Independentreview of the care and treatment of Mr G

a. Trust has up to date policy in place against which audits are completed
b. Regular audits of Community Treatment Order (CTO), incorporated into the trust Care Programme Approach (CPA) audits
c. Trust wide CPA audits - Ongoing
d. Trust working towards introducing Dialog Plus Care Planning - aim to produce robust co-production in care planning; 2020
a. CPA Policy reviewed and updated 2017; available to all staff via Trust intranet
b. Barnet has completed regular CTO audit - August 2019
c. Trust wide CPA Audit reports monitored by MHLC and Divisions
d. Announced Care Quality Commission (CQC) inspection in 2017 of CTO use in Haringey found good evidence of patient involvement in the discharge planning process.
e. Multi-disciplinary supervision policy for clinical and non-clinical staff revised in April 2019, available to all staff via Trust intranet. Policy supports structured discussions about specific service user care.

a) BEH to provide evidence of completion of action plans to Enfield CCG in the quarterly CCG, CSU and Trust SI panel meeting.
b)BEH to provide Enfield CCG historical high risk and Board SI reports and provide assurance on the completion of action plans
c) Attendance at BEH Serious Incidents Review Group agreed with Enfield CCG and NEL
a) Completed September 2019
b) January 2020
c) Bi-monthly (next meeting November 2019 and bi-monthly
d) Monthly BEHMHT CQRG meetings - next meeting 31st October 2019
• Link with NHSE project on family engagement and working with police.
• BEH link worker actively with Victim liaison officer (VLO) nominated by Court to understand and address current and ongoing issues.
• Quality improvement project implemented by the Patient Safety Team in 2020 promotes involvement of all those involved in an incident, in the investigation and report review process. As part of new process, a Family link worker role is being developed to ensure the Trust considers the victim and does right by them.
• Duty of Candour processes are in place. Compliance with Duty of Candour is reported by the Divisions monthly to the Patient Safety Incident Review Group, chaired by the Medical Director and monitored by the monthly Safe, Effectiveness and Experience Group.

a. Trust Management of Incidents Policy - to be reviewed and aligned to the new NHSE Patient Safety Incident Response Framework.
b. Contact neighbouring organisations to review how they engage victims of crime by their patients so lessons can be learnt
Policy updated September 2019 and Sept 2021
• Trust Management of Incidents Policy stipulates that engagement with and support to victims of incidents must be considered. Policy references guidance from NHSE on supporting family of victims and perpetrators of incidents. Critical Incident Support Framework (Supporting staff and teams following a critical incident) added to policy.
• Duty of Candour regulation does not apply to third parties. New NHSE Patient Safety Incident Review Framwork in development stipulates necessity for Trusts to ensure they are doing the right thing by third parties.

A) NHS England to develop collaborative guidance/podcasts with families and key stakeholders on supporting families following a mental health homicide.
B) Support guidance and podcasts to be published on the NHS England website
C) Support guidance and podcasts to be provided to providers and commissioners of Mental Health services
D) To include guidance on supporting victims of serious incidents and mental health homicides within the draft Patient Safety Incident Response Framework
A, B and C) Completed May 2019 published May 2019 materials can be accessed via: https://www.england.nhs.uk/london/our-work/mhsupport/ May 2019 launched guidance at Mental Health Patient Safety - Assessing and Managing Risk conference in London
D) Completed September 2019 Incorporated guidance by the Head of Patient Safety Investigation, NHS England and Improvement.

