West London Mental Health NHS Trust

1. Appendix 1 West London Mental Health NHS Trust CQC Action Plan Response to Recommendations Nigel McCorkell - Chairman Peter Cubbon – Chief Executive Ian Kent – Deputy Chief Executive

2. Presentation: • Recommendations and main headlines in response • How we intend to implement and monitor the recommendations • Questions

3. Recommendation 1: • 1 The Trust must improve its management of risk. This should include: • Appropriate reporting and proper investigation of incidents • Analysis of the risks raised by incidents and near misses to identify patterns or persistent concerns • Exploring how the learning from learning from incidents can be shared and embedded in practice with staff who already have busy workloads

4. Main Actions R1: • Review and further implementation of Risk Strategy • Centralised coordination of monitoring of incidents, investigation team and process, and implementation of recommendations • Risk assessment and management to be linked to CPA and care planning through reviewed training needs and implementation, supervision and PDR • Risk assessment standard to be developed with measurable criteria

5. Recommendation 2: • The Trust must ensure that the actual and potential risks that users of services pose to themselves or others are properly assessed and reflected in the risk management or treatment plans

6. Main Actions R2: • Risk assessment and training strategy developed, and an appropriate training programme for staff, service users and carers is developed – particularly Engagement and Observation training • Centralised risk assessment tool suite implemented • Risk to self and others linked to engagement and observation, care planning and monitoring of care

7. Recommendation 3: • Commissioners of the Trust’s services need to develop mechanisms for monitoring the reporting, investigating and learning from incidents in the services they commission, and give more priority to as part of commissioning

8. Main Actions R3: • Regular and effective 3way Chief Executives meetings • Work with PCTs and LAs to have clarity of processes • Commissioners receive regular updates on incidents, investigations and implementation of recommendations

9. Recommendation 4: • In collaboration with commissioners, the redevelopment plans for Broadmoor Hospital and Ealing must be progressed without further delay

10. Main Actions R4: • Outline Business Case approved September 2009 • FBC Approval NHS London July 2012 • On-going implementation of recommendations of thematic review and PB/RL will be monitored and linked to CQC actions

11. Recommendation 5: • The Trust and commissioners must ensure that there are sufficient beds for each patient group and a sufficient range of alternatives to hospital admission. However, all inpatients must have a bed and, where possible, this should be in a unit designed to meet their needs.

12. Main Actions R5: • Bed Management protocol and procedure developed and implemented across 3 boroughs • PICU patient criteria utilised • Single sex wards, and dignity and respect for all in-patients • Clinical pathways work on-going

13. Recommendation 6: • For people to receive safe and therapeutic care, the Trust must ensure that it has sufficient numbers of Staff, with the right skills, in all staffing groups

14. Main Actions R6: • Comprehensive action plan for generic and fast track recruitment has begun • Initial standards for recruiting newly qualified staff agreed, and appropriate training designed and implemented for all qualified and non-qualified clinical staff • Clinical Improvement work (time to care, refocusing CPA, preceptorship, skills escalator programme) continues

15. Recommendation 7: • The Trust needs to ensure that staff attend mandatory training and that attendance is monitored and accurately reported.

16. Main Actions R7: • Further review of mandatory training matrix and communication to staff • Monitor uptake and methods of mandatory training, including recording and feedback loop • Develop report by staff group and SDU • Competency tracking by ESR

17. Recommendation 8: • The physical healthcare of people who use the Trust’s services needs to be given a higher priority across the Trust, particularly in forensic services. The Trust must ensure that all people have access to the same range of primary and secondary services as other people have.

18. Main Actions R8: • Continue to develop and implement robust physical healthcare strategy • Revision of standards against strategy • Develop clinical pathways for physical healthcare • Link all physical healthcare plans to risk assessment, implementation and risk management strategies

19. Recommendation 9: • Medicines Management should be given a higher priority by the Trust. The role of the Chief Pharmacist needs to be strengthened by positioning it at the appropriate management level. Resources for pharmaceutical advice needs to be reviewed, and, where appropriate strengthened with investment, to ensure that staff and people who use services receive appropriate advice and support in relation to medicines management, wherever they are accessing or delivering care.

20. Main Actions R9: • Agree and launch medicines management strategy, in consultation with key stakeholders • Complete recruitment to revised in-house service • Establish requirements for pharmacy input into community services

21. Recommendations 10-14: • Board development • Aspire to be leader in mental health care • Non-Execs to have access to and challenge decisions made about Trust business • Stream-lined clinical governance system and process • SHA/PCT improved access to sharing scrutiny of Trust business

22. How we will implement the actions: • Lead person over-seeing whole plan and implementation • Action plan reviewed and implementation monitored at regular implementation group meetings • Actions plan progress reviewed at Executive Directors Meetings (every 3 weeks) and quarterly performance meetings for each SDU • Regular updates to Trust Board • Performance management meetings arranged with NHS London