CLINICAL AUDIT ANNUAL REPORT by omf20943

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									        CLINICAL AUDIT

        ANNUAL REPORT

   APRIL 2003-MARCH 2004


Monitoring……

               Improving……

                             Reviewing.
                                            West London Mental Health NHS Trust




Contents
                                                                  Page

  1.   Introduction                                               3

  2.   Organisation and Progress                                  3
       2.1 Commission for Health Improvement                      3
       2.2 Mapping of Clinical Audit Committees                   4
       2.3 Clinical Audit Strategy                                6
       2.4 Clinical Audit Handbook                                6
       2.5 Clinical Audit Database                                6
       2.6 Ensuring Good Clinical Audit                           7
       2.7 Clinical Audit & Research & Development                7
       2.8 Training                                               8
       2.9 Clinical Audit Training Evaluation                     9

  3.   Positive Changes in Practice                               9-11

  4.   Trust-wide Clinical Audit Projects                         12-18
       4.1 Seclusion                                              12-13
       4.2 Comparison of Levels of CPA                            14-15
       4.3 Baseline Assessment Audit CNST                         16-17
       4.4 Patient Information Audit                              18

  5.   Summary of Clinical Directorate Audits                     19-34

  6.   Clinical Audit Team                                        35-38


 7.    The Future                                                 39


  8.   Appendix 1                                                 41


  9.   Appendix 2                                                 42


  10. Appendix 3                                                  43


  11. References                                                  44



                              2        Clinical Audit Annual Report 2003/2004
                                                      West London Mental Health NHS Trust




1.0. Introduction
  During 2003/2004 the Trust has focussed on developing Clinical Audit as
  an integrated pillar of the Clinical & Research Governance framework.
  Structures to support Clinical Audit are now well established. This
  provides a firm basis from which to expand clinical audit activity during
  2005/05.

  The CHI review highlighted the need to enhance the organisational
  structures, prioritisation and learning from clinical audit. Positive steps
  have been taken in year to overcome difficulties previously experienced,
  and to move the audit agenda forward. A trust-wide Clinical Audit
  Committee has been established. Review of the Clinical Governance
  Support Service has led to a number of changes:

     •   The appointment of an Associate Director of Clinical Governance
     •   The appointment of a Head of Clinical Audit
     •   Training and raising the awareness of clinical audit.

  This 2003/04 Annual Report outlines progress made in organisational
  processes, audit projects undertaken across the Trust and by Clinical
  Directorates, and positive changes made to practice as a result. The
  activity of the Clinical Audit Team is, in addition, reported.

  It is envisaged that the Forward Plan 2004-2005 will provide further
  impetus to clinical audit activity throughout the Trust by focussing on and
  driving forward key priority areas. This will ensure meaningful completion
  of clinical audit, real improvements in practice, and raising the standards of
  care provided to the users of our services.


2.0 Organisational Progress

2.1 Commission for Health Improvement (CHI)
The Trust’s CHI Review took place between February and June 2003. The
key areas that the Trust was asked to address were:

     The need to develop a Trust-wide clinical audit strategy, establish clear
     structures for clinical audit and ensure that an audit programme is
     produced that details clinical audit priorities at each level within the
     organisation.

     The Trust should develop robust mechanisms for the dissemination of
     audit findings, ensuring changes to practice occur as a result and that
     changes are routinely re-audited.




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                                                         West London Mental Health NHS Trust




      The Trust should provide staff with appropriate opportunities to improve
      their understanding and ability to participate in clinical audit activity.

The Trust has recognised the need to build upon the existing processes within
the Clinical Governance framework and continues to progress work in this
area. Progress identified includes:

2.2 Clinical Audit Committee
During the last year the Trust has formed a Trust-wide Clinical Audit
Committee reporting to the Trust Clinical & Research Governance Group. The
Clinical Audit Committee is chaired by the Medical Director, Board Lead for
Clinical Audit. Membership 0f the Committee includes, Associate Medical
Directors, Associate Director of Clinical Governance, Deputy Directors of
Nursing, Director of Information, Head of Psychological Therapies, Head of
Allied Health Professionals and the R&D Manager.

The terms of reference of this group are as Table I.

The achievements of the Committee in 2003/04 include development of a
Clinical Audit Strategy, a Handbook, “7 Steps to Clinical Audit” and integration
with the Trust Research and Development Team. The Committee has given a
clearer Trust-wide focus to audit, has enabled prioritisation of projects and
has provided co-ordination of effort across the organisation.

As well as the Trust-wide committee, directorate clinical audit groups have
been established. These groups aim to:
      Establish and monitor the clinical audit agenda to reflect the Trust’s
      priorities and the local directorate governance agenda.

      Oversee the allocation and completion of audit projects

      Receive, review and quality assure completed projects, ensuring
      lessons are learned and changes to practice implemented

      Build on existing structures for administration and facilitation of audit
      projects and to assist in the development of local resources for audit

      Dissemination of audit findings

      Coordinate local training in clinical audit

      Report to the divisional clinical and research governance group.

A map of the clinical audit groups is provided as Appendix 1.




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                                                                                       West London Mental Health NHS Trust




          Table 1.
                          Clinical Audit Committee Terms of Reference


                                     Ensure user, carer and
                                   stakeholder involvement in              Ensure Trust staff can
                                  the process of clinical audit              access support and
                                                                           advice on methodologies
                                                                             through the Clinical
                                                                                 Audit Team


       Set priorities for                                                                                        Quality assure, and
      Clinical Audit within                                                                                      ratify Clinical Audit
            the Trust                                                                                                 proposals




Oversee the registration of all                                                                                     Support the
  Clinical Audit projects, to                                                                                    development of an
  maintain a register and to                                                                                    annual Audit Plan and
ensure appropriate and timely                                                                                     the annual Audit
           reporting                                                                                                   Report.


                                                        Clinical Audit
   Ensure links between
                                                         Committee                                            Ensure dissemination of
                                                                                                             audit outcomes across the
 information systems and                                                                                            organisation
   audit are robust and
          planned



                                                                                                           Oversee the development
   Ensure audits are carried                                                                              of a comprehensive Clinical
     out in line with Data                                                                                 Audit training programme
   Protection, Confidentially                                                                               available to Trust staff
  and security requirements



                                                                                                        Report to the Trust’s
    Ensure links with the R&D                                                                           Clinical and Research
    Office and R&D Strategy                                                                           Governance Group on the
    are robust and supportive                                                                         progress of Clinical Audit
                                                Through the Trust Clinical & Research
                                                     Governance structures, ensure
                                                coordination of Clinical Audit priorities
                                                  with the Trust Clinical Governance
                                                  agenda, in particular supporting the
                                                  Clinical Effectiveness strategy and
                                                               priorities




                                                                   5              Clinical Audit Annual Report 2003/2004
                                                        West London Mental Health NHS Trust




2.3 Clinical Audit Strategy
This year has seen the development of a Clinical Audit Strategy. The purpose
of this document is to set out the Trust’s approach to establishing clear
structures for clinical audit and to ensure an audit programme that prioritises
audit in line with the Trust’s Clinical Governance Strategy.

The strategy has been developed to ensure local ownership and
multidisciplinary involvement in clinical audit, whilst ensuring adequate
governance and prioritisation arrangements are in place. In developing the
Clinical Audit Strategy, the Trust is committed to ensuring:

   •   Clinical Audit priorities relate to the Trust Clinical Governance priorities
   •   Clinical Audit is led and undertaken by all members of Multidisciplinary
       teams
   •   Training, advise and support is provided to clinicians and service users
       by the Clinical Audit Team
   •   Service User involvement is integral to prioritisation, development and
       delivery of Clinical Audit.

The Clinical Audit Strategy has been endorsed by the Trust Clinical Research
& Governance Group and will be launched in June 2004.

2.4 Best Practice Clinical Audit Handbook – Making Positive
Changes in Practice

The clinical audit team has designed a ‘Clinical Audit Handbook’, which will be
launched in June 2004 in support of the Clinical Audit Strategy. This
handbook provides a guide for all staff on the completion of clinical audit. It
describes the resources and help available to assist completion of the full audit
cycle, from identifying an audit topic through to the implementation of changes
to practice.

Contained within the Handbook is a flowchart for staff identifying the steps
that need to be taken to conduct a clinical audit project. See Appendix 2

The Handbook will be launched alongside the Clinical Audit Strategy in June
2004.


2.5 Clinical Audit Database
The clinical audit team has designed a central database, which will enable the
Trust to monitor audit activity, to develop a resource base and to track
changes to practice as a result of audit undertaken. This database will be
available on the Trust’s ‘N’ drive facility so that staff can, readily access the
information and establish contact and learning opportunities between teams
and projects.




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                                                        West London Mental Health NHS Trust




2.6 Ensuring Good Clinical Audit
A Peer Review process has been agreed to ensure the quality, focus and
governance of clinical audits conducted within the Trust. The Trust-wide peer
review panel is a sub-group of the Clinical Audit Committee. Members of the
peer review panel are currently being identified. Areas that the reviewers will
look at include:

      If the audit is uni-professional will it link with the overall care of service
      users by the multi-disciplinary team?
      Does the clinical audit proposal contain the reason for undertaking this
      project?
      Does the proposal include how this audit will lead to quality
      improvement?
      Does the audit project relate to clinical governance priorities already
      identified?
      Has the methodology of the project been defined?
      Are the timescales for the project realistic?
      Does the proposal contain plans to implement findings and disseminate
      results?
      Have Information Governance issues been identified?
      Does the proposal indicate involvement of service users or partner
      agencies in design and outcome?

