85th Meeting of the Board of Directors
Thursday 5 June 2014
Room 4, Memorial Hospital
Board of Directors
Dave Mellish
Archie Herron
Anne Taylor
James Kellock
Seyi Clement
Steve James
Paul Ward
Stephen Firn
Helen Smith
Ify Okocha
Wilf Bardsley
Ben Travis
Simon Hart
Chair
Vice Chair and Non-Executive Director
Non-executive Director
Non-executive Director
Non-executive Director
Non-executive Director
Non-executive Director
Chief Executive
Deputy Chief Executive and Director of Service Delivery
Medical Director
Director of Nursing and Governance
Director of Finance
Director of HR and Organisational Development
In attendance
Ann Rozier
Susan Owen
Trust Secretary and Head of Governance
Risk Manager (Minutes)
Members of the Council of Governors in attendance
Chris Purnell
Service User/Carer Governor, Working Age Adult Mental Health
John Woolgrove
Public Governor, Bromley
Judy Wolfram
Public Governor, Greenwich
Action
1
Apologies for absence
None.
Noted
2
Minutes of the Board of Directors meeting 3rd April 2014 and Extraordinary Meeting 1st
May 2014
 Page 1 – Michael Witney was in attendance at the meeting on 3 April 2014
 Page 2 – Amend the first sentence of item 6 to read: The Trust took on the management of
the Children and Young Peoples Ambulatory Unit at the QMH site on 1 April 2014, for an interim
period, pending the outcome of the tender.
Pending these amendments, the minutes of the Board of Directors meeting on 3rd April 2014 were
approved as an accurate record.
The minutes of the Extraordinary Meeting of the Board of Directors meeting on 1st May 2014 were
approved as an accurate record.
Approved
3
Matters arising
Page 5 – The Trust was not successful with the bid for the Urgent Care Centre. The contract has
been awarded to the Hurley Group. Transfer will take place on 1 July 2014. Staff will retain NHS
terms and conditions.
Page 5 – The Liaison and Diversion Service has been awarded funding to expand in Bexley,
Bromley and Greenwich. Investment for the ALD dementia care worker been withdrawn. The
directorate is considering alternative options to address this.
Noted
4
Key Performance Indicators Report
All Monitor targets have been achieved. Attendance at the Urgent Care Centre remains high and
all patients were seen within four hours. Psychological Therapies waiting times continue to
improve steadily. In in-patient services, there have been few UEAs but sleepover activity remains
Noted
Page 1 of 9
Action
high. Occupancy is low at Atlas House but we are continuing negations with Bromley and Croydon
CCGs. A marketing plan is being developed. Recording of ethnicity and unoutcomed
appointments is improving. Patients with an estimated discharge date has improved on the Stepup, Step-down Unit but has decreased on the Bevan Unit.
DM – Can we access data on UCC performance after this has transferred to the Hurley Group?
HS – There is not much information in the public domain.
PW – How engaged are the Commissioners in terms of in-patient activity in working age adults?
HS – Greenwich are very involved. Much of the pressure is managed through the Home Treatment
Team. Bromley CCG have purchased less beds.
SC – Why are CAMHS not meeting the target for clients on a CPA caseload receiving a review
within six months?
SF – CAMHS have a clear focus on providing care to children and families. There are no safety or
quality concerns but clinicians are not always sighted on targets.
HS – There is some work to do to ensure that clinicians engage with data processes.
5
Service Delivery Report
The Bexley MSK Service is performing well. Activity levels have been sustained and both legacy
and new patients are being triaged and treated. Waiting times have reduced and the conversion
rate has improved from 25% to 60%. Lorraine Regan has been appointed as Clinical Director for
the Adult Mental Health and ALD Directorate. She will be supported by three Assistant Clinical
Directors; Dr Derek Tracy (inpatient and crisis services), Jane Harris (community mental health
services) and Sandra Baum (ALD services). Bromley CLDT are embarking on development work to
become an integrated health and social care team, with support from the Institute of Public Care.