As per action 10:
a) BEH to provide evidence of completion of action plans to Enfield CCG in the quarterly CCG, CSU and Trust SI panel meeting.
b)BEH to provide Enfield CCG historical high risk and Board SI reports and provide assurance on the completion of action plans
c) Attendance at BEH Serious Incidents Review Group agreed with ECCG and NEL
Ongoing
• All serious incident investigations sign off by BEH Medical Director and CCG.
• Monthly Divisional reports to the Patient Safety Incident Review Group and Safe, Effectiveness and Experience Group (SEEG) include action plan status. SEEG will provide exception report to the Quality & Safety Committee, a sub committee of the Trust Board.
• Quarterly meeting between the Trust and CCG where actions plans are reviewed and monitored and evidence provided as required. Formal review of the Trust's action plans from all Board Level Panel Investigations, including homicides initiated by the CCG in February 2020. This review is ongoing.

Patient Safety Team will ensure SI and BLPI reports and action plans are on divisional governance meeting agendas.
Patient Safety Team will send monthly reports and outstanding actions plans to Safety, Effectiveness and Experience Group (SEEG).
Ongoing
• Independent review of Trust governance processes undertaken in 2018-19. New Governance structure implemented October 2019.
• Monthly Divisional reports to Safe, Effectiveness and Experience Group (SEEG) reports to include action plan status. SEEG will provide exception report to the Quality & Safety Committee, a sub committee of the Trust Board.
• Exception report provided fortnightly to the Trust Patient Safety incident Review Group

1. Review of;
a) NCL CCGs Serious Incidents panel Terms of Reference
b) BEH MHT, Enfield CCG, NEL CSU quarterly SI panel Terms of Reference
c) NEL CSU Patient Safety Team & NCL CCGs Service Level Agreement
d) NEL CSU Patient Safety Team SI Trend and performance reports including KPIs
e) NEL CSU Patient Safety Team Mental Health quarterly report
a) Completed June 2019
b) Completed June 2019
c) Completed April 2019
d) On-going
e) December 2019

a) Enfield CCG to request evidence of completion of action plans from BEH MHT in the quarterly CCG, CSU and Trust SI panel meeting.
b) Enfield CCG to request historical high risk and Board SI reports from BEH MHT and provide a review of Quality and Clinical Governance in the BEH MHT Quality Improvement SI programme (July 2020)
c) Continually strengthen the relationship and quality assurance processes in place between Enfield CCG, BEH MHT and NEL CSU via collaborative formal and informal meetings
d) Any issues identified to be escalated to the BEH MHT CQRG
a) Completed September 2019
b) Completed and ongoing. Review of Quality and Clinical Governance in the BEH MHT Quality Improvement SI programme (July 2020)
c) Completed and ongoing 2021.
d) Monthly BEH MHT CQRG meetings

a) Enfield CCG, BEH MHT and NEL CSU patient safety team have agreed process for the submission of draft Board Level SI reports to NEL CSU patient safety team before sign off
a) Agreed and completed with recognition on-going process for future reports 24.09.19
• Board Level SI report quality assurance comments

a. Complete organisational re structure from Boroughs to Divisions with senior management restructure to strengthen pathways across trust
b. Leads in post across pathways of care
c. External review of governance structures, recommendations being finalised.
d. Shared Learning a priority workstream for the trust (Brilliant Basics; priority workstreams qualitative improvement programme)
e. Crisis Collaboration meetings
a. Organisational restructure to Divsions completed October 2019.
• Divisional quarterly Deep Dive meetings were in place 2016 - 2019 attended by all community and inpatient teams. Good practice, learning and experiences shared across teams.
• Trust has completed restructure from 4 Boroughs to 5 Divisions to strengthen management, governance and patient pathways.
b. Leads in post October 2019
• Pathway leads in post; regular meetings of pathway leads in place.
c. Governance structures in place October 2019
• Governance Committee structure revised following Independent review. First committee meetings held October 2019, attended by community and inpatient representatives.
d. Brilliant Basics porgramme - commenced April 2018 and on going
• Brilliant Basics (BB) programme in place with 10 priority workstreams applicable to all Trust services:
- Shared Learning
- Physical Healthcare Monitoring
- Mandatory Training
- Recruitment & retention
- Restrictive Practices
- Risk Assessment & care planning
- 132 rights
- Safe Environment
- Data
- Ward to Board
- Access to Beds
Workstreams use Quality Improvement methodology. Progress monitored at monthly Trust BB meeting. Representatives covering both community and inpatient areas attend monthly BB meetings; information, practice and experiences shared with all teams.
e. Shared learning occurs in many ways inclusive of:
network meetings
Quality Bulletin - sent to all staff
Blue Light Bulletins for urgent learning
Patient Safety Conference
Berwick Events
Quality Improvement project led by the multi-professional Shared Learning Collaborative commenced in 2020 to improve learning across Trust services and Divisional teams commenced in 2020.
Work underway with Safeguarding, Patient Experience and Patient Safety Teams to review exisiting processes and accessibility of information by all staff groups, and to implement change where required to ensure maximum opportunities for learning exists across the Trust.