This process will be conducted virtually, with two members of the peer review
team allocated to each project. Should there be a difference of opinion, a
third member of the panel will be identified. Advise of the Information Team
and Research and Development Office will be available at all times.

A response to the reviewed proposal will be returned to the project audit lead
within 5 working days of receipt.


2.7 Clinical Audit and Research & Development
Close links have been established between clinical audit, clinical effectiveness
and research & development.

Clinical Effectiveness involves receiving and reviewing research and good
practice evidence, benchmarking current practice against such evidence, the
development of clinical standards and training to continually improve services
and practice, and monitoring the effectiveness/impact of such change. An
evidence based approach and critical appraisal of available evidence is
essential. Prioritisation has taken into account the need to monitor and
evaluate implementation of NICE guidance and the National Service
Frameworks.

The Clinical Audit and Research and Development Teams work in close
collaboration. There are clear channels of communication between the Teams


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                                                       West London Mental Health NHS Trust




and the audit process designed to enable cross fertilisation and reference to
R&D expertise and transfer of projects between structures as appropriate.


2.8 Training
A programme of clinical audit training has been established within the Trust.
Training days have been programmed throughout the year, and available to
all staff. The training aims to:

   Explore the meaning of Clinical Governance and its structure within the
   Trust
   Provide a knowledge base and experience of clinical audit
   Increase confidence in the clinical audit process.

Four formal training events were held between December 2003 and February
2004 with a total of 73 staff attending. Further events are planned for 2004/05.
The events held have been evaluated, 96% (n=43) of attendees reported their
learning objectives were met and 4% (n = 2) said their needs were partially
met.

Suggested improvements to the training include:

   Certificates to be provided – Certificates are currently being designed and
   printed and will be available as of next training date.
   Providing Audit Training on site, not centrally. – The Audit Team agree,
   are keen to provide local training, and will look at how best to develop this
   service.
   Examples of audits as handouts – Training Packs distributed on
   completion of the training day now include examples of audits completed
   within the Trust. A Clinical Audit handbook is also included as an aide
   memoir.
   Receiving copies of slides at beginning of the training to make notes -
   Handouts are now circulated at the beginning each session.

   Discussion of different data collection methods – Various methods of data
   collection are discussed. Whilst the Audit team do not wish to overload
   people with too much information at once, the audit training will be
   adapted to meet the needs and level of experience of clinicians. The Audit
   Team is always on hand and available to offer advice on audit
   methodologies.
   Information provided prior to Training Day – the audit team will provide a
   timetable at the beginning of the day. Maps and the location of the
   Learning & Development Centre are available on the Trust ‘N’ Drive.
   Clinical Staff to present an example of an audit that has recently been
   completed – Excellent idea! The Audit team will engage clinicians willing to
   present audits at the training.

The training is evolving further, taking into account feedback from staff. Other
training sessions planned include:


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                                                      West London Mental Health NHS Trust




   Training sessions to be held within the localities, involving other agencies
   ‘Surgery’ type sessions for those staff completing audit who require
   support, assistance, or advice regarding their audit
   Training sessions to be held within the Working Sub Groups around
   identification of audit topics, writing audit proposals, designing audit
   methodology and report writing.


3.0 Positive Changes to Practice
As detailed in the following sections, there has been many audit projects
undertaken during 2003/04, with identified learning and changes to practice.
Highlights for the year include:

To follow is a brief summary of changes to practice across the West London
Mental Health NHS Trust that have taken place as a result of clinical audit
projects.

Following a service user survey, a pilot, is taking place within the Medium
Secure Service to introduce a be-friender service.
             ‘Letting through the Light’- Ealing Service User Survey, Page 21.

Members of staff surveyed requested the Trust run a seclusion de-escalation
course, to ensure de-escalation practices are consistent across the Trust.

  A Baseline Audit of Seclusion Rooms, Seclusion Records and Staff Views of
                                       Current Seclusion Practice, Page 20.

Guidelines are being developed for referral to arts therapy to aid discussion
with service users about the benefits of arts therapy.

                 Arts Therapies Audit of Medical Consultants’ Views, Page 34.

An audit of ward-based community meetings was completed with focus on
communication. The audit demonstrates high level of attendance of service
users and staff, good communication onward to the local Clinical Improvement
Groups. Initial findings of good practice will be rolled-out across the service.
The next stage will be an audit the response of Clinical Improvement Groups
to the issues raised.

Audit of Community Meetings – Local & Medium Secure Directorate, Page 34.

An audit of the use of HoNOSCA identified the need for regularly repeated
staff training sessions on the completion of HoNOSCA. To increase the rate of
HoNOSCA completion, the Ealing CAMHS service has agreed that staff
should complete the rating assessment interviews, and that files will have a
special marker removed on completion. The marker will highlight any ratings
not completed.
Clinical Audit into the use of HoNOSCA, Page 29.



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                                                       West London Mental Health NHS Trust




Following the completion of a survey of service users the Clozapine Clinic, a
more readable leaflet and posters are being produced to raise awareness of
the side effects of medication. Regular meetings between service users and
staff to discuss medications and side effects will also be established, and
many audit projects undertaken during 2003/04, with identified learning and
changes to practice. Highlights for the year include: a standard set to inform
service users of their blood results within four working days.

  Service User Satisfaction with the Avenue House Clozapine Clinic, Page 22.


A survey of Users attending the Ealing Cognitive Behavioural Therapy
Services identified that service users would like to be referred quickly and
easily by their GP for Cognitive Behavioural Therapy. They would like the
service to be based in the GP surgery, to have their say in the time and day of
their appointment and to be seen within 5 weeks. With this in mind the service
is adopting a partial booking system for all first appointments, is aiming to
reduce waiting time to 5 weeks, and is offering appointments in primary care
sites. The services will also offer access to specialist self-help packages with
brief therapist support as a first step for depression, and access to a specialist
computer aided self-help package for phobia/panic disorder.

 User Survey Audit of Ealing Cognitive Behavioural Therapy Service, Page 22.

Following an audit of seclusion practice, one Directorate is developing a leaflet
for users to provide information about the process and therapeutic use of
seclusion.

      Audit of Seclusion Practice- Adult Mental Health Services H&F, Page 25.

An audit of Prescribing Practicies established the need for a local procedure to
guide prescribing practices within a Therapeutic Community.

Investigation into Prescribing Practices in a Therapeutic Community, Page 32.

Systems have been established in one depot medication clinic to ensure
patients receive an annual physical check and medication review.

An Audit Monitoring the Levels of Polypharmacy at the Depot Clinic relating to
                                           Lampton Road, CMHT, Page 27.

An audit of Patient Information has led to the establishment of a group to
quality assure information provided to service users Trust-wide.

                 Patient Information Audit-Local &Forensic Divisions, Page 21.

Files with alphabetical dividers have been provided to ensure drug charts are
stored appropriately. This has helped to reduce the number of omitted doses



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                                                         West London Mental Health NHS Trust




of medication.

    Audit of Omitted Medication Doses-Adult Mental Health Services, Page 24.

Service users in one area requested, via a survey, provision of more day time
activities. This has been addressed by a new Activity Co-ordinator post. The
Coordinator will continue with service users and staff to ensure the take up of
available activities.

                      CUES – Service User Questionnaire, Hounslow, Page 26.

Following an audit of Antipsychotic prescribing, a rapid tranquillisation
procedure is being developed by the Drugs & Therapeutics Committee.

        Audit of Inpatient Antipsychotic Prescribing and Comparison with NICE
                                                           Guidance, Page 24.




A full list of all clinical audit projects completed during the period April 2003 to
March 2004 is provided at Section 5 of this report.




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                                                       West London Mental Health NHS Trust




4.0. Trust-wide Clinical Audit Projects
The Trust-wide priorities for clinical audit during 2003-2004, were identified by
the Clinical & Research Governance Group, in line with the Trust Clinical &
Research Governance Forward Plan. Four main clinical audit topics were
completed.


4.1 A Baseline Audit of Seclusion Rooms, Seclusion
Records and Staff Views of Current Seclusion
Practices
Audit Period:               February 2003 to February 2004


Introduction
As priorities in the Trust Clinical and Research Governance Forward Plan, an
audit of the use of seclusion was conducted trust-wide. The baseline
Seclusion audit coincided with the launch of the Seclusion Policy (S2) in
March 2004, and was undertaken by the Clinical Effectiveness & Audit
Department in conjunction with Clinical Directorates.

Methodology
This audit was conducted in three parts: Monitoring of the Seclusion rooms,
assessing the seclusion records and interviewing staff about their views of
current seclusion practice. Within the Forensic Clinical Directorates, staff were
asked to complete an anonymous questionnaire.

The sample size for the monitoring of Trustwide seclusion rooms identified 51
rooms currently in use, 5 in Local Services Division, 16 jointly in the Local
Secure and Medium Secure Directorates, and 30 at Broadmoor Hospital.

The sample size for seclusion records was 187 case files - 88 files from the
Adult Acute wards, 30 from the Ealing Local and Medium Secure Facilities
and 69 from Broadmoor.

Findings
Staff views indicated (42%, n =121) that there was to be no perceived need to
make changes to current practice as seclusion was never or rarely used, that
use of seclusion can represent good practice. Second highest response rate
and closely linked were training/education (12%) and a better understanding
of current Trust Policy (13%) to ensure that seclusion is used in the approved
manner. Suggesting that within the nursing profession there is a demand for
continuous review of educational provisions surrounding seclusion.

83% (n= 51) of the seclusion rooms Trust wide were deemed to be
‘adequately furnished’ for the manner in which they are intended. The



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                                                       West London Mental Health NHS Trust




remaining rooms lacked independent controls for heating, ventilation, sound
proofing or were in need of refurbishment.

