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BEH-MHT – Trust Board – 28.09.2015 4.1 - Clinical, Quality and Safety Report

Title:

Clinical, Quality and Safety Report

Report to:

Trust Board

Date:

28 September 2015

Security Classification:

Public Board Meeting

Purpose of Report: The purpose of the Clinical, Quality and Safety report is to provide an indication of the Quality and Safety of our services. It will outline key quality developments which are occurring and areas which may require further work to address variation in standards of practice. This report should be read in conjunction with the Integrated Performance and Quality Dashboard.

Recommendations: The Trust Board is asked to consider the report and discuss any further actions or assurance they require in respect of Clinical Quality and Safety of Trust issues.

Report Sponsor:

Mary Sexton, Executive Director of Nursing, Quality and Governance

Comments / views of the Report Sponsor:

Five MHA visits have been completed with the teams involved drawing up action plans to address areas for improvement. The borough leadership teams are establishing their forums to ensure they are able to deliver focussed work to maintain and further improve the quality and safety of their services.

Report Author:

Name: Mary Sexton Title: Executive Director of Nursing, Quality and Governance Tel Number: 020 8702 3032 E-mail: [email protected] Name: Melanie Ingham Title: Interim Deputy Director of Nursing & Governance Tel Number: 020 8702 6051 E-mail: [email protected]

Report History:

Regular Report

Budgetary, Financial / Resource Implications:

None

Equality and Diversity Implications:

None

mailto:[email protected]

mailto:[email protected]


Links to the Trust’s Objectives, Board Assurance Framework and / or Corporate Risk Register

Action taken will assist in delivering our objective of ‘Providing excellent services for patients’.

List of Appendices:


Report

1. Introduction and Background 1.1 The Clinical, Quality and Safety Report supplements the Integrated Performance and

Quality Dashboard by outlining the key clinical, quality and safety areas which the Executive Director of Nursing, Quality and Governance would like to bring to the attention of the Board.

1.2 It should be noted that there continues to be a number of senior posts vacant within the

Nursing and Governance Directorate senior team. Whilst these have now been recruited to, delays in recruitment have led to further delays in staff commencing in post. This has resulted in a number of key workstreams (preceptorship, Safe Care model implementation, and patient experience strategy) have not progressed at the pace originally intended as the remaining senior team are focussing on the forthcoming comprehensive inspection. The following appointments have been made:

Deputy Director of Nursing – Gillian Kelly commences 7 December 2015

Head of Safeguarding People – Ruth Vines commences 2 November 2015

Head of Effectiveness – Shila Mumin commences 2 November 2015

Head of Patient Experience – Amanda Jones commences 7 December 2015

2. CQC MHA Monitoring Visits and actions 2.1 04/06/15 - Thames Ward: Overall a number of minor concerns raised which were all

addressed by the team at the time of the visit. An action plan has been submitted to sustain improvements.

2.2 28/7/15 - Phoenix Unit: Awaiting report from CQC. 2.3 11/8/15 - Paprika Ward: Overall the visit feedback was very positive. The commissioner

raised concerns about a number of ligature points on the ward, and noted that the ban on rolling tobacco on the ward constitutes a “blanket restriction” and asked what alternative action the Trust has considered in relation to this issue. The Trust has submitted an action plan on the 17th August indicating that the ligature points have been identified within the work schedule. The action relating to the smoking restriction is being reviewed.

2.4 13/8/15 - Derwent Ward: Overall the visit feedback was positive. The commissioner noted

that care plans did not always contain as full and detailed evidence of patients’ views as the Code of Practice requires. Two patients felt that they were not always able to take their escorted leave due to staffing levels. Action plan in progress. Leave arrangements have been reviewed to address concerns raised by patients.

2.5 17/8/15 - Haringey Ward: Awaiting report from CQC 3. CQC Regulatory Visits 3.1 The Trust received no Regulatory Visit in respect of Essential Standards for Quality of

Quality and Safety for this period. 3.2 The Trust continues to receive a number of enquiries from the CQC which are responded to

in real time by the clinical teams.


4. Patient and Carer Experience 4.1 Patient and Carer experience satisfaction rates continue to perform strongly across the

Trust. 4.2 Patient and carer experience showed 88% indicating deterioration in the overall

satisfaction. The deep dive meetings identify areas and agree actions with borough teams. Patients and service users have identified that they are completing numerous surveys, which is having an impact on compliance in completion of Trust level patient experience surveys.