Trust wide working group led by Medical Director - review the risk assessment in use
Develop comprehensive risk assessment
New form agreed for IT RIO system - system used for patient records
Training on new risk assessment
Risk Assessment is one of Trust's Brilliant Basic workstreams
a. Risk Assessment conference workstream
b. Agreed form on RIO
c. Written standard for completion of risk assessment
d. Policy for clinical risk management updated and in use
e. training programme in place
f. audit programme for risk assessment in place
March 2020
• Following collaborative work with pan-London NHS Trusts, a risk assessment tool based on good practice was developed and adopted by BEH.
• BEH clinical risk training developed and rolled out. Risk assessment tool went live in November 2019.
• Brilliant Basics - Risk Assessment and care planning workstream in place, leading work across the trust to improve the quality of risk assessments and care plans and to ensure every service user has an updated risk assessment every six months and/or updated after an incident occurs. This work is ongoing.
• Risk Assessment are audited monthly across all clinical services> Audits are monitored via Divisional Governance meetings, and Trust Safe, Effectiveness and Experience Group (SEEG).

Pharmacy Audit - assessing the side effects of Depot Antipsychotic medication (POMH-UK- Topic 6d).
NICE Medicine Management Policy (Section 18.8) states “The monitoring of the service user for reported medicines- related adverse effects should be included in the care or plan for any service user who is prescribed medication.”
Physical health Policy (Section 7.7) states “Medical Staff are responsible for an in-depth, history, assessment and examination of a service user’s health and the assessment which includes “Record of all currently prescribed medication and adverse reactions to past medications (RIO – Physical health history). For service users on antipsychotics the examination should specifically include an assessment of side effects. A standard rating scale such as GASS or LUNSERS should be used as part of the assessment and uploaded onto RIO.”
BEH Pharmacy Audit - external parameters set and Local protocol upon request or minimal standards (CPA- 6 monthly, Care management - yearly) (Ad Hoc)
• (POMH-UK- Topic 6d) annual audit report 2019: 93% of the patients at BEH had documented evidence in their clinical records of assessment of side-effects in the last year.
• Physical Health Policy - revised and implemented since incident.
• Monitoring of side effects is part of day-today clinical practice. If clinician requires support in addressing side effects it can be addressed via supervision or in discussion with pharmacist. Care plans and monitoring of physical health reviewed as part of Trust audit programme. Shared/monitored as above.

Care Programme Approach (CPA) Policy in place
b. Discharge Policy review and updated - January 2020
a.Completed 2017
• CPA Policy revised in August 2017 and implemented. Policy sets out the processes to be followed when discharging patients who require CPA from hospital, and the need for communication with community care co-ordinators.
• Discharge Policy, revised February 2020 specifies that care co-ordinators must be involved in all formulation meetings.
• Audit by Access and Flow team of Pride and Joy (Bed management) system and formulation meetings. All delayed discharges are reviewed on daily basis.
• Ongoing monitoring of complaints and incidents in relation to this - addressed via Divisional Management Board.
• Access to Beds Brilliant Basics workstream
• Policy are reviewed by the relevent specialist group for approval before being ratification at the Trust Policy Review Group. Following this, the policy will go onto the Trust's intranet, and is highlighted in the BEH Bulletin and relevant staff forums for awareness.

