IMR Action Plan Guidance - Kent County Council

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IMR Action Plan Guidance

Overarching recommendation: Recommendations may stem from a variety of sources, including, Domestic Homicides reviews,

Inspections and reviews (internal and external), Audits (including peer reviews and case file audit) or single agency objectives.

Recommendations and their dated, source should be quoted here. This allows all action plans to be integrated into one overarching action

plan without losing the source.

Identified improvement area / desired outcome: Each recommendation may have several areas of improvement or outcomes. This

should be what you intend to achieve and include any specific numeric targets.

Identified improvement areas / desired outcomes and the corresponding specific actions must be SMART (Specific, Measurable,

Achievable, Realistic and Timely) and outcomes focused.

Planning

Action number: Each identified improvement area / desired outcome must be numbered, with separate actions under this having a sub

number (1.1, 1.2,1.3).

Specific action and timescale: Include each specific action you will take to achieve your desired outcome. Deadlines for completion

MUST be stated for all actions to aid monitoring.

Accountability: The agency with lead responsibility MUST be identified and should include a named professional.

Success indicators: Detail what indicators or performance measures will be used to measure success against the action and desired

outcome. Timescales MUST be identified. Consideration should be given to how you are able to demonstrate actions have been

completed and impact on practice and the welfare of children and families can be measured and evidenced.

Monitoring

Risks, progress and additional actions: Description of activity/progress that has been completed against the action and achievements

against success indicators. Activity/progress/achievements MUST be dated. Any risks to achieving outcome and any additional actions

taken as a result should also be recorded here.

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RAG rating: Each action should be given a RAG (Red, Amber, Green) rating according to the following definitions:

Progress/indicator RAG status

Work is significantly behind schedule and no progress has been made, and/or Progress has been made

but the timescale has not been achieved.

Progress is being made, progress is good and the action is likely to be achieved within timescale. Or the

action has been completed but evidence is required to demonstrate achievement.

The action has been completed and there is a record of evidence to support its completion.

Impact and evidence: Has the desired outcome been achieved? What evidence supports the achievement? Record the difference that

has been made to the lives of individuals and their families, how is the difference evidenced? N.B RAG rating cannot be green without

evidence recorded here. Sources may be staff or service user surveys/interviews, individual feedback, supervisions, improvements against

baseline, audits etc.

Using the template: Table can be copied and pasted; properties are set to allow boxes to expand and for rows to break over pages.

Additional lines can be added to the table as required.

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Safeguarding Adults Review - Action Plan – MS

Planning Monitoring

Action number

Specific action and timescale

Responsibility Success

indicators Risk, progress and additional actions

RAG rating

Impact and evidence

To be Reviewed March 2016

Overarching Recommendation: Implement all the Recommendations from the MS Safeguarding Adults Review

Source of recommendation: Safeguarding Adults Review re MS

Feedback workshops will be delivered to multi-agency staff to raise awareness of the issues which have come out of the last two SCR / SARs.

1. Identified improvement area / desired outcome:

Kent Police must ensure that their officers understand the power of arrest for breaching a restraining order.

Kent Police Kent Police will undertake to remind officers of their powers for breach of non-molestation orders.

Head of Public Protection

Kent Police

Database of Non Mols centrally held by CCOT already established working practice.

CCOT currently centrally collate Non Mols to ensure timely update of accurate information.

Yellow Orders Article re Civil Court Injunctions 3rd August 2015.

Force Policy strengthened to include positive action statement for Non Mols.

Update KPC to embed all recommendations into VA training across courses.

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2.

Identified improvement area / desired outcome:

Agencies that are the subject of this SAR must ensure that their processes for engaging with partner agencies at practitioner level are robust enough to ensure that meaningful outcomes can be achieved.

Dartford & Gravesham NHS Trust

To ensure that the processes for engaging with partner agencies at practitioner level are robust and meaningful.

Pathways and contacts to be identified within 6 months.

Lead:

Director of Nursing & Quality

Responsibility:

All Registered Nurses and Doctors

As this has yet to be implemented this cannot be currently measured.

Risk: Due to changing needs within the acute hospital, staff change, rotate and move departments. Communication between partner agencies may break down as a result of this.

Actions: Communication pathway needs to be developed and made available in all wards and departments including Emergency Department.