4.3 The total number of questionnaires completed from 1 August 2014 to 31 July 2015 is

15231. It has been previously highlighted that CAMHS are using a different feedback tool and teams have not been meeting their Patient Experience return targets. There is a plan in place to meet with CAMHS service leads to discuss this and agree on the use of consistent feedback tools and measures. This will ensure we have a fuller reflection of all services. There is a desire to utilise tools that have been benchmarked in other mental health trusts, this is being explored as a way off addressing the capture of patient experience for young people.

82

84

86

88

90

92

94

Overall Satisfaction Rate (%)

Survey Score

0

500

1000

1500

2000

Total Questionnaires

Questionnaires


4.4 The following table gives an overview of patient and carer information across both surveys from April 2015 to July 2015. The service user satisfaction rate of 88% and the carers satisfaction rate of 90% respectively are all above the Trust target of 80%.

4.5 General praise, positive staff attitude, individual praise, staff/service provision and training

were the emerging themes from the analysed comments. Improvement in facilities, environment and lack of activities on wards were other themes that emerged and services are taking action to make improvements.

4.6 The chart below illustrates the number of patient experience completed questionnaires

returned for Enfield Community Services (ECS) and the Mental Health Service (MH) from April 2015 to August 2015. A total of 5642 returns were received across the Trust with the MH receiving 3914 and ECS receiving 1728 respectively. The MH provides more services as compared to ECS which accounts for the difference in numbers.

5. Complaints 5.1 In this financial year 2015/16, 81 formal complaints have been received to date and

managed by the Patient Experience Team and Borough Directors. The trust target for responding to complaints within 25 working days is 90%. The table below provides a breakdown of all formal complaints received. Out of the 81 complaints received, 100% have

CARING Domain Freq A pr- 15 M ay- 15 Jun- 15 Jul- 15 A ug- 15 Sep- 15 Oct - 15 N ov- 15 D ec- 15 Jan- 16 Feb- 16 M ar- 16

Tru

st

Tar

get

2015-

16 to

date 2014-1

5

2013-1

4

Target

Source

Information

provided89% 86% 87% 85% 86% 87% 91% 89%

Trust

Involved in

decisions90% 86% 87% 87% 87% 87% 92% 90%

Trust

Treated

w ith dignity 95% 94% 93% 93% 94% 94% 97% 96%

Trust

Overall SU

satisfaction90% 87% 87% 89% 87% 88% 92% 90%

Trust

SU

completed

surveys

1075 886 1140 1003 945 n/a 5049 13106

Trust

Overall

Carer

Satisfaction

88% 90% 90% 92% 94% 80% 91% 96% 93%

Trust

Carers

completed

surveys

166 147 157 138 172 n/a 780 3553

Trust

Pati

en

t S

urv

eys

Mo

nth

ly

80%

0

200

400

600

800

1000

Apr-15 May-15 Jun-15 Jul-15 Aug-15

Axi

s Ti

tle

Apr-15 May-15 Jun-15 Jul-15 Aug-15

MH 795 740 757 852 770

ECS 446 107 130 278 347

Return Rate of MH & ECS


been responded to within the target response time. This is well above the trust response target of 90%.

5.2 It is a Department of Health requirement to acknowledge all formal complaints within 3

working days and during this financial year 96% of the 81 complaints were acknowledged within time. There has been a significant improvement in the response rate since last financial year.

5.3 There has been evident improvement in performance this year compared to 2013/2014,

with a current achievement of 100% compliance. This demonstrates that service users’ complaints are being responded to in a timely manner. Clearly there have been improvements in the service’s handling of complaints and an increased level of engagement by service line managers has been integral to the improvements that have been achieved.

6. Ombudsman Cases 6.1 During this financial year, two complainants have taken their cases to the Parliamentary

and Health Service Ombudsman (PHSO) to date in line with the right to review and final resolution as a result of not achieving resolution locally.

7. Friends and Family Test (FFT) 7.1 The Patient Reported Experience Measure has been revised to include the FFT questions

which has been in use at all Boroughs since 1 January 2015. As illustrated in the table below, a total of 9059 responses were received between 1 January 2014 and 31 August 2015 across all Trust services.

7.2 The response is low compared to the number of service users who have been seen during that period. The difference between the percentage of recommended and not recommended is due to some responses being selected as ‘don’t know’ or ‘neither agree or disagree’.

7.3 Managers are being encouraged to check the FFT feedback on at least a weekly basis and act upon any negative feedback as quickly as possible using the “You Said We Did” poster to inform patients of what is being done to address the feedback received.

