The report
This report has been removed at the request of the family.
TEWV response to NHS England independent investigation Emily Moore
Download TEWV response to the independent investigation – Emily MooreThe following assurance statements have been produced as a response to the Niche independent investigation into the care and treatment of EM by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and Cumbria, Northumberland, Tyne, and Wear NHS Foundation Trust (CNTW), commissioned by NHS England. (EM)
The independent investigation made a total of 13 recommendations.
This section addresses recommendations 1, 2, 3, 10, 12 and 13 in order as made by the report.
Recommendation number 4, 5 ,6, 7, 8, and 9 relate to other organisations and are therefore not included in this assurance statement. Recommendation 11 is a joint recommendation for TEWV, CNTW, NHS England and Durham County Council. This statement provides only the TEWV response.
Introduction
We would like to apologise unreservedly for the unacceptable failings in the care of Emily which the report clearly identifies.
We accept in full the recommendations made in the report – all the improvements required are being made where applicable to our services.
Following a governance review in March 2021, and the comprehensive public engagement exercise that followed, a new TEWV organisational and governance structure was put in place from 1 April 2022 with simplified governance processes and strengthened reporting from teams through two new care groups directly to the Trust’s Board, embedding increased line of sight and oversight from ward to Board.
As part of this, we have recruited two lived experience directors into our leadership team to make sure patient voice is heard at the very highest level in the organisation.
Importantly, all the necessary changes are being made to the services we deliver, with the knowledge and oversight of the CQC and NHS England and reviewed by them monthly at an external Quality Assurance Board, chaired by NHS England.
In the three years since these tragedies, we’ve made significant improvements – how we assess the risks to our patients, how we organise and staff our services, and how we more closely involve the families and loved ones themselves.
These improvements are being delivered through our five-year change programme “Our Journey to Change”, which sets out why we do what we do, driven by three big goals to create a great experience for our patients, carers and their families, for our staff, and for our partners.
This includes an unrelenting focus on patient safety, with clear priorities set out in our patient safety strategy – this is our absolute priority.
This is supported by a quality assurance programme, and our quantitative and qualitative data shows that we have made considerable progress, and these are continually measured, evaluated, and reported upon.
We are working hard to put patients and carers at the centre of everything we do – treating everyone with respect and compassion and taking responsibility for our actions.
These assurance statements outline the improvements we have made in response to the report recommendations.
Recommendation 1
Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) must ensure that young people in Child and Adolescent Mental Health Services (CAMHS) have a clear plan of care incorporating evidence-based practice.
TEWV response:
The Trust’s work around care planning continues to be a priority and is overseen by the Quality and Safety Programme Board as well as the Clinical Strategy Board.
Considerable work has been undertaken over the past 18 months to make sure care plans are developed with a young person and their family or carer, and that these are trauma-informed, recovery-focused, autism aware and meaningful for the children and young people themselves. The Trust recognises this is a work in progress and is subject to review and evaluation.
To make sure care plans developed for young people in CAMHS include evidence-based practice, we use what is known as a 5P formulation structure, to organise assessment information when children and young people come into the service. The 5Ps are: current Presentation, Pre-existing, triggers for current issue (Precipitating), any maintaining (Perpetuating) factors, and the Positives to understand what is going well. The 5P formulation structure is a standard format utilised in mental health services nationwide approved by the British Psychological Society.
We have found that this is a useful way of organising information and for children, young people and their families and carers, to develop a shared understanding and language with the clinical staff, to make sure it was patient-centred and easy to follow, and that the care plans are completed together in way which the young person and their parent / carer also understands.
Using this method to assess people, means decisions about an individual’s care is made with them and their family or carers. We have often received feedback from people who use our services that they don’t like having to repeat their stories. Developing a shared 5P formulation also helps with consistency for sharing relevant information and avoid having to do this.
In addition to the above, a quality improvement event was held in March 2022 to focus on the clinical model of care planning across the Trust. The event was well attended by people we support in our services, carers, and professionals from across the Trust’s geographical area
Consensus from the event was that care planning must be owned by the patient and contributed to by the care network involved in a person’s care.
Outcomes from the event included additional training sessions which took place in April and May 2022, to make sure staff have the appropriate skills to co-create meaningful, goal-orientated care plans. Awareness sessions were arranged for people we support in our services, carers, and our partners to facilitate a shared understanding of the changes. The event also looked at which parts of the care plan review could be stopped to reduce duplication and free up staff time to care.
The introduction of the Trust’s new electronic patient record system will also enhance the care planning process.