Progress: This needs to be developed so that all staff are aware of what partner agencies are involved with individual patients.

RED This process has not been started therefore the impact of the actions cannot be monitored at this stage.

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Kent County Council

Training to reinforce processes for engaging with partner agencies.

Operational Managers/ Operational Directors/ Head of Adult Safeguarding

All meetings, e.g. Professionals Meetings commence with robust Terms of Reference that inform the right audience and have clear outcomes.

Information sharing protocols available to all partner agencies.

Meetings will continue to be ineffective if there are no clear outcomes identified or attributable Actions within a clear timeframe.

Further safeguarding alerts will occur.

Staff are reminded of the importance of the processes for engaging with partner agencies through current adult safeguarding training.

Practice audits focus on paperwork completed and outcomes for individuals who are the subject of safeguarding alerts.

Workshops will be delivered to ensure that staff are aware of the lessons learnt from the SAR in order to improve practice in October 2015.

Kent and Medway NHS and Social Care Partnership Trust

Share Learning via a Special Edition of the CRSL Learning Bulletin.

CRSL Service Manager

All extraordinary Meetings, e.g. Professionals Meetings, commence with robust Terms of Reference that inform the right audience and clear outcomes.

Meetings will continue to be ineffective with no clear outcomes identified or attributable Actions being taken within a clear timeframe and further Serious Incidents occur.

To be monitored via a reduction in ‘near misses’ and actual safeguarding incidents being reported Trust wide.

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Already shared via the KMPT Learning Bulletin for May ’15.

Kent Police Kent Police to contact other agencies with relevant knowledge and experience of person.


Kent Police

Force Policy strengthened to include contacting other agencies with experience of person.

Force Policy Update w/c 10/08/15

Force Policy Update w/c 10/08/15 and Yellow orders


NHS England

All GPs at Practice A have adult safeguarding level 2.

Practice A All GPs provide certificates as evidence of training and provide evidence of review of procedures within the practice in relation to referral to other agencies.

Will be as part of the record card audit in action 3.

Significant event review held 5 January 2015 but did not address safeguarding issues, this feedback is currently being shared with the practice.

3.


When experiencing difficulties engaging with people with disabilities, Kent Police should consider contacting other agencies with relevant knowledge and experience.

Kent Police Multi Agency meetings when

Head of Public Force Policy Update Force Policy Updated w/c 10/08/15 and

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initiated by Kent Police must ensure representatives have aims outlined at an early stage to ensure agency representatives present have authority to commit resources and deliver agreed outcomes.

Protection

Kent Police

Yellow orders.


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4.


Kent Police must ensure that when they initiate multi-agency meetings, representatives attending have authority to commit the resources necessary to achieve the aims of the meeting.

Furthermore, they must ensure that the aims of the meeting are made clear when invitations are sent so that other agencies send representatives with an appropriate level of authority.

Kent Police Kent Police must engage sensitively with vulnerable people and do not seek to criminalise behaviour as a primary means of resolution.


Kent Police

Force Policy Update. Force Policy Updated w/c 10/08/15 and Yellow orders

‘Do the Right thing ‘CJ resolutions being promoted within Force.


DC White Specialist trainer aware and updating Uniform Training re this.

5.


Kent Police must ensure that its officers and staff deal sensitively with vulnerable people, engaging with other agencies when appropriate, and do not seek to criminalise their behaviour as a primary means of resolving a situation.

Kent Police All agencies to be aware of Self Neglect policy.


Kent Police

Force Policy update and link to document via KCC website once status of document ascertained.

Update KPC to embed all recommendations into VA training across courses

DC White Specialist trainer aware and

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updating Uniform Training re this.


KMPT must have a process that ensures requests for information are followed up if no reply is received.




Every Care Coordinator will have in place audit trail systems for all information requested from other Agencies / Professionals that includes a timescale for response and outcome, including any escalation required.

That vital information related to the patients care will not be available for Care Planning and Risk Management decisions.



Discussed at: Trust Wide Safeguarding Group on 17th June 2015 and Trust Wide Learning from Experience Group 27th May 2015.

KMPT Safeguarding Lead

Trust wide empowerment of KMPT staff to clarify the Terms of Reference and outcome for any meetings they convene or attend.

