Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Recommendations with Number
Action (To include how evidenced)
1. The trust should take steps to
Conduct Trust wide audit of
community teams and acute
inpatient services to benchmark
practice against CPA standards and
review if regular MDT reviews,
discharge plans and relapse plans
are in place.
ensure that patients are
reviewed by the
multidisciplinary team on a
regular basis so that timely
discharge and relapse plans are
put in place.
Audit report to be produced
(Mr J)
Develop plan to address any areas
that require remedial action.
Date
Evidence
Completion
Due
January
2015
February
2015
Audit tool and emails to team. Data collection
date finished early February
1
February
2015
May 2015
Report completed and action plan
March2015
February
Monitor quarterly and review in 12 2016
months.
Date
Actually
Completed
May 2015
This is part of annual audit plan.
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Date
Evidence
Completion
Due
Recommendations with Number
Action (To include how evidenced)
2. The trust should consider the
Implement digitalisation plan to
integrate electronic record
systems within the Trust and
between the Trust and other key
agencies.
January
2016
To support this the Trust has submitted a bid to the
“Integrated Digital Care Fund” The Trust has also
initiated a tender to support electronic integration
between our internal systems and with our
partners to enable sharing of clinical information.
The trust 2014/2015 Annual work
plan for Safeguarding includes the
objective that the clinical record
systems RiO, System 1 and Datix
will support safe and best practice
in safeguarding. The ultimate aim
is that clinical record keeping will
demonstrate the assessment,
analysis, and decisions made when
identifying and recognising a
vulnerable adult or child in need of
safeguarding.
February
2015
The RiO team have been working with specialist
advisors in the adult and children’s safeguarding
teams to produce safeguarding assessment forms.
These forms will be ready by the end of February
2015.
options available to refine and
develop its electronic record
systems in order to ensure
greater integration of
safeguarding, care planning
and care delivery systems.
(Mr J Mr L & Mr N)
The Nursing Directorate, Adult and Children’s
Safeguarding Teams have also asked for an alert
indicator in RiO to show that a service user has
safeguarding measures in place. To enable this to
take place the use of the alert indicator has to be
moved from pharmacy –This has taken place as
part of the Rio 7 upgrade and the system now
allows this.
2
Date
Actually
Completed
This is
completed
as the
Trust has
considered
it but is
ongoing
work as
part of
Trust
IM&T
plans
Dec 2015
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Date
Evidence
Completion
Due
Date
Actually
Completed
Recommendations with Number
Action (To include how evidenced)
3. To ensure the efficacy of the
Audit clustering records within
EIPs across the Trust.
January
2015
Audits from EIP services across the Trust and
exceptions completed
Identify inappropriate cases and
develop plan to transfer to other
Trust services.
February
2015
All cases that were not cluster 10 were
reviewed and exception reports produced and
plan to move the case to appropriate setting.
All exception cases were already in review as
part of step up/step down or assessment and
move to a different caseload.
January
2015
Review operational policies of the
EIP teams to benchmark against
Policy Implementation Guidance
and ensure clear instructions on
when and how to transfer patients
with a primary diagnosis of
personality disorder.
March
2015
EIS Trust wide group is working on this.
Evidence through email communication. as this
is a trust wide review it is taking longer than
initially identified.
April 2015
EIP team and the
appropriateness of care
delivery to patients, the trust
should routinely audit case files
to ensure that the EIP team is
focused on those patients with
psychosis, or at risk of
psychosis. Those patients with
a presentation suggestive of
personality disorder should be
transferred to other trust
services such as the CMHT or
psychological therapies.
(Mr N)
Quarterly audit of EIP caseload
profiles and review in 12 months
by exception report.
December
2015
3
Audit –March, June, September cases
Reaudit for MARCH – is completed
January
2015
April2015
July 2015
Oct 2015
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Recommendations with Number
Action (To include how evidenced)
Date
Evidence
Completion
Due
This audit has shown good fidelity to the
cluster. Throughout the year the exceptions
were explained and understood in the service.
4
Date
Actually
Completed
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Recommendations with Number
Action (To include how evidenced)
4. The trust should review its dual
Review Dual Diagnosis policy
against best practice standards &
amend as required
diagnosis policy and capacity to
ensure appropriate access to
specialist knowledge and drug
screening when services are
responding to presentations
that include both a mental
disorder and active substance
misuse.
