needs for future team development. High 1.4 Launch newly revised and printed bespoke record keeping packs for the Bradgate Unit. Division Lead Nurse Professional Standards August/ September 2013 New in use Medium 1.5 Trust-wide record keeping (second stage) to be completed on all Bradgate Unit wards in October 2013. Trust Clinical Effectiveness Lead October 2013 Audit support Audit data Report Action plan High 1.6 Review the care pathway for all patients at the Bradgate Unit through scrutiny and development of care plans on all wards. Systematically review all care records on Bradgate Unit ward. Identify and address shortfalls. Embed a system of ongoing monitoring. Chief Nurse Lead Nurse Seconded Matrons August 2013 Two Ward Matrons seconded Weekly reports Audit data 2. Develop standardised handover processes High 2.1 Completion of Trust-wide Observations (Handover) re-audit – this is being preceded by a programme of spot checks by a clinical audit assistant. Trust Clinical Audit Team October 2013 Auditors to be identified and released Audit report Medium 2.2 Review of Handover Policy in line with NHSLA requirements. Clinical Governance Lead AMH & LD November 2013 Revised policy 3. Cultural change High 3.1 Devise a cultural change programme for the AMH Division including a ‘culture’ dashboard. Milestones have been agreed with commissioners (see below) and a Division Senior HR Business Partner Results and report – September 2013 funding sourced to support the programme Final report Achieved actions
bespoke model is being worked through with an external provider – a steering group has been convened to scope the project and develop the audit. 1. Formation of a stakeholder Steering Group – July (completed) 2. Familiarisation and understanding – July/August (completed) 3. Design, development and distribution of a tailored culture audit survey - August 4. Culture analysis and first stage feedback (translation) - September 5. Reporting and action planning – September/October 6. Evaluation 4. Patient experience Medium 4.1 Consider how the division can use feedback from the patient experience programme in order to ensure the continuous improvement of the experience that people have using and delivering AMH services. Align this work with other improvement initiatives and service user and staff feedback, using the four themes – safe, cared about, involved and positively helped. Division Patient Experience Partnership Manager, Divisional Director, Lead Nurse August 2013 Programme outputs
Provide written feedback for service users and staff who contributed to the programme. Medium 4.2 Receive feedback from the Community and Inpatient Surveys and agree required actions (Community feedback received 7/8/13, Inpatient feedback to be arranged) Division Clinical Directors Heads of Service August 2013 Action Plan Medium 4.3 LPT to participate as a pilot organisation for the development of the Mental Health Friends and Family Test. Trust Patient Experience and Partnerships Manager Plans are at an early stage – timescale to be determined High 4.4 Recruit additional Occupational Therapists (OTs) and Therapeutic Liaison Workers (TLWs) to enable activities to be provided at the Bradgate Unit during evening and weekends. Service Service Manager October 2013 Additional OTs and TLWs in post High 4.5 Therapeutic Space CQUIN – Implement the revised patient satisfaction questionnaire at the Bradgate Unit. Division Service Manager July 2013 Revised questionnaires Completed questionnaires and collated data 5. Physical Health (new theme from recent Serious Incidents) High 5.1 Review the systems and processes in place in mental health inpatient facilities for monitoring physical health – position statement and options for the way forward to be produced. Division Clinical Director September 2013 Report on facilities for monitoring physical health Clinical Governance Group minutes
Medium 5.2 Introduce Early Warning Signs (Track and Trigger) tool at the Bradgate Unit and ensure all staff are trained in its use. Ensure staff are aware that incident reports must be completed for all concerns around the physical health of inpatients, following which an audit will be completed. Service Inpatient Lead Ward Matrons Medical Team November 2013 Tool Training pack tool Training attendance reports High 5.3 Physical wellbeing CQUIN – embed the new process surrounding wellbeing documentation at the Bradgate Unit and recruit to the CQUIN post to support this. Service Specialist Clinical Director (Access) October 2013 Monitoring results Risk recognition 6. Staff engagement with patient safety High 6.1 In response to the Appleby Report, convene a patient safety working to engage Bradgate Unit staff in the patient safety agenda and raise awareness of key processes. Develop prompt to use as a training and awareness tool for high risk processes such as observation, escorting patients and absconsion etc. Division Lead Nurse and Service Manager September 2013 Staff to be released Printing costs for resources Working group output, including prompt cards
7. Management of personality disorder High 7.1 Produce a report that demonstrates progress in response to the guidance on the personality Disorder Care Pathway written by mental health commissioners. to be presented to Quality Assurance Committee Division Clinical Director August 2013 QAC paper and minutes Medium 7.2 Following a review of the provision of psychology to the Bradgate Unit wards to aid management of patients with a personality disorder, the service will re-launch the psychology provision with an agreed framework for each ward to ensure effective use of the resource. A full time clinical psychology post will be advertised to support this. Division Head of Complex Care Services, Lead Clinical Psychologist September 2013 To be determined Ward psychology framework High 7.3 Undertake an overall review of psychology input across the division: Bradgate Unit – as 7.2 above Community - through the Community Services Redesign and PbR care pathway Complex Care – as part of the Clinical Excellence in Rehabilitation project Division Head of Complex Care Services, Lead Clinical Psychologist Bradgate Unit – September 2013 Community - Quarter two business case Complex Care – October 2013
