Enhanced Engagement and Observation:

1. Gillian Kelly, Acting Deputy Director of NursingFrancis Thompson, Head of Nursing Education & StandardsPaul Knowles, Patient Safety Lead Enhanced Engagement and Observation:

2. West London Mental Health NHS Trust • Provide care and treatment for about 20,000 people a year and serve a population of 700,000 residents • A large Trust employing some 4,300 staff and serve a local community of many races, religions and languages, across four London boroughs. This includes local mental health services for adults, older people and children in the boroughs of Ealing, Hammersmith & Fulham and Hounslow. • Our high secure services at Broadmoor Hospital in Berkshire are internationally recognised. With our West London Forensic Service, they make us a leading national provider of secure and specialist mental healthcare.

3. SUI’s 2013

4. Trustwide incidents

5. HSS Broadmoor Hospital Paul Knowles Patient Safety Lead/Practice Development Nurse & Modern Matron

6. Recent Historical Issues • 2 Recent SUI reviews into patient deaths (last 2 years) highlighted contributory factors regarding EE&O practice (particularly during night shift). • 5 staff have recently (last 2 years) been either dismissed or had local and or NMC sanctions against them for failing to adhere to policy re EE&O’s. • Rooms and site poorly designed (particularly Victorian buildings) do not necessarily support EE&O’s.

7. Actions taken • Routine review of CCTV by local nurse managers • Routine audits of EE&O practice by Senior Clinical Mangers • Unannounced out of routine hours audit of EE&O practice by Practice Development Nurses • Review of mandatory training to include simulation of practice • All staff to be assessed as having necessary skills and understanding by their local manager before carrying out EE&O’s • Learning Lessons events with particular focus on EE&O practice • SOP for nurses I/C of shifts with clear instructions for monitoring EE&O practice during the shift

8. Future developments • Electronic Monitoring: a) Heart rate monitors b) CO2 monitors c) Movement recognition • Recently announced rebuild a) Room design and observational windows reworked to take into account EE&O’s b) Line of site observation generally much improved part of design brief

9. Forensic ServicesClinical audit and the cycle of improvement Gillian Kelly, Acting Deputy Director of Nursing

10. Aims • Discuss experience and approach to EE&O audit with Specialist & Forensic CSU • What we found • What we did • What we still need to do

11. The Initial Audit Findings: What we found: July/Aug’ 12 • Some good practice • Areas of concern and significant risk • Preventing suicide components particularly concerning • risk assessment and management, engagement, care planning, activities and documentation • Staff awareness of requirements below acceptable standards • Patient involvement and information sharing below acceptable standards • not feeling safe, respected and that privacy/dignity is not maintained • Not receiving copy of care plan

12. The Formula: What we did • Monthly spot-check audits • Approach: • Team working across operational/Practice Development Roles -real strength in approach / pooled resources / fun / enhanced ownership / variety of experiences • Spot-checking / clinical areas not notified in advance • Initial auditors: Senior Nurses (8a>) • Pre-audit meeting/planning (teams allocated) • Team/Buddy system - allocated areas outside of normal workplace • Audit Day nominated / combined with WM’s meetings

13. The Formula: What we did • Immediate remedial actions are taken when auditors identify failures in EE&O practice • systemic and individual errors addressed • Post audit debriefs/discussions of findings held with ward managers and senior nurses to discuss issues and remedial actions shared; identifying actions requiring follow-up and priority areas for improvement (lessons learnt) whilst awaiting formal data analysis from audit • WM’s later involved in auditing to enhance ownership and raise awareness – healthy competitiveness developed / real pride in achievements • Audit report also discussed at WM’s Meetings

14. Actions Taken GOVERNANCE • EE&O included in CSU risk register • EE&O included within Suicide Prevention Strategy • Ongoing audit and reports discussed in Gov meetings PRACTICE • Remedial actions/debriefs as described • Directive from the DDN regarding accountability and areas for immediate action • Email from DDN - commending improvements and highlighting areas for ongoing development TRAINING • EE&O Tutorials • Enhanced Engagement for HCAs and B5 workshops

15. Going Forward: What we still need to do • Still room for improvements • Serious Incidents / High Risk Areas • where should we focus practice development initiatives? (high and low usage areas) • Quarterly V’s Monthly audit? • Who should undertake the audit? (MDT involvement / Band 5 / preceptees / Senior Nurses Qrtly) • Need for mandatory training in this area • Next audit important for understanding if improvements have been sustained • SU perspectives/involvement

16. Any questions / thoughts? Gillian.Kelly@wlmht.nhs.uk