Independent investigation into the care and treatment of Mr A and Mr B

1. Increase in whole time equivalent by 0.6 wte to increase staffing capacity and to reduce the team caseload in line with current working average across EIS. 2. Complete Quality Improvement Initiative (Qii) to promote discharges ensuring appropriate package of care has been delivered and discharge planning to CMHT when required. 3. Demand and capacity review of CPA/Care co-ordinator capacity. 4. Business case to be developed regarding additional resources as part of Community Transformation or cost pressures work with the CCG. Evidence of Completion: 1. 0.6wte is included in budget. Caseload management remains a priority, current caseload average is 19 with London wide average at 21. 2. Achievement of Qii Action Plan and caseload maintenance. 3. Document that outlines the needs of the service in meeting relation to Care Co-ordinator capacity . Capacity paper presented to Service Line Governance Group April 2019 4. Business Case and Demand Pressures requests to CCGs completed November 2019. The SWL – ICS/CCG has provided a significant amount of baseline investments into Community Services from 2021-22 and following the submission of a bid to NHSE the ICS/CCG has successfully secured a significant amount of monies to support the transformation of community services, including increased capacity in Psychology, nursing, community support roles, a newly developing community rehabilitation team for the Trust and an increase in therapies for people with Personality Disorders. Year 1 investment started April 21.

1. Masterclass to be held at the monthly Leadership Conference to remind staff of their obligations to comply with the Duty of Candour. 2. Trust to provide a monthly and 6 monthly compliance report against Duty of Candour core business. Evidence of Completion: 1. Masterclass Completed at November 2019 leadership event. 2. Monthly Performance Report and 6 monthly report detailing the Trust compliance against DoC which is approved at the QGG.

The Early Interventions Team to develop a standard operating procedure to enable clinicians to work outside normal office hours as many clients are in full time work. In addition the Trust's Lone Working policy aim is to safely meets needs of Service Users and is cross referenced within the SOP. Evidence of Completion: 1. SOP currently in place that detail the working out of office hours for staff.

1. Manager to regularly review Team Dashboard to ensure CPA's are booked and reviews are happening in a timely manner in line with the current audit tool. 2. Complete 6 monthly audit using developed audit tool. Evidence of Completion: 1. Up to date Dashboards 2. Report of Audit outcomes into Service Line Governance Group. This is currently showing over 95% for the EIS team.

1. Develop Audit tool in line with Zoning Guidance 2. Complete audit monthly as per Zoning guidance using developed audit tool. Evidence of Completion: 1. Outcome of the Audit reported. 2. core business.

1. Urine testing to continue to be incorporated into the care planning process. 2. Trust care plans are coproduced and this action will be done in collaboration with the service user unless stipulated within a Community Treatment Order where it is compulsory. Evidence of Completion: 1. Collaborative Care Plans will be monitored through the monthly Case Notes Audit process in conjunction with monthly supervision.

1. Session to be held with staff on the Clinical Disengagement and Did Not Attends Policy for staff in EIS Services to support the engagement and involvement of families in particular for those service users who are difficult to engage. 2. Compliance with policy to be reviewed via staff supervision which reinforces family engagement. Evidence of Completion: 1. Event held Clinical Disengagement, Did Not Attend & Was Not Brought Policy. 2. Supervision notes. MDT meetings and case reviews.

1. A Standard Operating Procedure to be developed jointly with key stakeholders. 2. Clear escalation process with the Local Authority where emergency accommodation needs to be accessed. This should include what to be done if emergency accommodation is not available. 3. New SOP and escalation process to be shared internally and externally. Externally through the Mental Health Housing forum and Internally via Supervision and ACCC. Evidence of Completion: 1. SOP agreed jointly with stakeholders and is in place. 2. Agreed escalation process how emergency accommodation will be accessed is as follow:- Firstly, Housing Charity/Providers existing housing stock - Secondly, Sourcing emergency accommodation through Local Authorities - Finally, The Trust Acute Care Coordination Centre who have the authority to commission accommodation 24/7. This has been written into our community and EIS Operational Policies 3. SOP noted at external meeting and at ACCC and mbedded inot boh Operation Policies

1. All Incidents that occur to be reviewed in supervision/MDT meetings and reinforced to staff that near misses should be reported as per Trust Policy. 2. Post Incident Reviews and Actions to be shared at Business meetings and Cluster Governance Group to support learning and improvements (applicable to SI's only) Evidence of Completion: 1. Supervision records/MDT notes 2. Post Incident Review (PIR) discussion at weekly Quality Matters Meetings where Serious Incidents are discussed and meeting is chaired by the Director of Nursing.

1. Trust Policy to be updated with specific details of support to be offered to staff. To include a flowchart on Post Incident Actions. 2. Staff Survey to be carried out for feedback on effectiveness of the support offered 3. As part of the Trauma Informed strategy the Service Line has identified staff to complete the trustwide debriefing training. Evidence of Completion: 1. Support for Staff involved in a traumatic event, complaint or claim policy ratified 28 August 2019. 2. Flowchart included at Appendix G. During the suicide prevention summit a survey was carried out with those in attendance, a presentation from a staff member who was involved in an incident and the support offered to them and how to improve this. Trust policy on supporting staff and policy in place. 3. The Service Line will identify 4 staff who will receive 2 day debrief training to support teams following traumatic events or incidents. In addition, The Trauma Skills Practice training is now available on the Trust's Compass trainign system and staff from across the Trust are accessing it. If is now part of the Band 6 Development programme for all Care Coordinators.