Mae hwn yn fersiwn HTML o atodiad i'r cais Rhyddid Gwybodaeth 'Effective checking procedures.'.


CQC ACTION PLAN
1 All SDU's
removed - cross referenced
n/a
1 All SDU's
Removed
Removed
1 All SDU's
(1.16) Work with Risk Department lead post holders to track themes recurring across the three boroughs to 
implement actions from learning - cascade of themes happening from Risk Dept

n/a
SDU Directors/Clinical Directors
1 All SDU's
removed
removed
1 Hounslow
(1.39) Maintain detailed local  database of incidents / progress of investigations to support WLMHT 
Aug 31 2009
electronic system
(1.39.2) AMP with WLMHT department analyse themes feed into primary prevention work which will steer training 
priorities at appropriate level
1 Hounslow
(1.42) Receive and scrutinise and continually analyse all Level 1 & 2 reports and oversee fair effective, 
Aug 31 2009
feasible action plan generation

DOCUMENT 
(1.42.2) Local and inter SDU pick up on themes and prompt corrective actions
EVIDENCE 
ATTACHED

Clinical Director
1 H&F
(1.20) Maintain current manual database which tracks the incident pathway from date of incident to 
Aug 31 2009
completion of action plans, while Trust online system is being developed
DOCUMENT 
(1.20.1) Review of local incident reporting/ management work flow processes against requirements of on-line 
EVIDENCE 
processes.
ATTACHED
Service Diretor
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
Caroline (CAMHS) Jones
Service Manager
1 All SDU's
(1.1) To Identify and recruit additional posts in risk reduction team to support RCA report writing, and 
Aug 31 2009
family liaison posts
DOCUMENT 
(1.1.1) Job descriptions advertised for 2 x 8A posts Trust wide - one post been offered - interviews for other post 
EVIDENCE 
pending
ATTACHED
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.1) To Identify and recruit additional posts in risk reduction team to support RCA report writing, and 
Sep 30 2009
family liaison posts
(1.1.2) Interview and appoint. Have recruited SUI systems manager in post. Temp project manager in post, and 
temp admin in post.
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.3) Review of Incident Policy
Sep 30 2009
DOCUMENT 
(1.3.1) Review policies from other similar mental health trusts and review produced for consideration.
EVIDENCE 
ATTACHED

Elizabeth Fellow-Smith
Medical Director - Extra PA
1 All SDU's
(1.5) Electronic monitoring and governance from incident to completion action plan to be rolled out and in 
Sep 30 2009
place across the Trust

DOCUMENT 
(1.5.1) Pilot electronic monitoring of incident review and action plan process – Ealing, Hammersmith & Fulham and 
EVIDENCE 
Hounslow SDUs
ATTACHED
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Sep 30 2009
DOCUMENT 
(1.6.1) Risk team to produce quarterly analysis of incidents and review of learning.
EVIDENCE 
To be received by the Quality and Risk Committee on behalf of the board.
ATTACHED
Gail Miller
Associate Director - Integrated Risk Reduction
1 H&F
(1.24) Carry out audit of the summary of level 2 & 3 review findings for the last year.
Sep 30 2009
DOCUMENT 
(1.24.2) Action Plan from findings to be developed
EVIDENCE 
ATTACHED

Service Director
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
1 Ealing
(1.17) Clinical Governance Co-ordinator  in place (secondment) to track SUI Reports, Action Plan and 
Sep 30 2009
monitor with the SDU Senior Management Team, the roll-out and implementation of all of the 
recommendations.

(1.17.1) Appointed - Chrissie Johnson appointed as clinical governance coordinator
Service Director
Jonathan Scott
Clinical Director - Ealing Mental Health Services
1 WLFS
(1.29) Increase frequency of SDU Incident Review Group to increase capacity of group
Sep 30 2009
(1.29.1) Need to increase IRG frequency to monthly from September onwards - HAPPENING
Director
1 Hounslow
(1.42) Receive and scrutinise and continually analyse all Level 1 & 2 reports and oversee fair effective, 
Oct 31 2009
feasible action plan generation
(1.42.3) Maintain monthly consultant peer supervision group - MINUTES?NOTES OF MEETING WILL BE ADDED

Medical Director/ Clinical Director/ Head of governance
1 Hounslow
(1.40) - Clinical audit cycle
Oct 31 2009
- Cross match of risk register and use of tool kits eg. NIMHE
Receive reports of a higher volume incidents below level 3
- particularly slips, trips, falls, medication errors, self harm at the Cassel, non injurious aggression

(1.40.1) Direct work with WLMHT Risk Dept. to enable inter - SDU thematic process – to ensure analysis of risk and 
near misses is captured and disseminated - Incident Review group is represented by Hounslow at monthly (last 
11th Nov 09)
Service and Clinical Director
1 Hounslow
(1.40) - Clinical audit cycle
Oct 31 2009
- Cross match of risk register and use of tool kits eg. NIMHE
Receive reports of a higher volume incidents below level 3
- particularly slips, trips, falls, medication errors, self harm at the Cassel, non injurious aggression

DOCUMENT 
(1.40.2) Health and Safety to receive and compare with manual data slips, trips, falls incidents, and to inform the 
EVIDENCE 
Dove Ward action plan
ATTACHED
Service Director/Head of Governance
1 Hounslow
(1.37) Integrate SDU clinical / non-clinical risk management via establishment of Head of Governance and 
Oct 31 2009
Risk post to coordinate: incident process; clinical audit; patient safety; complaints; business continuity/ 
flu / emergency planning; H&S; E&F liaison and Risk registration

DOCUMENT 
(1.37.4) Ensure up-to-date flu and emergency plan and appropriate cascade across SDU
EVIDENCE 
ATTACHED

Service and Clinical Director/ Head of Governance
1 Hounslow
(1.42) Receive and scrutinise and continually analyse all Level 1 & 2 reports and oversee fair effective, 
Oct 31 2009
feasible action plan generation
(1.42.1) Through the clinical governance structures disseminate recommendations and actions to the appropriate 
local team level. To improve further and strengthen SDU CG - Team - SDU CG - Team feedback loops and 
processes. This is in work of WLMHT IRG.
Service and Clinical Director

1 WLFS
(1.30) Ensure adequate  numbers of staff, including majority of senior clinicians and managers are trained 
Oct 31 2009
in Root Cause Analysis
DOCUMENT 
(1.30.2) Create a central database of SDU RCA trained staff who will undertake the investigations - STARTED BUT 
EVIDENCE 
NOT COMPLETE
ATTACHED
Dawn Harwood
Directorate Manager
1 WLFS
(1.31) Improve communication across the SDU
Oct 31 2009
DOCUMENT 
(1.31.1) Finalise arrangements for SDU newsletter and begin to publish monthly.
EVIDENCE 
ATTACHED

Denise Godleman
Head Of Administration
1 Hounslow
(1.37) Integrate SDU clinical / non-clinical risk management via establishment of Head of Governance and 
Oct 31 2009
Risk post to coordinate: incident process; clinical audit; patient safety; complaints; business continuity/ 
flu / emergency planning; H&S; E&F liaison and Risk registration

DOCUMENT 
(1.37.2) Systematically uplift new risks - as seen on SDU risk register
EVIDENCE 
ATTACHED

Service and Clinical Director/ Head of Governance
1 H&F
(1.21) Streamline process between completion of report & sign off of action plan
Oct 31 2009
DOCUMENT 
(1.21.1) Action plans to be constructed by D/CD within a week of completion of report
EVIDENCE 
ATTACHED

Service Director
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
1 All SDU's
(1.1) To Identify and recruit additional posts in risk reduction team to support RCA report writing, and 
Oct 31 2009
family liaison posts
(1.1.3) Re-advertise un-appointed post . Interview happened Friday 4th December - appointment pending. The 
December interviews were not successful. Interim IRF being progressed pending readvertisement
Gail Miller
Associate Director - Integrated Risk Reduction

1 Hounslow
(1.41) SDU monthly IMG with LBH, PCT and key clinicians e.g. SFC
Nov  3 2009
(1.41.1) Index learning from incidents WLMHT workshop (25 Mar ’09) SDU monthly IMG with LBH, PCT and key 
clinicians eg.  SGC. HAPPENED AND ATTENDED
Service and Clinical Director
1 Broadmoor
(1.45) Reinforce to all staff that IR1s must be completed for all incidents that occur
Nov 30 2009
DOCUMENT 
(1.45.1) Staff meetings and clinical team meetings will focus on the instruction from the policy, and the clinical 
EVIDENCE 
improvement groups will monitor this. 
ATTACHED
Through line management and supervision this will also be monitored
Clinical Nurse Managers & Heads of Services
1 Broadmoor
(1.46) Review the ToR and function of the Incident Monitoring & Review Group
Nov 30 2009
DOCUMENT 
(1.46.1) Initiate review at IMRG September 2009 
EVIDENCE 
Reconsider IMRG and emphasise educational and analytical function as well as process monitoring function
ATTACHED
Clinical Director
1 Broadmoor
(1.47) Increase local staff awareness of incidents and lessons learnt.
Nov 30 2009
DOCUMENT 
(1.47.1) All wards to have summary of incidents displayed on staff room notice boards, all wards to hold copies of 
EVIDENCE 
incident reviews and action plans in ward office and incident reviews to be standing agenda item on staff meetings
ATTACHED
Clinical Nurse Managers
1 Broadmoor
(1.47) Increase local staff awareness of incidents and lessons learnt.
Nov 30 2009
DOCUMENT 
(1.47.2) Roll out SoE initiative to other directorates to enhance awareness of incidents & findings using presentation 
EVIDENCE 
on disseminating findings from investigations more effectively. (as in IMRG August 2009
ATTACHED
Clinical Leads
1 All SDU's
(1.3) Review of Incident Policy
Nov 30 2009

DOCUMENT 
(1.3.2) Produce draft revised policy for consultation
EVIDENCE 
ATTACHED

Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Nov 30 2009
DOCUMENT 
(1.6.3) Quarterly analysis to be disseminated via SDUs to clinical staff - quarterly report issued from risk team to 
EVIDENCE 
SDU directors
ATTACHED
SDU Directors
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Nov 30 2009
DOCUMENT 
(1.6.4) Trustwide incident review group to receive and disseminate learning from SDU incident review groups - 
EVIDENCE 
report from the learning lessons workshop 3rd Nov 09
ATTACHED
SDU Director
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Nov 30 2009
DOCUMENT 
(1.6.5) Trustwide learning events to be convened twice yearly - workshop 3rd Nov09 , conference planned March 
EVIDENCE 
10
ATTACHED
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.5) Electronic monitoring and governance from incident to completion action plan to be rolled out and in 
Nov 30 2009
place across the Trust
(1.5.2) Finalise electronic process and rollout to West London Forensic SDU - rollout has commenced and will be 
on-going
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.4) Ensure understanding of incident reporting and review policy
Nov 30 2009
DOCUMENT 
(1.4.1) Monitor compliance with current policy - evidence will be SUI database monitoring within 60 day deadlines. 
EVIDENCE 
SHA writing to PC re: one remaining outstanding report. Monthly reports from the SHA will be commencing
ATTACHED

SDU Directors
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Nov 30 2009
(1.8.2) Link incident analysis and defined risk assessment tools to risk training. Review of training complete - 
commissioned clinical risk training
Tim Bullock
Consultant - Extra PA
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Nov 30 2009
DOCUMENT 
(1.8.5) Clinical change programme, linked to RiO implementation and CPA development, to be defined. Priorities to 
EVIDENCE 
reflect learning from incidents, and project design to include clinical practice monitoring indicators. Project outline to 
ATTACHED
Executive Directors for approval
Tim Bullock
Consultant - Extra PA
1 Ealing
(1.19) Bi-annual event to ensure the Lessons Learnt are implemented and understood into practice with all 
Nov 30 2009
staffing groups
(1.19.1) Leads for events to be identified - Jonathan Scott, Bridget Ledbury and Chrissie Johnson
Service Director/SUI CG Co-ordinator
Jonathan Scott
Clinical Director - Ealing Mental Health Services
1 Hounslow
(1.37) Integrate SDU clinical / non-clinical risk management via establishment of Head of Governance and 
Nov 30 2009
Risk post to coordinate: incident process; clinical audit; patient safety; complaints; business continuity/ 
flu / emergency planning; H&S; E&F liaison and Risk registration

DOCUMENT 
(1.37.3) Review as standing item SDU  H and S and quarterly at IMG
EVIDENCE 
ATTACHED

Service and Clinical Director/ Head of Governance
1 WLFS
(1.35) Identify themes and trends emerging from Untoward Incident Investigations and complaints, and 
Nov 30 2009
such information effectively communicated across the SDU and, where necessary, the Trust.
DOCUMENT 
(1.35.2) Introduce system to identify themes/trends. Introduce SDU-wide meetings to disseminate lessons learnt. 
EVIDENCE 
Regularly review action plans through Directorate Clinical Governance meetings.
ATTACHED
Clinical Director & Complaints Investigation Manager

1 WLFS
(1.36) Ensure SDU audit programme links to identified learning and supports development of practice
Nov 30 2009
DOCUMENT 
(1.36.1) Review current programme of audits across SDU. Identify from past investigations key audit topics, which 
EVIDENCE 
will form the basis of the SDU’s core audit programme.
ATTACHED
Clinical Director
1 WLFS
(1.36) Ensure SDU audit programme links to identified learning and supports development of practice
Nov 30 2009
DOCUMENT 
(1.36.2) Ensure audit department communicates effectively with SDU’s Complaints & Investigations Manager and 
EVIDENCE 
Clinical Governance Leads.
ATTACHED
Clinical Director
1 WLFS
(1.36) Ensure SDU audit programme links to identified learning and supports development of practice
Nov 30 2009
DOCUMENT 
(1.36.3) Complaints & Investigations manager to link with audit group  - andrew Silver attends
EVIDENCE 
ATTACHED