This means 92% files contained detailed account of seclusion. 1% (n =187) of
all case files examined had no note made of the seclusion. Only 7% of
records did not contain a detailed account of why the seclusion took place,
which equals just 14 files.

The first 37% of case files contained no evidence that a Doctor was present
every 4 hours and reveals a lack of detail in recording of seclusion activity.
Moreover, 41% of files did not record if Seclusion was reviewed 2 hourly by 2
nurses.

Staff interviews and questionnaires revealed a request for training in the use
of seclusion and de-escalation. It is proposed the importance of the case note
recording be emphasised during this training.

Changes required:
   To review Trust policies on a regular basis to ensure compliance with the
   Code of Practice.
   Training department to develop a rolling educational programme to
   regularly familiarise clinical staff with the Trust Seclusion Policy and good
   practice. Learning and development programmes should link with
   SMARG's to ensure incorporation of lessons learned and developing good
   practice.
   Estates Department to review the seclusion rooms in the light of staff
   comments, with regard to the number of rooms available for use and the
   provision of a soft furnishings room or ‘calm down area’ as an effective
   means to avoid the use of seclusion.
   Estates Department to review the heating, ventilation and toilet facilities in
   each of the seclusion rooms.
   Clinical Teams to improve the quality of case note recording, in particular
   the recording of start/end/duration of seclusion, outcome of the regular
   observations by medical and nursing staff and the impact of medication
   given.

Changes implemented:
   The Associate Medical Directors have established Divisional Seclusion
   Monitoring and Review Groups (SMARG's) to ensure clinical issues are
   discussed, trends in practice identified and lessons learned acted upon
   promptly.




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                                                    West London Mental Health NHS Trust




4.2 An Audit of Current Levels of Compliance With
CPA Documentation Trust-wide.
Audit Period:             February 2003 to February 2004


Introduction
As part of the continuing audit cycle for the Care Programme Approach (CPA)
documentation, an audit of current compliance was undertaken across the
Trust. Audits of CPA documentation since 1996 have demonstrated steady
improvement in compliance with documentation and the CPA processe. This
has been due to the result of a programme of initiatives including the
introduction of revised CPA documentation, mandatory training sessions
(Sept 01 to March 02), case load reviews and an ongoing CPA training
programme.

The CPA documentation was re-designed Trust-wide in 2003 to ensure a
consistent process and format. The documentation ensures review of CPA
are undertaken on a regular basis. It is often the case that national minimum
standards are maintained by all care co-ordinators, thus ensuring individual
service users receive consistent care throughout the Trust. The CPA process
also ensures service users are regularly involved in review of care plans.

Objectives
   1. To evaluate the compliance levels within the CPA documentation
      across the Trust.
   2. To develop and enhance the commitment of staff to CPA
      documentation compliance, ensuring that service users receive the
      highest possible standards in their individual care.
   3. To encourage staff to review their practice and use of CPA processes
      within the Trust.

Methodology
A total of 2,150 service users files were audited, 25 files (where available)
from each ward, CMHT, hostel or day hospital across the 12 Clinical
Directorates in the Trust. The CAMHS Directorate were audited but have not
been included in the overall analysis as the Trust CPA documentation has
only recently been implemented for older adolescents.

The data was collected using an audit tool based on standards indicated by
the Department of Health, ‘An Audit Pack for Monitoring the Care Programme
Approach’, and modified to reflect specialist services in the Trust.

The data collected from this audit was analysed using the arithmetic mean, on
an Excel spreadsheet. All data is anonymous and no attempt was made by




                                     14        Clinical Audit Annual Report 2003/2004
                                                      West London Mental Health NHS Trust




any member of the Clinical Effectiveness and Audit Team to identify service
users or staff in connection with this audit.

Findings
2,150 service user files were audited across the 12 Directorates in the West
London Mental Health NHS Trust. 55.5% (n=1193) had CPA documentation
on file. 44.5% (n=957) of service user files, did not contain the CPA
documentation.

Approximately two thirds of CPA documentation had completed demographic
information, nearest relative details, summary of history, and areas of risk and
protective factors detailed. Over half had completed the Psymon numbers, GP
details and name of the care co-ordinator.

50% had completed physical health, meaningful daytime activity/employment
and education sections of the needs assessment, with other needs
assessment information completed in slightly less than 50%.


Changes required:
   Standards devised in addition to the trust wide CPA Policy to act as a
   reference guide and thus ensure that basic mandatory NSF requirements
   are adhered to. The suggested format of a standardised CPA checklist
   should be introduced across all Services, to be placed at the front of the
   case files.
   Checklist to be incorporated into Service User/ Primary Nurse 1:1 sessions
   and reviewed during one to one staff appraisals with a Line Manager.
   Service Managers / Heads of Service to audit consistency of practice
   throughout their Directorate.
   Clinicians to benefit from additional CPA training and education sessions
   based on advanced knowledge on all CPA aspects via Special
   Practitioners such as the Care Process Development Manager.
   Attendance at academic sessions to be monitored and audited annually by
   organisers and academic tutors..
   Development of clinicians understanding of the mandatory CPA
   documentation needs to undergo a further review, as it does not currently
   capture all of the minimum NSF requirements to include HoNOS.




                                      15         Clinical Audit Annual Report 2003/2004
                                                       West London Mental Health NHS Trust




4.3 A Baseline Assessment Audit of Local Services
Case Files Assessing Compliance to Level 1 Clinical
Negligence Scheme for Trusts (CNST)

Audit Period:                      2003 to 2004

Introduction
The CNST Clinical Risk Management Standards, Level 1 Criterion 4.1.7
requires that there is “clear evidence of clinical audit of record keeping
standards for all professional groups in at least 25% of specialities, including
any high-risk specialties, within the 12 months prior to the assessment”. For
mental health, 25% of all clinical areas must be audited.

Minimum standards of case file recording must include:

       Date
       Time
       Identifiable signature
       Legibility
       Written in black or approved ink

An audit, within the       Local   Services    Division      was      undertaken           of
multidisciplinary files.

Findings

Wards Audited
97% of all ward files had ‘dates’ filled in for each clinical entry. ‘Times’ were
completed in 43% of files. ‘Identifiable Signatures’ were found in only 37% of
ward files, leaving 45% with only 61-80% of entries identifiable and 15% with
41-60% identifiable. 82% of all files were found to be legible and only 13%
had 61-80% legible entries. All but 5% of files were written in approved black
ink.
CMHT’s & Day Hospitals Audited
All CMHT, Day Hospital and Cassel Hospital files had ‘dates’ entered by each
clinical entry made by multi-disciplinary team members. Times were only
found in between 0-20% of files for 79% of the audit. Only 4% had times
written between 81-100%. ‘Identifiable signatures’ were present between 81-
100% in 21% of files audited. 32% of all files were found to be ‘legible’ with
39% between 61-80% legible. Approved ‘black ink’ was found in 68% of files
between 81-100%.

Comparison 2002/2003 AND 2003/2004

Audit Data was collected and analysed by the same team of people on both
audit occasions to ensure consistency in the standard of measurements used


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                                                      West London Mental Health NHS Trust




as a benchmark. Overall for all categories the compliance percentages have
risen from the previous year however, there is a marked decrease in the 81-
100 category from 73% down to 43%. There has been a decrease overall in
identifiable signatures, legibility and the use of black ink. 2003/2004 shows a
marginal increase overall in the 0-80% categories nevertheless, dates and
times have fallen by 6% and 5% respectively. There has been a slight
increase in the 0-80% (inclusive) categories however, in the 81-100%
category there has been a decrease. Principally in the Identifiable Signatures
and Legibility grouping both of which have decreased by half of their original
percentage.

Changes required:
   Times need to be entered next to each clinical note made in all files,
   particularly in CMHT & Day Hospitals
   Names need to be printed below all signatures.
   Clinical supervision and appraisal should include a review of staff
   handwriting in cases where legibility is known to be an issue. (Clinical
   Directors should review issues of handwriting with medical colleagues.)
   Ward/CMHT managers to make a concerted effort to ensure their teams
   date and time every entry made in to the MDT notes.




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                                                      West London Mental Health NHS Trust




4.4 Patient Information Audit

Audit Period:              June 2003


Introduction
A need was identified by the Trust to establish what service information is
made available for Service Users. A Local Services and Forensic Services
wide audit was conducted, excluding Broadmoor as a standardised Patient
Information Pack has already been developed in conjunction with Service
Users. Each service was requested to submit information specific to the
service provided.


Findings
The response rate was very high and the audit request generated a lot of
interest. The audit in itself has contributed to raising awareness of the
importance of making service leaflets available to service users.

Overall, the majority of services make relevant information available to service
users. One third do not, however, yet have information readily available in the
form of leaflets or booklets.

Changes Required:
   To ensure that every Ward, CMHT and Specialist Service has specific
   information that is given to the Users of the service.

Changes Implemented:
   A Trust-wide Patient Information group has been established to develop
   guidelines on the minimum data that should be made available and how it
   should be laid out.




                                       18        Clinical Audit Annual Report 2003/2004
                                                                           West London Mental Health NHS Trust




     5.0 Summary of Clinical Audits Undertaken in
     2003/2004
     Definitions

     Local
     ‘Local’ is defined as all areas providing care at the clinical interface e.g.
     ward/clinic/area, clinical team.

     Clinical Directorate
     There are 13 Clinical Directorates within West London Mental Health NHS
     Trust.

     Divisional
     The Trust is managed in 2 Clinical Service Divisions; Local Services Division
     and Forensic Services Division.


