28 October 2006
Subject: Chief Executive’s Report
Report of: Chief Executive
Summary: Chief Executive’s update to the Board
Recommendation: To note
Author Maresa Ness, Chief Operating Officer and Deputy
Date 19 October 2006
CHIEF EXECUTIVE’S REPORT
Anticipating a very difficult time for patients and staff on the Tolworth site, on
notification of the transmission date of the Dispatches programme, a co-ordinated
strategic response was agreed underpinned by a number of action plans
functioning at corporate and local level. This included seeking legal advice to
prevent transmission and accepting possible failure to do so because of the
public interest argument. A series of measures were planned to mitigate the
negative impact of the programme:
1.2 Prior to Transmission
Letters were sent to all 108 users advising them of the programme’s transmission
and encouraging them to ring their Care Coordinator for support if they wished.
Those who did not contact their Care Co-ordinator by Friday 6th October were
contacted to ensure they had received the letters and asked if they needed any
additional input or an early appointment. The letter also gave advice about a
Helpline set up and manned that they could contact immediately post
1.3 On evening of Transmission
Dr Joan Rutherford and Marie Dodd visited the in patient units on the evening
prior to transmission and after the programme, Jo Carmody; Service Manager
accompanied them after the programme to establish user and staff reaction and
also met the Duty Doctor to identify vulnerable patients. Additional staffing had
been put in place to ensure staff had time to discuss the programme or support
patients during transmission as it was expected that patients would wish to view
the programme. Some clients identified as possibly vulnerable were also invited
to come to the wards to watch the programme supported by staff. Only one user
did so and he was seen by staff as he was featured clearly in the footage and
was easily identifiable. He was given specific time to discuss his reactions after
1.4 Post transmission
A drop-in session from 3pm onwards on the 10th October (the day after
transmission) was set up for any patients who wished to see Dr Joan Rutherford
and Marie Dodd. The care coordinators received a number of calls, as did Marie
Dodd and Peter Houghton. The helpline received 4 calls (1 positive about their
care) and one person and their carers attended the drop-in session.
1.5 Ongoing patient support
To support users and carers, PALS coordinator Louise Dymock attended the
Tolworth site on 10th October. This was well publicised. Some patients wished to
make specific complaints to the programme makers. 8 people were seen. A
further session is scheduled for 31st October.
1.6 Ongoing risk assessments
All users who have been affected are being given high priority and additional
support targeted where necessary.
1.7 Impact on Staff
Staff are aware that the programme has raised many issues including those of
multidisciplinary working and lack of patient confidence in staff. We have been
working closely with the Executive to agree an appropriate and measured
response to ensure that lessons are learnt and change can be effected without
staff responding in an overly defensive manner.
A series of meetings with the ward staff have taken place in Kingston (and
Richmond where appropriate). Individual and group meetings are now underway
to discuss and address practice issues. For example, Marie Dodd and Joan
Rutherford are meeting with the Tolworth site Senior House Officers on Monday
Issues highlighted in transmission.
1.8 PRN Medication
This matter has been investigated by staff interviews and an independent view of
the notes and prescription chart in addition to close scrutiny of the film footage.
It is clear that oral PRN medication was administered, not an injection; the
footage shows a female member of staff contacting the duty doctor. The records
show that this was prescribed and is written up for the remainder of the
1.9 Locked Doors, Patient at Risk
This incident (patient absconded twice: once by pushing past a member of staff
and on a second occasion by stealing a key). These incidents did occur and an
investigation was conducted at the time. Procedures were changed and all locks
The site has three systems in place and we have been working with estates to
seek options to improve this as it is a mixture of dated systems. The potential
upgrade to Shamrocks would introduce another system and some rationalisation
urgently needs to be undertaken, which has cost implications.
BLIK system: Level One: Wall mounted with two mobile units, and summons
assistance from within the ward, and summons the Emergency Team.