A pr- 15 M ay- 15 Jun- 15 Jul- 15 A ug- 15 Sep- 15 Oct - 15 N ov- 15 D ec- 15 Jan- 16 Feb- 16 M ar- 16Trust

Target

2015-16 to

date

2014-1

5

2013-1

4

Target

Source

Acknow led

ged in time100% 94% 96% 97% 96% 100% 97%

Trust

Responded

in time100% 100% 100% 100% 100% 90% 100% 97% 69%

Trust

Formal

Complaints

rec'd

14 21 17 14 15

n/a

81 260 293

Trust

Closed

Complaints3 21 39 54 61

n/a21 246 270

Trust

Fully Upheld

3 3 3 5 6

n/a

3 26 34

Trust

Partially

Upheld 0 7 11 20 23

n/a

7 49 98

Trust

Not Upheld

0 10 20 27 28

n/a

10 171 113

Trust

% upheld

100% 31% 39% 28% 10%

n/a

31% 21% 31%

Trust

RESPONSIVE

Co

mp

lain

ts

Mo

nth

ly


7.4 The collected data is submitted to NHS England monthly including:

Total number of responses for each collection method;

Total number of responses for each response category.

The results will be published on NHS Choices website quarterly since April 2015. 7.5 Data has been collected using electronic and paper methods, but further work is on-going

to explore methods that will engage service users more effectively. The table below shows a summary of the FFT results since January 2015 with specific figures for August 2015. During August 2015, 88.5% have indicated that they would recommend the services of the Trust to their friends and family equating to 86% to date. 3% have indicated they will not recommend Trust services to their friends and family. The FFT Questionnaire is anonymous and we are developing a process to request patients to agree to us contacting them with a view to discuss the spectrum of the test particularly the 3% who would not recommend the service.

8. Infection Prevention and Control 8.1 Infection control training

Infection control training is part of the trust mandatory training and staff 3-yearly refresher programme is in place. The trust’s target is 85% but in July we dropped slightly below to 84%. Compliance recovered slightly to 85.5% in August. The trust has reviewed the delivery of the mandatory training programme and will be rolling out the new programme in October

Month Total number of staff Total number of staff

compliant

% Compliance

July-15 2815 2365 84%

August-15 2812 2405 85.5% Figures obtained from the Workforce directorate on the 02/09/2015

8.2 Infection Control audits

Three audits are carried out monthly, hand hygiene, hygiene assurance and the cleaning standard of the care environment. The Trust performance against these standards remains at 79%. The clinical hand wash basin replacement programme is under way and a number of hand wash basin has already been replaced.

8.3 Currently there is a focus on the community service and our community clinics and sites. All

areas will be subject to a formal inspection and follow up audit. This is a detailed action following a complaint and areas of non-compliance with the IC audits. A detailed action for all areas will be in place where non- compliance is identified. Unannounced inspections will be taking place in areas where there have been non-compliance.

8.4 There is a link nurse for infection control for all key services. This risk is being revised in

light of changes of staff.

Area Recommend Not

Recommend

Total

Responses

Extremely

Likely Likely

Neither

Likely or

Unlikely

Unlikely Extremely

Unlikely

Don't

Know

Summary 86% 3% 9320 4652 3400 573 163 138 394

Aug-15 88.52% 3% 1167 609 424 54 18 17 45


8.5 Notifications & Outbreaks No MRSA, MSSA, & E. Coli notified in July and August.

8.6 Flu group 8.6.1 The flu group was reconvened in June to plan the delivery of the annual flu campaign. The

vaccines will arrive in the week commencing the 28th September. Barnet Enfield and Haringey site at Chase farm pharmacy department have agreed to store vaccines to help with the transportation and storage issues experienced last year. Discussion is in progress with the new occupational health provider about the best way to run the clinics for this year’s campaign.

9. PLACE 9.1 Organisational Scores

Table 1 below shows BEH organisational scores for 2015. The organisation scored well above the national average in all the five domains that were inspected in 2015.

Table 1: organisational scores

Table 2 below shows the site scores for BEHMHT against the national average of similar organisation. Domain scores that are below the national average are highlighted in orange.