Clinical Director
1 Hounslow
(1.35) Identify themes and trends emerging from Untoward Incident Investigations and complaints, and 
Nov 30 2009
such information effectively communicated across the SDU and, where necessary, the Trust.
(1.35.1) SMT to agree system & frequency of reporting of themes / trends. Through monthly meetings trustwide - 
IRG, SDU IMG, and A&P last dates of each 9.12.09, 17.11.09, 10.12.09
Clinical Director
1 WLFS
(1.32) Ensure that staff are aware of the I-8 incident reporting policy, and how to implement it
Dec 31 2009
(1.32.1) To write to staff & arrange briefing sessions for staff at all levels across the SDU.
Director

1 WLFS
(1.33) Improve quality of incident reporting.
Dec 31 2009
(1.33.1) Rolling audit of IR1 forms. Audits to be reviewed at Directorate Management Team meetings.
Directorate Managers
1 WLFS
(1.30) Ensure adequate  numbers of staff, including majority of senior clinicians and managers are trained 
Dec 31 2009
in Root Cause Analysis
(1.30.1) Source and book additional RCA training from external provider - booked and complete
Directorate Manager
1 H&F
(1.25) Improve access to external panel members
Dec 31 2009
DOCUMENT 
(1.25.1) Seek out and identify additional resources/information from Risk Department
EVIDENCE 
ATTACHED

Service Director
1 H&F
(1.26) To develop a similar system for Fs as that for incidents
Dec 31 2009
DOCUMENT 
(1.26.1) System to be identified with resources available
EVIDENCE 
ATTACHED

Service Director
Caroline (CAMHS) Jones
Service Manager
1 Ealing
(1.17) Clinical Governance Co-ordinator  in place (secondment) to track SUI Reports, Action Plan and 
Dec 31 2009
monitor with the SDU Senior Management Team, the roll-out and implementation of all of the 
recommendations.

DOCUMENT 
(1.17.2) Review of level 1 and 2 incidents prior to commencement of electronic monitoring system to identify 
EVIDENCE 
common themes  and any possible outstanding actions
ATTACHED
Chrissie Johnson
Maggie Wilson
Head of Administration Services
1 Ealing
(1.17) Clinical Governance Co-ordinator  in place (secondment) to track SUI Reports, Action Plan and 
Dec 31 2009
monitor with the SDU Senior Management Team, the roll-out and implementation of all of the 
recommendations.


DOCUMENT 
(1.17.3) Put in place a system to track the review and dissemination of incidents and action plans integrated with 
EVIDENCE 
the electronic incident monitoring data base.
ATTACHED
Maggie Wilson
Head of Administration Services
1 All SDU's
(1.10) Disseminate Risk Management Policy I8 and train accordingly.
Dec 31 2009
(1.10.1) Train, disseminate and monitor staff knowledge through audit, supervision etc. - happening in all 5 SDUs
SDU Directors/Clinical Directors
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Dec 31 2009
DOCUMENT 
(1.8.1) Increase production of the Risk Matters bulletin from quarterly to monthly - completed
EVIDENCE 
ATTACHED

Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Dec 31 2009
DOCUMENT 
(1.6.6) SDUs to convene regular learning events and dissemination of incident analysis
EVIDENCE 
ATTACHED

SDU Directors
1 H&F
(1.24) Carry out audit of the summary of level 2 & 3 review findings for the last year.
Dec 31 2009
DOCUMENT 
(1.24.1) Disseminate audit findings to care groups
EVIDENCE 
ATTACHED

Service Director
Caroline (CAMHS) Jones
Service Manager
1 Broadmoor
(1.43) Enhance incident reporting functionality within directorates -
Dec 31 2009
DOCUMENT 
(1.43.1) Wards to use improved incident analysis functionality and cascade through CIGs
EVIDENCE 
ATTACHED


Clinical Nurse Managers, RCs
1 Broadmoor
(1.44) Presentation on Incident reporting features on the Exchange at SDU SMT? IMRG September 2009.
Dec 31 2009
DOCUMENT 
(1.44.1) Directorates to analyse incident activity across the directorate and promote learning and best practice and 
EVIDENCE 
report to IMRG
ATTACHED
Service Directors & Clinical Leads
1 Hounslow
(1.38) Deliver and maintain training programme
Dec 31 2009
DOCUMENT 
(1.38.1) Dissemination of I8. Head of Nursing delivering training primarily to  clinical staff on incident reporting in 
EVIDENCE 
response to staff survey feedback
ATTACHED
Jenn Fellows
Head of Nursing - Hounslow SDU
1 Hounslow
(1.38) Deliver and maintain training programme
Dec 31 2009
DOCUMENT 
(1.38.2) Complete and monitor training programme
EVIDENCE 
ATTACHED

Service and Clinical Director/ Head of Governance
Jenn Fellows
Head of Nursing - Hounslow SDU
1 Hounslow
(1.38) Deliver and maintain training programme
Dec 31 2009
DOCUMENT 
(1.38.3) Review, spot audit and refresh staff awareness
EVIDENCE 
ATTACHED

Service and Clinical Director/ Head of Governance
Jenn Fellows
Head of Nursing - Hounslow SDU
1 All SDU's
(1.7) To strengthen the feedback loop across the Trust to embed learning from investigations
Jan 31 2010
DOCUMENT 
(1.7.1) To strengthen the feedback loop across the Trust to embed learning from investigations
EVIDENCE 
ATTACHED

SDU Directors
Gail Miller
Associate Director - Integrated Risk Reduction

1 All SDU's
(1.7) To strengthen the feedback loop across the Trust to embed learning from investigations
Jan 31 2010
DOCUMENT 
(1.7.2) Scripted PowerPoint presentations to be presented on a quarterly basis in each SDU re: lessons learnt from 
EVIDENCE 
investigations in the SDU
ATTACHED
Clinical Directors
1 All SDU's
(1.7) To strengthen the feedback loop across the Trust to embed learning from investigations
Jan 31 2010
DOCUMENT 
(1.7.5) Communications team to work on regular “Learning Lessons” communications to staff eg. Lesson of the 
EVIDENCE 
month
ATTACHED
Deputy Director of Communications
1 All SDU's
(1.6) Regular analysis of incidents and review of learning to be established and disseminated
Jan 31 2010
DOCUMENT 
(1.6.2) Regular thematic review to be undertaken on a quarterly basis to identify emerging themes and patterns 
EVIDENCE 
from investigations, complaints and IR1s
ATTACHED
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.5) Electronic monitoring and governance from incident to completion action plan to be rolled out and in 
Jan 31 2010
place across the Trust
(1.5.3) Rollout to Broadmoor SDU.Arrangements for the roll out are in place, this is however not fully imbedded as 
yet and progress is being monitored.
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Jan 31 2010
(1.8.3) Complete risk assessment and management training review - completed
Tim Bullock
Consultant - Extra PA

1 Ealing
(1.17) Clinical Governance Co-ordinator  in place (secondment) to track SUI Reports, Action Plan and 
Jan 31 2010
monitor with the SDU Senior Management Team, the roll-out and implementation of all of the 
recommendations.

DOCUMENT 
(1.17.4) Collation of recommendations and action plans from which to generate a single incident action plan for the 
EVIDENCE 
SDU - started but single incident action plan still to be finished
ATTACHED
Chrissie Johnson
1 WLFS
(1.34) Recruit to substantive Complaints & Investigations manager position.
Jan 31 2010
DOCUMENT 
(1.34.1) Job description to be completed & banded, then advertise and recruit
EVIDENCE 
ATTACHED

Director
1 Hounslow
(1.37) Integrate SDU clinical / non-clinical risk management via establishment of Head of Governance and 
Jan 31 2010
Risk post to coordinate: incident process; clinical audit; patient safety; complaints; business continuity/ 
flu / emergency planning; H&S; E&F liaison and Risk registration

DOCUMENT 
(1.37.1) Collate SDU risk register to support WLMHT electronic risk register formation
EVIDENCE 
ATTACHED

Service/Clinical Director &Head of Governance
1 H&F
(1.26) To develop a similar system for Fs as that for incidents
Feb 28 2010
(1.26.2) Fund and recruit to local complaints post
Service Director
1 H&F
(1.27) Dissemination of I8 (Incident Monitoring Policy). Head of Nursing to develop and deliver training for 
Feb 28 2010
all clinical staff on incident reporting.
(1.27.1)Complete and monitor training programme
Sandra Bailey
Head of Nursing - H&F SDU
1 Ealing
(1.18) Dissemination of I8 (Incident Monitoring Policy) . Head of Nursing to develop and deliver training for 
Feb 28 2010
all clinical staff on incident reporting

(1.18.1) Complete and monitor training programme
Diane Wiles
Head of Nursing - Ealing SDU
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Feb 28 2010
(1.8.6) Ongoing clinical change programme to reflect learning from incidents and hence to continuously embed 
practice. Project plan and focus to be reviewed every 3 months by the Quality and Risk Committee
Tim Bullock
Consultant - Extra PA
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Feb 28 2010
(1.8.7) Clinical change programme to be supported by clinical indicators to monitor changing practice. To be 
monitored through the trust Info Delivery Tool.
Tim Bullock
Consultant - Extra PA
1 All SDU's
(1.3) Review of Incident Policy
Feb 28 2010
(1.3.3) Revised policy agreed
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.2) Further review central resource to support investigations and learning from incidents
Feb 28 2010
(1.2.1) Best practice in other similar mental health trust practice to be evaluated and review produced. Temp project 
manager in post, and visits to other trusts arranged to look at best practice and benchmarking
Elizabeth Fellow-Smith
Medical Director - Extra PA
1 All SDU's
(1.3) Review of Incident Policy
Mar 31 2010
(1.3.4) Implement policy across the trust
Gail Miller
Associate Director - Integrated Risk Reduction

1 All SDU's
(1.7) To strengthen the feedback loop across the Trust to embed learning from investigations
Mar 31 2010
(1.7.3) SDU leads to establish or strengthen feedback and Information loops to cascade learning to CMHT/teams 
etc
Local Borough SDU Directors
1 All SDU's
(1.7) To strengthen the feedback loop across the Trust to embed learning from investigations
Mar 31 2010
(1.7.4) Audit cycle linked to action plans and recommendations, and cascade of information clarified
AD For Clinical Governence
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Mar 31 2010
(1.8.8) Develop monitoring, evaluation and feedback mechanism to establish how staff at ward level understand 
and utilise policy and procedures
SDU Directors
Gail Miller
Associate Director - Integrated Risk Reduction
1 All SDU's
(1.8) Further develop the process to support  translation of learning into practice
Mar 31 2010
(1.8.4) Rollout training in support of Clinical Risk Assessment and Management Policy – see below
Tim Bullock
Consultant - Extra PA
1 All SDU's
(1.14) Analysis of incidents and embedding learning from Level 1 and 2 Incidents will be standing agenda 
Mar 31 2010
item at all SDU CIGs
Trust wide - All SDUs
Five SDU - SDU CD and Director
1 All SDU's
(1.15) Identify risks from complaints and action as above
Mar 31 2010
(1.15.1)  Monitor knowledge of process through staff feedback mechanisms - as above include service users and 
carers in feedback mechanism. Trust-wide - all five SDUs
Five SDU x SDU CDs and Directors

1 H&F
(1.24) Carry out audit of the summary of level 2 & 3 review findings for the last year.
Mar 31 2010
(1.24.3) Audit of past action plans to date to determine whether actions have been implemented and sustained.
Service Director
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
Caroline (CAMHS) Jones
Service Manager
1 H&F
(1.23) Identify a core team with ring fenced time to do reviews
Mar 31 2010
(1.23.1) Currently one post in place with ring fenced time to carry out reviews
Service Director
Caroline (CAMHS) Jones
Service Manager
1 WLFS
(1.31) Improve communication across the SDU
Mar 31 2010
(1.31.2) Review success of newsletter as method of communication via local partnership subgroup
Service Director
1 All SDU's
(1.12) Ensure Borough Incident Monitoring Groups effect audit of recommendations from investigations, 
Apr 30 2010
and action accordingly
Three borough SDUs
Three borough SDUs
1 All SDU's
(1.4) Ensure understanding of incident reporting and review policy
Jun 30 2010
(1.4.2) Conduct focus groups to discuss policy understanding and compliance
Gail Miller
Associate Director - Integrated Risk Reduction
1 H&F
(1.24) Carry out audit of the summary of level 2 & 3 review findings for the last year.
Jun 30 2010
(1.24.4) Implement recommendations of audit of level 2 & 3reviews
Service Director

Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
1 H&F
(1.20) Maintain current manual database which tracks the incident pathway from date of incident to 
Oct 31 2010
completion of action plans, while Trust online system is being developed
(1.20.3) Integration of  trust on-line system with local procedures
Service Director
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs
Caroline (CAMHS) Jones
Service Manager
1 Ealing
(1.19) Bi-annual event to ensure the Lessons Learnt are implemented and understood into practice with all 
Oct 31 2010
staffing groups
(1.19.2) Develop and implement events
TBI
1 Hounslow
(1.39) Maintain detailed local  database of incidents / progress of investigations to support WLMHT 
Dec 31 2010
electronic system
(1.39.1) Database in place, summarising core work of IMG and A&P
Service Director
1 H&F
(1.22) Identified need for more training on report writing, as well as investigative skills.
Oct 31 2015
(1.22.1) Implement training & development across all staff disciplines who are currently carrying out reviews
Service Director
Caroline (CAMHS) Jones
Service Manager
1 H&F
(1.20) Maintain current manual database which tracks the incident pathway from date of incident to 
Oct 31 2015
completion of action plans, while Trust online system is being developed
(1.20.2) This will also be an ongoing process
1 H&F
(1.28) To ensure that learning from incidents is addressed at IMG monthly
Oct 31 2015