Recommendation 2
TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family.
TEWV response:
In addition to the information provided above, the Trust has developed new safety summary and safety plan documents. These support a psychological formulation approach to risk assessment with children, young people, their families and carers. The documents require a consideration of a young person’s history regarding what has happened to them, and any patterns to help understand when they have been better or become more unwell. The risk assessment and management plans need to be developed alongside a thorough understanding of the young person within their context. It is therefore an integral aspect of their care, and building on the assessment, formulation and shared decision-making process described above.
These were introduced into CAMHS in April 2021. Our Quality Assurance Programme currently shows that 96.8% of children in treatment have a safety summary and safety plan in place across the Trust. We continue to work with clinicians to enhance the quality of these documents and have established processes to support this via caseload supervision, clinical supervision and daily discussions (huddles). We have assurance processes including fundamental standards and peer reviews in place to ensure clinicians have a variety of sources of support.
Recommendation 3
TEWV must ensure that the management of restrictive interventions (including contraband items) is part of an agreed philosophy and approach, with clear protocols embedded to guide practice.
TEWV response:
We have made significant progress in the management of restrictive interventions and have a Trust-wide agreed philosophy and approach, enhanced by our supporting behaviours that challenge policy to guide good practice.
We have clear aims to reduce all forms of restrictive practices across inpatient areas and we are delivering this by focusing on a number of areas. These are outlined below.
Training
In April 2021, the Trust updated mandatory training for all staff working in an inpatient setting, to improve our response to behaviours that challenge. Our new competence-based Positive and Safe Care training courses focus on prevention, human rights and trauma-informed care. They are nationally accredited by the Restraint Reduction Network and comply with the Mental Health Units (Use of Force) Act.
In line with the national standards, we have extended the length of training for new staff and all staff are now required to update their training annually. Training is delivered trust-wide. A number of our trainers have experience of mental illness and can share their insights, to show colleagues the impact that restrictive interventions can have on individuals. This puts patient experience at the very heart of the way we deliver care.
We have worked alongside our partners from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) and University of Cumbria to develop post-graduate training in the field of reducing restrictive intervention. The training has now been completed by 45 multi-professional staff. The aim is to develop leaders in the field of service improvement and reducing restrictive interventions. The 18-month long course is now recognised nationally and the third cohort of 40 students will commence study in September 2023.
Behaviour support plans
Creating good quality and collaboratively developed behaviour support plans for all patients continues to be a key priority within our improvement plan for reducing restrictive practice. We have worked alongside the regional positive behaviour support coalition to make master’s level training available for specialist practitioners in this area. In 2021, 26 staff across the Trust achieved their post graduate certificate in Positive Behaviour Support.
In 2021, we changed the way we record and store our behaviour support plan in Paris, our electronic patient recording system. We now have designated care documents that are collaboratively developed and easily available for staff to access which supports the practice to become more embedded.
Pilots
Whilst it is always our priority to prevent incidents from occurring, it is essential that we take all reasonable steps to learn and improve when incidents do happen. To support this process, we are currently piloting the use of body worn cameras across 10 of our inpatient wards to support post incident reviews for staff and patients.
In 2021, NHS England worked in partnership with the Restraint Reduction Network to develop an audit toolkit for the use of restrictive practices and blanket restrictions. We have recently piloted this tool across 14 wards in our secure inpatient services, which has enabled us to identify issues and make improvements. We have developed service improvement plans including new training programmes for frontline staff and the recruitment of additional behavioural specialists to support teams. We are currently reviewing the use of this tool across all inpatient areas, including ways it can be incorporated into our procedures and governance frameworks for reducing the use of restrictive practice.
HOPE(S) model
Since June 2022, the Trust has been working with partner organisations to support people through the introduction of the HOPE(S) model, a human rights-based approach that has enabled us to reduce restrictive interventions, supported by external expertise. This model has now been adopted by NHS England and therefore endorsed as a national approach to reducing restrictive interventions.
Recommendation 10
TEWV must provide assurance that clinical records are kept to expected standards.
TEWV response:
In June 2021, the Trust introduced a new quality assurance programme focusing on the quality of clinical record keeping in relation to key clinical records including care plans, observation records, risk assessment and management plans recognising that high quality documentation is an enabler to good patient care. This is in line with national clinical record keeping policy and professional guidance for record keeping.
