TRUST BOARD, 26 NOVEMBER 2009 LEARNING FROM THE CQC INVESTIGATION INTO WEST LONDON MENTAL HEALTH NHS TRUST (WLMHT)

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1 TRUST BOARD, 26 NOVEMBER 2009 L LEARNING FROM THE CQC INVESTIGATION INTO WEST LONDON MENTAL HEALTH NHS TRUST (WLMHT) Summary In July 2009, the Care Quality Commission (CQC) published the above report. The investigation was triggered by concerns from a number of sources regarding the responsiveness of WLMHT to serious untoward incidents within the trust, such as suicides, and its arrangements for investigating, reporting and learning from these incidents. The CQC found serious flaws within the Trust s systems for learning lessons from serious incidents and taken action to prevent the same thing happening again. All NHS Trusts have a responsibility to consider the recommendations that are relevant to them and ensure that lessons are learnt. This paper details the actions that we have taken in light of the findings and presents an assurance check against the key recommendations. Recommendation(s) Trust Board is asked to note the findings of the West London review and receive assurance that any actions and associated plans will be reviewed by Senior Clinical Group (SCG) in January and included in a formal action plan (Learning from reviews) to be monitored through Performance and Assurance Executive (PAE). Implications for consideration Strategic implications The corporate risk register captures all risks to delivery of strategic goals Main Strategic Goal Operating as a high performing organisation, (description in full) held to account for living our values Financial (funding discussed None identified and confirmed as available with Finance Department) Consultation Executive directors and lead clinicians Risk Risks to delivery of strategic goals Main Healthcare Governance Standard (description in full) C1 Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and

2 information derived from the analysis of incidents Author Bal Johal Director of Risk Assurance Presented by Jackie Ardley Director of Quality & Innovation *Disclaimer: This report is submitted to the Trust Board for amendment or approval as appropriate. It should not be regarded or published as Trust Policy until it is formally agreed at the Board meeting, which the press and public are entitled to attend

3 Report to Trust Board November 2009 Learning from the CQC Investigation into West London Mental Health NHS Trust (WLMHT) 1 Introduction & Background 1.1 In July 2009, the Care Quality Commission (CQC) published the above report. The investigation was triggered by concerns from a number of sources regarding the responsiveness of WLMHT to serious untoward incidents within the trust, such as suicides, and its arrangements for investigating, reporting and learning from these incidents. 1.2 The CQC found serious flaws within the Trust s systems for learning lessons from serious incidents and taken action to prevent the same thing happening again. The report includes nine recommendations which are specific to the Trust and a further five that have a much wider potential application. The main recommendations are attached in Appendix Aim 2.1 The aim of this report is to provide Board with an overview of the findings and to provide assurance that appropriate learning for the Trust is reviewed and any risks are acted on. 3. Recommendations 3.1 Trust Board is asked to note the findings of the West London review and receive assurance that any actions and associated plans will be reviewed by SCG in January and included in a formal action plan (Learning from reviews) to be monitored through PAE. 4. Discussion 4.1 Findings of the review The CQC found serious flaws in the Trust systems for learning the lessons from serious incidents and taking action to prevent the same things happening again. They also raised major concerns about the timescale for planned refurbishments, and improvements needed in bed management, staffing levels and recruitment, and into the Trust s performance in terms of meeting the physical healthcare needs of people who use their services.

4 The report made nine recommendations which are specific to the WLMH Trust and a further five that have a much wider potential application (see appendix 1).The key findings of the report were categorised across three themes as follows: (1) Providing a safe environment and protecting people from harm Policies and procedures for complaints and incidents management were complex and contradictory and not consistently understood across the Trust. Investigations into Serious Untoward Incidents (SUI) were hampered by confusion, lack of resources, expertise and a lack of innovative and lateral thinking by the trust. SUI investigations were taking an excessive length of time to complete and the quality of SUI reports was variable with findings and recommendations repeated across investigations implying that learning from investigations was not taking place. Action plans were produced without involvement of key staff and staff were unclear about responsibility for their implementation. A number of the Trust s premises were aging and deemed not fit for purpose. Bed occupancy in local services was a major problem with patients sleeping on sofas when there were no beds (2) Enabling good outcomes for people through high quality care There was little evidence of a collaborative environment between the Effectiveness of governance activity was questioned, and the response to clinical risk was reactive with little challenge from senior staff. trust and the commissioners over risks and little evidence of intervention from the SHA. Medicines management was given low priority in the trust; the chief pharmacist had insufficient authority to influence Trust decisions. Processes for meeting the physical healthcare needs of service users were found to be fragmented. The system for collecting information about incidents was not robust and feedback to staff was variable. The trust s response to clinical risk was reactive not proactive staffing levels were low and impacted on attendance at mandatory training and, these risks were not perceived by leaders as significant. (3) Governance arrangements for managing risk and scrutiny of care quality Effectiveness of governance arrangements was questionable and there was little evidence of challenge from senior staff.

