Independent investigation into the care and treatment of Mr J

1. The Team Manager to undertake random qualitative Croydon Early Intervention audits of risk assessments and care plans/ risk Service Team Manager, management plans on a quarterly basis. Psychosis Clinical Academic Group (CAG) First quarterly audit due end quarter two (30/09/2016), repeated each quarter for one year Final review of audit September 2017 Action Complete • Random qualitative risk audit completed for each quarter • Final audit completed in September 2017 • Findings discussed with staff within team meetings with learning identified around updating risk assessments when there is a change in risk i.e. transition from Home Treatment Team to the service. Team are focussing on improving the quality of information they record in risk assessment e.g. criminal justice contact • Findings indicated that safeguarding issues to be reflected in Care Plans and risk assessments were completed appropriately • The final audit demonstrated that the quality of care plans and risk assessment had improved with clear links between risk assessments and care management plans.
2. Quantitative reports are reviewed at supervision and Croydon Early Intervention any gaps in individual performance will be addressed on Service Team Manager, a monthly on-going. Psychosis CAG Monthly for one year from September 2016 12 month review September 2017 Action Complete • Quantitative audits completed on a monthly basis • The Trust uses the Insight reporting system to provide data to support monitoring by the Team Manager within supervision • Exception reports provided to the Clinical Service Lead within Team Manager meetings as standing agenda items. • The final audit identified evidence of improved practice in this area
3. Completion and quality of risk assessments and care Croydon Early Intervention plans/ risk management plans to be monitored through Service Team Manager, Supervision to ensure actions are being taken. Psychosis CAG On-going as part of supervision Action Complete • Supervision templates now include risk assessment for each staff member to ensure that the completion and quality is monitored and the learning from audits shared • Supervision is monthly with the Team Manager addressing any identified gaps • Learning identified from the audits - what have the service learned
4. Monitoring of this recommendation is through the Deputy Director, Early Early Intervention Pathway performance meeting Intervention Pathway, chaired by the Deputy Director of Early Intervention and Psychosis CAG Complex Care. Monthly for one year from September 2016 12 month review September 2017 Action Complete The main learning has been using the audits process including completion of final audit to improve the quality of the content of care plans and risk assessments by ensuring that; • Care plans are kept up to date and reflect current needs • Care planning leads to coherent risk management plans • Care plans reflect current risk especially when there is a transfer of care between services or change in the individuals circumstances • When an individual in placed in our Red zone (A risk management tool-red being high risk), this is reflected in all care plans and risk assessments is also updates. • Clear crisis plans are in place on risk assessment and are now regularly reviewed as part of the supervision process The audit process established that the quality of care plans and risk assessments has improved.

1. Psychiatric Intensive Care Unit (PICU) Operational Service Director, Acute Care policy to be updated to include expected standards and Clinical Academic Group audit arrangements in relation to discharge and transfers (CAG) including Home Treatment Team involvement. 30/11/2017 • Revised operational policy • Ratified at Acute CAG Governance Exec.
2. HTT Operational policy to be updated to include the Completed on 31/03/2017 PICU Deputy Director Crisis process for referral from PICU Action Complete Services • Specific reference to discharge from PICU added to HTT Policy (P48 of policy ratified in March 2017) • Inclusion of PICU referral process will ensure that there is a more consistent approach to the referral processes between PICU and the HTT
3. The Acute Clinical Academic Group (CAG) Audit of last • Completed audit 6 months of discharges to home from each Trust PICU Clinical Service Lead for 31/12/2017 • Audit findings reviewed at Acute CAG Governance exec to identify any further learning and changes in Ward PICU, Acute Care CAG policy

1. Early Intervention Pathway Leadership team to ensure Deputy Director, Early that Early Intervention services are fully appraised on Intervention Pathway, how to refer and access Forensic advice. Psychosis Clinical Academic Group (CAG) in conjunction the Clinical Director, Behavioural and Developmental Psychiatry (BDP) CAG Completed on 20/09/2016 Action Complete • Meeting held between the Deputy Director, Early Intervention Pathway and the Forensic Pathway to clarify the forensic referral process as planned and how the team will be supported with complex cases. An agreed pathway was completed. • Learning from this meeting was shared with the Croydon Early Intervention Service (COAST) on 20/09/2016. A forensic team member met with the team to clarify their criteria for acceptance on forensic team caseload and how to make referral to the team. All COAST team members can access to the forensic leaflets, referral forms and referral guidelines through the COAST team shared folders on the ICT network. • The CAG are confident that the COAST team can access forensic support and advice as required.
2. Forensic services review to ensure there are adequate Service Director and Clinical systems to provide advice to other clinical teams within Director of BDP CAG the Trust. The system should be documented in each Completed on 31/03/2017 team's local operational protocol. Action Complete • The Forensic Community Service Operational Policy was updated in March 2017, this details the referral process into Forensic Community Services which includes Assessment Clinical Reviews which support referrers where a patient does not meet the criteria for the Forensic Community Services. • Each Forensic Community Team Leader has shared any changes in local protocol with their local community mental health teams. Assurance is in place that local protocols are working well with team leaders being contacted to provide advice.
3. To provide assurance on the current systems, an audit • Audit to be drafted will be undertaken to check the knowledge of 2 Team Director of Nursing 31/12/2017 • Findings of audit to be reviewed in the Trust Serious Incident Review Group with agreement for Leaders from each SLaM Borough on how to access additional actions as required. Forensic Advice.