These audits are completed monthly and are verified through a peer review process. Results from Jun-21 to Jun-22 activities demonstrate consistent practice standards are being achieved across the organisation in terms of implementation of the minimum standards, in line with the Good Practice Guidance for the safety summary / safety plans, observation and engagement plans, and leave documentation within the patient electronic care record system. The Practice Development Practitioners continue to monitor compliance and to facilitate areas where focussed improvement work is required in collaboration with clinical teams.
In addition, clinical risk assessment and management guidance is provided to clinical staff to support their practice in line with the Trust’s revised Harm Minimisation policy (clinical risk assessment and management). Multi-disciplinary team (MDT) huddles were introduced in inpatient areas and outcomes are now recorded in clinical records. The quality assurance (QA) programme that was introduced in June 2021 includes the following:
- Assurance self-declaration: a fortnightly assurance tool reviewing all patients on inpatient wards. The tool monitors compliance with completion and updating of safety summaries, safety plans, incident reporting, leave and observation plans as well as associated documentation. The tool was updated on 23 October 2021 to provide a more focused and detailed review of the quality of patient records and clinical record keeping.
- Modern matron quality review: a monthly review of quality indicators and information in inpatient areas. This includes 33 standards relating to safety summaries, safety plans, patient carer involvement, leave plans, and observations plans. Each ward or team have developed continuous improvement plans based on intelligence gathering from reviews and case note reviews.
- Practice development review: a monthly assurance tool led by the practice development team. The practice development practitioners (PDPs) observe MDT discussions in relation to risk, leave, level of observations, mental state, medication compliance and effectiveness of medication regime, and whether everyone in the MDT is felt to have a voice. PDPs now work with staff across both inpatient and community services focusing on completing robust risk assessments and ensuring the quality of mental state examinations and record keeping, including observation levels.
The quality assurance programme has provided evidence that observation and engagement plans, for both day and night, were present in 99% of cases. It also showed that patient observation levels documented in the clinical records matched the paper sheets and visual control board. There was 100% compliance with observation recording forms being fully completed, specifying the named member of staff responsible for carrying out observation and engagement for each specified time-period.
Recommendation 11 *
TEWV, CNTW, NHS England and Durham County Council must provide assurance that all transitions between services for children and young people are completed in line with the NICE guidance on the Transition of Children and Young people.
* We have provided some detail on actions we are taking to address this important issue, working alongside colleagues in the local authorities and health care providers.
TEWV response:
The Trust and all the local authorities across our geographical area have signed up to implementing the iTHRIVE system framework. This is recognised nationally as a way of promoting good practice, and its pathways follow evidence-based National Institute for Clinical Excellence (NICE) guidance and have been developed by staff using the available evidence-base and clinical expertise. This means that progress is being made with all our partners and describes a whole-system approach. This is an important and positive change to our approaches to joint working with targeted support.
We are also working closely with our partner agencies to improve how we work together to support children, young people and their families. In Durham, we have been developing multi-agency decision making following a whole-system pathway development. This work has been led by the Trust over the past three years. Family hubs are also being developed in Consett, County Durham, Billingham, Stockton-on-Tees and in North Yorkshire and York. Included in the whole-system approach, we have also been developing an integrated multi-agency approach for high risk, vulnerable young people with joint accountability. Using this approach, risk assessment and management plans, safety plans are co-created between agencies and young people, their families and carers. Support comes from all sectors including family, social, activity, education and employment to enable the children and young people to settle back into their life in the community. Intensive home treatment (IHT) teams provide planned support which is tailored and bespoke for each individual, and this support is available in the Durham and Tees areas. There are also dedicated 24/7 CAMHS crisis teams across the Trust. The IHT and crisis teams work together with the multi-agency network, including CAMHS, to support children and young people when they leave inpatient accommodation.
TEWV have an active working group for 16-25’s, which is led by an Associate Director of Therapies supported by a project manager. The working group oversees the transition process for CAMHS, Adult Mental Health Services (AMHS) and learning disability services. Transition panels are in place for each AMHS team. Active planning for the transition starts at six months prior to the young person’s 18th birthday, with a discussion with them and their parent / carers which is recorded in the transition plan on electronic care records. A monthly report for team managers, overseen by modern matrons, provides assurance. The last transition audit was completed in April 2020. An audit of transition planning formulations for complex presentations is planned for the next audit cycle.
For young people who are more vulnerable, we start to make links with AMHS when a young person is 17 years and a quarter, with transition plans in place at 17 years and six months. We know that this transition time can be particularly difficult, especially for people in the care of the local authority, so we make sure that this is proactively done through preparation and follow-up actions. Multi-agency working across the transition time can be complicated, and it is recognised that young people often require additional support because of this.