Communicating risk 9. Information sharing (new theme) Medium 9.1 Access and Community Services Interface Meeting members to undertake a review of information sharing between LPT services, with reference to addressing key themes from Serious Incidents (e.g. communication, documentation, and risk assessment). Division Head of Community Services, Clinical Director and Clinical Governance Lead November 2013 Revised information sharing protocols and operational policy 10. Risk assessment and management Medium 10.1 Integritas commissioned to provide twelve full-day risk assessment and management workshops for community clinical staff – to commence in September 2013 and end in March 2014. Division Lead Nurse September 2013 to March 2014 Funding and staff release Training attendance and feedback Medium 10.2 Development of an approach for inclusion of clinical risk assessment and management in supervision sessions. Review current policy and guidance to reflect and the new approach. Division Dr N Chakraborty and Dr S Muhammad October 2013 Supervision policy and paperwork Protocols and procedures 11. Suicide prevention High 11.1 Review Trust guidance on suicide prevention (in-patient and community) based on best practice, SI report findings and research. Trust Medical Director and Nurse, Patient Safety Lead August 2013 Revised guidance available Medium 11.2 A programme of half day suicide awareness sessions for Trust Patient Safety Lead June 2014 Funding secured Training and attendance
Archived Actions – all actions completed The prevention of specific errors 1. Staff professional responsibility and accountability to maintain patient safety and provide a high standard of practice High 1.2 To deliver a professional practice programme to raise staff awareness of their personal and professional responsibility and accountability to maintain patient safety and provide a high standard of practice and care at all times – one day workshop to be delivered for all members of staff within Access Services. Division Head of Service and Lead Nurse February 2013 2013 Staff to be released Facilitation and venue Programme attendance and feedback High 1.3 In-patient medical staff to attend a half day professional practice workshop to consider in detail the findings of the Appleby Report and lessons learned from the SI reports of suicides reviewed. Division AMH Clinical Director and Specialist Clinical Director Access Service May 2013 to be released Facilitation and venue Programme, workshop date (24th May) and attendance High 1.4 To undertake a baseline of the Record Keeping Audit at the Bradgate Unit. Clinical Effectiveness Lead January 2013 Audit support Audit data Report Action plan 2. Development of standardised handover processes across the unit High 2.1 A Standard Operating Procedure (SOP) for handovers developed at the Bradgate Unit to ensure that all relevant information including clinical risk is passed on to staff in a timely manner. Division Service Manager and Lead Nurse October 2012 SOP and audit tool SOP in use on all Audit results and action plan
High 2.2 Completion of Trust-wide Observations (Handover) audit Clinical Audit May 2013 SCQG minutes, May 2013 Action plan High 2.3 Development and implementation of divisional handover policy Division Service Manager and Clinical Governance Lead March 2013 Policy Audit results High 2.4 Head of Service, Service Manager and Inpatient Lead to each attend a ward handover on a monthly basis to ensure that the SOP is being utilised appropriately across Bradgate Unit wards for a 3 month period Service Head of Service, Service Manager and Inpatient Lead Briefing note from handovers attended with any relevant actions – per month 3. Ward therapeutic programme and activities High 3.1 Provide a therapeutic programme on Bradgate Unit ward supported by therapeutic liaison workers (TLWs) and occupations therapists (OTs) supernumerary to the core ward staffing. Service Service Manager TLWs employed on all wards OT input to all wards Printed programme and notice board of activities. Risk recognition 4. Risk management training High 4.1 Integritas commissioned to provide three full-day risk assessment and management workshops for Access clinical staff. Division Lead July 2013 Funding and release Training attendance and feedback
Ligature points 5. Ligature risk assessment High 5.1 The Trust should task estates and health & safety to consider the suitability of the shower room doors and locks and to make appropriate recommendations to reduce risk. Estates and health and safety to consider the suitability of the shower room doors and locks and to make appropriate recommendations to reduce risk. Divisional Service Manager, Estates Manager and Health & Safety Security Manager November 2012 Risk register High 5.2 Inpatient facilities Service Manager (Access) , Estates and Health and Safety to review doors on all wards as part of ligature risk assessment and make appropriate recommendations to reduce risk. Inpatient facilities Service Manager, Estates and Health and Safety to review doors on all wards as part of ligature risk assessment and make appropriate recommendations to reduce risk. Divisional Service Manager, Estates Manager and Health & Safety Security Manager February 2013 Risk assessments in place with recommended actions to reduce risk 6. Escort Observations and Leave High 6.1 All AMH acute inpatient staff to be conversant and competent with the current observation policy. Service Lead Nurse and Ward Matrons December 2012 Training dates Head of Service email confirming achievement of competency assessment
AMH lead to deliver training to all AMH acute ward matrons on the use of the policy. Matrons to cascade training to all ward staff. Matrons to ensure that all staff have completed competence assessments in line with the observation policy. High 6.2 Trust Patient Safety and Experience Group to develop guidelines to manage all aspects of leave and ensure links to relevant Trust policies i.e. Clinical risk, Observation Policy and the Mental Health Act Code of Practice Trust Lead for Patient Safety, Senior MHA Administrator April 2013 Escorting Patients Policy, Section 17 Policy, Section 17 Audits (September 2012)