AH – With regard to the Healthy Weight programme, we need to be careful about how concerns
are communicated to parents and children. There has been some negative media coverage about
the way in which providers have done this.
JK – Is the number of changes in clinical directors a positive move?
IO – The changes will enable clinical directors to focus on improving quality and developing our
relationship with GPs.
SC – What services will be affected by the Supreme Court ruling on the Mental Capacity Act and
Deprivation of Liberty safeguards?
IO – This will affect dementia patients, those with functional mental health needs and also the
work of Approved Mental Health Professionals (AMHPs). The impact on work is substantial.
SC – How will we address this?
IO – We will need to have focus on ensuring that clinicians test capacity and understanding and
monitoring that this is documented.
PW – How are we approaching the HMP Belmarsh bid?
HS – The Forensic Directorate are very focused on this and a structure is being developed.
PW – Are there any re-design issues?
HS – We are not sure of the detail at this stage.
AH – We will need to ensure that there is an adequate balance between price and quality.
Noted
6
Audit Committee and Procurement Update
KPMG have introduced a RAG rating scale to replace the one used last year. The audit on NED
succession planning arrangement received an opinion of Green. The HR and payroll audit made
recommendations to streamline processes. Counter-fraud services have been assessed as
adequate and sufficient. The Annual Report and Accounts and Quality Accounts for 2013/14 have
been approved.
Procurement update
There is a national focus on reducing procurement costs. A rationalised pricing list is being
developed. It is projected that there will be a core list of 1000 items by September 2014 with
5000 items by 2015. The Trust has established a Strategic Procurement Group.
Noted
7
Governance Board update
The Corporate Risk Register has been updated to reflect the strategic priorities in the two-year
Operational Plan. There are five new risks and nine carried over from the 2013-14 risk register.
The new risks include one significant (4 x 4 = 16) risk escalated from the Children and Young
Noted
Page 2 of 9
Action
Person’s Directorate. This relates to defending the Greenwich CAMHS contract, which is due to be
re-tendered by October 2014. This has been rated as significant as this is a strategically important
contract for the Trust and there are a number of credible competitors. A directorate Re-tender
Project Group has been established to ensure that there this is a high level of focus on preparing
the bid. The Directorate has been asked to ensure that there is clinical leadership.
DM – We know we have a high quality service; much work will be needed to ensure that we can
defend this.
AT – What is the position with the Bexley CAMHS tender?
SF – Bexley CCG intend to re-tender all children’s services using a prime contractor model.
Regulatory update
The Governance Board received an update on the CQC’s new approach to regulating, inspecting
and rating services, to be rolled out from October 2014. The Trust’s Peer Review programme has
been remodelled to ensure that services are preparing for the new regime.
8
Crisis Care Concordat – Trust position
The Mental Health Partnership Board working group is overseeing implementation of the Crisis
Care Concordat action plan. We have increased our focus on monitoring the use of s136.
PW – How much will this cost and what are the priorities?
WB – This will be taken forward within existing resources. Areas that require partnership working
will need greater consideration.
DM – We will need detailed information on s136. This will put additional pressure on services.
9
Quality Report
Noted
QSIP – April 2014
The number of QSIP indicators has reduced from 27 to 23. Pressure ulcer information is provided
in a separate report. The RAG rating thresholds have been changed so that red is greater than
6% from the target and Amber is less than 5% from the target. The two red indicators are:
 Consent to treatment (S58): There was one patient out of 18 where consent could not be
located in the records. This has since been addressed.
 Completion of one year checks by 14 months: The April position is under target by 27.3% (357
out of 527). High risk children are being targeted.
The five amber indicators are:
 Carer details recorded on RiO – under target by 4.1%.
 48 hour follow up for patients admitted following self-harm/suicide attempt – one patient out
of 33 was not seen within 48 hours. This has since been addressed.
 Patients detained provided with information (S132) – there were three CTO patients where
evidence of discussion could not be found.
 Care plans on RiO for community teams – under target by 4%.