That vital information related to the patients care will not be available for Care Planning and Risk Management decisions.


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That vital information related to the patients care will be available for Care Planning and Risk Management decisions.

7.


Where KMPT receive information that may indicate that criminal offences are being committed, it must be referred to Kent Police.




KMPT staff will recognise that a possible crime of abuse has been disclosed to them and that they take the appropriate action informed by the JAPAN principles of consulting the police for advice and possible further action.

Staff will not have the confidence to consult with the police regarding the possibility of reporting potential crimes.

Vulnerable adults will be exposed to further risk of criminal abuse.

To be monitored via a reduction in ‘near misses’ and actual safeguarding and Serious incidents being reported Trust wide.

Kent and Medway NHS and Social Care

Discussed at: Trust Wide Safeguarding Group on 17th June 2015; Trust Wide


KMPT staff will recognise that a possible crime

Staff will not have the confidence to consult with the police regarding the

To be monitored via a reduction in ‘near misses’ and actual safeguarding and

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Partnership Trust

Learning from Experience Group 27th May 2015 and Trust Wide Quality Committee May 2015.

of abuse has been disclosed to them and that they take the appropriate action informed by the JAPAN principles of consulting the police for advice and possible further action.

There will be Executive and Operational management authority in support of this good practice requirement.

possibility of reporting potential crimes.


There will be a lack of managerial and Executive oversight of all these Actions.

Serious incidents being reported Trust wide.


Joint Working with the Police and other Agencies included in all levels of Safeguarding Adult Children.

KMPT Safeguarding Team Trainers

KMPT receive reinforced messages about the importance of joint working to safeguard those in their care.

Staff will not have the confidence to consult with the police regarding the possibility of reporting potential crimes.



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8.


KMPT must ensure that they have a process in place to ensure that work done by student social workers is effectively supervised.




All Social Work Students are allocated a Supervisor and all their records, significant decisions and interventions are monitored and approved.

Students are unsupervised and those in their care could be exposed to risk of abuse.

Embed National and KCC Supervision Policy Documents for Student Social Workers.

9.


KMPT should examine the contradictory decisions made following Client’s final referral to establish whether there is a need to make their internal communication process more effective.




KMPT staff within the various teams is as a matter of routine checking Patient Information Systems to clarify if the referee is already open to KMPT and so negate the need for a new referral.

There will be delays in the vulnerable client accessing care with potential serious consequences.

There will be frustration amongst partner agencies with loss of confidence and reputation as a provider care of safe


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nature.


Discussed at: Trust Wide Safeguarding Group on 17th June 2015; Trust Wide Learning from Experience Group 27th May 2015 and Trust Wide Quality Committee May 2015


KMPT staff within the various teams is as a matter of routine checking Patient Information Systems to clarify if the referee is already open to KMPT and so negate the need for a new referral.

There will be Executive and Operational management authority in support of this good practice requirement.

There will be a lack of managerial and Executive oversight of all these Actions.


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10.


When reviewing and amending their DNA policy, KMPT should emphasise the need to consider consulting other agencies who the person might be more willing to engage with.




Those clients who will not engage with Mental Health Services are ‘signposted’ to other agencies they are more comfortable working with and therefore their vulnerability / safety is monitored and managed if necessary.

Vulnerable adults will not be safeguarded properly and so exposed to possible on-going abuse or neglect.



Identify a means of auditing the manner in which a sample of clients who have DNAd their appointments have been further managed by the team during the months of July, August and September 2015.



That KMPT staff are responsible and ‘creative’ in the manner in which they manage those clients difficult to engage.

There will be evidence that KMPT staff are not ‘going the extra mile’ to connect with those clients who are assessed as requiring some level of mental health service.

Outcome of audit.

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KCC should produce and implement a policy containing directions and guidance about the methods of contact and number of attempts that are made before a case is closed.

Kent County Council

Awareness raising training sessions for staff

Operational Managers/ Operational Directors/ Head of Adult Safeguarding

Risk assessments will be completed, proportionate to the presenting need

The use of professionals meetings when SU is not engaging and at risk is understood and implemented by staff

Risk panels will be convened and where appropriate with other agencies.

Further training will be delivered to ensure staff are aware of and know how to implement policies and procedures.


12.