     The following tables, provides a summary of completed clinical audit activity
     within the period. With audit being a continuous process, there is in addition
     much ongoing audit activity that will be reported in future as projects are
     completed.


Trust Wide Audits

Audit Title                         Registered   Agency undertaking         Changes to practice
                                                 Audit
An audit to review seclusion        Feb 04       Clinical Teams/Audit       Establishing Seclusion Monitoring &
rooms, documentation and staff                   Team                       Review Groups, review existing
views throughout Local and                                                  policy, training to include a de-
Forensic services                                                           escalation course which would
                                                                            emphasise the importance of record
                                                                            keeping and ensure practices are
                                                                            consistent across the Trust.
A comparison of current levels of   Feb 04       Clinical Teams/Clinical    Standards to be devised to act as a
compliance with CPA                              Audit Team                 reference guide to staff, checklist to
documentation throughout Local                                              be incorporated into the CPA
and Forensic Services                                                       documentation to ensure compliance
                                                                            with NSF requirements.
Review of all clinical audits       Jan 04       Clinical Audit Team        Establish a framework for reporting
undertaken across the Trust                                                 outcomes of clinical audit. A
                                                                            database has been established to
                                                                            track audit activity and to provide a
                                                                            reporting mechanism. The database
                                                                            will be available on the Trust’s ‘N’
                                                                            drive by June 2004.




                                                      19            Clinical Audit Annual Report 2003/2004
                                                                         West London Mental Health NHS Trust




Local Services Division Wide Audits

Audit Title                         Registered   Agency undertaking        Changes to Practice
                                                 Audit
A review of compliance levels       Sept 2003    Clinical Audit Team       The audit established there has been
with Level 1 Clinical Negligence                                           decreased in the Identifiable
Scheme for Trusts (CNST)                                                   Signatures and Legibility grouping.
Standard 4.1.7                                                             Changes to practice include: Times
                                                                           to be entered next to each clinical
                                                                           note made in all files, particularly in
                                                                           CMHT & Day Hospitals; Names need
                                                                           to be printed below all signatures;
                                                                           Clinical supervision should include a
                                                                           review of staff handwriting in cases
                                                                           where legibility is known to be an
                                                                           issue. Clinical Directors should
                                                                           review issues of handwriting with
                                                                           medical colleagues; Ward/CMHT
                                                                           managers to make a concerted effort
                                                                           to encourage their teams to date and
                                                                           time every entry made in to the MDT
                                                                           notes.
A comparison of current levels of   Sept 2003    Clinical Audit Team       Standards to be devised to act as a
compliance with CPA                                                        reference guide to staff, checklist to
documentation throughout Local                                             be incorporated into the CPA
Services                                                                   documentation to ensure compliance
                                                                           with NSF requirements.
                                                                           Implementation plan to be outlined.
Letting through light - ethnic      Aug 2003     Ealing User               Data analysis and report completed.
monitoring                                       Involvement Project &     Changes to practice include: a be-
                                                 Trust Ethnicity           friender service is being established
                                                 Advisor                   Trust-wide, a pilot of which is
                                                                           currently taking place within the
                                                                           Medium Secure Service.
An audit to review seclusion        Jul 2003     Clinical Audit Team       Establishing Seclusion Monitoring &
rooms, documentation and staff                                             Review Group, review existing policy,
views throughout Local Services                                            training to include a de-escalation
                                                                           course which would emphasise the
                                                                           importance of record keeping and
                                                                           ensure practices are consistent
                                                                           across the Trust. Implementation
                                                                           plan being developed.
Patient Information Audit           May 2003     PALS                      Trust-wide patient information
                                                 Manager/Clinical          Steering Group established. A
                                                 Audit Team                minimum data set of information
                                                                           available to our service users to be
                                                                           produced.




                                                    20              Clinical Audit Annual Report 2003/2004
                                                                            West London Mental Health NHS Trust




Adult Acute Services-Ealing
Audit Title                            Registered   Agency undertaking        Changes to Practice
                                                    Audit
Link Nurse Audit – evaluation          Oct 2003     Clinical Psychologist     Audit established that the Link-nurse
role of link nurse to facilitate the                                          role was useful and effective. The
transition of ward patients to the                                            decision was taken to continue the
community                                                                     role as substantial improvements had
                                                                              been made to service provision.
Audit of case note quality.            Sept 2003    Psychotherapy             This was a re-audit and the outcome
                                                    Department, Ealing.       is a vastly improved quality of note
                                                                              keeping and organisation.
An Audit Examining The Quality         Aug 2003     Southall/Norwood          Changes to practice identified
Of Note Keeping Of Medical Staff                    medical staff             developing a stamp for recording
At Southall-Norwood Community                                                 whether risk assessment has been
Mental Health Resource Centre.                                                completed. Re-audit will be
                                                                              undertaken.
Psychological Therapy Forum            Jul 2003     Psychological             Findings variable, involvement of
Audit of CPA Documented                             Therapy Forum             psychological therapies minimal. To
Referrals Across Adult Acute                        Group                     increase activity. Re-audit planned
Directorates                                                                  Oct 2004.
Service User Satisfaction of           May 2003     Clinical Audit Team       Changes to practice to include:
Clozapine Clinic                                                              raising the awareness of medication
                                                                              side effects by producing a more user
                                                                              friendly leaflet/poster for service
                                                                              users, two sessions a year t be held
                                                                              for service users to meet with staff to
                                                                              discuss side effects of medication.
CBT User Survey                        Feb 2003     Ealing Audit              Adoption of a partial booking system
                                                    Directorate               for all first appointment. Access to be
                                                                              offered to self-help packages with
                                                                              brief therapist support as a first step
                                                                              treatment for depression, computer
                                                                              aided self-help packages for
                                                                              phobia/panic disorders.




                                                       21              Clinical Audit Annual Report 2003/2004
                                                                        West London Mental Health NHS Trust




Adult Acute Services – Hammersmith & Fulham

Audit Title                        Registered   Agency undertaking        Changes to Practice
                                                Audit
Audit of Multidisciplinary Notes   Dec 2003     3 South Ward              Documentation in future to be filed
                                                                          within the correct sections as
                                                                          currently difficult to find certain
                                                                          documents. On accepting transfers,
                                                                          check for risk assessment and make
                                                                          sure care plans are up to date. If
                                                                          paperwork is incomplete, ensure it is
                                                                          completed. Care plans to be reviewed
                                                                          more regularly, especially for new
                                                                          admissions.
Audit of reported violent          Nov 2003                               Audit completed. Presented to the
incidents.                                                                Acute Care Forum. Outcome: all staff
                                                                          to attend mandatory training on de-
                                                                          escalation, PMVA and Breakaway
                                                                          Techniques. Managers to ensure all
                                                                          staff wear name badges and ensure
                                                                          those staff having bleeps know how
                                                                          to respond. Re-audit to take place in
                                                                          Sept 04 this will allow a settling in
                                                                          period within the new building. A
                                                                          comparison will then be made.
Survey of the demand for           Nov 2003     Clinical Psychologist     There is a clear unmet need for this
cognitive assessments within MH                                           service. Meeting the need for
Services                                                                  cognitive assessments will require a
                                                                          number of different actions:
                                                                          Limiting the assessments to the
                                                                          highest priority cases
                                                                          Focusing on longer-term benefit from
                                                                          testing
                                                                          Using alternative methods to assess
                                                                          the patients' needs
                                                                          Increasing the psychology resource
                                                                          with the teams.
                                                                          Limiting the cognitive assessment
                                                                          service to a general screening for
                                                                          potential functional impairments.
                                                                          Ensuring the skills of the CMHT
                                                                          psychologist are maintained and
                                                                          updated through relevant training and
                                                                          supervision.
Audit of seclusion from Jan –      Nov 2003     3 West Ward               Leaflet devised to provide information
June 03                                                                   on the therapeutic use of seclusion to
                                                                          patients.
Depot Medication Prescriptions     Nov 2003     Area 2 CMHT               Re-audit completed. This years audit
at a community Mental Health                    Gloucester House          showed an overall improvement in
Team                                                                      most depot activities. As
                                                                          recommended in the previous audit,
                                                                          depot clinic nurses are now
                                                                          informing/alerting the RMO prior to
                                                                          when a prescription becomes invalid.
                                                                          All prescriptions are now only written
                                                                          maximum of three months. All depot
                                                                          charts are reviewed weekly. The
                                                                          DNA part of chart is now completed if
                                                                          patient does not attend and a three
                                                                          monthly CPN review meeting to
                                                                          ensure smooth running of the clinic
                                                                          has commenced. Annual re-audit is
                                                                          planned.