 Care plans on RiO for District Nursing teams - under target by 5%.
Pressure ulcers – April 2014
There were 22 pressure ulcers in 21 people. Two Grade 3 pressure ulcers have been classified as
avoidable. One patient was on a palliative care pathway and the second did not follow advice.
SJ – Is there a consequence to missing the consent to treatment target?
IO – I write to the consultant and monitor performance.
JK – At what point would a doctor be referred to the GMC?
IO – If the error were made consistently.
Clinical Effectiveness Group
Care Planning and Engagement: A good start has been made. There is clarity on the
objectives of the project but a change of culture is required.
Clinical Audit: A new NICE repository has been made available. From July 2014, DatixWeb will
be used to track action plans from audits.
Outcome measures: The CEG has agreed four measures which will be piloted in Crisis and Home
Treatment Teams. These are patient reported outcome measures; patient reported experience
measures, clinically reported outcome measures and functioning.
JK – Will there be measures for non-mental health teams?
IO – We will learn lessons from the pilot indicators.
Page 3 of 9
Noted
Action
DM – NED involvement on the Quality Board is to be increased. PW and SJ will attend the Quality
Board and SC will continue to attend the CEG.
10 Compliance Report
Mental Health Act visits
Since the last report to the Board, the Trust has received six new reports from recent CQC Mental
Health Act Commissioners visits. Key themes are access to and completion of T2 and T3
documentation, Care planning and discharge planning. In relation to Heath Ward, the Seclusion
Policy does allow for use of a seclusion gown to maintain patient safety as a last resort but this is
to be reviewed. Seclusion gowns will not be used whilst this review is taking place.
CQC concerns raised
There have been two enquires from the CQC, both of which are being followed up. One relates to
the care of a patient on Camden Ward and the other to a medication incident at North House.
MHA data
The use of s136 is increasing, both in terms of numbers and as a percentage of all sections.
Patient Safety
The Central Alerting System have issued two patient safety alerts, with a number of high level
actions due for completion by 19 September 2014. The Director of Nursing will be the Board level
lead for medical devices and the Medical Director the Board level lead for medicines error
reporting. Ten serious incidents were reported in April 2014. The current Level 5 homicide inquiry
will be report to the Board in July. The independent inquiry into the homicide committed by NE
has been delayed. The latest NRLS Organisation Patient Safety Incident Report shows that the
Trust is now the second highest reporter of all trusts in the same cluster. We are an outlier in the
“infrastructure” category, due to the high level of reporting sleepovers. The criteria for reporting
these are to be reviewed.
Complaints
Clinical care remains the most frequently raised complaints issue. There were no new referrals to
the Ombudsman in March and April 2014. Ten cases were referred in 2013/14 and eight of these
were not upheld. Of the two upheld cases, one related to the Step-up, Step-down Unit and the
second the Greenwich District Nursing Service.
SJ – How often is seclusion used and why?
SF – Burgess Clinic and Heath Clinic are the only wards that have a seclusion suite.
WB – Use of seclusion is not routine. It would only be used to ensure patient safety when
managing highly disturbed behaviour. All incidences of seclusion are clinically reviewed.
SC – Is ‘time out’ an issue?
AR – This has been checked and we have found that people understand that ‘time out’ is de facto
seclusion and must not be used.
DM – We need to do further work on ensuring there is access to activities at the weekends. This
to be on the agenda for the Board of Directors meeting in September 2014.
AT – Some of the serious incidents clearly occurred in the patient’s home, but others are not clear.
WB – This will be made clearer for future reports.
DM – The report should also include a comment on why it is a Level 4 as opposed to a Level 5.
SF – The judgment is based on whether there has been a significant failing or there is likely to be
significant public interest.
PW – Does the increase in sections indicate an increase in risk level?
WB – It is a reflection of higher levels of occupancy and demand.
IO – There is a higher level of acuity on our wards. Monitoring incidents on the wards is one way
of measuring this.
