. It is run on a monthly basis in partnership with My Care Academy, part of Middlesex Improvements required in regard to University. data quality around training rates. b) Measuring the quality of crisis plans is Director of Nursing September 2017 The Trust has met the requirements of the CQUIN for quarters 1-CQUINS are monitored at Clinical included in the Division’s Audit Plan 2016/17. Medical Director 3. Quality Review Group with The quality of crisis plans are also measured in Clinical Directors commissioners and are part of the the Trust’s local CQUIN which audits the Board Performance Report. number of crisis plans that include the following key items: a) relapse triggers recorded; b) personalised contact information; c) more than one option for out of hours care; d) evidence of input from the patient; and e) were completed within the last year. c) In addition to above Risk Assessment and Audits reports. This will be monitored monthly at Crisis Planning will be audited in supervision the service QI (Quality Improvement) with clinicians (for Service Users on CPA). The Group within Trust Division. (The Division will undertake a quarterly randomized audit will be presented to the Trust audit using the same supervision audit to assess Quality Committee). impact on the quality of crisis planning and risk care plans. Director of Nursing Medical Director July 2017 The Clinical Risk Assessment and Management Clinical Directors Quarterly balance score cards Policy are currently under review and expected Quarterly balance score cards. measure crisis plans, and are to be finalised in July 2017. The revised policy presented at Performance review will ensure that the heightened risk of the role meetings. of alcohol and drug misuse is emphasised Policy review group in place. sufficiently. The policy will be re-launched to staff. d) A series of lessons learned workshops are Director of Nursing December 2017 Lessons learned workshops have already begun and will be Reports on SIs and learning are being planned throughout 2017 to support the Medical Director rolled out further across the Trust. shared with commissioners and the re-launch of the updated clinical risk Clinical Directors Board.

The Information and Communications Head of Information Completed June 2015 The Trust will carry out a randomized audit in August 2017 to Quality Governance Group Technology (ICT) Team run regular Technology check the process is improving. GP registration is an important Demographics Batch Service (DBS) trace on all part of supporting service users with their physical health needs patients known to the Trust to gather and which a strategic priority for the Trust. update patient records. The ICT Team are using the latest Mandatory Data Set (MDS) information from the Spine i.e. Patient Name, Post code, Practice code, Deceased status etc. to update data on the electronic patient record system, and therefore allowing staff to identify if a service user is registered with a GP. In line with divisional performance meetings, Clinical Director for the July 2017 Part of the clinical dashboard (episode information). Divisional performance meetings business partners will now liaise with ICT to run Recovery and monthly reports of GP status and report these Rehabilitation Division back to the relevant teams for action. Associate Director for the Recovery and Rehabilitation Division Service users are encouraged to register with Clinical Director for the September 2017 Audit reports. Quality Governance Group GPs as part of the process of assessing, Recovery and reviewing and planning their care. Where the Rehabilitation Division service user is not registered with a GP a plan Associate Director for for supporting registration should be recorded the Recovery and in the notes. Rehabilitation Division

All communication related to CPA reviews or All Trust Divisional Completed April 2016 & 15/16 the CQUIN measure was audited quarterly and the CQUINS are monitored at Clinical discharge plans are communicated to the GP Directors 2017 National target was 90%. The Trust demonstrated a 93% Quality Review Group with via electronic method of emails. In 2015/16 the compliance rate for timeliness and 68% in quarter 4 for quality. commissioners Trust participated in the National CQUIN In 16/17 and 94% was achieved for sharing information and relating to Communication with GPs, which quality of information. required the Trust to share an updated care programme approach care plan or a comprehensive discharge summary to the GP by secure electronic communication within 5 working days.

a) The current Policy Book for Primary Medical Patient Safety Lead September 2017 Minutes of the Independent Investigation Review Group with NHS England Independent Services does not include this requirement. Mental Health NHS evidence of progress. Investigation Review Group There needs to be change to the Personal England(London) (London) Medical Services (PMS) and General Medical Services (GMS) contracts which reflect that people with a CPA care plan are not deregistered from their GP without contacting Adult Social Care and/or the Mental Health Trust first. b) This will be escalated to NHS England Chair of the September 2017 Minutes of the Independent Investigation Governance NHS England Independent Investigation Governance Independent Committee with evidence of progress. Independent Investigation Committee and NHS England primary care Investigation Governance Committee contracts team for inclusion in the next Governance Committee amendment of contracts. c) To circulate a Regional Medical Directorate Medical Director for September 2017 Copy of the Newsletter NHS England Independent Newsletter to include this recommendation North East Central Investigation Review Group London (London)

