External Action Plan 2015 / 11721 No* Recommendation / Area of concern Action (in SMART format) Lead Level for Action Monitoring Target date Evidence of action implementation What issue has been identified? Issues must be listed individually with an associated action point assigned. Note: Issues must be considered from an individual patient care perspective, but also from a service perspective. How will the issue be addressed? The action point must directly state how it will address the area of concern in a clear and measurable way to ensure improvements are achieved. A single person should have responsibility for the implementation of an action point to avoid confusion and ensure clear lines of accountability. Note: this must be discussed with the nominated individual and agreement obtained Is the action applicable to: An individual member/s of staff Team Service Directorate Borough Division Trust How and when will progress be measured? E.g. audit, survey. How will you demonstrate that the action point has addressed the issue identified? In order to demonstrate action point implementation the evidence must be obtained by the person responsible for the action point. A copy of the evidence must be sent to the Quality Assurance, Research and Innovation Unit for corporate reporting. 2 PCFT should seek assurance that the current CTO Policy is realistic and fit for purpose, and it as required to ensure it is line with other relevant Trust processes, and then seek assurance that the requirements of the CTO policy are being adhered to and implemented correctly Review the CTO Policy by Task and Finish Groups Audit already implemented for care planning and code of practice compliance MM (Mental Health Law Manager) KT;MP;HM Community Consultant Inpatient Consultant ☐Individual ☐The Team ☐The Service ☐The Directorate ☐The Borough ☐The Division ☒The Trust Task and Finish (HMcC) Policy (MM) Audit (LC); re-measure between 2016 audit results and Q4 2017 May 2017 May 2017 Q4 Revised policy Revised policy Audit results Action plan
3 PCFT should revise the zoning protocol to include clarity on who should attend from different disciplines, and a minimum meeting interval should be specified. This should then become a policy and its implementation monitored Develop a Task and Finish Group to review Trust wide process T&F group in progress Data-set of practice collected for analysis CMc MW Individual The Team The Service The Directorate The Borough The Division The Trust Policy produced and ratified July 2017 Policy on intranet 4 PCFT must provide assurance that systems are in place to ensure that all patients on ‘CPA plus’ have updated care plans Develop internal assurance process overseen by Positive and Safe group. HMcG met with P&I and ICT re tableau. Report for CPA plus and care plan to be produced for team manager level. CPA+ register by CSM and Governance HMcG DE ☐Individual ☐The Team ☐The Service ☐The Directorate ☐The Borough ☐The Division ☒The Trust Developed assurance process that is understood at local level Compliance framework for CPA plus care planning to be developed as per above July 2017 Reporting structure Integrated governance dashboard DIGG
5 PCFT & NHS HMR CCG should assure themselves they have appropriate resources to meet demands of patients who meet the requirements of CPA plus, and/or an ‘AOT approach’ Meeting with PCFT and HMR CCG on 20th February to look at issues, prioritise and resources HMcG KS (CCG lead) Individual The Team The Service The Directorate The Borough The Division The Trust Minutes of meeting July 2017 Revised contract 7 PCFT should evidence that risk assessments are robust and then followed by a clear risk management plan that should be an essential part of CPA care planning Review risk assessment tool MW (Task and Finish Group) Individual The Team The Service The Directorate The Borough The Division The Trust Tier 4 Group will look at themes Borough level actions Team level for individual actions July 2017 10 PCFT should clarify what additional enhanced risk management follows from registration on CPA plus Look at the structure, attendance, involvement, format etc. of CPA plus meeting and links to other processes e.g. MAPPA Task and Finish Group to review CPA policy and MC – Medical staff CMcC; DE; DS Individual The Team The Service The Directorate The Borough The Division The Trust Review of the clinical risk assessment policy for CPA plus patients September 2017