DM – In the future, a full complaints report is to be presented when Michael Witney attends to
present the Patient Experience Report. In the intervening meetings, report by exception only.
Noted
11 Carers Survey
The Trust commissioned the Carers Survey in October 2013. The survey was sent to 1000 carers
of whom 400 responded. The report was published in February 2014. The results show that we
need to make improvements in providing support to carers and sharing information. An action
plan has been developed and directorates have been asked to respond to areas of concern.
Noted
Page 4 of 9
WB/IO
WB
WB/MW
Action
National Carers week is 9 to 15 June 2014 and the Trust is working to partners to run events in
each borough.
AH – Half the respondents said that they did not have or were not sure if they had a care plan. It
needs to be clearly communicated that the Standard CPA Care Plan is in the form of a letter.
AT – Why is the Friends and Family Test score zero?
WB – The methodology used only counts the most positive score.
SJ – Are these results a consequence of the increase in demand?
WB – This is a cultural issue. There needs to be more focus on carers.
DM – An update on progress is to be included in the quarterly patient experience report.
WB/MW
12 Business Committee update
Noted
There are two bids in progress; Bromley Older Peoples Services and Bromley Community Wellbeing
Service for Children and Young People. The Committee noted the strategic importance of growing
our presence in Bromley. The Committee noted the new Trust Communications Strategy. The
Business Committee agreed a proposal to strengthen oversight of the Trust’s charitable funds.
The Business Committee will act as a sub-committee to the Trustees and will receive a detailed
report every six months prior to a formal report being presented to the Trustees. A letter setting
out the proposals for mental health bed reconfiguration will be sent to the Council of Governors in
advance of the June meeting. The contract for the refurbishment of Reeves and Chislehurst
wards at Queen Mary’s Hospital is currently being tendered. The Business Committee approved
that the contract for mattress and pressure relieving equipment is awarded to Westmeria. Open
RiO has been selected as the new clinical system to replace the current version of RiO by October
2015. A saving of £1.0m has been negotiated.
13 NED report – Board visits
DM – Bromley Home Treatment Team: Staff raised some concerns about transfers to the Short
Term Intervention Team and the allocation of Care Co-ordinators. The s136 suite is in need of
improvements. Avery Ward: An impressive amount of work around physical health. Staff said
that having a consultant on the ward was valuable. Some concerns about parking were raised.
Bexley Home Treatment Team: There is a reduced demand for beds.
PW – Shenton School: There is an increase in demand. Staff commented that they are not always
able to influence decisions. There was a high level of satisfaction with the service. QMS
paediatric service: The integration work is paying dividends.
AT – Older Persons Community Team: Staff commented that they would like more clinical space.
Completing panel paperwork requires a MDT approach. Estelle Frost to raise this with the LA.
AH – Greenwich Community Learning Disability Team: Integration works well. Positive feedback
was given.
SJ – The Source: This is small team which is highly valued by the community it serves but does
appear to be vulnerable.
SC – HMPs Blantyre, Sutton Park, Maidstone and Elmley: The teams work well in a difficult
environment. Increased use of ‘lockdown’ by prison staff means that it is more difficult for the
teams to gain access to patients. The triage and reception arrangements for new prisoners could
be improved. There is no access to RiO. Some concerns about the safety of staff were raised.
JK – Bromley Recovery East: This is a strong team dealing with a complex patient group. Staff
were mainly positive. Bexley Recovery: Demand is increasing. Staff were critical of primary care.
Two patients spoken to complemented the team. Action points will be picked up by the
directorate.
14 Council of Governors update
The next meeting will be held on 19 June 2014. The main items are the Nominations Committee
and NED succession planning. The process for appointing the Chair will commence in June 2014.
The new appointee will shadow the current Chair for four months and will be involved in the
appointment of two non-executive directors. It has been proposed that the Constitution should
be changed to allow candidates from beyond Bexley, Bromley and Greenwich to apply.
Noted
15 Finance Report
As at the end of Month 1, the Trust delivered a surplus of £0.2m which is £0.1m higher than plan.