(1.28.1) Ensure appropriate distribution of incident vignette and action plans occurs and is taken to relevant Clinical 
Governance groups
Michael Phelan
Clinical Director - Hammersmith & Fulham Mental Health 
Servs

8 All SDU's
removed
removed
8 Broadmoor
(8.17) Broadmoor SDU to draw up an interim proposal for Physical Health provision as the preferred 
Sep 30 2009
provider is not longer available.
(8.17.1) Lead Service Director and Dr Cohen to draw up proposal for submission to CEO.
Service Director And GP
8 WLFS
(8.13) To work jointly with Ealing Hospitals Trust to ensure systems are in place to support effective joint 
Oct 31 2009
working
DOCUMENT 
(8.13.1) Interface meeting established. Currently developing work plan & action groups
EVIDENCE 
ATTACHED

Clinical Director
8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Oct 31 2009
(8.8.2) Treatment room for in-patient unit to be completed - completed
Head of Nursing
8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Oct 31 2009
(8.8.4)Equipment on order for the new improved facilities. Ordered
Head of Nursing
8 Ealing
(8.9) To recruit to the CDW post
Oct 31 2009
(8.9.1) Post out to advert – to recruit. Advert out

8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Nov 30 2009
DOCUMENT 
(8.8.6) Physical health Champions in place,
EVIDENCE 
ATTACHED

Associate Director for Primary Care
8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Nov 30 2009
DOCUMENT 
(8.8.1) To become a standing agenda item on the in-patient CIG meetings at both ward and unit level
EVIDENCE 
ATTACHED

Service Manager/Clinical Lead
8 All SDU's
(8.1) Develop a robust Physical Healthcare Strategy
Nov 30 2009
DOCUMENT 
(8.1.1) Develop and approve  the strategy for consultation
EVIDENCE 
ATTACHED

Associate Director of Primary Care
8 All SDU's
(8.2) Model of Physical Healthcare to be agreed to ensure same access to whether living in the community 
Nov 30 2009
or an inpatient
(8.2.1) To be defined in the strategy and linked to SDUsPHC strategy details the model of care that will be adopted 
throughout the Trust. The Model is detailed on page 3 of the strategy. This will be implemented once the strategy 
has been agreed.
Associate Director of Primary Care
8 All SDU's
(8.3) Establish adequate physical healthcare\primary care provision in forensic settings
Nov 30 2009
DOCUMENT 
(8.3.1) Implement primary care contracted service at Broadmoor Hospital. Due to preferred provider going into 
EVIDENCE 
liquidation before commencement of contract, hospital has put in place interim physcial healthcare arrangements 
ATTACHED
supported by CE and COmmissioners
High Secure CD

8 All SDU's
(8.3) Establish adequate physical healthcare\primary care provision in forensic settings
Nov 30 2009
DOCUMENT 
(8.3.2) Approve and establish an adequate level of primary care and physical healthcare provision at Broadmoor 
EVIDENCE 
Hospital in the event that a fully contracted service is not feasible.
ATTACHED
High Secure CD
8 All SDU's
(8.4) Review and improve the environment for assessment and treatment of physical healthcare
Nov 30 2009
(8.4.1) All inpatient service areas to have access to appropriate   physical healthcare facilities. Audit of each 
inpatient area against minimum standards. Ealing - almost completed. 
Hounslow - completion date Jan
H and F - completion date end Jan
WLFS - completed
BM- need to follow up
Deputy Director of Nursing
8 All SDU's
(8.4) Review and improve the environment for assessment and treatment of physical healthcare
Nov 30 2009
DOCUMENT 
(8.4.3) Develop and audit documentation on RiO to record physical healthcare. Audits have been undertaken. 
EVIDENCE 
Reaudit cycle to commence
ATTACHED
Deputy Medical Director
8 Broadmoor
(8.18) Additional focus on high-impact changes in management of obesity discussed at SMT September 
Nov 30 2009
2009
DOCUMENT 
(8.18.2) Recruitment of another dietician for the SDU - locum in post 1st December 09
EVIDENCE 
ATTACHED

Service Director
8 All SDU's
(8.1) Develop a robust Physical Healthcare Strategy
Dec 31 2009
(8.1.4) Review clinical pathways for physical healthcare. This is an objective in the Implementation plan. It has been 
agreed that the Trust wide PHC Group will review all PHC guidance and advise SDU's of the action required.
Associate Director of Primary Care/ Clinical Directors

8 All SDU's
(8.1) Develop a robust Physical Healthcare Strategy
Dec 31 2009
(8.1.2) Agree strategy and develop an implementation plan with priority areas identifiedFurther progress is strategy 
approved at OPs Boards 26.11.09 to be implemented as a working document. Implementation plan drafted.
Associate Director of Primary Care/Chair Physical Healthcare Group/SDU Directors
8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Dec 31 2009
DOCUMENT 
(8.8.5) Physical Healthcare Action Plan to be implemented
EVIDENCE 
ATTACHED

Associate Director for Primary Care
8 H&F
(8.10) To improve the physical health care of patients
Dec 31 2009
DOCUMENT 
(8.10.1) Profile raising of physical healthcare policy and strategy
EVIDENCE 
ATTACHED

Service and Clinical Director
8 WLFS
(8.11) To identify an interim primary care provider to provide service and undertake a full health needs 
Dec 31 2009
assessment which will lead to a tendering process
DOCUMENT 
(8.11.1) Physical healthcare group to work alongside Commissioners in order to identify interim primary care 
EVIDENCE 
provider and agree process for needs assessment.
ATTACHED
Director  Clinical Director  & Clinical Lead
8 WLFS
(8.12) To bring together the current strands of physical healthcare and optimise these, supported by an 
Dec 31 2009
SDU physical healthcare strategy
DOCUMENT 
(8.12.1) Review role of physical health lead in SDU and recruit to new post
EVIDENCE 
ATTACHED

Director  & Clinical Director

8 WLFS
(8.14) Establish physical healthcare suite in each secure building
Dec 31 2009
(8.14.1) Current refurbishment work to be completed by December 2009 in the Tony Hillis Wing, and the RSU. Suite 
in place in the Orchard.
Senior Nurse Manager
8 Broadmoor
(8.18) Additional focus on high-impact changes in management of obesity discussed at SMT September 
Dec 31 2009
2009
DOCUMENT 
(8.18.1) New strategy to limit supply of high – calorie foods on hospital shop, improved patient education by healthy 
EVIDENCE 
living groups, better information of healthy choices for ward meals and revised physical healthcare provision with 
ATTACHED
better dietetic input agreed at SMT September 2009
Service Directors and  Clinical Director
8 Hounslow
(8.16) 0.4 consultant psychiatrist to secondary/primary care interface appointed Jul ‘09
Jan 31 2010
(8.16.1) Clarification and protocols re. primary/secondary PHC monitoring. This will be informed by next stage of 
virtual clinic and 2.28.2
- Meeting regarding QOF and CQUIN being set up.
Clinical Director
8 Broadmoor
(8.17) Broadmoor SDU to draw up an interim proposal for Physical Health provision as the preferred 
Jan 31 2010
provider is not longer available.
DOCUMENT 
(8.17.2) If proposal approved, schedule of training and service realignment to be agreed and implemented.
EVIDENCE 
ATTACHED

Service Director and GP
8 WLFS
(8.12) To bring together the current strands of physical healthcare and optimise these, supported by an 
Jan 31 2010
SDU physical healthcare strategy
(8.12.2) Physical healthcare strategy to be drafted and implemented via SDU Physical Healthcare Group, in 
partnership with the physical healthcare strategy development
Clinical Director
8 WLFS
(8.12) To bring together the current strands of physical healthcare and optimise these, supported by an 
Jan 31 2010
SDU physical healthcare strategy

(8.12.3) Ensure that all inpatients receive 6-monthly physical healthcare check and that this is included in the SMT 
performance data
Clinical Director
8 H&F
(8.10) To improve the physical health care of patients
Jan 31 2010
DOCUMENT 
(8.10.3) Identification and fit out of physical healthcare room
EVIDENCE 
ATTACHED

Service Director/Head of Nursing
8 Ealing
(8.8) To improve the routine monitoring of physical health in the in-patient unit.
Jan 31 2010
(8.8.3) Physical examination rooms being finalised within the SDU.
Two physical examination rooms completed in OPS - completed
Head of Nursing
8 All SDU's
(8.1) Develop a robust Physical Healthcare Strategy
Jan 31 2010
(8.1.3) Revise the physical healthcare standards against the strategy. Not completed
Deputy Director of Nursing
8 All SDU's
(8.3) Establish adequate physical healthcare\primary care provision in forensic settings
Jan 31 2010
DOCUMENT 
(8.3.3) Approve and establish an adequate level of primary care and physical healthcare provision in West London 
EVIDENCE 
Forensic Services
ATTACHED
WLFS Director
8 Hounslow
(8.15) Local PHC strategy launched ’09. Established working CIG with management and Consultant Clinical  Jan 31 2010
Lead.

DOCUMENT 
(8.15.4) Progress against POMHs monitored through A&P. SDU fully engaged in POMH cycle.
EVIDENCE 
ATTACHED

Clincal Director

8 All SDU's
(8.1) Develop a robust Physical Healthcare Strategy
Feb 28 2010
(8.1.5) Develop clinical pathways for transfer to and from acute sector. This will be defined by local acute hospital 
arrangements. Pathways to be collated and approved.
Associate Medical Director
8 All SDU's
(8.5) Develop and implement a physical healthcare training and skills development programme
Feb 28 2010
(8.5.1) Utilise physical healthcare leads in each SDU to plan and implement relevant physical healthcare training, 
monitoring and recording
Associate Director of HR L&D /Physical Healthcare leads
8 All SDU's
(8.5) Develop and implement a physical healthcare training and skills development programme
Feb 28 2010
(8.5.2) Link all physical healthcare plans to risk assessment training, implementation and risk management 
strategies
Deputy Medical Director
8 All SDU's
(8.6) All staff will understand the need to carry out a full physical health assessment on admission, and 
Mar 31 2010
where to enter information on RiO
(8.6.1) All staff will understand and implement physical health monitoring through admission. RGNs being 
introduced to in-patient wards to suport physical healthcare assessment on admission
Five SDU x SDU Directors/Clinical Directors
8 All SDU's
(8.4) Review and improve the environment for assessment and treatment of physical healthcare
Mar 31 2010
(8.4.2) Review the physical healthcare equipment in inpatient settings. Trust-wide audit as above
Deputy Director of nursing
8 All SDU's
(8.6) All staff will understand the need to carry out a full physical health assessment on admission, and 
Mar 31 2010
where to enter information on RiO

(8.6.3) Physical Healthcare has priority in the clinical governance programme
Five SDU x SDU Directors/Clinical Directors
8 H&F
(8.10) To improve the physical health care of patients
Mar 31 2010
(8.10.4) Over view audit of physical healthcare audit findings
Clinical Director
8 H&F
(8.10) To improve the physical health care of patients
Mar 31 2010
(8.10.5) Automatic referral to  inpatient GP service when patient transferred from admission to recovery ward
Clinical Director/Inpatient service manager
8 Broadmoor
(8.17) Broadmoor SDU to draw up an interim proposal for Physical Health provision as the preferred 
Mar 31 2010
provider is not longer available.
(8.17.3) Review of interim arrangements
Service Director and GP
8 Hounslow
(8.15) Local PHC strategy launched ’09.  Established working CIG with management and Consultant Clinical  Apr 30 2010
Lead.

(8.15.1) Develop case for funding of staff
Head of Nursing /Service Manager
8 All SDU's
(8.6) All staff will understand the need to carry out a full physical health assessment on admission, and 
Apr 30 2010
where to enter information on RiO
(8.6.2) Pathways developed to more specialist and emergency physical healthcare for each site
Five SDU x SDU Directors/Clinical Directors

8 Hounslow
(8.15) Local PHC strategy launched ’09.  Established working CIG with management and Consultant Clinical  Jun 30 2010
Lead.

(8.15.2) PHC suite to open Jun ’10 at Lakeside
Service Director
8 Hounslow
(8.15) Local PHC strategy launched ’09.  Established working CIG with management and Consultant Clinical  Jun 30 2010
Lead.