Recommendation 12
TEWV must provide assurance that that all ligature risks identified in Tunstall Ward in 2019 have been addressed.
TEWV response:
The Trust established an environmental risk group in January 2020 to oversee a comprehensive ligature reduction programme across the Trust. This included the replacement of ensuite bathroom furniture and fittings across all adult inpatient assessment and treatment wards to an agreed standard. This work was completed on Tunstall Ward in September 2020.
We have invested over £5m in our ligature reduction programme to date, with a further £2.8m due for completion by March 2023.
A comprehensive door replacement programme is also underway across the Trust. As part of this, ensuite doors were replaced on Tunstall Ward in April 2022. Installation of new bedroom doors will be completed in November 2022.
Where ligature points cannot be removed or are in low-risk areas of the ward, these are managed as part of individual and ward risk assessments. Staff are aware of these risks, and they are discussed as part of the daily ward safety reviews.
An annual assessment of ligatures within the ward environment is undertaken in accordance with the Trust’s Suicide Prevention Environmental Survey and Risk Assessment Procedure. This was last completed on 22 July 2022.
In addition, since the time of this incident, Oxevision has been installed in a number of wards, including Tunstall Ward. This system supports clinical teams and enhances patient safety by using contact free, vision-based monitoring technology to monitor a patient’s vital signs and high-risk activity. This offers safe and unobtrusive care, which is respectful of people’s privacy, and we are developing and evaluating our services to ensure we embrace the benefits of this assistive technology.
Recommendation 13
TEWV must ensure that the Supportive Observation and Engagement Procedure requires that care plans specify whether to enter the individual’s room if they cannot be observed from the doorway.
TEWV response:
The Trust’s Observation Policy has been updated to specify that care plans should include whether to enter the individual’s room if they cannot be observed from the doorway.
To strengthen the recording of mental health observations, the Trust’s policy around Supportive Observation and Engagement was reviewed in December 2020. A new competency-based assessment was introduced for all clinical staff prior to the policy going live, to make sure staff understood it and what was required of them.
In January 2021, the Trust held a five-day quality improvement event to make sure robust systems were in place to assess and mitigate patient risk, including the management of observations and observation levels. The aim was to develop a simplified and streamlined framework to enable effective assessment, risk assessment, care planning and care delivery.
The outcome was a ‘plan on a page’ framework, which simplified the electronic patient record in the form of the safety summary and safety plan, leave plan, observation plan and care plan.
Staff took part in training sessions to recognise and understand:
- areas of harm and the need to take immediate action,
- working collaboratively with the multi-disciplinary team (MDT) and the patient when determining observation levels,
- how to review static and dynamic risk factors that may affect potential harms,
- the importance of maintaining simultaneous records, and;
- clarity of roles and responsibilities in relation to observation levels
In addition, clinical risk assessment and management guidance is provided to clinical staff to support their practice in line with the Trust’s revised Harm Minimisation policy (clinical risk assessment and management). Multi-disciplinary team (MDT) huddles were introduced in inpatient areas and outcomes are now recorded in clinical records. The quality assurance (QA) programme that was introduced in June 2021 includes the following:
- Assurance self-declaration: a fortnightly assurance tool reviewing all patients on inpatient wards. The tool monitors compliance with completion and updating of safety summaries, safety plans, incident reporting, leave and observation plans as well as associated documentation. The tool was updated on 23 October 2021 to provide a more focused and detailed review of the quality of patient records and clinical record keeping.
- Modern matron quality review: a monthly review of quality indicators and information in inpatient areas. It includes 33 standards relating to safety summaries, safety plans, patient carer involvement, leave plans, and observations plans. Each ward or team have developed continuous improvement plans based on intelligence gathering from reviews and case note reviews.
- Practice development review: a monthly assurance tool led by the practice development team. The practice development practitioners (PDPs) observe MDT discussions in relation to risk, leave, level of observations, mental state, medication compliance and effectiveness of medication regime and whether everyone in the MDT is felt to have a voice. PDPs now work with staff across both inpatient and community services focusing on completing robust risk assessments and ensuring the quality of mental state examinations and record keeping, including observation levels.
The quality assurance programme has provided evidence that observation and engagement plans, for both day and night, were present in 99% of cases. It also showed that patient observation levels documented in the clinical records matched the paper sheets and visual control board. There was 100% compliance with observation recording forms being fully completed, specifying the named member of staff responsible for carrying out observation and engagement for each specified time-period.