Noted
Page 5 of 9
Action
Under the new Monitor Risk Assessment Framework, the Trust scored 4 (no evident concerns)
which is in line with plan. Bank and agency spend is increasing. Some of this is due to the
mobilisation of new services, but this trend will be kept under review. Overall debt levels are
£9.5m but debts of over 90 days have decreased to £1m. The Memorial fraud trial is due to
commence on 14 July 2014. This is estimated to last for four to six weeks and some publicity is
expected. Support has been provided for staff called as witnesses.
16 Safe Staffing Report
Noted
This is the first formal report to the Board. Whilst there is some further work to do, the overall
conclusion is that staffing levels are safe. In-patient nursing data for May must be uploaded to the
Unify system by 10 June 2014. Data for this has been collated manually using the information
displayed on ward noticeboards. Establishments are being reviewed. There is no validated tool
for mental health services, but ratios of between 1:5 and 1:8 have been recommended by NICE
and the RCN. The financial ledger, Health Roster and ESR have been used to generate
establishment data. There are some discrepancies with the baseline data which need to be
resolved. There are super-numerary roles in some services and we will need to consider how this
is captured. The Safe Staffing Group has recommended the percentage adjustments to take
account of headroom, is allowance for sickness absence and leave. The following
recommendations have been made by the Safe Staffing Group:1. Agree escalation process to ensure availability of nursing staff when required.
2. Review the Health Roster wards templates to ensure accurate reflection of shift requirements.
3. Consider augmenting the functionality of Health Roster to support capacity planning and
monthly reporting.
4. Review vacancies across all directorates and agree recruitment.
5. Agree headroom allowances and apply to establishments.
6. Further review utilisation of temporary staffing; absence and sickness management.
7. To reconcile discrepancies between Finance/ESR and Health Roster.
8. To pilot the use of Professional Judgement model when guidance becomes available to
conduct an establishment review in bed based services.
JK – Are there cost implications?
SH – Yes. There are some areas where is it difficult to recruit HCAs.
PW – We need to model the financial consequences.
WB – Temporary staff are being used to cover vacancies, sickness absence and high levels of
acuity. Where acuity is a regular reason for needing additional staff, we will need to review the
establishment.
AR – Have NHS Choices given any guidance on how the data will be rated?
WB – They will note trusts that do not contribute. NHS England will also check. This is being
linked to the ‘Sign up to Safety’ initiative dashboard.
SH – Vacancies are actively being recruited to and are not being held to save costs.
17 Workforce Report
Sickness absence in April 2014 was 4.58%, an increase from the March figure of 4.43%. The
majority of this is long term absence. Vacancy rates are 10.34% but there is variation across
directorates. Adult Community Services has an overall vacancy rate of 19% with significant
vacancy rates for qualified nursing staff and AHPs. The overall number of recruitment campaigns
stands at 349. The average time from requisition to start date is 16.6 weeks and ways to reduce
this further are being considered. There was a positive response to the recent marketing
campaign but there was less interest from AHPs. PDR completion stands at 84%. All mandatory
and essential skills training is above 80% with the exception of patient handling. There are 13 live
disciplinary cases. There are four members of staff suspended from duty and three tribunal claims
against the Trust. There have been fewer dismissals compared to last year. A full equality impact
assessment is undertaken annually. The new Supervision Policy has been launched. All staff must
receive a 1:1 supervision session every six to eight weeks and record this on NHS Learn. A
trajectory approach will be used to monitor this. An update on supervision will be brought to the
next Board.
IO – Clinicians have expressed concerns about how supervision documentation will be used.
Page 6 of 9
Noted
SH
Action
SH – The onus is on managers to document actions to address performance concerns. Both
parties are able to review the record.
SJ – How many new staff have we recruited from the recent marketing campaign?
SH – It is too soon to say.
SJ – Why is there so much recruitment activity?
SH – Some are re-advertisements and some are related to mobilisation for new contracts.