a) The new Electronic Patient Record System – Head of ICT Completed September 2015 Annual record keeping audit This will be monitored via an annual Carenotes – was implemented in September Medical Director record keeping audit and an audit of 2015 and standardises the system for recording notes in supervision. These will be all care episodes. reported to the Quality Committee b) To ensure improvements are continuous and Clinical Director for the September 2017 Audit reports This will be monitored via an annual monitored in the Rehabilitation and Recovery Recovery and record keeping audit and an audit of Division supervisors will audit notes in Rehabilitation Division notes in supervision. These will be supervision. This is to ensure that recording reported to the Quality Committee standards and the quality of notes is sustained. Associate Director for Those Staff with identified areas of the Recovery and improvement in relation to the quality of Rehabilitation Division recording will have individualised plans to address their practice. Head of Governance and Quality Assurance

a) The Practice Development team have been Director of Nursing Completed 2016 Policy review group in place This will be reported to the Quality supporting improvements to care planning and Medical Director Committee risk assessment. The current risk assessment training includes substance abuse as a risk. b) The Clinical Risk Assessment and Director of Nursing July 2017 Lessons learned workshops have already begun and will be Trust Board and Clinical Quality Management Policy are currently under review Medical Director rolled out further across the Trust. Review Meeting and expected to be finalised in July 2017. The Reports on SIs and learning are shared with commissioners and revised policy will ensure that the heightened the Board risk of the role of alcohol and drug misuse is emphasized sufficiently. The policy will be re- launched to staff. c) A series of lessons learned workshops are Head of Governance December 2017 Lessons learned workshops have already begun and will be Trust Board and Clinical Quality being planned throughout 2017 to support the and Quality Assurance rolled out further across the Trust. Review Meeting launch of the updated clinical risk assessment Reports on SIs and learning are shared with commissioners and policy the Board

There was an extensive Bed Management Associate Director for Completed March 2015 & Crisis resolution team provide gatekeeping for all inpatient Trust Quality Committee and Clinical Policy review in 2015. The Trust’s Bed the Acute Division updated January 2017 admissions. This is measured via monthly performance reports Quality Review Meetings Management Policy has been further reviewed, and routinely exceeds the national target of 95%. revised, and updated in January 2017. The Policy details the duties and responsibilities of A prospective audit of the process will be done in July 2017 to the Crisis Response and Resolution Teams provide assurance. This will be added to the Trust audit plan; (CRRT): ‘to ensure that the CRRT team act as the results will be presented to the Trust quality committee and ‘gate keeper’ for patients requiring admission commissioners. and that beds are found as swiftly and efficiently as possible once the need for a bed has been verified by the Duty Nurse at the Highgate Mental Health Centre.’ In the policy there is a clear bed management escalation process (BRAG), guidance on escalating delays, the gatekeeping process and an escalation protocol. There are daily, weekly and monthly bed management meetings. A referral list is distributed daily. Individual ward teams must inform the duty nurse about bed management decisions (i.e. discharges, on leave activity and transfers) at the earliest opportunity. There is now an embedded bed management team with a Band 7 team Manager and a matron who oversees this team (alongside the assessment team and 2 other wards).

The Trust’s Current Bed Management Policy Associate Director for Completed March 2015 & There is Strategic Bed Management Group that review and Updates from the Strategic Bed section 9 details the ‘whole system approach’ the Acute Division updated January 2017 monitor the bed management process. Management group presented to to bed management. This includes: details of the Executive Management Group the weekly and monthly strategic bed and the Board. management meetings; systems to ensure that an up to date bed state is known and communicated, and referrals are logged; and the ‘bed management escalation process’ in the event that delays have been identified in locating a bed. A log is maintained of all pending and accepted referrals for a bed where there is not one immediately available. The pending list is circulated to a wide stakeholder group. The bed management team reviews that list 3 times a day. No one is removed from the list without discussion and agreement with the referrer. Support is provided to ensure those waiting for beds are kept safe and comfortable (with regular review) until a bed becomes available. There is a London wide compact that has been drafted; this will further inform the current trust approach. At a cross divisional workshop back in 30th June 2015 we agreed the following statement: The responsibility for coordinating the support