Table 2: Site Scores

Site Cleanliness Food Org Food

Ward Food

Privacy, Dignity and Wellbeing

Condition Appearance and Maintenance

Dementia

CFH 99.03% 95.22% 91.33% 96.75% 91.12% 95.8% 86.11%

Springwell 100% 92.77% 90.57% 94.67% 91.3% 94.39% 83.28%

Baytree 96.07% 93.50% 89.27% 96.06% 87.01% 91.11% 88.84%

Edgware 97.24% 92.11% 87.90% 95.00% 83.68% 87.11% 75.99%

St Ann’s 98.95 90.58% 87.97% 92.22% 87.23% 86.00% 74.10%

National Average

97.6% 89% 85.5% 91.75% 90.7% 91.1% 84.8%

St Michaels

98.71% 92.64% 91.01% 93.44% 79.95% 80.20% 81.07%

National Average

94.5% 90.4% 87.2% 93% 85.4 90.8% 78.2%

Cleanliness Food Privacy, Dignity and Wellbeing

Condition Appearance and Maintenance

Dementia

BEH 2014 BEH 2015

99.64% 98.75%

92.15% 93.93%

93.85% 89.11%

94.52% 92.51%

- 83.19%

National Average-2014 National Average-2015

97.25% 97.57%

88.79% 88.49%

87.73% 86.03%

91.97% 90.11%

74.51%


The facilities, infection control and borough teams are working together to implement an action plan to address areas of variation.

10. Serious Incidents 10.1 Number and category of Serious Incidents requiring Root Cause Analysis (RCA)

investigations reported to NELCSU July / August 2015

10.1.1 Total incidents reported from 1 April to August 2015 is 30.

In the period (1 July 2015 – 28 August 2015), 9 Serious Incidents have been reported to North and East London Commissioning Support Unit (NELCSU). This compares to 13 incidents reported in the May – June report.

Borough/Teams July August Total

Barnet 2 2 4

Younger Adults Community Services 1

Adult Inpatient Services (Avon Ward) 1

Community Services Older Adults 1

Community Services Older Adults 1

Enfield 2 2 4

Adult Mental Health CRHT 1 1

Adult Mental Health Complex Care Team

1

Adult Mental Health Sussex Ward 1

Haringey 0 0 0

Specialist Services 0 1 1

Specialist Inpatient Service Beacon Centre 1

Total 4 5 9 10.1.2 Breakdown of Serious Incidents by Type/Month/and Borough

AttemptedHomicide

AttemptedSuicide

Neglect ofCare

SuspectedSuicide

UnexpectedDeath

Barnet July 1 1

Enfield July 1 1

Barnet Aug 2

Enfield Aug 2

Specialist Services Aug 1

0

0.5

1

1.5

2

2.5

Nu

mb

er

of

Seri

ou

s In

cid

en

ts

Serious Incidents by Type, Month & Borough


10.1.3 Moderate Incidents requiring Concise Investigations

10 Moderate incidents requiring Concise Investigations were reported during this period (July - August 2015).

Borough/Teams July August Total

Barnet 1

1

Adult Inpatient Services (Thames Ward) 1

Enfield 1 1 2

Adult Mental Health CSRT (Pentonville Prison)

1

Enfield Community Services AOP 1

Haringey 0 0 0

Specialist Services 6 1 7

Specialist Inpatient Services Beacon 2 1

Community Outreach Services 1

Specialist Inpatient Service Forensics 3

Total 8 2 10

11. Safeguarding Children and Young People 11.1 A Head of Safeguarding People for the Trust has been successfully appointed and due to

start beginning of November, 2015. A further safeguarding advisor has been recruited to the Enfield Community (ECS) team to assist in the increased growth in Health Visiting services

11.2 The Trust lead for Safeguarding Children has resigned and will leave the Trust in

November 2015. 11.3 There is currently no Named Doctor for Haringey borough following the retirement of Dr

Geoff Isaacs. The Clinical Director is currently addressing this with her consultant colleagues.

11.4 Quality Assurance Activity 11.4.1 Safeguarding children is everybody’s business and remains an on-going priority for the

Trust and is a key component within all assessments and care provided. All staff are encouraged to have the ‘ child in mind ‘ and always create opportunity for the child`s voice to be heard.

11.4.2 BEHMHT continues to be represented at a range of meetings and LSCB sub groups to

inform safeguarding children and young people`s practice especially around risk from Female Genital Mutilation (FGM), Child Sexual Exploitation (CSE) and Domestic Violence and Abuse (DVA).

11.4.3 The Board is kept up to date with safeguarding children issues through regular feedback

from the safeguarding children`s committee meeting that is chaired by the Executive Director of Nursing, Quality and Governance. The monthly safeguarding surgery creates opportunity for staff to discuss complex safeguarding issues, work collaboratively and be kept up to date with new legislation.