a. Division to hold quarterly meetings with their CCG.
B. To discuss and agree GP representative to attend team meetings
a. Barnet completed
b. 01/04/2020
• Barnet primary care link working team, otherwise known as Barnet Transformation Adults Team has been in existence since 2016. The team is commissioned by Barnet CCG to work with Barnet GPs to bridge the gap between primary care and secondary care services in context of ensuring prompt services for clients who may be in need of psychiatry services.
• Link working team remit includes review of GP referrals and ensuring onwards referrals to community mental health teams or other community agencies where clients’ needs could be met promptly. Additionally, they process referrals from the police, MASH and social services. Ongoing evaluation and monitoring of the link worker role.
• Planned transformation of community mental health teams in 2021 - to have appropriately resourced team in each Primary Care Network i.e. Place-based care.
• All community mental health team caseloads were reviewed to understand which client requires further and immediate support from the team.

The Trust will review and update its Discharge/Transfer Policy within three months
Jan-20 Policy approved February 2020 and available on trust intranet and cascaded to all staff via bulletin.

The trust will implement suitable support mechanisms for staff who work with families in relation to care and treatment plans.
Mar-20
• Introduction of Open Dialogue which involves training healthcare staff in family therapy and psychological skills, to enable to work with the whole family, encouraging involvement of families. It is a very transparent approach to looking at issues.
• Clinicians use their team meetings, reflective forums, supervision and peer groups to gain support and suggestions around how best to work with these patients and their families. Clinicians will be considering legal and ethical issues in the areas of capacity, confidentiality, competence and minimising harm, respecting autonomy and fairness. Staff Support Policy
• Community (ward) meetings open to carers and family members in place across all teams. Meetings provide carers with an opportunity to raise issues. Oct 2019.docx
• The Trust promotes a holistic and Think Family approach with consideration of individual needs.
• High Dose Monitoring form and policy in place. Monitored by Pharmacy and advice provided to staff where necessary.
• System in place for staff to check with pharmacy, patient leaflets and to discuss in weekly safety huddle - well established for every team to receive senior support.
• New Servic User Involvement and Engagement Strategy developed and designed by service users, launched September 2020. The strategy outlines the importance of actively involving service users, their families and carers in shaping, delivering and evaluating their care.
• Monthly Patient and Carer Satisfaction survey data sent to Divisions to review and action where necessary; data monitred at monthly Safe, Effective and Experience Group.

Trust wide Working group set up to establish uniform data systems to evaluate, scope and collect data on waiting lists
-Examine the model of delivery for types of waiting lists and therapies – define and implement a standardised approach to the pathways
-Examine the structure and processes to enable monitoring and managing of waiting lists
-Demand capacity modelling – workforce capacity, how is this measured against service user throughout
November 2019 COMPLETE
• In-depth project to review waiting list for psychological therapy, to assess and prioritise patients waiting for treatment undertaken in response to CQC recommendation The trust should continue to improve waiting times for patients to access psychological interventions, and ensure that patients are safely monitored whilst waiting for the interventions. Action completed and closed by Board.
Three phases of project:
- Review of Productivity/demand and capacity
- Defining the measure of waiting lists
- Interventions to reduce waiting lists
January 2020
• Trust wide psychological therapists group established
March 2020
• Standardised productivity set in terms of contacts per staff group
• Trust dashboard in development to record waiting times for assessment and from assessment to treatment.
• Waiting list review undertaken every 3 months. Data reported to Board via the Intergrated Performance Report.
• Model of delivery for types of therapies reviewed – standardised approach to the pathways defined and implemented.
• The Trust commissioned an independent psychological review in2018. Recommendations have been implemented.