*Independent investigation into the care and treatment of Patient 2009/3245: January 2014

1.1That the Trust has in place a process to identify potential impact on practitioners’ workload and efficacy from organisational change. 1.1 To review the Project Management Framework/Quality Impact Analysis introduced following the 2009/3245 incident to include impact on practitioner workload and efficacy in the Project Management Framework/Quality Impact Analysis process. Director of Planning and Quality Q1 2014/15 1.1 Copy of the revised Project Management/Quality Performance Impact Analysis process. 1.2 That community clinical workload is monitored during the periods of organisational change that have the potential to impact on community practitioners’ workload and efficacy. 1.2 To agree the workload monitoring arrangements and implement with community practitioners as part of the plan when indicated from QIA outcomes. Chief Operating Officer Ongoing from July 2014 1.2 Project plans and change plans describe the arrangements for workload monitoring and a completed implementation plan.

2. That the Trust has implemented a standardised transfer process including a a summary of care when patients are transferred between care co-ordinators or consultants. 2. To develop and ratify a standard clinical transfer process for use in the care co-ordination processes . Chief Operating Officer / CPA Project Manager Q1 2014/14 2. - Standard work process description for case transfer. -Date of EMT ratification.

3.1 That the Trust holds a contemporary register of ISAs with review dates with registration and review processes in place.. 3.1 To develop and implement ISA registration and review processes and establish an ISA register. Director of Nursing and Governance / Head of Records Management 3.1/3.2 A workstream for ISA registration has been established by the Head of Records Management 3.2 That the Trust ISA register includes agreements with all current partner agencies. 3.2 To establish a process to check the ISA register for all current partner agencies and agree where new ISA or review of ISA required. Head of Records Management -Standard work process description for ISA review and establish processes.

4..1 That the Trust has a framework to identify the Trust staff roles and functions in the MAPPA processes and sets standards for the training and development of staff. 4.1 To develop and implement a framework for internal MAPPA processes. Director of Nursing and Governance/ Head of Safe-guarding Adults Q2 2014/15 4.1 -MAPPA framework document - MAPPA training plan and compliance data 4.2 That the Trust has an internal register that identifies open cases that are registered with MAPPA 4.2 To establish standard processes to identify for MAPPA referral/registration with and registration MAPPA

5. That the Trust clinical risk management model and policy has been reviewed and redesigned. 5. To review the Clinical Risk Assessment and Management (CRAM) Policy and implementation processes. Director of Nursing and Govern-ance/ Head of Patient Safety and Risk Q2 2014/15 5. -Revised CRAM policy - Implementation plan The work has commenced with identification of principles of a new clinical risk model.

6. That the Trust has implemented a ratified inter-agency Section 117 policy. 6. To agree an overarching Section 117 policy framework and local procedures for the seven partner Local Authorities with implementation plan. Director of Nursing and Governance/ Head of MH Legislation Q1 2014/15 6. -Ratified Section 117 Policy and Procedures . - Implementation plan A section 117 policy and procedures is drafted and interagency group established for implementation .

7. That the Trust has reviewed the CPA systems and processes and has an implementation plan in place to improve policy compliance. 7. To review the interagency CPA policy and processes and develop a project plan and implementation plan for the revised CPA processes. Chief Operating Officer/ CPA Project Manager Q2 2014/15 7. 2008 CPA policy has been reviewed and project established to develop new policy, documentation and training.

8. That the Trust has an improved policy compliance monitoring process in place as part of the governance systems. 8. To develop and implement a policy compliance monitoring process as part of the governance systems. Director of Finance and Information/ Policy Redesign Project Manager. Q1 2014/15 8. -Standard work process description for the policy compliance monitoring system. - Implementation plan Policy redesign project in place.

That the Trust has a standard system for the dissemination of lessons learned. To include a standard system for lessons dissemination in the new Learning Lessons processes Director of Nursing and Govern-ance/ Learning Lessons Project Manager Q2 2014/15 -Standard work process description for Learning Lessons dissemination Learning lessons project in place.