(8.15.3) ECG machine procured for Lakeside site.  Staff to be fully trained for Jan ‘10
Service Director
8 H&F
(8.10) To improve the physical health care of patients
Oct 31 2015
(8.10.2) Monthly RIO audit of RIO record
Lead Nurse

2 Broadmoor
(2.44) Broadmoor SDU psychological services risk assessment advisory group provides support for clinical  Dec 31 2008
risk assessment
SDU Suicide & DSH review group relaunched December 2008 following previous difficulties in attendance 
now meeting regularly & commissioning work as appropriate

(2.44.1) Done – already in place
Head of Psychological therapies/Clinical Director
2 Hounslow
(2.31) Star Wards Implementation
Jul 31 2009
(2.31.1) Commenced on Kestral Ward 2008, 2nd ward commencing 2009 and remaining wards 2010
Head of Nursing
2 Broadmoor
(2.45) Learning lessons and implementation of recommendations from the PB/RL enquiry.
Sep 30 2009
(2.45.1) Hospital wide distribution of copies of report
Clinical Director
2 Broadmoor
(2.46) PB-RL report published September 2009: learning re risk to others & bullying to be taken forward on 
Sep 30 2009
basis of this report
(2.46.1) Presentation of the report at Hospital wide staff forum.
Clinical Director & RCs
2 Hounslow
(2.39) Level 3 safeguarding children for all  staff who work primarily with those under 18 years
Sep 30 2009
(2.39.1) Collated by Safeguarding Children board. All bar one (in hand) staff at Cassel has completed.
Clinical Director
2 H&F
(2.17) Develop more ‘in house’ clinical risk expertise that is available to supervisors to take into the 
Sep 30 2009
supervision process
DOCUMENT 
(2.17.1) To develop a CPA checklist to support accurate completion of RIO fields. This includes risk assessment 
EVIDENCE 
fields
ATTACHED
Clinical Lead for Education

2 Broadmoor
(2.40) All patients have risk to self and others considered as part of 6 monthly CPA
Oct 29 2009
In addition risk reconsidered following any significant incident or major event eg allocation of rooms 
following ward move or at time of increased stress such as Christmas

(2.40.1) Completed and monitored through directorate & SDU performance monitoring
2 Broadmoor
(2.40) All patients have risk to self and others considered as part of 6 monthly CPA
Oct 29 2009
In addition risk reconsidered following any significant incident or major event eg allocation of rooms 
following ward move or at time of increased stress such as Christmas

(2.40.2) All Clinical teams to review risks when indicated outside usual CPA timescales or when asked to do so at 
time of increased general risk
Clinical Director and RCs
2 Broadmoor
(2.41) Trustwide learning event march 2009 hosted at Broadmoor
Oct 29 2009
(2.41.1) Done – see corporate action plan
Medical Director
2 Broadmoor
(2.42) All patients will have active HCR 20 assessments reviewed at CPA meetings.
Oct 29 2009
(2.42.1) Extensive investment in HCR-20 training
RCs
2 Broadmoor
(2.42) All patients will have active HCR 20 assessments reviewed at CPA meetings.
Oct 29 2009
(2.42.2) Review of CPA documentation
RCs
2 Broadmoor
(2.43) All patients to have in place a care/risk management plan for the risks they pose to themselves 
Oct 29 2009
and/or others.

(2.43.1) Reinforcement to Primary Nurses that they have a responsibility to produce and review care plans for their 
patients.
Deputy Director of Nursing/Primary Nurses
2 Broadmoor
(2.43) All patients to have in place a care/risk management plan for the risks they pose to themselves 
Oct 29 2009
and/or others.
(2.43.2) Clinical teams to review and endorsed individual care/risk management plans as part of CPA and on 
dynamic basis.
RCs
2 Hounslow
(2.38) Pathways for antenatal psychiatric care and support funded through WMUH
Oct 29 2009
DOCUMENT 
(2.38.3) Complete and disseminate pilot, audit referrals to children services for WLMHT SGC
EVIDENCE 
ATTACHED

Clinical Lead
2 Broadmoor
(2.46) PB-RL report published September 2009: learning re risk to others & bullying to be taken forward on 
Oct 31 2009
basis of this report
DOCUMENT 
(2.46.3) Action plan drafted to reflect recommendations within the report and implementation of actions. (Action plan 
EVIDENCE 
to be monitored and managed via IMRG and SMT)
ATTACHED
Clinical Director and Director
2 Hounslow
(2.38) Pathways for antenatal psychiatric care and support funded through WMUH
Oct 31 2009
DOCUMENT 
(2.38.1) Participate in WLMHT workstream against CEMACH
EVIDENCE 
ATTACHED

Clinical Lead
2 Hounslow
(2.38) Pathways for antenatal psychiatric care and support funded through WMUH
Oct 31 2009
(2.38.2) Deliver and drive outcome from Trustwide workshop Sep ‘09 - HAPPENED
Clinical Lead

2 H&F
(2.19) To ensure that key staff can consistently comply with Trust policy for use of RiO including risk 
Oct 31 2009
assessment
DOCUMENT 
(2.19.1) Plan to carry out RiO refresher sessions and evaluate usefulness
EVIDENCE 
ATTACHED

Clinical Lead for Education
2 Ealing
(2.11) To prioritise the Trust CPA audit which currently includes analysis of the completion of risk 
Oct 31 2009
assessment
DOCUMENT 
(2.11.1) The feedback from the audit will be disseminated through the governance structure
EVIDENCE 
ATTACHED

AMD and Clinical Director
2 Ealing
(2.14) To ensure ligature review recommendations are implemented
Oct 31 2009
DOCUMENT 
(2.14.1) Regular review through SMT - Lead Nurse has six week plan re: implementation. Senior Op Manager 
EVIDENCE 
identified to work with lead nurse.
ATTACHED
Head of Nursing
2 Ealing
(2.15) Identification of risk factors to be completed on in-patient wards
Oct 31 2009
DOCUMENT 
(2.15.1) Risk Reduction Team working with Inpatient Wards looking at Risk Zoning 
EVIDENCE 
Presentation at Inpatient CIG July 2009
ATTACHED
Service Manager
2 H&F
(2.16) To ensure that the further 30/40 staff booked on risk training undertake it and take forward
Oct 31 2009
DOCUMENT 
(2.16.1) Arrange Training & Deliver Training
EVIDENCE 
ATTACHED

Service Manager

2 Hounslow
(2.32) Time to Care
Oct 31 2009
(2.32) Implemented on two wards Kestral and Finch wards
Head of Nursing
2 Hounslow
(2.26) RiO including risk assessment record is implemented
Oct 31 2009
DOCUMENT 
(2.26.1) Ensure 100% and multi-disciplinary compliance across the SDU Participate in choice and increase use of 
EVIDENCE 
Risk Assessment tool suite. 
ATTACHED
Re-audit scheduled
Clinical Director
2 Hounslow
(2.27) October ’08 – base line audit of RiO risk crisis and contingency planning: disseminated
Oct 31 2009
(2.27.1) Receive and action 
Demonstrate 30% enhanced practice - RESULTS TO DISSEMINATE AT DEC A&P
Service Managers
2 WLFS
(2.22) Develop Peer Review Programme in Men’s Medium Secure Service.
Oct 31 2009
DOCUMENT 
(2.22.1) Introduction of joint referrals meetings. Further development of weekly Academic Case Conference to 
EVIDENCE 
include participation of all disciplines.
ATTACHED
Clinical Lead & Directorate Manager
2 All SDU's
(2.1) Establish Trustwide risk assessment tools and embed in a clinical risk assessment and management 
Oct 31 2009
policy
DOCUMENT 
(2.1.1) Define suite of clinical risk assessment tools
EVIDENCE 
ATTACHED

Tim Bullock
Consultant - Extra PA

2 All SDU's
(2.1) Establish Trustwide risk assessment tools and embed in a clinical risk assessment and management 
Oct 31 2009
policy
DOCUMENT 
(2.1.2) Develop draft Clinical Risk Assessment and management policy
EVIDENCE 
ATTACHED

Deputy Medical Director
2 All SDU's
(2.4) Monitor clinical practice through regular case note audit
Oct 31 2009
(2.4.1) Audit of risk assessment and management plans – commence a programme of RiO audits bimonthly, paper 
record audits bimonthly
Deputy Medical Director
2 Broadmoor
(2.46) PB-RL report published September 2009: learning re risk to others & bullying to be taken forward on 
Nov 30 2009
basis of this report
DOCUMENT 
(2.46.2) To be repeated by each ward /directorate in CIG meeting
EVIDENCE 
ATTACHED

2 All SDU's
(2.3) All service users have a CPA care plan based on assessed risk to self and others
Nov 30 2009
DOCUMENT 
(2.3.3) Clinical change programme plan as above at recommendation 1 to include care planning and contingency 
EVIDENCE 
planning.
ATTACHED
Deputy Medical Director/Dep Director of Nursing
2 All SDU's
(2.1) Establish Trustwide risk assessment tools and embed in a clinical risk assessment and management 
Nov 30 2009
policy
DOCUMENT 
(2.1.3) Approve policy for consultation - out for consultation
EVIDENCE 
ATTACHED

Deputy Medical Director
2 WLFS
(2.21) Further develop training for staff across the SDU relating to the assessment and management of  risk  Nov 30 2009
of harm to self & others


DOCUMENT 
(2.21.1) Improve the assessment and management of risk of harm to self and others. Identify and implement tool to 
EVIDENCE 
improve assessment of risk to self.
ATTACHED
Clinical Director
2 Ealing
(2.9) Service to focus on completion of risk assessment
Nov 30 2009
DOCUMENT 
(2.9.1) Audit to be undertaken on number of risk assessments completed in SDU for all service users - AUDIT 
EVIDENCE 
BEING UNDERTAKEN
ATTACHED
Service Managers
2 Ealing
(2.10) Ensure staff understand the core components of the RiO case record that must be completed for 
Nov 30 2009
each service user, including risk assessment
DOCUMENT 
(2.10.1) In-patients meetings with all staff already planned for October and November – the outcome of these 
EVIDENCE 
meetings will be a common, simplified process
ATTACHED
Service Manager
2 H&F
(2.17) Develop more ‘in house’ clinical risk expertise that is available to supervisors to take into the 
Nov 30 2009
supervision process
DOCUMENT 
(2.17.2) To carry out audit of CPA care plans and risk assessments – adult services
EVIDENCE 
ATTACHED

Clinical Lead for Education
2 Hounslow
(2.37) In-patient unit delivering to Women’s Strategy.
Nov 30 2009
(2.37.2) Maintain weekly antenatal psychiatry clinic - HAPPENING
2 H&F
(2.17) Develop more ‘in house’ clinical risk expertise that is available to supervisors to take into the 
Dec 31 2009
supervision process
DOCUMENT 
(2.17.3) To pilot CPA checklist; adult services
EVIDENCE 
ATTACHED


Clinical Lead for Education/Service Manager
2 H&F
(2.18) To ensure ligature review recommendations are implemented
Dec 31 2009
DOCUMENT 
(2.18.1) Regular review through SMT
EVIDENCE 
ATTACHED

Service Manager
2 H&F
(2.19) To ensure that key staff can consistently comply with Trust policy for use of RiO including risk 
Dec 31 2009
assessment
DOCUMENT 
(2.19.2) Complete case audit in adults and OPS in relation to RiO checklist
EVIDENCE 
ATTACHED

CMHT Managers
2 WLFS
(2.20) Ensure that care plans are in place to assess and manage all relevant risks.
Dec 31 2009
(2.20.1) Devise and introduce CPA training for clinical staff. Started in women's service, in development in rest of 
directorate.
Clinical Director/Head of Nursing
2 WLFS
(2.20) Ensure that care plans are in place to assess and manage all relevant risks.
Dec 31 2009
DOCUMENT 
(2.20.2) Introduce programme to audit quality of risk assessments and associated care plans. Programme being 
EVIDENCE 
developed, now need to implement
ATTACHED
Clinical Director/Head of Nursing
2 WLFS
(2.20) Ensure that care plans are in place to assess and manage all relevant risks.
Dec 31 2009
(2.20.3) Develop standards for nursing care plans and circulate such standards with implementation guidance.
Head of Nursing

2 WLFS
(2.20) Ensure that care plans are in place to assess and manage all relevant risks.
Dec 31 2009
DOCUMENT 
(2.20.4) SDU Clinical Risk Steering Group to develop standards for risk assessment across the SDU.
EVIDENCE 
ATTACHED

Clinical Director
2 Ealing
(2.10) Ensure staff understand the core components of the RiO case record that must be completed for 
Dec 31 2009
each service user, including risk assessment
DOCUMENT 
(2.10.2) CMHT group to review current practice and identify any outstanding actions required, to ensure clarity 
EVIDENCE 
around RiO risk assessment for that staff group
ATTACHED
Service Manager/Clinical Lead
2 Ealing
(2.10) Ensure staff understand the core components of the RiO case record that must be completed for 
Dec 31 2009
each service user, including risk assessment
(2.10.3) Sector managers of other adult teams to do the same for their teams
Service Managers
2 Ealing
(2.10) Ensure staff understand the core components of the RiO case record that must be completed for 
Dec 31 2009
each service user, including risk assessment
DOCUMENT 
(2.10.4) Older adults governance meeting to review current practice
EVIDENCE 
ATTACHED

Associate Director of Primary Care
2 WLFS
(2.24) Improve the participation of service users and carers in care planning, including in  the assessment 
Dec 31 2009
and management of risk
(2.24.1) User involvement leads to develop strategy for assessing, monitoring & supporting user and carer 
involvement.
Head of Nursing

2 Hounslow
(2.25) Risk Assessment training provided 
Dec 31 2009
- 3 x 1 day course Nov 2008 
- Crime Scene Management (with Met.) 13 Jan & 12 Feb ‘09
- Additional investment by PCT CRT / HTT 24/7 target activity and gate keeping 
- Managed admission and discharge
- Admission purposeful

DOCUMENT 
(2.25.3) Enhance compliance with management of leave guidance. Check third re-audit
EVIDENCE 
ATTACHED