KCC must ensure that all staff who may receive referrals understand what action they must take to ensure that the appropriate response is provided.

Kent County Council

Email will be sent to staff from Andrew Ireland, Corporate Director in September 2015.

The email will remind staff and managers that processes need to be in place to ensure appropriate

Head of Adult Safeguarding

Managers understand what action they must take to ensure appropriate responses are provided.

Appropriate responses are not provided where referrals are received.

Staff are reminded of the importance of ensuring appropriate responses are provided through current adult safeguarding training.

Workshops will be delivered to ensure that staff are aware of

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responses are provided.

the lessons learnt from the SAR in order to improve practice in October 2015.


KCC must ensure that urgent work is covered when staff are absent and there are systems to support this.

Kent County Council

Email will be sent to staff from Andrew Ireland, Corporate Director in September 2015.

The email will remind staff and managers that processes need to be in place to ensure urgent work is covered when staff are absent. This includes the use of out of office messages and ensuring adequate cover arrangements.

Head of Adult Safeguarding

Staff ensure that urgent work is covered when staff are absent.

Urgent work may not be completed if there are not systems in place to support such work being covered when staff are absent.


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14.


GPs must review their approach to safeguarding adults and children, which must include the requirement to refer safeguarding concerns to other agencies as appropriate.

NHS England

Level 2 Safeguarding Training signposted by designated nurses with the GP Practices.

Time: Rolling schedule re above.

Director of Nursing, NHS England/ Or CCGs

Training completion, all practitioners obtaining Level 2 adult and Level 3 child safeguarding training.

NHS England and CCGs share a responsibility for ensuring that GPs have undergone Safeguarding training.

Operation Landscape Action Plan suggested that all GPs should aspire to Level 2.

Evidence of all child and adult safeguarding training was requested from the Practice A. NHS England have made it a mandatory requirement for ALL practitioners to achieve Level 3 child safeguarding and Level 2 Adult safeguarding by the 5th October 2015 and if that training was over a year old for it to be redone. All practitioners complied and completed all the required training and submitted evidence to support this.

15.


NHS England must ensure that there is a review of the medication prescribed to all other patients at Practice A who are subject to polypharmacy.

NHS England

50 record card audit to be undertaken on patients on

Medical Director, NHS

That the audit of Practice A produces results

Awaiting Audit results. Report due

Practice A was asked to review all patients on polypharmacy by

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polypharmacy by the 30.09.2015.

England showing that polypharmacy patients are managed appropriately.

30/09/2015. the 16th October 2015. The practice has confirmed that all patients have been reviewed and that this is complete. NHS England is in the process of conducting an audit to ensure that this process has been completed adequately. Confirmation is due by the 30th November 2015.

16.


NHS England must consider what action is appropriate in the light of the serious concerns about Practice A that are described in this review.

NHS England

Individual clinicians in the care to be identified and referred to the Performance Advisory Group (PAG)

06.08.2015.

Medical Director, NHS England

Evidence of appropriate CPD conducted.

Reasonable explanation and actions in line with GMP and NICE guidelines.

Discussion within yearly appraisal documented.

4 out of 5 clinicians completed the PAG process in August 2015 and successfully remediated.

1 outstanding – further information available 17/9/15.

An investigation into the death of patient MS was conducted. All identified clinicians involved in the care of the patient were subject to NHS England’s performance process. Operational deficiencies within the practice were highlighted and these have been passed to

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NHS England’s direct commissioning department to manage as part of the practice’s contract with NHS England. Further to this, NHS England commissioned an audit to look at the safety and management of patients on polypharmacy at Practice A. The audit revealed that the management was broadly safe however identified an individual clinician with deficiencies in his/her practice. This practitioner has entered the performance review process to ensure that appropriate learning and remediation occur.

17.


The Chair of KMSAB should seek to establish the outcome of any NHS England investigation of this case in order to satisfy the Board that patients at Practice A are not at risk of harm resulting from the issues identified during this review.

Chair of KMSAB

The Chair of KMSAB wrote to NHS

Chair of KMSAB The KMSAB is satisfied that

Patients at Practice A continue to be at risk

Patients at Practice A are not at risk of harm

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England, asking to be advised of the outcome of the NHS England investigation by 31 October 2015.

patients at Practice A are not at risk of harm resulting from the issues identified during this review.

of harm. resulting from the issues identified during this review.

