Service Action Evidence Lead/Ownership Target Date Central and North West London Foundation Trust Recommendation 1 The Trust must ensure that when a team is liaising with a secure inpatient unit regarding care for a patient following discharge, the receiving team must ensure that they are clear what legal framework applied to the period of Inpatient care and treatment. A Clinical Alert stating that all staff need to be clear of the type of legal framework that was applied to a patient’s admission to a secure inpatient unit should be disseminated to all mental health staff. Clinical Alert Mental Health Law Manager 30 September 2016 Central and North West London Foundation Trust Recommendation 3 The Trust must undertake a review of record keeping across the Trust, paying particular attention to the child and adolescent mental health service, and implement an on-going audit An annual rolling programme of Care Records Audits is in place across the Trust co-ordinated by the Care Records Group. Audit templates are under review and are being developed by the Quality Directorate The audit will pay particular attention to record keeping compliance within the Child and Adolescent Mental Health Service. Completed audit forms Revised audit form Written analysis and recommendations to each division. Written communication and feedback to teams and services from each divisional leads. Head of Information Governance 28 February 2017 30 November 2016
with the record keeping policy. Where there are concerns about compliance, the Trust must implement a training programme to ensure that all staff understand the importance of all communications regarding a patient being filed within the clinical record. The Trust must also implement on on-going programme of audit to provide assurance that records are completed correctly. Communications to written and sent out trust wide via weekly news Quick Reference Guides to support staff in relation to data quality (record keeping) available on the Learning and Development Zone, (e learning). To support the Data Quality System standards of practice are being developed for clinicians dependent on level of responsibility to be overseen by Divisional Directors, Service Directors and Team Managers in conjunction with Performance Quality Leads QRG’s Ratified Policy Written Communications in Trust weekly news Example Quick Reference Guide Data Quality System standards of practice for the different levels within the organisation 30 September 2016 30 September 2016
Central and North West London Foundation Trust Recommendation 6 The Trust must work with partner agencies providing accident and emergency services to ensure that the joint operational policies are complied with, in particular that clinical records are available to psychiatric liaison staff in a timely fashion, to facilitate fully informed assessment of patients. A Clinical Risk Alert will be circulated to all Psychiatric Liaison Teams who will review the alert within team meetings and supervision sessions. This will outline learning from this incident and requesting that the local Operational Policy should outline guidance emphasising that all Psychiatric Liaison clinicians should review the patient’s A and E assessment (CAS card) prior to completing the mental and state and clinical risk assessment. The alert will also include guidance on the actions to be taken in any instance where this process is not followed i.e. incident reporting and documentation within the clinical record Clinical Risk Alert and evidence of cascade to teams Minutes of Psychiatric Liaison Team meetings Supervision records Copy of Psychiatric Liaison Team Operational Policy Clinical Safety Manager 30 September 2016 31 October 2016 Central and North West London Foundation Trust Recommendation 7 The Trust must ensure that operational policies are followed. The Trust must implement a The Trust welcomes this recommendation as it enables us to build upon our existing systems. The Clinical Policies group oversees and approves clinical polices, trust wide. Each Clinical Policy must follow a standardised template (cover sheet). Key aspects of each Clinical Policy are Standardised template Associate Director of Quality and Service Improvement 31 October 2016
process to ensure that staff understand the importance of key aspects of policies. The Trust must also implement a systematic process to provide assurance regarding compliance. highlighted on the title page to inform staff of aims and objectives of the policy. All new policies or new policy updates are communicated to staff trust wide in the Trust’s weekly news Assurance re compliance with clinical policies to be sought via Clinical Supervision Appraisal Completion of mandatory training and essential to role training Completion of competency frameworks and assessments Signed statements by staff that key polices have been read and understood Trust induction Local induction Example standard front page Example communications for trust weekly news Trust compliance re appraisals and mandatory training Supervision records Training attendance Competency frameworks e.g. medicines assessments Trust and local induction attendance records 30 September 2016 31st October 2016 31st October 2016 Central and North West London Foundation Trust Recommendation 8 The Trust must review the risk assessment policy to clarify how The Trust’s Clinical Risk Assessment and Risk Management Policy require additional guidance as outlined. The Policy needs to be ratified by the Clinical Policy Group The Revised Clinical Risk and Risk Assessment Policy The Revised Clinical Risk and Risk Assessment Policy-ratified by the Executive Director of Nursing and Clinical Safety Manager 31st January 2017 31st January 2017