Clinical Director/ Service Manager
2 All SDU's
(2.4) Monitor clinical practice through regular case note audit
Dec 31 2009
DOCUMENT 
(2.4.3) Benchmarking of audits to be included in scorecards and actions to improve practice agreed through the 
EVIDENCE 
CPA steering group, actions to be rolled out by SDU Directors and CDs.
ATTACHED
Deputy Medical Director
2 All SDU's
(2.4) Monitor clinical practice through regular case note audit
Dec 31 2009
(2.4.4) Standard of CPA and care plans to be established
Dep Director of Nursing/ Head of AHPs/Associate Director of HR L&D
2 Broadmoor
(2.44) Broadmoor SDU psychological services risk assessment advisory group provides support for clinical  Dec 31 2009
risk assessment
SDU Suicide & DSH review group relaunched December 2008 following previous difficulties in attendance 
now meeting regularly & commissioning work as appropriate

(2.44.2) Done – December 2008
New training for risk of self harm n longer term detained population commissioned Spring 2009
2 Hounslow
(2.33) Think Family Conference Jun ’09 to raise awareness of all social system in care and positive risk 
Jan 31 2010
management
DOCUMENT 
(2.33.2) Arrange launch of CSCIE 30 across Hounslow SDU with senior clinicians and managers.  Workshop 
EVIDENCE 
January ’10 to action against benchmark
ATTACHED
Clinical Director/ Service manager

2 All SDU's
(2.3) All service users have a CPA care plan based on assessed risk to self and others
Jan 31 2010
DOCUMENT 
(2.3.1) Training on integrated care planning and contingency planning to be included in risk training – including 
EVIDENCE 
positive risk taking to support 10 essential shared capabilities etc. training delayed to March 2010 due to mandatory 
ATTACHED
training demands
Deputy Medical Director/Dep Director of Nursing
2 All SDU's
(2.3) All service users have a CPA care plan based on assessed risk to self and others
Jan 31 2010
DOCUMENT 
(2.3.2) Role of care coordinator to be clarified and included in training
EVIDENCE 
ATTACHED

Deputy Medical Director/Dep Director of Nursing
2 All SDU's
(2.1) Establish Trustwide risk assessment tools and embed in a clinical risk assessment and management 
Jan 31 2010
policy
(2.1.4) Approve policy
Tim Bullock
Consultant - Extra PA
2 Hounslow
(2.28) CPA Practice Development Forum. Established 2009
Jan 31 2010
DOCUMENT 
(2.28.1) Increase use of Threshold of access to secondary CMHT psychiatry decision support tool. Align practice of 
EVIDENCE 
3 CMHT SPoR and allied functions. Receive and action the national and local Service user surveys and feedback. 
ATTACHED
Build up service user and carer direct input into work. Funded roll out of virtual clinic from Feltham CMHT to other 
CMHT's (proposal embedded)
- TAG explored (audit embedded)
- Potential leverage of HoNOS needs investigation
- Working with Hammersmith and Fulham SDU to seek to harmonise clinical thinking regarding threshold 
management
Clinical Director/ Service Manager
2 WLFS
(2.24) Improve the participation of service users and carers in care planning, including in  the assessment 
Jan 31 2010
and management of risk
DOCUMENT 
(2.24.2) Develop clear systems to monitor the effectiveness of service user and carer involvement
EVIDENCE 
ATTACHED

Head of Nursing

2 WLFS
(2.23) Continue programme of relational security training.
Jan 31 2010
(2.23.2) Continue to support current programme. Incorporate relational security into the SDU security Induction - 
completed in first draft
Service Director
2 All SDU's
(2.5) Ensure staff are clear of their roles and responsibilities in relation to therapeutically assessing and 
Feb 28 2010
managing risk
(2.5.2) Embed roles and responsibilities in a ‘personal responsibility’ approach to risk assessment and 
management, including management of boundaries with patients. Approach to be developed and launched 
Trustwide
Medical Director
2 Hounslow
(2.34) High vulnerability groups
Mar 31 2010
n/a
Clinical Director/ Service Manager
2 Hounslow
(2.36) Dual Diagnosis lead post in place – completed 100% training for inpatient staff
Mar 31 2010
(2.36.1) Project now rolling out to community
Service Manager
2 Hounslow
(2.37) In-patient unit delivering to Women’s Strategy.
Mar 31 2010
(2.37.1) Deliver inequality agenda specific training as commissioned.
Service Manager
2 All SDU's
(2.8) Ligature risk monitoring standard is applied to operational protocols
Mar 31 2010

(2.8.1) Staff should be aware of high risk groups and the skills needed to care plan for these people
Five SDU x SDU CDs and Directors
2 All SDU's
(2.5) Ensure staff are clear of their roles and responsibilities in relation to therapeutically assessing and 
Mar 31 2010
managing risk
(2.5.1) Staff competency as defined in the Risk Assessment and Management Policy to be  measured through 
supervision of Engagement and Observation skills, risk assessment and care planning
Associate Director of HR L&D/SDU Directors
2 All SDU's
(2.4) Monitor clinical practice through regular case note audit
Mar 31 2010
(2.4.2) Audit of content of risk assessments and management plans – commence a programme of case note audits 
to monitor compliance with Clinical Risk Assessment and Management Policy
Deputy Medical Director
2 All SDU's
(2.2) Rollout training in risk assessment and management to support policy implementation. Review of 
Mar 31 2010
training as at recommendation 1.
(2.2.1) Training to be reviewed as at recommendation 1 and rolled out to support policy implementation. Training 
sessions to commence.
Deputy Medical Director
2 Hounslow
(2.29) Enhanced therapeutic milieu
Mar 31 2010
- Substantial environmental works agreed at Lakeside through operational capital programme 09/10
(2.29.1) Approved capital bids to develop facilities.:
- Work rehabilitation 
- Cafeteria
- Internet café
- Secure entrance to Dove ward
Service Manager
2 Hounslow
(2.30) Anti-ligature operational capital works agreed 09/10.
Mar 31 2010
(2.30.1) New windows to all ward “high traffic” areas in progress
7 new shower rooms in progress
Service Manager

2 Hounslow
(2.25) Risk Assessment training provided 
Mar 31 2010
- 3 x 1 day course Nov 2008 
- Crime Scene Management (with Met.) 13 Jan & 12 Feb ‘09
- Additional investment by PCT CRT / HTT 24/7 target activity and gate keeping 
- Managed admission and discharge
- Admission purposeful

(2.25.2) Ongoing scrutiny LOS and occupancy %, maintain compliance 7 day follow up,
Ensure 7 day follow up target i.e. 95% is achieved each qtr.
Exception report to SMT any use of private sector outliers
Clinical Director / Director
2 Hounslow
(2.33) Think Family Conference Jun ’09 to raise awareness of all social system in care and positive risk 
Mar 31 2010
management
(2.33.1) “Think Parent, Think Child, Think Family” CSCIE30 benchmark to complete Q3 – focus on SGC 
responsiveness. Informed by feedback from current Hounslow Ofsted and CQC Inspection of safeguarding children 
and looked after children
Clinical Director/ Service Manager
2 Ealing
(2.13) To review the Trust CPA Audit with respect to the analysis of risk management
Apr 30 2010
(2.13.1) To work with the Dep MD and Trust Audit Lead to develop the audit – rolling audit includes these factors
Clinical Director
2 WLFS
(2.21) Further develop training for staff across the SDU relating to the assessment and management of  risk  Apr 30 2010
of harm to self & others

(2.21.2) Identified additional training will be developed and delivered to staff across the SDU
Clinical Director
2 WLFS
(2.23) Continue programme of relational security training.
Apr 30 2010
(2.23.1) Continue to support current programme. Incorporate relational security into the SDU security Induction

Service Director
2 All SDU's
(2.6) To ensure that staff have a good working knowledge of the practice of risk assessment, and 
Apr 30 2010
understand that it is fundamental and links to the care plan, crisis and contingency plan for all service 
users

(2.6.1) Staff understand that the RiO case record must be completed for each service user, including risk 
assessment, through training and shared learning
Five SDU x SDU CDs and Directors
2 All SDU's
(2.7) Clinical Risk assessment and management training is delivered and monitored in all boroughs
Apr 30 2010
(2.7.1) Work with L&D to ensure that risk assessment and management becomes part of Trustwide training 
programme, including engagement and observation
Five SDU x SDU CDs and Directors
2 Ealing
(2.12) To ensure sharing of best practice at a local level.
Jul 31 2010
(2.12.1) To establish a framework and monitoring system to ensure that each team is undertaking risk management 
training on a regular basis
Service and Clinical Director
2 Hounslow
(2.25) Risk Assessment training provided 
Nov 30 2010
- 3 x 1 day course Nov 2008 
- Crime Scene Management (with Met.) 13 Jan & 12 Feb ‘09
- Additional investment by PCT CRT / HTT 24/7 target activity and gate keeping 
- Managed admission and discharge
- Admission purposeful

(2.25.1) Ensure all care group coverage and rolling access to risk training. Regular monitoring through SDU training 
meetings.  Fully participant in WLMHT revised clinical risk training
Service and Clinical Director/ Service Manager
2 Hounslow
(2.35) Monthly Police Liaison CIG – high risk individuals receive HCR 20 rating and inter-agency input in 
Dec 31 2010
care plan
(2.35.1) Plan joint training between Hounslow police and WLMHT senior inpatient staff. Particular focus on 
admissions, AWOLs & S136

Service manager

9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Jan 31 2009
DOCUMENT 
(9.12.6) Data quality check  reports of medication errors.
EVIDENCE 
ATTACHED

Chief Pharmacist/Service Director
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Jul 31 2009
DOCUMENT 
(9.12.3) Proactive use of Pharmacists as consultative advisors on reviews
EVIDENCE 
ATTACHED

Service Director/Clinical Director
9 All SDU's
(9.1) Complete recruitment to revised in-house service
Sep 30 2009
DOCUMENT 
(9.1.2) New 8a post awaiting approval from HR  to advertise; vacancy from 16th Oct
EVIDENCE 
And Additional Technician appointed
ATTACHED
Led by Chief Pharmacist
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Sep 30 2009
DOCUMENT 
(9.12.2) Discussions to take place to support the project to bring H & F pharmacy service in house
EVIDENCE 
ATTACHED

Service Director/Clinical Director/Chief Pharmacist
9 Hounslow
(9.15) In SDU Medication Management in ToR and priority focus of clinical effectiveness / clinical 
Sep 30 2009
governance workstream.
DOCUMENT 
(9.15.1) Ensure medical nursing staff have clear understanding of location in RiO of reporting physical health 
EVIDENCE 
assessment, medicine reconciliation and physical health monitoring and complete.
ATTACHED
Clinical Director
9 All SDU's
(9.1) Complete recruitment to revised in-house service
Oct 27 2009

DOCUMENT 
(9.1.1) Project to bring H+F in-house beginning 14th Sep with meetings at Charing Cross Hosp Pharmacy.
EVIDENCE 
ATTACHED

Led by Chief Pharmacist
9 Ealing
(9.11) To ensure greater interface with pharmacy occurs
Oct 31 2009
(9.11.1) Members of the Pharmacy Team form part of the SDU Senior Management Meeting - now members
Chief Pharmacist/Service Director
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Oct 31 2009
DOCUMENT 
(9.12.4) Participate in recruitment and induction of the new post holder
EVIDENCE 
ATTACHED

Service Director/Clinical Director
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Oct 31 2009
DOCUMENT 
(9.12.7) Review of non medical prescribing in OPS
EVIDENCE 
ATTACHED

Head of Nursing
9 Broadmoor
(9.21) Increased involvement of the pharmacy team in the SDU management and governance structures.
Oct 31 2009
DOCUMENT 
(9.21.1) Lead pharmacist to review pharmacy provision and input into SDU management and governance 
EVIDENCE 
structures.
ATTACHED
Lead Pharmacist
9 Hounslow
(9.19) Raise the profile of the medicines management strategy during consultation
Oct 31 2009
DOCUMENT 
(9.19.1) From Medicine Management Strategy (approved at the Trust Board meeting – Sept 09) consider the 
EVIDENCE 
strategic objectives and prioritise into Q3 of the annual work plan for the SDU
ATTACHED

SDU Leads
9 All SDU's
(9.3) Review the Chief pharmacists role
Oct 31 2009
(9.3.1) Restructure of  pharmacy team to create trust wide leads for operational and clinical aspects of service 
delivery. Role of Chief Pharmacist still to be agreed
Chief Pharmacist and Director of Nursing and patient experience
9 All SDU's
(9.8) Ensuring appropriate and effective use of medicines in people’s care
Nov  2 2009
(9.8.1) To have a clinical pharmacy service that is available each day with pharmacy staff operating as part of the 
multi-disciplinary team in inpatient units and as part of the community teams. Completed
Chief Pharmacist
9 Hounslow
(9.16) Qtrly pharmacy meeting established, attended by Head of Nursing and Clinical Director
Nov  2 2009
(9.16.2) Annual medication management priority plan drawn up from issues from incidents, SDU risks and NICE, 
POMHs and national agenda. Signed off Clinical Effectiveness November 20th 09 - for monitoring through Clinical 
Effectiveness meetings
9 Hounslow
(9.18) NMP established in CAMHS re.ADHD
Nov  2 2009
(9.18.1) Pharmacy services operating functional split effective Aug ’09 (particularly to enhance community 
medications management.  DONE
Service Director/Director of Nursing and Patient Experience
9 All SDU's
(9.4) Agree and launch medicines management strategy
Nov  9 2009
as above Trust wide
Chief Pharmacist / Dir Nursing and Patient Experience