5 5. LPT Position There was little evidence of discussion of key risks and clinical engagement / involvement was not consistent. 5.1 We have undertaken a benchmark review of the West London findings and compared the recommendations to LPT practice and activities. The report, referenced in the Board Information Pack in September 2009, has been circulated for an in-depth review of all the recommendations, through Directors, lead clinicians and senior managers to seek perceptions and identify potential risk areas for the Trust. A timeframe has been set to review the recommendations and associated assurances at the Senior Clinical Group in January. 5.2 For the purposes of corporate assurance against the risk areas identified in the report a review has been undertaken to check our controls and governance arrangements against the key recommendations and identify the mitigations that we have in place to address the recommendations that are relevant to LPT. 5.3 A gap analysis has also been undertaken by the Medical Director and Director of Quality & Innovation to identify any areas for strengthening the Trusts position and improving systems and processes. This has not identified any significant risks for LPT. 5.4 With regard to current assurance against the recommendations for WLMHT and relevant national recommendations, in LPT the position is as follows: (1) Providing a safe environment and protecting people from harm During the last 18 months revised our complaints and SUI management arrangements and have a robust policy and scrutiny systems in place Risk assurance systems have been established that manage, processes, and significant training has been provided to staff to support investigations and report writing standards implementation. The Trust has a corporate SUI plan and the TRAIL newsletter that support learning from incidents and complaints across the organisation. The trust has invested in a revised risk management system and software and incident reporting systems have been re-established and are monitored centrally. The Trust has in place an estates strategy and plan and the adult inpatients centres of excellence programme is under implementation, (2) Enabling good outcomes for people through high quality care The Trust has reviewed the current clinical risk assessment training and plans are in place for expansion of this training to cover more staff.

6 Mandatory training attendance is reviewed through the Senior Operational group, our PDP targets continue to improve and the current mandatory training policy is under review as part of the Trust academy plans. Medicines management is given a high priority within the Trust and our medicines lead is actively involved in safety and governance arrangements with clear leadership through the Medical Director. Our PCT commissioner quality schedule includes the monitoring of our arrangements for the reporting, investigating and learning from incidents. We are actively involved in the National consultation on SUI systems which is taking place through the National Patient Safety Agency, our Head of Patient Safety and members of the risk team are participating in the national events during November. (3) Governance arrangements for managing risk and scrutiny of care quality The Trust governance arrangements have undergone review and reestablishment and Business units all feed into this arrangement. The Trust Senior Leadership Group meets together on a quarterly basis and clinical leadership arrangements are in place across the Business Units. All business units have service monitoring and assurance arrangements in place and these are reported through to the Trust Senior Clinical Group. 5.5 The emerging assurance analysis and any further actions following review by clinicians will be considered alongside the findings from Mid Staffs and then risk assessed to determine priorities for action. 5.6 No issues have currently been identified as high risk; we have in place good risk management procedures and incident reporting arrangements to alert senior management and executives to any key risk issues. 5.7 A combined action plan encompassing the learning from Mid Staffs and WLMHT will be submitted to the Senior Clinical group in January identifying any further learning points that are to be addressed; this process will also confirm clear executive lines of accountability. 6. Conclusion 6.1 Members of the Board are asked to note the recommendations from the investigation into West London Mental Health NHS Trust, and to support the local review of the recommendations which will be undertaken and led by the Senior Clinical Group.

7 APPENDIX 1 Recommendations from the CQC Investigation into West London Mental Health NHS Trust (WLMHT) Recommendations specific to the WLMHT Providing a safe environment and protecting people from harm 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 incidents can be shared and embedded in practice with staff who already have busy workloads 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. 3. Commissioners of the Trust services need to develop mechanisms for monitoring the reporting, investigating and learning from incidents in the services they commission, and give more priority to this part of commissioning. 4. In collaboration with Commissioners the redevelopment plans for Broadmoor Hospital and Ealing must be progressed without further delay. 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 in patients must have a bed and, where possible, this should be in a unit designed to meet their needs. Enabling good outcomes for people through high quality care 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. 7. The Trust needs to ensure that staff attend mandatory training and that attendance is monitored and accurately reported. 8. The physical healthcare of people who use the Trust services need 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.

8 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. Sources 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, whenever they are accessing or delivering care. National Recommendations Recommendations which the CQC believe need to be considered for wider application to all Mental Health Trusts and Commissioners. 10. Providers of mental health care, along with the relevant NHS, statutory, professional and use led organisations should work together to devise a robust, clear and proportionate framework for internal and external investigations and reviews. The framework should focus on good practice in nationally published guidance and issues identified in this report, such as the classification of incidents, clear accountability within the organisation for the investigation/review and the sharing of knowledge and outcomes that will need to continue service wide learning, and promotion of understanding and best practice. 11. Strategic Health Authorities and/or Consortia PCTs should work together, with providers to develop a shared mechanism to manage reviews where a degree of external scrutiny is required. This could include providers identifying experienced and appropriately trained clinicians who would be available to act as external reviewers and share learning from investigations. 12. Commissioners of services need to develop mechanisms to monitor the arrangements for the reporting, investigating and learning from incidents in the service they commission, and give more priority to this part of commissioning. 13. The Mental Health Trusts need to ensure that the physical healthcare of people who use services is given a high priority, particularly in Forensic Services. They must ensure that all users of services have access to the same range of primary and secondary services as the rest of the population. 14. Mental Health Trusts need to ensure that medicines management is given a high priority with due consideration of the recommendations made in Talking about Medicines (Healthcare Commission, 2007)