Level Two: this is a nurse call system and operates only within the ward to
In addition, there are also personal alarms.
It is possible that there are areas of the ward where the system is blind. Policy
and use of these alarms are being reviewed. In the interim staff are being advised
that additional vigilance is needed and a high corridor presence is required.
1.11 Staff Attitude
Training needs have been highlighted and in some cases professional practice
has been less than ideal. Kingston management team are working closely with
Sandy Gillett and Mary Chambers to address these issues. This also applies to
the use and training of bank staff.
1.12 External Contacts
Contact has been made and letters written to partner agencies and stakeholders.
To date the Healthcare Commission, PCTs, the SHA, and the Mental Health Act
Commission have not received specific complaints related to the transmission of
the programme. The Trust has discussed the actions it has taken with the
Healthcare Commission who consider these to be appropriate and proportionate.
1.13 Training and Induction
The Trust has already effected many changes since this filming was done,
including the introduction of the Expert Seminars led by the Chief Operating
Officer, which is specifically targeted at Ward Managers and ward based staff. In
addition, the Clinical Leadership Programme led by the Chief Nurse is about to
commence which is specifically targeted to Health Care Assistants. It is important
to note that the Patient Survey results 2006 were considerably improved
compared to 2005.
Kingston and Richmond recognise that there is considerable progress to be made
in relation to the delivery of excellent patient care. While we deplore the
techniques used and the infringement on patients’ rights to confidentiality, the
programme has given us a unique insight into the ward environment that we must
now use to change practice.
2. CMHT Review
The CMHT review programme is a key element of the Trusts Business plan for
2006/7 and is essential to achievement of national community service targets. A
Programme Brief has now been drafted to define the Trusts' CMHT Review
programme, form the basis of its management and the assessment of its
success. The document clarifies key milestones as well as setting Trust-wide
cost and quality constraints. The quality constraints include the requirement to
meet the targets set out in the Mental Health NSF and the service specifications
outlined in the Policy Implementation Guide for community teams. The
Pre-consultation engagement to take place during October-December
Formal 3 month consultation to begin by 17 January 2007
Implementation of new models to begin in April 2007
Implementation of new models to be complete by April 2008
Each borough will work with local stakeholders to develop service models and
implementation plans that meet the Trust's minimum specifications. A Trust
CMHT Review Programme Board, chaired by the Chief Operating Officer, will
meet monthly to coordinate this work and deal with any risks, issues or
exceptions to the programme brief. This Board will report to the Clinical Services'
Development Programme (CSDP) Steering Group.
3. Contestability of Services
At the end of September the Commissioners gave the Trust their commissioning
intentions for all the specialist services. This includes a review of the Mother and
Baby service and an audit of the addictions services. However, also included
was a proposal to put the adult eating disorder services out to tender in October,
with the contract to be awarded around February next year.
This is the first of the specialist services to be tendered by the local
commissioners and as such will be a test-bed for the Trust's ability to respond
and the commissioning processes. The Trust feels that it now has very good
local eating disorder services, especially as the new community day hospital
model has had excellent initial outcomes. Alongside this, the Trust has attracted
activity from other providers, which has diversified the income streams. For these
reasons it is likely that the Trust will be able to compete for this tender, once it is
4. Annual Performance Ratings 2005/06
A breakdown of the Trust’s rating is attached (Appendix TB(06)122A). In terms of
the position for 2006/7:
4.1 Core standards
The Trust expects to be able to declare compliance against all of the core
standards with the exception of those relating to buildings. Although a programme
of environmental improvements is continuing this year, the Healthcare
Commission is likely to challenge any change in compliance status for these two
standards before the completion of the Wandsworth Acute Unit and new PICU.
4.2 Existing national targets
The staffing and activities levels in CAMHS services are dependent on
Commissioning decisions. PCT commissioners have indicated that this is a
priority for them in the year ahead, but the financial position in the sector means
achieving this target will remain at risk.