9 All SDU's
(9.5) Strategy and work plan to be developed in consultation with  key stakeholders
Nov 30 2009
(9.5.1) Medicines management group developing and advising on work plan
Director of Nursing and Patient experience
9 Hounslow
(9.18) NMP established in CAMHS re.ADHD
Nov 30 2009
(9.18.2) Monthly report received re expenditure by location.reports regularly received to CD
Clinical Director
9 Hounslow
(9.18) NMP established in CAMHS re.ADHD
Nov 30 2009
(9.18.3) Secured for NMP training Feb ‘10 for 4 x Band 7 nurses across the SDU. NHS London have agreed 
funding for 5 nurses in Hounslow to undertake MMP Course commencing Feb 2010 with TVU in the following areas: 
Clozapine clinic, CAMHS, AOT, HTT and EIS.
Head of Nursing
9 Hounslow
(9.18) NMP established in CAMHS re.ADHD
Nov 30 2009
(9.18.4) Write protocols for shared prescribing for Adult ADHD and dementia. Adult ADHD sign off 15.12.09. Re: 
dementia received H&F prototype. Hounslow version complete. Meeting to propose action by GPs and PCT 
scheduled January 2010
Clinical Director/PG
9 Broadmoor
(9.21) Increased involvement of the pharmacy team in the SDU management and governance structures.
Nov 30 2009
DOCUMENT 
(9.21.2) Review outcome and recommendations to be submitted to SDU SMT for consideration and implementation 
EVIDENCE 
where agreed.
ATTACHED
Lead Pharmacist
9 WLFS
(9.13) Ensure that medication errors (including issues relating to consent to treatment) are identified and 
Nov 30 2009
addressed, and that learning from these errors is shared
DOCUMENT 
(9.13.1) Monitor medication errors and prepare reports identifying common themes and trends for Directorate 
EVIDENCE 
Clinical Governance meetings.
ATTACHED

Clinical Director/ Chief Pharmacist
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Nov 30 2009
DOCUMENT 
(9.12.5) Identify space for pharmacist
EVIDENCE 
ATTACHED

Service Director
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Dec 31 2009
DOCUMENT 
(9.12.8) Implement findings
EVIDENCE 
ATTACHED

Service Manager/Head of Nursing
9 All SDU's
(9.1) Complete recruitment to revised in-house service
Jan 31 2010
DOCUMENT 
(9.1.3) Band 7 advert
EVIDENCE 
ATTACHED

Led by Chief Pharmacist
9 Hounslow
(9.16) Qtrly pharmacy meeting established, attended by Head of Nursing and Clinical Director
Feb 28 2010
(9.16.1) Embed in induction and through Tutor reconciliation reaudit
Pharmacist
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Feb 28 2010
(9.12.9) 6 places secured for Non medical prescribing from February 2010
Head of Nursing

9 All SDU's
(9.6) Medicines Management strategy has clear focus and priority in each Borough Clinical Governance 
Mar 31 2010
programme
(9.6.1) Produce Work Plan to deliver on the strategic objectives 2009 – 2012 Trust Strategy
Starting with objectives 1-3 to be delivered by March 2010 as below
SDU Leads
9 All SDU's
(9.6) Medicines Management strategy has clear focus and priority in each Borough Clinical Governance 
Mar 31 2010
programme
(9.6.2) Trust Clinical staff will understand medicines reconciliation and agree and achieve consistent documentation 
on RiO for Meds Management
Clinical Directors
9 All SDU's
(9.7) Involving people in decisions and management of their medicines
Mar 31 2010
(9.7.1) To ensure that all care plans cover the role of medicines, ongoing monitoring requirements and the person’s 
preferences for medicines, including advanced directives if appropriate
SDU CDs and Directors
9 All SDU's
(9.7) Involving people in decisions and management of their medicines
Mar 31 2010
(9.7.2) To ensure that service users and carers have access to a range of appropriate medicines information which 
they can discuss with a knowledgeable healthcare professional.
SDU CDs and Directors
9 All SDU's
(9.8) Ensuring appropriate and effective use of medicines in people’s care
Mar 31 2010
(9.8.2) To ensure regular checks of the safety and effectiveness of service users’ medicines take place at 
appropriate intervals during their care, starting on admission. (M11 medicines reconciliation policy)
SDU CDs and Directors
9 All SDU's
(9.9) Efficiently and effectively providing and administering medicines
Mar 31 2010
(9.9.1) To ensure that the supply and administration of medicines to service users is safe, efficient and supports 
effective care.

SDU CDs and Directors
9 All SDU's
(9.9) Efficiently and effectively providing and administering medicines
Mar 31 2010
(9.9.2) To ensure that medicines-related errors are reported and that lessons are learned.
SDU CDs and Directors
9 All SDU's
(9.9) Efficiently and effectively providing and administering medicines
Mar 31 2010
(9.9.3) To ensure that the role of medicines are considered as part of serious untoward incident investigations.
SDU CDs and Directors
9 Ealing
(9.10) As above implement MM Strategy
Mar 31 2010
(9.10.1) Objectives 1-4
SDU clinicians
9 WLFS
(9.14) As above implement MM Strategy Objs 1-4
Mar 31 2010
implement strategy objs
SDU clinical leads
9 H&F
(9.12) As above to ensure that the developing medicines management strategy is embedded within the SDU Mar 31 2010
(9.12.1) As above Objectives 1-4
SDU clinical leads
9 All SDU's
(9.2) Further establish the requirements of our community services for pharmacy input
Mar 31 2010
(9.2.1) E + H services have allocated a pharmacist for community teams and are making appointments for regular 
visits to determine input required

Led by Chief Pharmacist
9 Hounslow
(9.17) Plans to develop onsite pharmacy
Mar 31 2010
(9.17.1) Capital bid required
Service Director
9 Broadmoor
(9.20) As above implement MM Strategy
Mar 31 2010
(9.20.1) Objectives 1 - 4
SDU clinical leads
9 All SDU's
(9.2) Further establish the requirements of our community services for pharmacy input
Mar 31 2010
(9.2.2) Consultant Community Pharmacist post, jointly funded as liaising with PCT pharmacists ,and oversee 
community based MH pharmacists
Led by Chief Pharmacist
9 Hounslow
(9.15) In SDU Medication Management in ToR and priority focus of clinical effectiveness / clinical 
Jun 30 2010
governance workstream.
(9.15.2) 20% per mth improvement for inpatients to target to 100%.
Clinical Director

5 Hounslow
(5.16) Annual use of unit surveys continue – provide LIT and service with knowledge of bed use
Apr 30 2009
(5.16.1) Enhanced continuing care assessments and panels. Agree with PCT  on future of OPS liaison spend and 
role in new CCA team
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Aug 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.1) Formal project structure to be created to take forward redesign
EVIDENCE 
ATTACHED

Service Director/ Clinical Leads
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Sep 30 2009
discharges and improving quality of care
DOCUMENT 
(5.10.2) Dedicated inpatient Consultants per wards
EVIDENCE 
ATTACHED

Clinical Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Sep 30 2009
discharges and improving quality of care
(5.10.6) CRT target being met - VERBAL REPORT
Service Managers
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Sep 30 2009
discharges and improving quality of care
DOCUMENT 
(5.10.7) High level escalation process in place on delayed discharges
EVIDENCE 
ATTACHED

Service Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Sep 30 2009
discharges and improving quality of care

DOCUMENT 
(5.10.9) Bed management protocol reviewed and out for consultation
EVIDENCE 
ATTACHED

Service Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Oct 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.16) Paper to refocus  clinical teams in wards
EVIDENCE 
ATTACHED

Head of Nursing
5 WLFS
(5.12) Introduction of community forensic services (7 days p/week and extended hours)
Oct 31 2009
DOCUMENT 
(5.12.2) To explore the possibility of developing similar teams across the wider catchment area through discussion 
EVIDENCE 
with Commissioners and providers in other Consortium PCT areas. Currently developing service with Harrow for 
ATTACHED
late 09/10 and further discussions with CNWL regarding other areas
Service Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Oct 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.5) CRT gatekeeping in place and being audited
EVIDENCE 
ATTACHED

Service Director/ Service Managers
5 Ealing
(5.9) In OP service to maintain the current progress on bed reduction.
Oct 31 2009
(2 to be closed in September 2 to be closed October)
(5.9.4) Ops Capital Bid to create single bedrooms being worked up. 2 beds closed in Sept, 2 further beds to be 
closed are now identified for winter pressures
Service manager OPS/ Service Director
5 WLFS
(5.14) Continued close monitoring of bed usage, referral process, waiting times and delayed discharges in 
Oct 31 2009
partnership with commissioners

DOCUMENT 
(5.14.1) Monthly data to be collected and provided to commissioners and DMTs ; to be formally discussed  in 
EVIDENCE 
Consortium reporting arrangements
ATTACHED
Head of Business Management & Performance
5 All SDU's
(5.1) To work with all relevant commissioners to ensure that all bed management issues are addressed.
Oct 31 2009
DOCUMENT 
(5.1.2) Delayed discharge meetings established and escalation procedures in place if issues cannot   be resolved 
EVIDENCE 
locally
ATTACHED
Deputy Chief Exec/ Commissioners/ SDU Directors
5 All SDU's
(5.1) To work with all relevant commissioners to ensure that all bed management issues are addressed.
Oct 31 2009
DOCUMENT 
(5.1.3) Trust, PCT and LA to work together to optimise usage of existing beds, including reducing delayed 
EVIDENCE 
discharges
ATTACHED
Deputy Chief Exec/ Commissioners/ SDU Directors
5 All SDU's
(5.2) Review and agree Bed Management protocol and procedures
Oct 31 2009
DOCUMENT 
(5.2.2) Ensure single sex accommodation is available for all service users
EVIDENCE 
ATTACHED

5 All SDU's
(5.5) Develop and utilise Bed Management Protocol to improve bed management system and appropriate 
Oct 31 2009
delivery of service user admissions
complete
5 Ealing
(5.8) In the adult service, maintain the current management of bed pressures system
Oct 31 2009
(5.8.2) Ensure accurate delayed discharge data.
Currently to continue to maintain the effective use of the bed management meeting. Improve delayed discharges by 
10% to year end-Adults. Local partnership discussions re: delayed discharges as a result of a one in - one out 
placement system introduced by the borough - end Nov 09. Discussed with DepCE

Service manager
5 Hounslow
(5.17) Ensure robust Clinical Governance programme with  benchmarking
Nov 30 2009
DOCUMENT 
(5.17.1) UU6 - completed
EVIDENCE 
ATTACHED

Clinical Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Nov 30 2009
discharges and improving quality of care
DOCUMENT 
(5.10.10) Bed Management Protocol finalised
EVIDENCE 
ATTACHED

Service Director
5 All SDU's
(5.2) Review and agree Bed Management protocol and procedures
Nov 30 2009
DOCUMENT 
(5.2.3) Ensure all service users are afforded privacy and dignity at all times through relevant  feedback mechanism 
EVIDENCE 
eg. Patient Experience Tracker
ATTACHED
Deputy Director of Nursing
5 All SDU's
(5.2) Review and agree Bed Management protocol and procedures
Nov 30 2009
DOCUMENT 
(5.2.1) Consider appropriate clinical pathways for adolescent service users - on going work also
EVIDENCE 
ATTACHED

Deputy Chief Executive/ Safe Guarding Children Lead
5 All SDU's
(5.2) Review and agree Bed Management protocol and procedures
Dec 31 2009
DOCUMENT 
(5.2.4) Criteria for service users requiring PICU bed is clarified and utilised at all times
EVIDENCE 
ATTACHED

Service Directors H&F and Ealing

5 Ealing
(5.8) In the adult service, maintain the current management of bed pressures system
Dec 31 2009
DOCUMENT 
(5.8.3) Future delayed discharge process to be reviewed through performance meetings and three borough bed 
EVIDENCE 
management protocol - Led by deputy CE - local one complete - three borough one in train
ATTACHED
Service Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Dec 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.11) Review of project redesign structure
EVIDENCE 
ATTACHED

Project Board
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Dec 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.17) Introduce PET
EVIDENCE 
ATTACHED

Head of Nursing
5 Ealing
(5.9) In OP service to maintain the current progress on bed reduction.
Dec 31 2009
(2 to be closed in September 2 to be closed October)
(5.9.3) To reduce  staffing establishment in line with bed closures (2 staff posts over establishment removed) - two 
posts removed from staffing establishment on OP wards
Service manager OPS
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Dec 31 2009
discharges and improving quality of care
DOCUMENT 
(5.10.4) Negotiations with the PCT under way but not concluded regarding under funding
EVIDENCE 
ATTACHED

Service Director/ Dep CE/ Director of Finance

5 WLFS
(5.12) Introduction of community forensic services (7 days p/week and extended hours)
Dec 31 2009
DOCUMENT 
(5.12.1) Community Forensic Service established in partnership with CNWL in K&C and Westminster.
EVIDENCE 
ATTACHED

Service Director
5 Broadmoor
(5.19) We actively cooperate with all reviews of bed capacity and operate within an agreed 93% ceiling.
Dec 31 2009
DOCUMENT 
(5.19.2) Review ToR and function of Bed Management group.
EVIDENCE 
ATTACHED

Bed Management Group
5 Hounslow
(5.18) Now hold five successive year studies to compare against hospital episode, previous MHAC and 
Dec 31 2009
Borough data
DOCUMENT 
(5.18.1) Third HIC toolkit
EVIDENCE 
ATTACHED

Clinical Director
5 Hounslow
(5.15) Occupancy pressure in Hounslow is to OPS
Dec 31 2009
Adult wards percent occupancy <100 percent
2008-9
Q1Q2Q3Q4
91999893

OPS Occupancy % > 100%
2008-9
Q1Q2Q3Q4
103103103107

DOCUMENT 
(5.15.1) Optimise fair access and clinical pathways re. mental health need for    Hounslow OPS through Mental 
EVIDENCE 
Health and Acute provision
ATTACHED
Clinical Director through Borough OP Strategy