                                                   22              Clinical Audit Annual Report 2003/2004
                                                                       West London Mental Health NHS Trust



Audit of patients signing their     Nov 2003   4 West Ward               The Community Mental Health Team
CPA Care Plans                                                           have now established contact with
                                                                         out patients once a month so they
                                                                         can go through their CPA and ensure
                                                                         patients understand and sign their
                                                                         care plan.
Audit to assess the standard of     Nov 2003   Len Ram/Cressida          Audit completed. The audit identified
note keeping                                   King                      the level of CPA, enhanced and
                                                                         standard is well documented in the
                                                                         notes. The main demographic sheets
                                                                         are fully completed. Areas identified
                                                                         as lacking in detail have been
                                                                         rectified as part of the process of
                                                                         case checking. Clarification to be
                                                                         provided to staff on who the relevant
                                                                         carer is. Care co ordinators to check
                                                                         that an appointment has been made
                                                                         to attend out patient clinics. Re-audit.
Follow-up of patients during EPS    Nov 2003   EPS Team                  Awaiting report.
contact.
Audit of omitted medication         Nov 2003   Pharmacy                 File with alphabetical dividers supplied
doses                                                                  to all wards in which drug charts etc
                                                                       stored. This has helped to reduce the
                                                                       number of omitted doses.
Audit of Adherence to NICE          Nov 2003   Directorate/Area          Training of junior doctors in the
Guidelines for Patients with                   Team                      importance of consent and accurate
Schizophrenia on Atypical                                                documentation of discussion with
Antipsychotics                                                           users.
Audit of Inpatient Antipsychotic    Nov 2003   Pharmacy                  Need for the development of a Rapid
Prescribing and Comparison to                                            Tranquilization procedure identified,
NICE Guidance                                                            passed to the Drugs and
                                                                         Therapeutics Committee.
Audit of Allergy Alert Completion   Nov 2003   Pharmacy                  Amend medicine policy to state “No
on Inpatient Medication                                                  known drug allergy” NKDA or if
Prescription Charts                                                      information cannot be found to be
                                                                         endorsed UNKNOWN. To be passed
                                                                         to the Drugs and Therapeutics
                                                                         Committee.
Standards of Record Keeping in      Nov 2003   Directorate               A completed physical sheet shall be
Charring Cross Hospital                                                  placed on MDT folder. Many patients’
                                                                         folders will be replaced due to
                                                                         overuse.
The use of seclusion in mental      Nov 2003   Directorate               Changes to practice identified:
health service at Charring Cross                                         Nurses must write in time seclusion
Hospital                                                                 commenced and time ended
                                                                         Intake of food, reading of newspaper
                                                                         and attending toilets must be entered
                                                                         in seclusion forms.
                                                                         A leaflet in the process of being
                                                                         devised to provide secluded patients
                                                                         some information in the therapeutic
                                                                         use of seclusion.




                                                  23              Clinical Audit Annual Report 2003/2004
                                                                        West London Mental Health NHS Trust



Audit to measure clinical practice   Nov 2003   Directorate               A training programme to be
in the use of supportive                                                  specifically designed to equip staff
observation                                                               with appropriate skills in the use of
                                                                          Close supporting Observation;
                                                                          Every patient should have risk
                                                                          assessed; The Care plan should
                                                                          mention if a service user is on Close
                                                                          Observation; There should be proper
                                                                          communication between staff during
                                                                          handover of a patient under close
                                                                          observation; Hourly entries in reports;
                                                                          service users’ ethnic and religious
                                                                          requirements. Nurses to be more
                                                                          active in encouraging patients on
                                                                          close observation to attend
                                                                          therapeutic activities; Patients should
                                                                          be informed why they are on Close
                                                                          Observation. Where necessary, the
                                                                          patient should receive a copy of the
                                                                          observation care plan translated into
                                                                          his or her own language.
                                                                          Consideration should be given to the
                                                                          roles of relatives and/or carers in
                                                                          observation. Consideration should be
                                                                          given to move Observation practice
                                                                          from a purely Nursing responsibility to
                                                                          a Multi-disciplinary model.
An evaluation of all formal          Nov 2003   Directorate               Integrated Adult Mental Health
complaints received in H&F Adult                                          Services in H&F have been taking
Acute, measuring response rate                                            action to meet the 20 working day
against Complaint Policy from                                             deadline by looking at each individual
Jan to Dec 2002                                                           complaint. Head of Service now holds
                                                                          monthly meeting with Customer Care
                                                                          & Complaints Manager, Trust
                                                                          Complaint Coordinator and the
                                                                          Quality Monitoring Officer - H&F to
                                                                          monitor the progress of each
                                                                          individual complaint.
Audit of complaints breakdown        Nov 2003   Directorate               On average, H&F are taking 19 days
from Jan to Mar 2003                                                      to respond.
Audit of physical examination of     Nov 2003   Directorate               Changes to practice identified
in-patients                                                               development of a
                                                                          Questionnaire/Checklist to address
                                                                          key areas to improve the standard of
                                                                          care and help prevent physical
                                                                          health.
HAS recommendation: Sec              Nov 2003   Directorate               Psymon information systems must be
135/136 MHA 83                                                            updated accordingly so reliable data
                                                                          is available for research and audit.
                                                                          Discharged patients must have a
                                                                          well-organised file. The admitting
                                                                          nurse must ensure a copy of Sec 136
                                                                          is placed in the patients file.
Consent to Treatment (Sec 58)        Nov 2003   Directorate               Audit highlighted need for training for
as referred by the MHA 83.                                                nurses on Consent to Treatment.
Client Occupational Status           Nov 2003   Gloucester House          Use of access to work adjustments or
                                                                          support within the workplace. Long
                                                                          term mentoring to maintain
                                                                          employment. Use of local projects
                                                                          i.e.: City fix, Blake’s and Link.
                                                                          Continuous use of adult education
                                                                          and volunteering services.




                                                   24              Clinical Audit Annual Report 2003/2004
                                                                   West London Mental Health NHS Trust



An audit of inpatient substance   Oct 2003   Dual Diagnosis          Audit completed. Following the audit
awareness.                                   Specialist/Day          a Substance Awareness Group has
                                             Services OT             become a permanent weekly group, it
                                                                     is co facilitated by Day Services and
                                                                     Inpatient services staff. Inpatient staff
                                                                     from each unit will be involved in the
                                                                     further development of the substance
                                                                     awareness group. Training and
                                                                     educational resources are to be
                                                                     targeted, supervisory and support
                                                                     resources be identified for staff.
                                                                     Development of substance misuse
                                                                     and co morbid issues awareness be
                                                                     formally endorsed by the Trust
                                                                     Clinical & Research Governance
                                                                     Group through the development of
                                                                     policies regarding dual diagnosis
                                                                     detection, assessment and
                                                                     management planning for inpatient
                                                                     settings.
Dual Diagnosis Session            Oct 2003   Dual Diagnosis          Audit completed. Awaiting report.
Assessment Pilot Audit.                      Specialist              Jennifer sending
Audit of Assessment and           Oct 2003   Dual Diagnosis          Audit completed. Awaiting report.
Outcome of Dual Diagnosis                    Specialist
patients in H&F.
Audit of the appropriateness of   Oct 2003   Pharmacist              Poor documentation makes it difficult
prescribing of Risperdal Consta                                      to assess whether the trust is
                                                                     adhering to NICE guidance. While the
                                                                     majority of prescriptions are initiated
                                                                     at an appropriate dose and
                                                                     frequency, many patients are not
                                                                     receiving an oral test dose or
                                                                     antipsychotic cover until Risperdal
                                                                     Consta® becomes clinically
                                                                     therapeutic. This highlights a number
                                                                     of areas for improvement.




                                                25            Clinical Audit Annual Report 2003/2004
                                                                         West London Mental Health NHS Trust




Adult Acute Services – Hounslow
Audit Title                        Registered   Agency undertaking         Changes to Practice
                                                Audit
Scrutiny documentation audit of    Jan 2004     Directorate                Audit completed. 1) Highlighted
detained patient files                                                     primary care nurses documentation
                                                                           habits. 2) Ability to follow up risk
                                                                           assessments etc. Keeping track of
                                                                           standards.
Risk Assessment Documentation      Jan 2004     Directorate                Audit completed. 1) Results to be
(Paper Version)                                                            compared to those of e-CPA audit in
                                                                           which new patient admissions shall
                                                                           be analysed.
The use of modern anti-            Dec 2003     Pharmacist                 Similar atypical antipsychotic
psychotics amongst ethnic                                                  prescription patterns were found in
minority patients                                                          the minority and non-minority ethnic
                                                                           groups. There was no evidence to
                                                                           suggest ethnic disparities. The use of
                                                                           depot medication was found to be
                                                                           greater in minority compared to non-
                                                                           minority ethnic groups, although this
                                                                           result is consistent with findings of
                                                                           similar studies. A number of limiting
                                                                           factors restricted the significance of
                                                                           the data including: small sample size,
                                                                           features such as diagnosis, length of
                                                                           treatment, past treatment history and
                                                                           compliance were not taken into
                                                                           account, current symptoms and side-
                                                                           effects were not recorded thus
                                                                           preventing any assessment of
                                                                           treatment effectiveness, and patient
                                                                           characteristics such as precise ethnic
                                                                           origin and language spoken were not
                                                                           considered. Therefore, significant
                                                                           changes could not be identified.
                                                                           Following this audit the government
                                                                           launched a three-month consultation
                                                                           with local communities. The plan is
                                                                           to review the criteria used within the
                                                                           audit, consult local communities and
                                                                           re-audit
Study of increases in Asian        Dec 2003     Directorate                Audit completed. Further research
women using of Mental Health                                               required into the recognition and
Services                                                                   treatment within primary care of
                                                                           common mental disorders amongst
                                                                           ethnic minorities.

Compliance in the use of           November     Clinical Director          Awareness workshops for Healthcare
Risperdal Consta Medication –      2003                                    professionals to be run.
Baseline Audit                                                             On the introduction of a new drug
                                                                           therapy, clear guidelines to be
                                                                           established as per Trust Policies.
CUES - Service User                Nov 2003     Directorate                Changes to practice identified the
Questionnaire                                                              need to develop a consistent
                                                                           approach to information for services
                                                                           users via Acute Care Forum. An
                                                                           activity co-ordinator has been
                                                                           introduced locally.
A Study on DNA- ‘Did not attend’   Nov 2003     Directorate                Reminders to be sent to users to
in outpatient clinics.                                                     improve attendance. Estates looking
                                                                           into environment, in particular parking
                                                                           & waiting room facilities.
PRN medication                     Nov 2003     Directorate                Audit completed.