1. The Trust has developed close links with the police as Local Security Management evidenced in policy guidance, committees and onsite Specialist and Service police presence. Director linked to Police Liaison Accessing and engaging with police to inform risk assessments. • Blue Light Bulletin - Police Disclosure to Inform Risk Assessment - sent in July 2015. A bulletin was disseminated to all clinical teams providing guidance on how to access police information for risk assessments. • The Local Security Management Specialist maintains intranet pages with current link to the Borough commanders who are linked with each SLaM Borough. Operation Metallah • Management of emergency situations – in place. Operation Metallah has been running for a considerable time on the Bethlem site and is well embedded. The Lambeth, Southwark and Lewisham sites rolled it out in the last 8 months. SLaM signed a MoU with the police re attendance on site this Completed on 30/09/2017 month (September 17). This takes place via Operation Metallah. Operation Metallah is primarily a Action Complete system/structure which is embedded within inpatient units. The ideology behind Operation Metallah is to improve communication, risk assessment of any immediate risks and joint planning/working to safely co- ordinate resources and manage any given situation. This applies to all persons reported missing from hospital. Police liaison committee and local Police liaison groups • Held on a quarterly/ bi monthly basis with fixed agenda items for example Operation Metallah, AWOLS and prosecutions. PSTS training incorporates guidance on liaison with the police • All staff undergo a level of Promoting Safe and Therapeutic Services training. Liaison with the police is included in the course content.
2. The Trust's current engagement with probation is on a Director of Nursing case by case basis. To improve the interface between the Trust and • Agenda and actions from meeting with probation. probation a meeting with be arranged with each of the 31/12/2017 • Action plan to be taken forward to address any identified areas for improvement. Local Probation areas to identify any keys areas to • Learning to be disseminated across the Trust improve working relationships. The Trust will review the learning from this and share 31/03/2018 • Item to be presented at next Team Leader event to share with team leaders from all CAGs. through the next team leader event.

1. The medicines management policy has been updated Deputy Director of Pharmacy to reflect that poor insight should be highlighted as a predictor of poor compliance to early intervention teams, when identified it is important that all medication monitoring options are explored. Completed on 30/06/2017 Action Complete • The Medicines Management Policy was strengthened in June 2017 Section 7.13 Medicines Adherence was updated to include “Clinicians must assess for individual patients the risk of non-compliance with medication. Clinicians must evaluate the risk and ensure that both the appropriate medication is prescribed and that the patient is supported to continue treatment.” • Changes in policy communicated through Policy Bulletin and dissemination to key stakeholders. • All services have access to medicines information from the SLAM pharmacy team for advice and guidance. For prescriptions that the SLaM pharmacy dispense they will assess prescriptions for safety (clinical screen) before dispensing.
2. The Trust commissions a Medication Management Assistant Director of Nursing, course through Kings College London (KCL). The Trust will (Professional Development) ensure that this recommendation is reviewed with KCL to 31/12/2017 • To be taken to next key account meeting on 25/10/2017 for discussion and inclusion in the course material ensure that the course addresses treatment options. • Minutes to be provided as evidence with details of any changes to the course
3. The Trust has updated the way community care plans Professional Head of are recorded on the electronic clinical notes system Occupational Therapy and (ePJS). A single Recovery and Support plan is now used Trust Social Inclusion & which includes Recovery Lead Action Complete • Updated care plan has provided a holistic view of a patient's care, when interventions should be increased and who this should be communicated with. • early warning signs and triggers • accessing help in a crisis • how and who the plan should be communicated to
4. To provide assurance on the current systems, the • Audit to be drafted Trust will audit the knowledge of 2 Team Leaders from Director of Nursing 31/12/2017 • Findings of audit to be reviewed in the Trust Serious Incident Review Group with agreement for each SLaM Borough on how to access advice from additional actions as required. pharmacy

1. Audit of safeguarding mandatory training of team Team Leader and Clinical members. Service Lead Completed on 30/11/2016 Action Complete • The Trust moved to a new training monitoring platform on 30 November 2016 which provides a full overview of learning and performance data on a single platform. • The Croydon Early Intervention Service (COAST) are supported to comply with training by the Psychosis Clinical Academic Group Business Manager who provides monthly updates to the Team Manager. • The COAST team has a designated Safeguarding lead who oversees Adult and Child safeguarding referrals. • A local Adult safeguarding folder and Children Development of local safeguarding tracker is now maintained on the COAST team shared folders on the ICT network which all staff can access. • Safeguarding is part of the supervision structure within COAST with records reviewed in supervision The audit has provided assurance that a high quality of care is provided and that the policy is understood and embedded effectively.
2. Training dates to be booked and confirmed for all Clinical Service Lead with team if gaps in mandatory training discovered Deputy Director Completed on 31/03/2017 Action Complete • All team training is up to date for Safeguarding Children Level 1/level2 and Safeguarding Adults Alerters Plus (3 years) with exceptions for unexpected staff absence
3. The Trust has updated the electronic clinical notes Completed in July 2016 Safeguarding Adults Lead system (ePJS) to ensure that all staff are aware of Action Complete safeguarding requirements and that risk information is recorded and updated on ePJS. • In July 2016, the Trust updated the electronic clinical notes system (ePJS) to ensure there is better recording of Safeguarding concerns. New forms and guidance is in place o ePJS Safeguarding Children Form o ePJS Safeguarding Adults Form o Help with the Safeguarding Adults Template o Help with the Safeguarding Children Template