Date
Evidence
Completion
Due
March
2015
Require updated policy
Review access to specialist
knowledge and drug screening for
patients presenting with mental
disorder and active substance
misuse
March
2015
(Mr N)
Draft document re the way forward with
supporting emails from deputy directors. There
is a clear plan for the way forward.
A further updated document on the
comprehensive review dated June 2015
March
2015
Policy review has been completed and policy
submitted for Clinical policies group for final
approval on the 26/1/15 and then EMT on the
4/2/16.
Feb 2016
Review has taken place, costing identified. The
lab has sent 2 results. Review of pilot to take
place. From evidence it looks like the screening
will be taken forward and will put the trust in a
excellent position re drug screening.
5
Date
Actually
Completed
April 2015
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Date
Evidence
Completion
Due
Recommendations with Number
Action (To include how evidenced)
5. The trust should seek to
Audit compliance of Trust against
NICE guidance for PD (update
previous reviews of compliance
against the guidance)
Use Quality Standards that will be
published in May 2015 which
includes NICE guidance
June 2015
Develop plan with remedial action
July2015
Implement action plan
July 2016
Monitor plan at each steering
group and review in 12 months
July 2016
provide assurance to
commissioning bodies of
compliance with NICE Guidance
in the treatment and
management of personality
disorder (appendix C) through
an audit process.
(Mr N)
6
The Trust does have the baseline audit for the
quality standard guidance (QS88). This has
been worked through with clinical services.
There have been issues with data quality re
diagnosis so work is taking place to resolve this
issue which will take time –the plan is to use
cluster data rather than ICD10 code.
The audit shows partial compliance.
Action plan is being developed for gaps and
this will be monitored as per all NICE guidance
standards.
Date
Actually
Completed
Dec 2015
Action plan update
Evidence reviewed by Emma Bownas along with Julie Eskins
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials: Mr N, J, L
Recommendations with Number
Action (To include how evidenced)
6. The trust should maintain and
Audit current performance in
meeting 18 week maximum
waiting time.
improve on current
performance in delivery of
psychological therapies to
ensure that 18 weeks is the
maximum waiting time rather
than, as at present, the
average.
Date
Evidence
Completion
Due
June 2015
Develop plan with remedial action
and implement.
Monitor quarterly and review.
(Mr N)
7
Current monitoring show the service meets
97% .
Over the years there has been a year on year
rise in referrals to the point where we are now
receiving over 2000 referrals a year (2056 14/15). The Trust continue to endeavour to see
everyone within 18 weeks (not an average of
18 weeks) of referral and in general we are
successful despite the pressure on the system
continuing to increase. Where we have not
reached a 100%, we produce exception reports
every month to explain to commissioners the
reasons why. E.g service users cancel their
appointments and the clinician is not able to
re-book an appointment before the breach
date
Date
Actually
Completed
Aug2015
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials:
Recommendations with Number
7. Commissioning bodies should
ensure that the trust is
adequately resourced to meet
population demand to enable it
to comprehensively achieve the
18 week target.
Action (To include how evidenced)
1. Monitor 18 week pathway
from Providers through
Contact meetings
2. Work with Providers to
audit activity to ensure
that psychological therapy
services are operating
within an agreed service
specification so capacity is
being utilised
appropriately
3. Work with providers to
audit NICE compliance and
understand demographic
change to formulate an
action plan to ensure the
18 week target is
maintained within existing
resources.
Date
Completion
Due
March
Monthly performance report received and
2015
discussed at monthly contract meeting with issues
highlighted in meeting notes
Evidence available from Karen Hall (contracting)
Kirklees – performance monitored through
performance report and contract meeting.
Currently within performance within agreed service
specification
Date
Actually
Completed
March
2015
May 2015
Service development and improvement plan in
place for 2015/16 to review psychology provision in
line with CCG strategies and best practice.
Priorities to be agreed by 30th June 2015
Action plan agreed by 31st July 2015
Evidence to be shared by Karen Hall in line with
deadlines
Confirmation received that the service is NICE
compliant and maintained within existing resources
8
Jan 2016
Ref No:
Date:
Serious Incident – Recommendations and Action Plan
Initials:
Recommendations with Number
Action (To include how evidenced)
Date
Actually
Completed
Date
Completion
Due
This section for
completion by
Lead
Director(s)
only:
9
I can confirm that the above
recommendations have been actioned and
implemented.
Signed: ………………………………………..
Date:………………..