11.4.4 There is a safeguarding champions group set up in Barnet and Enfield and the group in Haringey is to be re-established.

11.5 Training Needs Analysis

A training proposal and work plan has been put forward to address the increase in demand for staff to be trained at level 3 safeguarding children as a result of changes within the Intercollegiate Document, 2014. The safeguarding team continue to liaise with the work force team to identify staff requiring the level 3 training and to monitor training compliance. Quarter 1 training compliance for level 3 safeguarding children is 75%. A one day combined adult and children’s safeguarding level 1 and 2 training day commences September 2015 and will include domestic violence and abuse. Quarter 1 training compliance for level 1 and 2 safeguarding children is 85%.

11.6 Child Health

Child Health Enfield continues to be commissioned by NHS England and monitored on a monthly basis through our action plan. We are meeting all of our actions at present liaising with other sources and receiving and manually inputting. We are part of the North Central East London Group to work closely with our child health colleagues in setting up an interface or automatic upload of CSV files to our RiO system. Our immunisation coverage is between 85% and 95% for under 5 imms. Our bloodspot reporting is 99.8 – 100%. We are on track and achieving and meeting all of our targets.

12. Pressure Ulcer Prevention Forum 12.1 At the August Forum Sarah Kiernan, Nurse Consultant, Tissue Viability, gave a

presentation on Debridement using Larval Therapy providing two case histories demonstrating the positive impact for the patients of the intervention. There was review of classification of pressure ulcers which need to be reported on DATIX.

12.2 Discussion took place on the use of the Body Map Chart, which can be found in the

Pressure Ulcer Prevention and Management Policy (Appendix 12) and reminded those present that the use of the Body Maps should become routine practice now in clinical care settings when patients have wounds, including Pressure Ulcers. This standard will be added to the next Essence of Care Pressure Ulcer Documentation Audit and compliance will be measured, commencing September 2015.

12.3 A discussion on completing a MUST assessment when it is not possible to weigh the

patient took place. As a result there will be a presentation from a community dietician Sue Race from the community dietetic team at the September Forum on alternative methods.

13. Breaking down the Barriers: working with multi-specialty teams to improve physical

& mental health 13.1 The second phase of the project managed by UCLP funded via HENCEL has ended. 13.2 Project 1: Practice Nurse Project: This project was devise to develop mental health nurse

educators to provide training to practice nurses to develop their knowledge and understanding of patients with mental health conditions.

13.3 Five nurses from the Trust attended the programme, one has completed all the modules

and is able to provide the training to other nursing colleagues on all the modules, three of the group are able to provide elements of the programme and one staff member has left the Trust.


13.4 The project is undergoing re-branding to include all primary care staff, the materials are accredited by the RCGP.

13.5 The programme is planned to be embedded into Mental Health Trusts. Additional training

dates have been negotiated between HENCEL and HENCEL based universities and will be available for colleagues to attend as a refresher as well as deliver training to Lecturers and tutors. The training will deliver a dementia module.

14. Health Education North Central East London Allied Health Services Support Worker

Policy Landscape SWAP project 14.1 Health Education North Central East London (HENCEL) has commissioned the Allied

Health Enterprise Development Centre (AHEDC), which is a joint venture between Allied Health Solutions and Buckinghamshire new University, to undertake this project over a 12 month period between May 2015 and April 2016.

14.2 The emphasis of this project is threefold:

Raising local AHPs’ awareness of the new support worker policy landscape, .

Identifying service needs in terms of role boundaries, career opportunities, new roles and education and training for the Allied Health services support workforce.

Identifying the opportunities for apprenticeships in Allied Health services across HE NCEL.

The work will be undertaken within the CEPN structure and will involve three sites. A. Barking and Dagenham, Havering, Redbridge (Wave Two) B. Barnet (Wave One) C. Tower Hamlets (Wave One)

The Trust representative on the Steering Group is Gill Bransby, AHP Leadership Project Manager.

15. Psychological Therapies 15.1 Crisis Concordat – Trust wide Project

The Psychological Therapy Leads along with the Asst Director of Patient Services and CDs are developing a piece of work for the Trust to map our current service user experience of the crisis pathway including adult inpatients, Recovery Houses, CRHTTs, Beacon and AOT. It was agreed that there was a need to consult with users by experience so that current MH crisis responses can be modified and developed accordingly. The consultation will consider if people in crisis experienced:

Dignity and respect being displayed

Timely responses being facilitated

Perception of safety from response It was suggested that in order to shape future multiagency coordinated crisis responses, we need to understand:

How and why you access support for your MH; what is the most useful support; what might have prevented a crisis point?