18 5 Year Strategic Plan
Agreed
The Trust has a three year Service Development Strategy and a two year operational plan. The
five year strategic plan will focus on the final three years from 2016/17 to 2018/19. Monitor have
asked all FTs to review their assumptions in the two year operational plan. The Trust is
recommending that our plans are realistic and are forecasting a break even by year five. The Plan
must be submitted to Monitor by 30 June 2014. The Board of Directors was asked to agree that
final approval is delegated to the Business Committee meeting on 17 June 2014.
AH – Some trusts are considering moving away from Agenda for Change terms, is this something
Oxleas would consider?
PW – This would have to be balanced against paying the market rate.
SF – The issues and options will be discussed at a future Informal Board meeting. Representatives
of the Council of Governors will be invited to attend.
AH – We need to consider how we can use our properties to expand the scope of our activities.
DM – We are certain about the next two years. We need to be conservative and explore all
possibilities before considering changes to terms and conditions.
Agreed: The Board of Directors agreed that final approval is delegated to the Business
Committee.
19 Chief Executive Update
The Trust has been invited by NHS England to be one of the twelve ‘trailblazer’ organisations in
the Sign Up to Safety campaign. A launch event will be held on 24 June 2014. The Director of
Nursing and Head of Patient Safety attended an introductory workshop on 29 May 2014. We have
been asked to respond to make five pledges, respond to six key questions and develop our own
implementation plan. The responses to the six questions will be circulated to the Board and
agreed by SF and JK. An update will be brought to the July Board meeting.
Noted
20 Any Other Business
None raised
Noted
19 Written questions from the public
Noted
Will the new version of RiO have the functionality to record an alert for those deemed to be at
high risk of suicide?
WB – This has been included in the specification for Open RiO.
Next meeting of the Board of Directors
Thursday 3rd July 2014
Room 4, Memorial Hospital
I confirm that the minutes of the Board of Directors meeting of 5th June 2014 are a true record
Signed
Dave Mellish, Chair
Date:
Page 7 of 9
WB
Jargon buster
This jargon buster is a glossary of acronyms and abbreviations.
It is intended that we will update this on a regular basis but we will also agree standards to reduce jargon usage.
If you feel there are more that should be included on the list please email anne.rozier@oxleas.nhs.uk
ACS – Adult
Community Services
DN – District Nurse
CDM – Chronic Disease
Management
DNA – Did Not Attend
ADHD – Attention
Deficit Hyperactivity
Disorder
CEG – Clinical
Effectiveness Group
ECR – Electronic Care
Records
ADL – Assessments of
Daily Living or Activities
of Daily Living
CIP – Cost
Improvement
Programme
ECT – Electro
Convulsive Therapy
IMHER – Integrated
Mental Health Electronic
Record
IM&T – Information
Management and
Technology
EI – Early Implementer
ISA – Information
Sharing Agreement
ESR – Electronic Staff
Records
KPI – Key Performance
Indicators
ETP – Electronic
Transfer of Prescriptions
KSF – Knowledge and
Skills Framework
LAS – London
Ambulance Service
CPC – Cost Per Case
FCPN – Forensic
Community Psychiatric
Nurse
FOI – Freedom of
Information
CPN – Community
Psychiatric Nurse
HCA – Health Care
Assistant
LGBT – Lesbian, Gay,
Bisexual, and
Transgender
CRB – Criminal Records
Bureau
HEE – Health Education
England
LHC – Local Health
Community
ASBO – Anti-Social
Behaviour Order
CRE – Cash Releasing
Efficiency