4.3 New national targets
The Trust is now compliant on the smoking and infection control indicators.
Work is in progress to achieve the Older People CMHT integration target.
However success in completion this year will be dependent on the outcome and
pace of the service redesign consultation process
4.4 Adult Community Mental Health Services
The Trust and PCT Directors are working on improvement plans for individual
Boroughs. Progress with the CMHT re-design project will be crucial to success.
Wandsworth services will be subject to inspection following their overall rating as
weak. Delivering the targets has been prioritised in all the Boroughs and in
Wandsworth we expect the inspection to show services as better than rated.
A report on the overall expected position of the Trust with regards to compliance
in 2006/7 will be submitted to the December Board.
Deputy Chief Executive
19 October 2006
26 October 2006
Subject: Addendum to Chief Executive’s report
Summary: The Making Connections service review is a
comprehensive examination of the management of our
services for challenging and offender patients. Chaired by
Professor Tony Madden who has been nominated to this
role by the Department of Health, the review committee
has recently met for the first time and finalised the attached
scope and terms of reference paper.
The final report will be completed in February 2007. This
will be subject to external scrutiny prior to submission to
Recommendation: That the Trust Board notes the paper.
Author: Alison Hooper, Service Director Richmond
Date: October 2006
MAKING CONNECTIONS SERVICE REVIEW
TERMS OF REFERENCE, PROCESS AND WORKSTREAMS
The role of medium and low secure services, PICUs and challenging behaviour rehabilitation
services within the Trust
Background to the Review
1. It is clear that a number of Trust services which deal with our most difficult clients work in
isolation from each other and that there is no clear pathway of care or sharing of clinical
expertise between and across medium, low secure, PICUs or challenging behaviour services.
2. There are differential levels of nursing staff and multi-disciplinary input across the 2 PICUs,
although they both deal with a similar client group.
3. There is differential access to low secure and challenging behaviour beds for different
boroughs, based on history and accident rather than a true reflection of need.
4. There is a perception that forensic services are inward focussed and unwilling to engage with
the needs of patient care within the wider Trust. Relationships between forensic services and
local borough mental health services are sometimes strained: local services feel that forensic
services are not sufficiently responsive to requests for assessment and advice on the
management of dangerous patients: forensic services feel local services are slow to take
patients back into the boroughs.
5. There is no clear model for the ongoing treatment of community patients within forensic
services, and variation in practice between different clinical teams.
6. There is scope to review the function and purpose of forensic services within the whole
system of mental health care, and in particular mental health care provided to the offender
population in the community and in prison.
some of our most difficult clients are not receiving the service that most appropriately
meets their needs
clients are being shunted between services, or stuck in a part of the service that does not
adequately meet their needs
ill feeling develops between clinicians in different parts of the service who feel that they
are being left with problems they cannot manage
opportunities for sharing clinical expertise are being lost
the specific expertise of clinicians in managing risk amongst the offender population or in
the management of challenging behaviour is not being fully utilised for the benefit of
patients across the Trust
8. It is proposed to address these problems and maximise these opportunities by establishing a
Review Team led by an independent clinician.
The Terms of Reference for the Review
The Terms of Reference for this Review Team will be as follows:
8.1. To review the current organisation and delivery of the forensic service at low and
medium security and to recommend changes where necessary in:
The structure and organisation of wards and clinical teams
The delivery of a community service
The relationship with Wandsworth prison, court diversion and the criminal justice system
The provision of risk assessments in relation to the assessment, treatment and
management of offenders across the Trust
The relationship with borough mental health services, PICUs and challenging behaviour
8.2. To examine the varying roles of medium and low secure services, PICUs and
challenging behaviour units in order to:
Identify individual patients across these services whose needs are not appropriately met
in their current location
Recommend more appropriate ways of managing patients where necessary, including
those who could return from placements in the independent sector
Clarify how services are currently used in terms of length of stay, referral pathways and
referral criteria, and recommend improvements
Determine how pathways of care should operate in future
8.3. To determine how to achieve services that are better integrated, less isolated, and have
a shared network of expertise.