5 WLFS
(5.15) Occupancy pressure in Hounslow is to OPS
Dec 31 2009
Adult wards % occupancy <100%
2008-9
Q1Q2Q3Q4
91999893

OPS Occupancy % > 100%
2008-9
Q1Q2Q3Q4
103103103107

(5.15.2) With WLMHT, develop 3 Borough strategy re OPS provision
Clinical Director through Borough OP Strategy
5 Hounslow
(5.15) Occupancy pressure in Hounslow is to OPS
Dec 31 2009
Adult wards % occupancy <100%
2008-9
Q1Q2Q3Q4
91999893

OPS Occupancy % > 100%
2008-9
Q1Q2Q3Q4
103103103107

DOCUMENT 
(5.15.3) For Hounslow OPS, leverage SDU formation including stronger clinical management, Clinical Lead for OPS 
EVIDENCE 
appointed and Dove Ward forward plan developed.
ATTACHED
Clinical Director through Borough OP Strategy
5 Hounslow
(5.15) Occupancy pressure in Hounslow is to OPS
Dec 31 2009
DOCUMENT 
(5.15.4) Partnership action to dementia strategy
EVIDENCE 
ATTACHED

Clinical Director through Borough OP Strategy
5 Hounslow
(5.15) Occupancy pressure in Hounslow is to OPS
Dec 31 2009

DOCUMENT 
(5.15.5) Functional split
EVIDENCE 
ATTACHED

Clinical Director through Borough OP Strategy
5 All SDU's
(5.1) To work with all relevant commissioners to ensure that all bed management issues are addressed.
Jan 31 2010
DOCUMENT 
(5.1.1) Action agreed  to commission care pathway work across three boroughs commissioned by the three way 
EVIDENCE 
PCT Chief Executives meeting
ATTACHED
Deputy Chief Executive
5 Ealing
(5.9) In OP service to maintain the current progress on bed reduction.
Feb 28 2010
(2 to be closed in September 2 to be closed October)
(5.9.1) 2 step down beds being negotiated with the PCT.
5 Ealing
(5.9) In OP service to maintain the current progress on bed reduction.
Feb 28 2010
(2 to be closed in September 2 to be closed October)
(5.9.2) 2 more to close-New Year- holding steady state whilst addressing impact of anticipated Winter pressures
Service Director/Clinical Leads/Service Manager
5 Broadmoor
(5.20) With commissioner support we are implementing a major revision of assertive rehab wards over the 
Mar 31 2010
remainder of this financial year, to reduce patient numbers on wards, improve staff skills mix and develop a 
personality disorder service

(5.20.1) The clinical service improvement plan is implemented as per schedule.
SDU Director
5 Broadmoor
(5.20) With commissioner support we are implementing a major revision of assertive rehab wards over the 
Mar 31 2010
remainder of this financial year, to reduce patient numbers on wards, improve staff skills mix and develop a 
personality disorder service

(5.20.2) By March 2010 all wards will have no more than 15 beds.
SDU Director

5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care
(5.10.8) Review of high level DD process
Service Director/ Commissioning Leads LA/PCT
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care
(5.10.3) Refurbishment of MHU under way to increase number of open beds and create admission & recovery 
wards
Service managers/ PCT leads
5 WLFS
(5.11) Development of alternative models for long term secure care in partnership with commissioners, 
Mar 31 2010
based on assessed needs
(5.11.1) Long-term secure care project team - to report revised needs assessment. Agree service developments 
with Commissioners
Service Director & Project Lead
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care
(5.10.12) Admission ward in place
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care
(5.10.13) Recovery wards in place
Clinical Director
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care

(5.10.14) Review of high level DD process
Service Director/ Commissioning Leads PCT/LA
5 H&F
(5.10) Reconfiguration of inpatient wards as a means of improving throughput, reducing delayed 
Mar 31 2010
discharges and improving quality of care
(5.10.15) Consider the need for ward for 3 boroughs for dementia
3 Boroughs/Deputy chief executive
5 All SDU's
(5.2) Review and agree Bed Management protocol and procedures
Mar 31 2010
(5.2.5) Review the role and function of the Home Treatment Teams in relation to clinical pathways to support whole 
treatment teams
Service Directors H&F and Ealing
5 All SDU's
(5.3) To ensure that the functional split in OPS delivers effective and efficient in-patient care
Mar 31 2010
Three Boroughs
Three local borough SDU Directors and CDs
5 All SDU's
(5.4) To deliver on Home Treatment team targets and 100% gatekeeping
Mar 31 2010
Three Local Borough SDUs
Three Local Borough SDU Directors and CDs
5 All SDU's
(5.6) Admission assessments will consider discharge plans, and anticipate and act on minimising delayed 
Apr 30 2010
discharges
Work Across three local borough services
Tim Bullock - Three Local Borough Services

5 All SDU's
(5.7) Maximise capacity for bed facilities for OPS, adolescent etc. across three boroughs
Apr 30 2010
Three Local borough services
Ian kent - Dep Chief Exec
5 Ealing
(5.8) In the adult service, maintain the current management of bed pressures system
Apr 30 2010
(5.8.1) Complete the conversion of office space to an additional four overspill beds.
Service Manager
5 WLFS
(5.13) Evaluation of WEMSS model and development of future (permanent) service model
Jan  1 2011
(5.13.1) Continue work with DoH and WEMSS commissioners to evaluate WEMSS model and develop permanent, 
funded  service
Service Director  & Clinical Lead
5 Broadmoor
(5.19) We actively cooperate with all reviews of bed capacity and operate within an agreed 93% ceiling.
Oct 31 2015
(5.19.1) Continue to monitor bed capacity as part of performance management
Performance Manager

6 H&F
(6.24) To have constant overview of recruitment and recruitment
Aug  5 2009
(6.24.4) Recruitment campaign in inpatient services
Business Manager/Head of Nursing
6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Aug 31 2009
DOCUMENT 
(6.23.1) Inpatient OPS working towards AIMs level 2
EVIDENCE 
AIMs for PICU being pursued
ATTACHED
Service Manager/ Lead Nurse
6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Aug 31 2009
DOCUMENT 
(6.23.2) Ops Staff in the Community applying Creating Capable Teams
EVIDENCE 
ATTACHED

Service Manager/ Lead Nurse
6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Aug 31 2009
(6.23.3) Adult inpatient wards applying for AIMs level 1, and PICU - Sarina Martin leading for Trust, local SDU leads 
attend
Service Manager/ Lead Nurse
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Aug 31 2009
DOCUMENT 
(6.24.1) Identification of ‘hot spots’ in recruitment in H&F
EVIDENCE 
ATTACHED

Service Director / Head of Staffing solutions
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Aug 31 2009
DOCUMENT 
(6.24.2) Agree vacancy targets
EVIDENCE 
ATTACHED


Service Director / Head of Staffing solutions
6 H&F
(6.25) To have in place mechanisms to support skills development of staff
Aug 31 2009
DOCUMENT 
(6.25.5) AMHP refresher programme
EVIDENCE 
ATTACHED

Social Care lead practitioner
6 All SDU's
(6.6) Review of recruitment and selection processes and procedures up to and including induction
Sep 21 2009
DOCUMENT 
(6.6.2) Issue feedback questionnaires to recruiting managers and all candidates who have withdrawn from 
EVIDENCE 
campaigns in the past 12 months.
ATTACHED
Business Manager HR
6 Broadmoor
(6.37) Additional recruitment of consultant medical staff scheduled September 2009
Sep 30 2009
(6.37.1) 3 new appointees to replace retiring & career break vacancies
Clinical director
6 Hounslow
(6.32) New Head of Nursing across SDU appointed April ’09 Lead nurses in post across all care group – 
Sep 30 2009
SDU wide Nursing Governance Forum established to enhance nursing practice, ensure implementation of 
policies, build nursing leadership  capacity and improve standards

DOCUMENT 
(6.32.1) Head of Nursing has convened SDU good practice sharing nursing conference Sep 09 theme “Driving Up 
EVIDENCE 
Quality” - AWAITING EVIDENCE
ATTACHED
Head of Nursing
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Sep 30 2009
DOCUMENT 
(6.24.3) Recruitment campaign in CRT
EVIDENCE 
ATTACHED

HR consultant

6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Sep 30 2009
(6.23.4) Productive Ward Champion in place.
Head of Nursing
6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Sep 30 2009
(6.23.5) Adult Wards rolling out Time to Care project including Productive Wards to two more teams. STAR Wards 
in place. Conway ward and Mary Seacole have started first learning module of Productive Wards
Clinical Lead, Inpatient Service Manager
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Sep 30 2009
DOCUMENT 
(6.24.5) Detailed monthly monitoring of Bradford Scores
EVIDENCE 
ATTACHED

Service Directors/ Service Managers
6 H&F
(6.25) To have in place mechanisms to support skills development of staff
Sep 30 2009
DOCUMENT 
(6.25.1) Band 6 inpatient development programme
EVIDENCE 
ATTACHED

Head of Nursing/Deputy Director of Nursing
6 All SDU's
(6.6) Review of recruitment and selection processes and procedures up to and including induction
Oct  5 2009
DOCUMENT 
(6.6.3) Obtain feedback from Staff Solutions employees via staff meeting/questionnaire/ individual discussion.
EVIDENCE 
ATTACHED

Business Manager HR
6 All SDU's
(6.6) Review of recruitment and selection processes and procedures up to and including induction
Oct 26 2009

DOCUMENT 
(6.6.4) Using information collected, seek to identify improvements in efficiency for the recruitment process.
EVIDENCE 
ATTACHED

Business Manager HR
6 All SDU's
(6.20) Three borough Senior Management teams to work towards and deliver on recruitment targets
Oct 30 2009
DOCUMENT 
(6.20.1) Develop and use procedures to track and manage planned and unplanned absenteeism - HR consultants 
EVIDENCE 
in SDUs to use template report to monitor recruitment and mandatory targets at SMTs
ATTACHED
SDU Directors/Clinical Directors
6 All SDU's
(6.20) Three borough Senior Management teams to work towards and deliver on recruitment targets
Oct 30 2009
(6.20.2) Review vacancies on regular basis with HR and implement required actions
SDU Directors/Clinical Directors
6 All SDU's
(6.20) Three borough Senior Management teams to work towards and deliver on recruitment targets
Oct 31 2009
(6.20.3) Target hotspots with appropriate recruitment campaigns
SDU Directors/Clinical Directors
6 All SDU's
(6.14) Deliver Recruitment and Selection Training
Oct 31 2009
DOCUMENT 
(6.14.1) Continue to deliver R&S training via the Leadership and Management Programme
EVIDENCE 
ATTACHED

Head of Staffing Solutions/Employee Development advisor
6 All SDU's
(6.7) To fully implement the local CRB exemption process to fast track the recruitment of staff.
Oct 31 2009
DOCUMENT 
(6.7.1) To monitor and review candidate progress through the recruitment system and identify potential candidates 
EVIDENCE 
for exemption 4 weeks after conditional offer made; to review candidate suitability for exemption in accordance with 
ATTACHED
the policy.
Recruitment Manager/Recruiting Managers

6 H&F
(6.25) To have in place mechanisms to support skills development of staff
Oct 31 2009
DOCUMENT 
(6.25.2) HCA Development programme
EVIDENCE 
ATTACHED

Head of Nursing/Deputy Director of Nursing
6 H&F
(6.25) To have in place mechanisms to support skills development of staff
Oct 31 2009
DOCUMENT 
(6.25.3) Preceptor Programme in place
EVIDENCE 
ATTACHED

Ward Manager OPS
6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Oct 31 2009
DOCUMENT 
(6.23.6) Respect and Dignity Audit being undertaken - Head of Nursing done
EVIDENCE 
ATTACHED

6 Ealing
(6.23) Develop skills within specialities with targeted learning and development
Oct 31 2009
(6.23.7) Need to table Capital works business case December 2009 for Ops wards in relation to single rooms - draft 
business case completed, now part of Trust capital programme
6 Ealing
(6.22) Specific targeted campaigns where we experience difficulty in recruiting in Ealing
Oct 31 2009
DOCUMENT 
(6.22.1) AOT and EIS, specific campaigns being designed for nursing staff.-SDU working with HR.
EVIDENCE 
ATTACHED

Service Director

6 WLFS
(6.26) Reduce number of unplanned vacancies across the SDU
Oct 31 2009
DOCUMENT 
(6.26.1) Recruitment / vacancy targets to be agreed and monitored across the SDU
EVIDENCE 
ATTACHED

HR Consultant & Service Director
6 WLFS
(6.29) SDU Local Partnership Forum to continue to monitor & support staffing issues
Oct 31 2009
DOCUMENT 
(6.29.1) LPF to receive performance data and reports relating to recruitment, training & education, & service 
EVIDENCE 
developments
ATTACHED
Service Director & HR Consultant
6 All SDU's
(6.6) Review of recruitment and selection processes and procedures up to and including induction
Nov  2 2009
DOCUMENT 
(6.6.1) Audit the recruitment process for a random sample of new starters from the past 12 months - AWAITING 
EVIDENCE 
MINUTES AND RESULTS OF AUDIT
ATTACHED
Business Manager HR
6 All SDU's
(6.11) Review Employer branding
Nov 24 2009
DOCUMENT 
(6.11.1) Work with preferred advertising agency to rebrand recruitment products and monitor via R & R Forum
EVIDENCE 
ATTACHED