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18.


Dartford & Gravesham NHS Trust must ensure that a mental capacity assessment is undertaken in appropriate cases and that this, together with the results of the assessment, are clearly recorded.


Mental capacity assessments (MCA) are undertaken in appropriate cases.

With immediate effect.

Lead:

Director of Nursing & Quality

Responsibility:

All registered professionals and Doctors

MCA are completed in all areas for health treatments and discharge from hospital. The MCA is completed by the most appropriate registered professional.

The MCA would need to be audited in order to measure the success of the recommendation.

Risk: MCA are not carried where appropriate resulting in decisions made by the patient, who does not have capacity, to be unsafe.

Progress: MCA whole day training delivered by a Kent County Council (KCC) trainer is available to all registered professionals. MCA is covered in Core induction training and Mandatory updates. Support to complete an MCA is offered where assistance is asked for.

Additional actions: An audit of patient notes to identify the consistency of the MCA.

All staff continue to attend mandatory updates which include MCA, this is also delivered in core induction.

All registered professionals are frequently reminded of when MCA training delivered by KCC. The number of staff who have received MCA training continues to improve.

This will be an ongoing requirement due to staff turnover in the acute setting.

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Mental Capacity Assessments (MCA) must be clearly and appropriately recorded in all wards and departments

With immediate effect

Lead: Director of Nursing & Quality.

Responsibility:

All registered professionals including Doctors

MCA forms are available in the electronic patient system. Patient information is populated from the electronic record and then stored in the individual’s records.

Risk: MCA not recorded appropriately with correct documentation could lead to unsafe decisions being made. The documentation of mental capacity when someone self-discharges is not always documented, this needs to be improved.

Progress: MCA whole day training delivered by a Kent County Council trainer is available to all registered professionals. MCA is covered in Core induction training and Mandatory updates. Support to complete an MCA is offered where assistance is asked for.

Additional actions: Audit of patient notes to review the information that is recorded on the MCA

All staff continue to attend mandatory updates which include MCA, this is also delivered in core induction.

All registered professionals are frequently reminded of when MCA training delivered by KCC.

The number of staff who have received MCA training continues to improve.

This will be an ongoing requirement due to staff turnover in the acute setting

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but also the documentation with regards to the MCA in the patient notes.

19.


All agencies represented on KMSAB must ensure that staff at all levels are aware of the Kent and Medway Multi-Agency Policy and Procedures to Support People who Self-Neglect, and that they understand and implement it.

Kent County Council

The Self Neglect Policy has been circulated to all KCC staff in 2015.

Safeguarding Adults Policy and Standards Manager

That KCC staff recognise where and when self-neglect is occurring in a problematic way and thereafter are confident in it’s management per the Policy.

Self-neglecting clients do not receive the appropriate assessment of their Capacity to make decisions about their self-care and thereafter receive the appropriate interventions to safeguard them.

Additional Self Neglect Workshops will be delivered to multi-agency staff across Kent and Medway in the Autumn/Winter 2015.


Kent County Council

Workshops were delivered to staff across Kent and Medway in 2015.

Further workshops are planned for 15/16.

Safeguarding Adults Policy and Standards Manager

That KCC staff recognise where and when self-neglect is occurring in a problematic way and thereafter are confident in its management per

Staff at all levels are not aware of the Self-Neglect Policy and Procedures.

Additional Self Neglect Workshops will be delivered to multi-agency staff across Kent and Medway in the Autumn/Winter 2015.

Workshops will be delivered to ensure

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the Policy. that staff are aware of the lessons learnt from the SAR in order to improve practice in October 2015.


The Self Neglect Policy has been circulated to all KCC and KMPT staff in 2015.


That KCC and KMPT staff recognise where and when self-neglect is occurring in a problematic way and thereafter are confident in it’s management per the Policy.

Self-neglecting clients do not receive the appropriate assessment of their Capacity to make decisions about their self-care and thereafter receive the appropriate interventions to safe-guard them.


Kent Police All agencies to be aware of Self Neglect policy.


Kent Police

Force Policy update and link to document via KCC website once status of document ascertained.


DC White Specialist trainer aware and updating Uniform Training re this.

IMR Action Plan Guidance - Kent County Council

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