                                                    26              Clinical Audit Annual Report 2003/2004
                                                                          West London Mental Health NHS Trust



Nursing Standard Documentation       Oct 2003     Directorate               Audit completed. 1) Findings
                                                                            disseminated amongst all inpatient
                                                                            acute wards 2) Nursing staff who’s
                                                                            documentation practices are not in
                                                                            line with the set standards have been
                                                                            re-trained 3) ward managers taken
                                                                            lead to re-audit on a monthly basis.
Single Point of Entry Referral       Sept 2003    Directorate               Improvements required in primary
Panel Audit                                                                 care treatment of depression.
                                                                            Knowledge of local counselling and
                                                                            other relevant services need to be
                                                                            made available. Review/retraining of
                                                                            primary care mental state
                                                                            examinations by using mental health
                                                                            training pack/toolkit for GPs.
Evaluating Standards of Physical     Sept 2003    Directorate               While the standard nursing practice of
Care Amongst Psychiatric In-                                                temperature, pulse and respiration
Patients at Lakeside Mental                                                 rates and BP were carried out,
Health Unit                                                                 comparatively simple procedures
                                                                            such as weight, height, urinalysis and
                                                                            blood glucose levels were not
                                                                            routinely carried out. This audit
                                                                            recommended that a minimum set of
                                                                            tests at admission be developed to
                                                                            include routine monitoring of weight
                                                                            and height. Re-audit identified.
Prior antipsychotic prescribing in   July 2003    Directorate               A Clozapine Clinic bringing Hounslow
patients registered at WMUH                                                 in line with other local acute services.
currently receiving Clozapine.                                              Increased practitioners awareness
                                                                            and practices of prescribing
                                                                            Clozapine are to be addressed.
Monitoring the Levels of             July 2003    Directorate               Systems with staff at depot clinic to
Polypharmacy at the depot clinic                                            ensure patients receive at least
relating to Lampton Road, CMHT                                              annual physical check and
                                                                            medication review.



Specialist Services For Older People

Audit Title                          Registered   Agency undertaking        Changes to Practice
                                                  Audit
Audit profile of admission to 9N,    Nov 03       Directorate               The audit identified the need to
Hammersmith & Fulham                                                        further explore the management and
                                                                            treatment of some of users groups to
                                                                            identify deficits in community
                                                                            provision. Re-audit recommended.
Anti Dementia Treatment Service      Nov 03       Directorate               Changes identified providing carers
Carer Satisfaction Audit                                                    with more information about the
                                                                            service. Re-audit recommended.
Audit Discharge Summaries            Oct 03       Directorate               Training needs identified and a local
across Directorate                                                          procedure to be developed.
A Qualitative Evaluation Of A        Sept 2003    Clinical Audit Team       Recommendations for size of the
Solution-Focused Group Based                                                group and length of treatment were
In Chiswick Lodge Day Hospital                                              made.
Audit to evaluate the falls          Jul 2003     Directorate               Audit identified training to be provided
pathway and efficiency of the                                               on Risk Assessment Tool. Falls
assessment tools to identify                                                Pathway to be introduced across the
potential ‘fallers’                                                         service, Falls Protocol to be
                                                                            circulated to all clinical areas. Re-
                                                                            audit recommended.
Evaluation of shared record          Jul 2003     Divisional Audit          Data Improvement Group established
keeping post implementation of                    Group                     following the audit.
changes in Falls Assessments




                                                      27             Clinical Audit Annual Report 2003/2004
                                                                  West London Mental Health NHS Trust



Profile of admissions to       Jun 2003   Divisional Audit          The audit established that the delay
continuing care services in               Group                     in securing placements for this patient
Chiswick Lodge.                                                     group could impact on the service
                                                                    provided on 9 North in reducing bed
                                                                    availability for acute patients and may
                                                                    potentially alter the ward philosophy.
                                                                    To explore further by conducting a re-
                                                                    audit.
Allied Health Professions &    Apr 2003   Directorate               Outcomes of audit to be taken
Clinical Psychology Referral                                        forward to clinical effectiveness as
Forms                                                               MDT or cross boundary.




                                              28             Clinical Audit Annual Report 2003/2004
                                                                       West London Mental Health NHS Trust




Child & Adolescent Services
Audit Title                         Registered   Agency undertaking      Changes to Practice
                                                 Audit
Services provided for autistic      Jan 2004     Ealing                  Developing a new model of service
spectrum children and young                                              delivery involving time limited
people by neurodevelopmental                                             packages of multidisciplinary
Team                                                                     assessment and feedback on
                                                                         treatment.
Audit of interpreter service.       Oct 2003     CAMHS Ealing            Changes identified, training for
                                                                         CAMHS staff on other cultures
                                                                         choosing an appropriate interpreter,
                                                                         organising Pre & Post-session
                                                                         clinician interpreter meetings and
                                                                         introduction of a Family Feedback
                                                                         Form. Service to recommend a clear
                                                                         policy for the use of interpreters for
                                                                         WLMHT.
Health of the Nation Outcome        Oct 2003     Ealing                  Areas for change included regular
Scales for Children and                                                  training sessions, regular written
Adolescents (HoNOSCA)                                                    reminders to all clinicians involved in
                                                                         triage, completion of HoNOSCA
                                                                         scores immediately following triage,
                                                                         addition of a special marker in the
                                                                         files that would easily be removed
                                                                         once HoNOSCA completed. Re-audit
                                                                         recommended.
Youngest Users Baseline Study       Aug 2003     Clinical Governance     The audit identified the need to
                                                 Coordinator for         review the frequency of the young
                                                 Hounslow                persons route of access mechanisms
                                                                         so that any anomalies may be acted
                                                                         upon, along with mapping the
                                                                         distribution patterns of the young
                                                                         users.


Cassel Hospital
Audit Title                         Registered   Agency undertaking      Changes to Practice
                                                 Audit
An Investigation Into Prescribing   Jan 2003     Directorate             Changes to practice include
Practices in a Therapeutic                                               development of a local procedure for
Community                                                                the prescribing of psychotropic
                                                                         medications in the therapeutic
                                                                         community.




                                                    29            Clinical Audit Annual Report 2003/2004
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Forensic Service Division Wide Audits
Audit Title                         Registered   Agency undertaking       Changes to Practice
                                                 Audit
Review seclusion rooms,             Nov 03       Clinical                 Audit completed. Changes to
documentation and staff views                    Teams/Clinical Audit     practice include: establishing
throughout Local Services                        Team                     Seclusion Monitoring & Review
                                                                          Groups, review existing policy,
                                                                          training to include a de-escalation
                                                                          course which would emphasise the
                                                                          importance of record keeping and
                                                                          ensure practices are consistent
                                                                          across the Trust.
A comparison of current levels of   Nov 03       Clinical                 Audit completed. Changes to
compliance with CPA                              Teams/Clinical Audit     practice include: Standards to be
documentation throughout                         Team                     devised to act as a reference guide to
Forensic Services                                                         staff, checklist to be incorporated into
                                                                          the CPA documentation to ensure
                                                                          compliance with NSF requirements.
Secondary Induction                 Sept 03      John Cattermole          Changes to practice identified further
                                                                          review of secondary induction
                                                                          provided to staff, development of core
                                                                          and local competencies for staff, to
                                                                          provide a Foundation and Mentorship
                                                                          Awareness Course, promotion and
                                                                          external training to commence one
                                                                          year after employment following both
                                                                          parts of the secondary induction
                                                                          process.




Forensic High Secure –All Directorates
Audit Title                         Registered   Agency undertaking       Changes to Practice
                                                 Audit
Audit of Psychological input into   Jan 04       Consultant Clinical      Re-audit completed. Audit identified,
Clinical Directorates.                           Psychologist.            that in comparison to the previous
                                                                          audit, there was a more even spread
                                                                          of group work across the
                                                                          Directorates. The audit also
                                                                          demonstrated that action has been
                                                                          taken to improve the level of service
                                                                          on one ward in particular.
Baseline CPA Audit                  Nov 03       Clinical Audit Team      Provided a baseline of new CPA
                                                                          documents implemented per ward to
                                                                          assist in correlation of overall Trust-
                                                                          wide audit of CPA.
A study of met and unmet need       Apr 03       Psychology               Changes identified included need for
for non-drug therapeutic                                                  more effective multidisciplinary
interventions.                                                            communication, a more holistic
                                                                          approach to needs and additional
                                                                          resources to address areas of unmet
                                                                          needs.




                                                    30             Clinical Audit Annual Report 2003/2004
                                                                      West London Mental Health NHS Trust




Forensic High Secure Directorate – London Directorate
Audit Title                        Registered   Agency undertaking      Changes to Practice
                                                Audit
A review of current uniform –      Feb 2004     Uniform Working         The audit provided the working group
survey of staff                                 Group, Vocational       with staff views on the current uniform
                                                Services                and suggestions of improvements.
                                                                        Following costing, staff will be
                                                                        approached again.
 Audit of patients attendance at   Jan 2004     Vocational Services     Audit has provided data to enable the
non smoking sessions.                                                   Vocational Services to benchmark
                                                                        activity following re-audit in June
                                                                        2004. Changes identified designation
                                                                        of a smoking area within each area,
                                                                        and staff to be proactive in
                                                                        encouraging patients to attend non-
                                                                        smoking sessions.
Review of Activities offered by    July 2003    Vocational Services     Suggested recommendations for the
the Vocational Services                                                 units to hold ‘Open Days’ to enable
                                                                        patients to visit and discuss activities
                                                                        available, advertise activities, explore
                                                                        options around offering specific
                                                                        activities, improve methods of
                                                                        seeking patients views, and to create
                                                                        more awareness as to what is
                                                                        available. Re-audit July 2004.
Assertive Rehabilitation Review    May 03       Deputy Director of      The audit led to pilot sites being
                                                Nursing                 identified to implement assertive
                                                                        rehabilitation, specific training being
                                                                        available to staff working on these
                                                                        areas, the appointment of a dedicated
                                                                        senior nurse to provide leadership
                                                                        and developmental skills/support.
Patients Progress Review           Apr 2003     Vocational Services     The audit established that following
                                                                        the introduction of a Patients
                                                                        Progress Form reporting on progress
                                                                        had improved. Areas for
                                                                        improvement included involvement of
                                                                        all staff as Link Workers to raise
                                                                        communication within Clinical Teams,
                                                                        establish why there is disparity
                                                                        between units and the number of
                                                                        reports submitted, to produce a guide
                                                                        to report writing, and to provide a
                                                                        timescale for the production of
                                                                        reports.