How and why you needed urgent/ emergency access to MH crisis care; what was and was not useful at your MH crisis point, what might have been a better response to your crisis (NB was it your crisis point)?


How did you receive treatment and care as a result of your MH crisis; what was useful and what was not; what might have been more useful?

How did you recover from your crisis; what will help you to stay well and reduce reaching crisis point and used of crisis responses in the future?

To this end, a questionnaire has been developed by the psychology leads and an evaluative methodology to capture quantitative and qualitative data to inform services accordingly. Project in progress and regular updates will be provided to colleagues as part of our wider Concordat activities.

15.2 Psychological Therapies Report Featuring Enfield 15.2.1 Project 1: Utilising Lean Methodology to streamline waiting lists in Enfield Complex

Care Team (CCT): The Enfield Lead Psychological Therapist, along with other Consultant Psychologists and waiting list co-ordinators have convened a waiting list working group to review current practice and introduce key steps using Lean process, in order to simplify each stage of the patient journey from assessment to discharge. At the first meeting in August 2015, an examination of the assessments within the care pathways was undertaken. It was agreed by the group that there were multiple assessments currently carried out, firstly by Triage, and then by CCT which were potentially unnecessary (unless there was a complexity about the case that needed to be investigated and understood). This impacted on treatment waiting time as resources were being diverted to assessing cases in order to clarify which treatment stream to allocate each patient to. It was noted that:

That Triage undertakes a full psychiatric assessment but are currently not able indicate either the appropriateness or the specifics of which psychological treatment should be offered.

A proposal was made for a psychologist to be based for one a day a week to work with Triage and offer consultation to the team regarding the appropriateness of referring to CCT and which treatment stream to allocate them. It was also discussed that this psychologist could undertake some assessments at Triage, but this should be kept at a minimum.

It was noted that at present service users can sometimes sit on a waiting lists for treatment and it becomes apparent that they require the services of another treatment stream (due to change of circumstances or developments whilst on the waiting list).

It was agreed that a seamless transition needs to take place between treatment streams and waiting times minimised.

In keeping with Enablement model, it was agreed that it would be essential for clients to have a clear idea of the type of therapies on offer so they can make an informed decision about their own treatment.

It was discussed and decided that each treatment lead could develop a leaflet on their treatment approach (e.g. CAT or CBT) and this could be given to each client either at assessment at Triage or at the ‘Introduction to Psychological Therapies’ group

Feedback has been received from Triage that some of the IAPT therapists have been informing clients, the types of treatments they are going to get in CCT. This has created a high expectation in clients and some of whom are currently not agreeing to be signposted to community services as a result

It was decided that the psychologist who was working with Triage could take on the role of liaising with IAPT.

Time scale: Three more monthly meetings to consider access, treatment and discharge and post-discharge options.


15.2.2 Project 2: Supporting Positive Behaviours

Aim: It was agreed that the aim of the Supporting Positive Behaviour Project would be ‘ To bring together a group of relevant clinicians and managers to work towards building a culture of promoting positive behaviour, on all the wards in Enfield. Lead Psychological Therapist for Enfield, Kajori Mukherjee will be chairing (rotating chair) these meeting for the first three months. The ethos of this working project is of joint multidisciplinary participation/ownership underpinned by enablement principles and the chair will rotate in future. The remit of the Supporting Positive Behaviour Project is to encompass behaviours of staff as well as patients on the wards in an effort to reduce the numbers of violent incidents and injuries that are currently being experienced by both staff and patients. This project will aim to utilise a number of bio-psychosocial models to understand why a range of challenging behaviours occur on the wards and seek to ways of addressing these. It was agreed that this group will endeavour to challenge variations in practice to strengthen practice and deliver sustained improvement.

Methodology / Process:

Membership from Dorset, Suffolk, Sussex and Somerset Wards

All Consultant Psychiatrists, Ward Managers, Acute Care Services Team Leader, OT staff, Consultant Clinical Psychologist, Clinical Psychologists.

Clinicians from other services (e.g. Forensics and OP), Dr Matt Liveras, Helen Price (Enablement Lead), Service manager, AD and CD will all be invited in due course if felt to be appropriate.

A number pilot interventions/ projects will be developed to introduce a culture of enablement on the wards which by definition will require positive risk taking. It is envisaged that Service Managers, AD and CD will be invited to join us once these interventions/ projects have taken shape and we have a greater understanding about what we will be providing and resources needed to support these quality improvements.

Ends.

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