HID – Hospital
Integrated Discharge
Team
LSP – Local Service
Provider
ASD – Autistic Spectrum
Disorder
CRHTT – Crisis and
Home Treatment Team
ASW – Approved Social
Worker
C&YPS – Children and
Young People’s Service
BMs – Business
Managers
AfC – Agenda for
Change
AHP – Allied Health
Professional
ALBs – Arms Lengths
Bodies
ALD – Adult Learning
Disabilities
AMH – Adult Mental
Health
AMHP – Approved
Mental Health
Professional
CLDT – Community
Learning Disability
Team
CNST – Clinical
Negligence Scheme
Trust
CPA – Care Programme
Approach
HIMP – Her Majesty’s
Inspectorate of Prisons
LD – Learning Disability
LTC – Long Term
Condition
HR – Human Resources
MAPP – Multi Agency
Protection Panel
CQC – Care Quality
Commission
HTT – Home Treatment
Team
MCA – Mental Capacity
Act
CAMHS – Child and
Adolescent Mental
Health Services
CQUIN –
Commissioning for
quality and innovation
HV – Health Visitor
MDA – Multi-disciplinary
Assessment
CAPA – Choice and
Partnership approach (a
new way of managing
referrals into CAMHS)
DADL – Domestic
Activities of Daily Living
CAS – Central Alerts
System
CBT – Cognitive
Behavioural Therapy
CCG – Clinical
Commissioning Group
DESMOND – Diabetes
education and self
management
programme for ongoing and newly
diagnosed
DH – Department of
Health
ICP – Integrated Care
Pathway
ICT – Information
Communication
Technology
MDO – Mentally
disordered offender
MDT – Multidisciplinary
team
iFox – Trust Business
Information System
MEWS – Modified Early
Warning Score Tool
IGG – Information
Governance Group
MH – Mental Health
IGT – Information
Governance Toolkit
Page 8 of 9
MHA – Mental Health
Act
MH MDS – Mental
Health Minimum
Dataset
MHRA – Medicines
Healthcare and
products Regulatory
Agency
PEG – Patient
Experience Group
PD – Personality
Disorder
PDR– Personal
Development Review
MSK – Musculo-skeletal
Services
PDS – Patient
Demographic Service
(national repository
holding demographic
information)
NCC – National
Consortium of Colleges
NEDs – Non Executive
Directors
NHSLA – NHS Litigation
Authority
NICHE – National
Institute for Health and
Care Excellence
RPST – Risk Pooling
Scheme Trust
PDP – Personal
Development Plan
MHRN – Mental Health
Research Network
NAC – Nursing Advisory
Committee
RMN – Registered
Mental Nurse
RMO – Responsible
Medical Officer
SAP – Single
Assessment Process
SCG – Specialist
Commissioning group
SDS – Service
Development Strategy
SLaM – South London &
Maudsley NHS Trust
PEAT – Patient
Environment Action
Team
SLR – Service Line
Reporting
PFI – Private Finance
Initiative
SMs – Service Managers
PICU – Psychiatric
Intensive Care Unit
SN – School Nurse
POMH – Prescribing
Observatory for Mental
Health
NIHR - National
Institute for Health
Research
PRUH – Princess Royal
University Hospital
NPSA – National Patient
Safety Agency
PSA – Personal Safety
Awareness
NSF – National Service
Framework
QEH – Queen Elizabeth
Hospital
OOHs – Out of Hours
QMS – Queen Mary’s
Hospital Sidcup
OPD – Outpatients
Department
OPM – Office for Public
Management
OPMH – Older Peoples’
Mental Health
PEEP – Personal
Emergency Evacuation
Plan
PQQ - Pre Qualification
Questionnaire
PADL – Personal
Activities of Daily Living
PALS - Patient Advice
and Liaison Service
QRP – CQC Quality and
Risk Profile
SPD – Safety, Privacy
and Dignity
SUI – Serious Untoward
Incidents
TDA – NHS Trust
Development Authority
TSA – Trust Special
Administrator
TUPED – Transfer
Under Present
Employment
UEAs – Uncontracted
Emergency Admissions
VTE – Venous
thromboembolis
QSIP – Quality and
Safety Improvement
Plan
RAG –
Red/Amber/Green
RC – Responsible
Clinician
RCA – Root Cause
Analysis
RGN – Registered
General Nurse
RM – Risk Management
Page 9 of 9