                                                   31            Clinical Audit Annual Report 2003/2004
                                                                       West London Mental Health NHS Trust




Forensic High Secure Directorates – South of England Directorate
Audit Title                          Registered   Agency undertaking     Changes to Practice
                                                  Audit
Antipsychotic prescribing audit on   Feb 04       SpR Henley Ward        Consideration to be given to
Henley Ward                                                              developing a trust-wide protocol
                                                                         addressing the issue of high dose
                                                                         antipsychotic prescribing, developing
                                                                         standards to ensure consent is
                                                                         documented and assess whether
                                                                         consent for antipsychotic drugs is
                                                                         specifically documented. To be
                                                                         passed to the Drugs and
                                                                         Therapeutics Committee.
An audit of antibiotic use in-       Dec 2003     Ward Team and          Findings indicated that patients on
patients on Clozapine.                            Pharmacy               clozapine are more likely to be
                                                                         prescribed antibiotics. Reasons to be
                                                                         explored further leading to proposals
                                                                         for changes in practice.
A qualitative audit of Care Plan     Sept 2003    Ward Team              Variable quality of CPA documents.
documents on Folkestone Ward                                             CPA processes implemented to
                                                                         address the issues raised within the
                                                                         audit. Re-audit May 2004.
Audit of CPA processes –             June 2003    Ward Team              Difficulties in CPA process were
Mendip Ward                                                              identified and changes suggested.
                                                                         To participate in the Trust-wide CPA
                                                                         audit.



Forensic High Secure Directorates – Women’s Service
Audit Title                          Registered   Agency undertaking     Changes to Practice
                                                  Audit
Atypical Antipsychotics - Preston    Nov 03       Pharmacy               Audit completed.
ECG - Preston                        Nov 03       Pharmacy               Audit completed.



Forensic High Secure Directorates – DSPD
Audit Title                          Registered   Agency undertaking     Changes to Practice
                                                  Audit
DSPD – Flexi shift Pattern Audit     Jan 04       Gillian Tuck           Audit completed awaiting
                                                                         recommendations and actions.




Forensic Medium and Local Secure Directorates
Audit Title                          Registered   Agency undertaking     Changes to Practice
                                                  Audit
Referrals from HMP Wormwood          Mar 04       SHO                    Audit completed. Awaiting full report.
Scrubs to the Bentham Unit
Review of Community Meetings         Feb 04       Senior Nurses          Areas of good practice are to be
                                                                         replicated across the Directorate to
                                                                         ensure service user involvement.
Physical Healthcare, long stay       Feb 04       Consultant             Following physical examination on
Medium Secure                                     Psychiatrist           admission, half of the patients were
                                                                         referred to specialist services. 60% of
                                                                         patients had not had 6 monthly ECG
                                                                         checks. As a result standards are
                                                                         being devised in conjunction with
                                                                         Broadmoor Physical Healthcare
                                                                         Group.



                                                      32          Clinical Audit Annual Report 2003/2004
                                                                       West London Mental Health NHS Trust



Psychological Therapies             Feb 04                               All consultants said that
Consultant Satisfaction.                                                 psychoeducation should be available
                                                                         for all patients, some said that coping
                                                                         skills / stress management,
                                                                         supportive psychotherapy and social
                                                                         skills should be available to all. IQ
                                                                         testing, neuropsychology and
                                                                         addiction relapse prevention were
                                                                         requested at referral. The least
                                                                         popular interventions were family
                                                                         therapy, and psychoanalytic
                                                                         psychotherapy.
Arts Therapies - Audit Of Medical   Jan 2004   Art Therapy Dept          There was a high level of satisfaction
Consultants’ Views                                                       with the arts therapies service and
                                                                         access to it. The main perceived
                                                                         value of the arts therapies is for
                                                                         ongoing assessment of patients’
                                                                         mental state and behaviour, and
                                                                         exploration of relationships in a
                                                                         group. The need for more specific
                                                                         initial assessments was identified, as
                                                                         was a general need for more
                                                                         individual and group therapy. Many
                                                                         respondents seemed to perceive an
                                                                         occupational value to the arts
                                                                         therapies. There was a lower
                                                                         awareness of the area of treatment
                                                                         where arts therapists view work as
                                                                         central,     that     of   the   internal
                                                                         psychological         and      emotional
                                                                         functioning of the patient. Clearly this
                                                                         affects the perceptions of the
                                                                         contribution of the arts therapies to
                                                                         index offence related work.
                                                                         This highlighted the need for us to
                                                                         raise awareness of how the arts
                                                                         therapies contribute to patients’
                                                                         treatment goals. It also highlighted
                                                                         the      need     for    more   in-depth
                                                                         discussions between our department
                                                                         and the clinical teams about
                                                                         individual patient treatment goals.
Arts Therapies - Audit Of           Jan 2004   Head of Arts Therapy      The Audit had highlighted opportunity
Supervision                                                              for clinicians to:
                                                                         Focus on clinical work, Input and
                                                                         learn from others,
                                                                         Share concerns, ideas and support,
                                                                         Understand institutional perspectives
                                                                         Suggestions:
                                                                         Peer supervision
                                                                         Supervision for supervisors
                                                                         More regular supervision.
Referrals to maximum security       Oct 03     Clinical Audit Team       Audit established that referrals were
                                                                         suitable for treatment in Regional
                                                                         Secure Unit. And were presently
                                                                         appropriately placed. To be taken
                                                                         forward to the Admissions Panel.
                                                                         Associate Medical Director has
                                                                         recommended topic for research.

Nursing Records                     Jul 03     Practice Development      There seems to be a clear difference
                                                                         between what registered nurses
                                                                         consider to be good record keeping
                                                                         and what is actually demonstrated in
                                                                         practice. This report is to be
                                                                         forwarded to the Nursing Strategy
                                                                         Group to develop an action plan and



                                                  33              Clinical Audit Annual Report 2003/2004
                                                                         West London Mental Health NHS Trust



                                                                          agreed time scales.
The Prevalence of the DSM IV         Jul 2003     Psychology              The notes of 162 patients were
Diagnostic Criteria for Borderline                                        reviewed to assess for the presence
Personality Disorder in a Male                                            (definite or possible) or absence of
Forensic Inpatient Settings and                                           reporting of any of the nine symptoms
Implications for Treatment                                                of BPD (as described in the
                                                                          Diagnostic and Statistical manual of
                                                                          Mental Disorders Version IV: DSM-
                                                                          IV).



Audits involving Partner Agencies
Audit Title                          Registered   Agency undertaking      Changes to Practice
                                                  Audit
Review of the West London            July 03      Health & Social Care    The audit identified the need for
Medium Secure Unit, Three                         Advisory Service        development of a protocol for
Bridges.                                                                  admissions clearly defining the unit,
                                                                          to improve contact with
                                                                          representatives from the local
                                                                          community, to review of interventions
                                                                          provided on the wards, the
                                                                          development of a service user forum.




                                                     34           Clinical Audit Annual Report 2003/2004
                                                     West London Mental Health NHS Trust




6.0 THE CLINICAL AUDIT TEAM
This year has seen the Clinical Audit Team consolidate its approach to a
Trust-wide service. The Team continue to support and develop Clinical Audit
and to support clinical governance structures throughout the Trust.

Individual members of the clinical audit team have been allocated to specific
clinical areas to ensure comprehensive support for developing clinical audit.

The clinical audit team has designed a ‘Clinical Audit Handbook’, which will be
launched in June 2004. This handbook contains a guide for all staff on the
completion of clinical audit, describes the resources and help available to
assist to complete the audit cycle.

 The clinical audit team has developed a database, to enable the registration
and monitoring of audit activity, and track changes to practice, as a result of
clinical audits. A baseline audit of project activity has been undertaken.




                                     35         Clinical Audit Annual Report 2003/2004
                                                        West London Mental Health NHS Trust




6.1 OBJECTIVES 02/03:
Objective 1
To facilitate the communication and understanding of Clinical Governance,
Effectiveness and Audit throughout Local Services.

The clinical audit team has now established good channels of communication
via attendance at appropriate forums eg. Audit groups, clinical improvement
groups, directorate clinical improvement groups and working groups.

Objective 2
To support staff by offering a series of training opportunities on Clinical Audit.

As previously mentioned the clinical audit team has been providing and will
continue to provide formal training sessions. The team has also been
providing on-site sessions as requested.

Objective 3
To participate in Clinical and Research Governance Committees and Clinical
Improvement Groups (CIGs), offering advice and support.

Each clinical audit team member is identified to support a particular
directorate. They attend meetings with an audit remit and assist in facilitation
of audit groups.