8.4. To ensure that Government policy, best practice and guidance is fully utilised in the
development of new service models and pathways of care.
Overarching Questions to be answered during the Review
1. What should the nature, role, function and purpose of the following Trust services be in
Challenging Behaviour service
2. What should the relationship and interface between these services be?
3. What should the interface with local adult services be ?
4. What are the gaps in service provision?
Membership of the Review Team
Professor Tony Maden: External Chair, nominated by DoH
Consultant Forensic Psychiatrist, DSPD Unit, Broadmoor
Senior Nursing representative: external appt tba
Senior representative from DoH: tba
Dr Nigel Lester: Consultant General Psychiatrist, Assertive Outreach Service,
Dr Joan Rutherford: Consultant General Psychiatrist, Kingston & Associate Medical
Tom Clarke: Associate Borough Director Nursing, Wandsworth.
Dr Charlotte Harrison: Consultant psychiatrist, Rehabilitation Service, Phoenix Unit
Elizabeth Rushton: General Manager, Forensic Service
Damien Brennan: General Manager, Kingston.
Prof. Nigel Eastman: Consultant Forensic Psychiatrist, Shaftesbury Unit
Dr Crystal Romilly: Consultant Forensic Psychiatrist, Shaftesbury Unit
Alison Hooper: Service Director, Richmond
Stuart Thomson: Service Director, Wandsworth
Process behind Review
The Service Review will commence in October 2006 and conclude with a full report and
recommendations in February 2007. This report will be scrutinised by an external panel of
experts, and will go to the Trust Board for approval.
The Review process will be co-ordinated through a small Review Team made up of senior
clinicians and managers across the Trust . It will be chaired by an external chair, Professor Tony
Maden . Whilst the team will need to meet every 2 or 3 weeks throughout the review process,
much of the work will take place in small workstreams involving clinicians from all disciplines and
managers from all parts of the service. We aim in this way to achieve maximum ownership of the
issues discussed. We will also invite individual clinicians and managers to attend Review Team
meetings on a topic by topic basis, to present work undertaken in workstreams, and to facilitate
Each workstream will be chaired by a different clinician or manager, with project management and
The proposed workstreams are as follows:
1. Delivery of a comprehensive service for mentally disordered offenders in the Trust
What service and interface should the Trust provide to Wandsworth prison?
What should the nature of the relationship be between Trust services, MAPPAs, court
diversion services in London and the criminal justice system?
How can forensic expertise in risk assessment assist in the care and treatment of
offenders elsewhere in the Trust system?
2. Delivery of PICU services
How similar/dissimilar are the services provided by Shamrocks and John Meyer Unit ?
What are the gaps , problems and interface issues with local services and forensic
What needs to change to improve the quality of patient care ?
What needs to change to improve service delivery ?
3/4 Difficult to place patients and delivery of Challenging Behaviour Services
How many patients cared for within these services have needs that are not being met in
their present location ?
How could their needs be met more appropriately?
Criteria for patients being treated by challenging behaviour units – Phoenix, Horizon and
What new services are required?
5. Delivery of a community forensic service
a. Should the forensic service deliver a community service?
Who is it for?
How should it be organised?
How should it interface with local mental health services?
6. Function and organisation of forensic wards
What in patient facilities are needed to return people from out of area placements?
How should wards and clinical teams within the forensic service be organised ?
How can multi disciplinary working be further developed and improved?
Where are there service gaps?
7. Delivery of forensic rehabilitation services
What inputs should patients receive during the process of rehabilitation?
How can the forensic service deliver to the social inclusion agenda?
8. Substance Misuse service
How can patients in these services receive appropriate inputs to address their substance
What model of care/ treatment is needed?
How can this be delivered?