Objective 4
To undertake Trust-wide and Local and Forensic Division clinical audits and to
facilitate staff to undertaking local audits.

This year has seen the clinical audit team developing a proactive relationship
with wards/areas/services in the identification and completion of clinical audit.
The approach has been one of support to ensure Trust staff are empowered to
complete audit, are provided with the necessary skills, knowledge and
expertise and own the benefits and outcome of clinical audit.

Objective 5

To offer all staff the facility of being able to contact the teams to gain ‘expert
advice’ on issues such as obtaining current national standards, audit tools,
literature searches, help with audit design and analysis.




                                        36         Clinical Audit Annual Report 2003/2004
                                                       West London Mental Health NHS Trust




The clinical audit team has concentrated on promoting clinical audit at the
local interface, through a range of approaches such as attending ward/area
meetings to attending specific working groups. This has assisted the clinical
audit team in developing a positive rapport with Trust staff. Over the last year
communication with the clinical audit team has increased.


6.2 OBJECTIVES 04/05:
Whilst the clinical audit team has maintained the above objectives throughout
2003/2004, new objectives for the coming year have been identified.

To achieve these objectives the clinical audit team has identified a number of
Standards, which will be shared with Trust staff.

To train and empower service users and staff to undertake, participate and
promote clinical audit.

Standards:
             •   Formal clinical audit training is provided monthly
             •   Specialist clinical audit training is provided when required
             •   Attending monthly clinical audit groups within each
                 directorate
             •   To provide ongoing support and advice to those completing
                 audit projects.




To provide advice, information, expertise and support in improving service
users care through clinical audit.

Standards:
             •   To promote ownership and empower service users and staff
                 to complete audit
             •   A particular priority is to ensure those undertaking clinical
                 audit projects have an understanding of the audit process
                 prior to commencing a project. To facilitate this we will offer
                 help in:
                            • Writing a clinical audit proposal
                            • Ensure peer review of the proposal
                            • Identify expert advice and relevant literature
                               sources if needed
                            • Support when submitting a clinical audit
                               proposal
                            • Support and advice to clinical audit leads to
                               undertake quality audit in their areas.




                                      37          Clinical Audit Annual Report 2003/2004
                                                       West London Mental Health NHS Trust




To influence positive changes in practice we will monitor, record and identify
clinical audit projects on an ongoing basis.

Standards:
             •   To maintain, on the information we receive, a database of all
                 audit activity which we will share via the n.drive
             •   To attend relevant forums to assist in the identification and
                 feedback of clinical audit projects
             •   To advertise the positive benefits of undertaking clinical audit
                 by:

                                  •   Workshops
                                  •   Surgeries
                                  •   Seminars
                                  •   Presentations
                                  •   Email
                                  •   Posters
                                  •   Magazines
                                  •   Publications

To ensure clinical audit findings are shared throughout the Trust.

Standards:
             •   To provide a forum to share positive changes to practice
             •   To advertise via the intranet and Trust publications
             •   To ensure clinical audit activity is decentralised throughout
                 the Trust and visa versa




                                      38          Clinical Audit Annual Report 2003/2004
                                                        West London Mental Health NHS Trust




7.0 The Future
Launch of strategy and handbook

Ongoing training:

   •   Delivery of Clinical Audit priorities
   •   Establishing protocol peer review group and mechanisms to quality
       assured audit reports

Through the processes of training, experiential learning, advice and support in
all aspects of clinical audit and dissemination of findings, the Trust wishes to
raise the profile of audit. To this end a Clinical Audit Strategy has been
drafted, also a Clinical Audit Handbook has been designed.                  These
documents will be launched in June 2004. These documents with the
previously outlined Clinical Governance Strategy and Research Governance
Strategy will ensure that the West London Mental Health NHS Trust continues
to promote clinical audit activity as a requirement of all staff working within the
Trust.

To promote dissemination of audit findings and positive changes to practice, a
clinical audit database has been established. The database will include all
clinical audit activity taking place and planned, and identified improvements in
care. This will be available to all staff through the Trust shared drive. The
Clinical Audit Team are also pursuing a web page to share good practice.



7.1 Programme of Clinical Audit 2004-2005
Trust-wide Clinical Audit priorities have been agreed (Table 1), and a
programme (Appendix 3) of activity developed. This will provide a guide for
Clinical Directorates and assist in forward planning of local audit programmes.

Working groups and local Clinical Improvement Groups will be engaged in the
development of the audit proposals, methodology, questionnaires etc to
enable inclusion of issues relevant to their service.




                                        39         Clinical Audit Annual Report 2003/2004
                                                         West London Mental Health NHS Trust




TABLE 1

                         Trust Audit Priorities 2004/2005


Trust Wide Audits 2004/2005
1.Re-audit of seclusion practice via Seclusion Monitoring and Review Groups

2. Re-audit of Compliance with CPA documentation

3. NICE Audit - Use of Atypical Antipsychotic drugs in the treatment of Schizophrenia

4. NICE Audit – Use of Donepezil, galantamine and rivastigmine for the treatment of
dementia

5. NICE Audit – Use of methylphenidate for ADHD

6. NICE Audit – Use of ECT

7. Suicide Prevention Audit

8. National Audit of Violence

9. Mental Health Service User Survey

10. Safe Guarding Children

11. Risk Assessment Audit

12. A review of compliance levels with Level 1 Clinical Negligence Scheme for Trusts
(CNST) Standard 4.1.7

13. Review partnership risk management arrangements.

14. Copying patient’s letters.




                                         40         Clinical Audit Annual Report 2003/2004
                                                                     West London Mental Health NHS Trust




                                                                                           Appendix 1




                                   Local Clinical Improvement
                                             Groups




                                         Hounslow
                                            Adult,
                                        Clinical Audit
                 Charing Cross              Group                        High Secure
                 Adult , Audit &                                           Audit &
                 Performance                                             Performance
                    Group                                                   Group




     Ealing                                 Trust                                         Local/Medium
     Adult                              Clinical Audit                                       Secure
      Audit                              Committee                                         Audit Group
     Group




                                                                        Cassel Hospital
                CAMHS                                                    Clinical Audit
              Audit Group                                                    Group

                                        Older Peoples
                                          Services
                                        Clinical Audit
                                            Group




                                                                                           Forensic Division
Local Division                                                                                Clinical &
  Clinical &                                                                                  Research
  Research                                                                                   Governance
 Governance                                                                                     Group
   Group



                                         Trust Clinical &
                                        Audit Committee




                                                 41             Clinical Audit Annual Report 2003/2004
                                                              West London Mental Health NHS Trust




                                                                                  Appendix 2

 IDENTIFY AUDIT                  10 STEPS TO CLINICAL AUDIT
     TOPIC



     BEGIN AUDIT                 Make Changes and                                Action
       PROCESS                     Disseminate
                                    Define action plan               Audit lead to write report
                                    Consider re-audit                and forward to sponsor
 Establish audit project           Disseminate widely
                                Notify Clinical Audit Team           Present findings locally
          lead
                                         and CAC
 Check audit data base                                               Inform Clinical Audit team
             1                            10                                        9

                                                                       Monitor by Project
    Contact with
                                                                           Sponsor
    Clinical Audit
    Team                                                               They inform the Clinical
                                                                       Audit Team of progress
Audit project lead contacts
clinical audit team for audit
proposal form & guidance
notes
                                                                                    8
             2

                                                                            Approval/
    Project Sponsor                                                      Commencement of
                                                                             Project
  Trust wide or Divisional
  wide lead to sign audit                                                Back to audit lead and
         proposal                                                           audit sponsor


                                                                                     7
             3


Submit Audit Proposal                                                    Clinical Audit Team
to Clinical Audit Team                                                       Assistance
                                     Peer review                         Trust wide audit priorities
   Submit completed audit                                                   will be provided with
          proposal                                                       assistance. Local audits
                                   Clinical Audit                        will be supported through
                                   Committee                               training and access to
                                                                          resources and material

             4                             5                                         6

                                            42           Clinical Audit Annual Report 2003/2004
                                                                             West London Mental Health NHS Trust




                                                                                                     Appendix 3



                CLINICAL AUDIT ANNUAL PROGRAMME 2004/2005


               AUDIT                    Apri   May   June       July   Aug   Sept     Oct     Nov      Dec   Jan     Feb   Mar
                                        l 04   04     04         04    04     04      04      04       04    05      05    05
NICE – Atypical
NICE – Dementia
NICE – ADHD
NICE – ECT                               -      -      -         -     -       on     hold       -      -        -   -      -
National Audit of Violence – Module 1
National Audit of Violence – Module 2
National Audit of Violence – Module 3
Suicide Prevention
Seclusion Re-audit
CPA Quantitative Re-audit
CPA Qualitative New audit
Mental Health Service User Survey-
Outpatient
Mental Health Service User Survey-
Inpatient
Safe Guarding Children                                           -     no    date       -    -          -        -   -      -
Risk Assessment Audit                                            -     no    date       -        -      -        -   -      -



                                 NICE – ECT Audit: Awaiting ratification of Trust policy.




                                                           43           Clinical Audit Annual Report 2003/2004
                                                   West London Mental Health NHS Trust




References

West London Mental Health NHS Trust, Clinical Audit Annual Report
2002/2003.

West London Mental Health NHS Trust, Clinical Governance Strategy, 2003.

West London Mental Health NHS Trust, Clinical Audit Strategy, 2004.

West London Mental Health NHS Trust, Best Practice Clinical Audit
Handbook – Making Positive Changes in Practice, 2004




                                    44        Clinical Audit Annual Report 2003/2004

								
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