Head of Staffing Solutions/Euro Riley R&R Forum
6 All SDU's
(6.8) Develop and deliver generic and bespoke recruitment campaigns
Nov 30 2009
DOCUMENT 
(6.8.1) Establish task and finish groups for nursing, OT, A&C and medical staff groups to develop bespoke 
EVIDENCE 
recruitment and retention strategies.
ATTACHED
Head of Staffing Solutions/Professional Heads/R&R Forum

6 All SDU's
(6.8) Develop and deliver generic and bespoke recruitment campaigns
Nov 30 2009
DOCUMENT 
(6.8.2) Develop associated action plans for the above with targets for delivery and monitoring via the R&R Forum.
EVIDENCE 
ATTACHED

Head of Staffing Solutions/Professional Heads/R&R Forum
6 All SDU's
(6.8) Develop and deliver generic and bespoke recruitment campaigns
Nov 30 2009
DOCUMENT 
(6.8.3) Identify recruitment hotspots, collate and analyse data to establish issues and develop action plan for 
EVIDENCE 
delivery of recruitment campaigns  and monitoring via the R&R Forum
ATTACHED
Head of Staffing Solutions/R&R Forum/SDU leads/HR Consultants
6 All SDU's
(6.9) Develop fast track process to recruit OT and Nursing newly qualified staff.
Nov 30 2009
DOCUMENT 
(6.9.1) Establish action plan with Deputy Director of Nursing and Assistant Head of AHP to devise and implement 
EVIDENCE 
fast track process.
ATTACHED
Deputy Director of Nursing/ Associate Head of AHPs/Heads of Nursing/Head 
Ots/Head of Staffing Solutions

6 All SDU's
(6.10) Develop rotation schemes for qualified nursing staff and improve internal transfer process
Nov 30 2009
DOCUMENT 
(6.10.1) Review Trust’s current arrangements and establish new protocol for internal transfer process.
EVIDENCE 
To include positive rotation scheme
ATTACHED
Deputy Director of Nursing/Heads of Nursing/ Head of Staffing Solutions
6 All SDU's
(6.6) Review of recruitment and selection processes and procedures up to and including induction
Nov 30 2009
DOCUMENT 
(6.6.5) Produce a report with recommendations for immediate improvements and/or further exploration of 
EVIDENCE 
processes/data for longer term strategy.
ATTACHED
Business Manager HR
6 All SDU's
(6.12) Continue to develop proactive approach to employment of people with mental health issues
Nov 30 2009

DOCUMENT 
(6.12.4) OT Consultant post advertised to lead on Vocation and Employment
EVIDENCE 
ATTACHED

Head of AHPs
6 All SDU's
(6.2) Integrated Preceptorship Programme continues to support newly qualified nurses and AHPs 
Nov 30 2009
throughout their first year post-qualification
DOCUMENT 
(6.2.2) Preceptorship policy agreed at Policy review group and presented to Board
EVIDENCE 
ATTACHED

Head of AHPs
6 WLFS
(6.28) Improve recruitment to administrative roles across the SDU
Nov 30 2009
DOCUMENT 
(6.28.1) Review of admin vacancies & difficulties in recruitment to be undertaken & discussed at the Trust-wide 
EVIDENCE 
R&R forum
ATTACHED
Head of Admin /HR Consultant  & Service Director
6 WLFS
(6.26) Reduce number of unplanned vacancies across the SDU
Nov 30 2009
DOCUMENT 
(6.26.2) Develop action plans to address recruitment and retention issues in specific posts/clinical areas
EVIDENCE 
ATTACHED

HR Consultant
6 WLFS
(6.27) Increased compliance with PDR process to identify training & development needs of staff
Nov 30 2009
DOCUMENT 
(6.27.1) System of monitoring compliance for all staff groups to be developed and incorporated into SDU 
EVIDENCE 
performance management processes
ATTACHED
HR Consultant & Head of Business Mgt
6 WLFS
(6.27) Increased compliance with PDR process to identify training & development needs of staff
Nov 30 2009

DOCUMENT 
(6.27.2) Inform all staff that the expectation is that PDRs will be completed, and is part of their job
EVIDENCE 
ATTACHED

HR Consultant
6 Hounslow
(6.30) Own and plan delivery to SDU allocated recruitment target (10%)
Nov 30 2009
DOCUMENT 
(6.30.3) Build into terms of reference for HMT
EVIDENCE 
ATTACHED

Head of Nursing/ Service Manager
6 Hounslow
(6.31) Monthly medical staffing meeting established
Dec 31 2009
DOCUMENT 
(6.31.1) With Medical Director review skill mix and escalation pathways for medical workforce (specifically allocation 
EVIDENCE 
of trainees/experience and current speciality doctor recruitment pressure)
ATTACHED
Clinical Director
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Dec 31 2009
DOCUMENT 
(6.24.6) Recruitment and selection training of managers
EVIDENCE 
ATTACHED

Service Directors/ Service Managers
6 All SDU's
(6.2) Integrated Preceptorship Programme continues to support newly qualified nurses and AHPs 
Dec 31 2009
throughout their first year post-qualification
DOCUMENT 
(6.2.1) Preceptees and Preceptors follow programme and policy - going to Dec 09 Ops Board for ratification
EVIDENCE 
ATTACHED

Associate Head of AHPS/Head of Nursing Education
6 All SDU's
(6.1) Continue to develop, implement and monitor the Time to Care project
Dec 31 2009

DOCUMENT 
(6.1.1) Pilot wards are supported to continue to implement Star Wards, Productive Wards and Respect and 
EVIDENCE 
Responsibility programme
ATTACHED
Deputy Director of Nursing/Time to Care project Lead
6 All SDU's
(6.12) Continue to develop proactive approach to employment of people with mental health issues
Dec 31 2009
DOCUMENT 
(6.12.2) Permitted work posts have a comprehensive HR process to get people into post as soon as possible.
EVIDENCE 
ATTACHED

Head of Staffing Solutions
6 All SDU's
(6.5) Staff will be aware of and will have access to Consent to Treatment training, which will be part of the 
Dec 31 2009
MHA and Capacity training within the Mandatory training cycle
(6.5.1) Consent to treatment approved to be in training by panel
Associate MD
6 All SDU's
(6.10) Develop rotation schemes for qualified nursing staff and improve internal transfer process
Dec 31 2009
DOCUMENT 
(6.10.2) To consider unique selling points of Trust to attract quality staff and promote on website. Link to re-
EVIDENCE 
branding project - work in progress
ATTACHED
Generic recruitment group
6 All SDU's
(6.4) The Trust must ensure that staff are able to observe, engage and work with service users to enable 
Jan 31 2010
accurate risk assessment and care plans to take place
DOCUMENT 
(6.4.1) Review E&O training across Trust to ensure it is robust, meets the requirements to address quality of 
EVIDENCE 
engagement and links to risk assessment and management, and that staff are able to access and attend across the 
ATTACHED
Trust
Head of AHPs/ Deputy Director of Nursing/ Associate Director HR L&D
6 All SDU's
(6.3) Recruitment strategies linked to recruiting staff with the right skills
Jan 31 2010
DOCUMENT 
(6.3.2) Skills Scanning tool developed for recruitment of nurses and AHPs
EVIDENCE 
ATTACHED


Deputy Director of Nursing/Head of Staff Development
6 All SDU's
(6.18) Improve access to and the quality of supervision, PDR and development
Jan 31 2010
DOCUMENT 
(6.18.2) Review and implement PDR Policy - draft policy completed and will be implemented when it goes on online 
EVIDENCE 
April 2010
ATTACHED
Associate Director of HR L&D/ Head of staff development
6 Broadmoor
(6.36) Review of secondary inductions and new staff induction for PD service to be implemented
Jan 31 2010
DOCUMENT 
(6.36.1) Secondary induction review to be completed and revisions to be made as necessary.
EVIDENCE 
ATTACHED

Deputy Director of Nursing
6 Broadmoor
(6.36) Review of secondary inductions and new staff induction for PD service to be implemented
Jan 31 2010
DOCUMENT 
(6.36.2) Secondary induction for staff working in new PD service to be designed and implemented
EVIDENCE 
ATTACHED

Deputy Director of Nursing
6 Hounslow
(6.34) Up-skilling of workforce in the inpatient unit underway
Jan 31 2010
08/09 priorities 
- Gender training (2 days team based)
- Dual Diagnosis (2 days team based)
- Recovery Training (2 days team based)
- Therapeutic opportunities with ceasing smoking – alternative activities, health gains, motivation 
consolidation (1 day training)

DOCUMENT 
(6.34.1) Local process to confirm staffs understanding of Engagement and Observation
EVIDENCE 
ATTACHED

Head of Nursing
6 Broadmoor
(6.35) Increase recruitment to allow the reconfiguration of wards with additional nursing staff as per the 
Feb 28 2010
Clinical Services Improvement Plan.

(6.35.1) Bespoke Open Recruitment Day.
SDU Director
6 All SDU's
(6.18) Improve access to and the quality of supervision, PDR and development
Feb 28 2010
(6.18.3) Review and Re-launch Supervision Policy
Acting Head of OD&Diversity (Staff)
6 All SDU's
(6.18) Improve access to and the quality of supervision, PDR and development
Feb 28 2010
(6.18.1) Implement on-line PDR
Head of Staff Development
6 All SDU's
(6.17) Develop Integrated Workforce Plan for 2010/11 to 2013/14 and review recruitment and selection 
Mar 31 2010
strategy to support delivery of workforce requirements
(6.17.1) Agree with SDU leads their workforce requirements in conjunction with Finance and service planning
(6.17.2) Work with local HEIs to ensure the quality and safety of student placements
Workforce and Information Manager/SDU Directors
6 All SDU's
(6.18) Improve access to and the quality of supervision, PDR and development
Mar 31 2010
(6.18.4) Comprehensive review of supervision training and implementation across the Trust
Acting Head of OD&Diversity (Staff) /SDU Directors
6 All SDU's
(6.12) Continue to develop proactive approach to employment of people with mental health issues
Mar 31 2010
(6.12.3) Work Placements are available to service users as part of pathways to work
Social Inclusion Lead/Deputy Director of HR/Head of Staffing Solutions/Head of 
Staffing Solutions


6 All SDU's
(6.13) Quarterly review of recruitment activity against agreed targets
Mar 31 2010
(6.13.1) Develop SDU based action plans to deliver reduction in vacancy rates and monitor monthly via the SMT 
meetings and quarterly via the R&R Forum
Head of Staffing Solutions/SDU Directors/HR Consultants
6 All SDU's
(6.14) Deliver Recruitment and Selection Training
Mar 31 2010
(6.14.2) Review bespoke R&S training course
Develop programme for delivery of R&S training across SDUs and linked to campaigns
Head of Staffing Solutions/HR Consultants
6 All SDU's
(6.15) Review retention initiatives and set turnover targets
Mar 31 2010
(6.15.1) R&R Forum to agree retention initiatives. Develop SDU based action plans to deliver retention initiatives. 
SDU to set turnover targets and monitored via R & R Forum.
R&R Forum/ SDU leads/HR Consultants
6 All SDU's
(6.3) Recruitment strategies linked to recruiting staff with the right skills
Mar 31 2010
(6.3.3) A comprehensive risk assessment and management package of tools and processes is understood and 
utilised by staff
Medical Director/ Associate Medical Director/ Head of AHPS/ Deputy Director of 
Nursing

6 All SDU's
(6.5) Staff will be aware of and will have access to Consent to Treatment training, which will be part of the 
Mar 31 2010
MHA and Capacity training within the Mandatory training cycle
(6.5.2) Consent to treatment training rolled out
Associate MD
6 All SDU's
(6.1) Continue to develop, implement and monitor the Time to Care project
Mar 31 2010
DOCUMENT 
(6.1.2) Roll out continues across Trust, including Forensic services
EVIDENCE 
ATTACHED

Deputy Director of Nursing/Time to Care project Lead

6 H&F
(6.25) To have in place mechanisms to support skills development of staff
Mar 31 2010
(6.25.4) Training strategy in place to support Service redesign
VM/Service Managers
6 All SDU's
(6.20) Three borough Senior Management teams to work towards and deliver on recruitment targets
Apr 30 2010
(6.20.4) Maintain and monitor local training needs analysis, and identify skills needed in each area of speciality
SDU Directors/Clinical Directors
6 WLFS
(6.27) Increased compliance with PDR process to identify training & development needs of staff
May 31 2010
(6.27.3) Support and encourage a Trustwide review of the current PDR paperwork in order to maximise compliance 
rate
Service Director
6 H&F
(6.24) To have constant overview of recruitment and recruitment
Sep 30 2010
(6.24.8) Consider the reduction of working hours from 60 to 48
Service Director/ Deputy Director of HR
6 Hounslow
(6.34) Up-skilling of workforce in the inpatient unit underway
Oct 31 2010
08/09 priorities 
- Gender training (2 days team based)
- Dual Diagnosis (2 days team based)
- Recovery Training (2 days team based)
- Therapeutic opportunities with ceasing smoking – alternative activities, health gains, motivation 
consolidation (1 day training)

(6.34.2) Ensure attendance at forthcoming… 
- Working with dementia & strokes 13-15 Oct ‘10
- CBT Key K&S – 17 Nov ‘09
- RAID (extreme behaviour) 19-21 Jan ‘10
Service Managers

6 Hounslow
(6.32) New Head of Nursing across SDU appointed April ’09 Lead nurses in post across all care group – 
Dec 31 2010
SDU wide Nursing Governance Forum established to enhance nursing practice, ensure implementation of 
policies, build nursing leadership  capacity and improve standards

(6.32.2) Support Trustwide integrated preceptorship programme for newly qualified nursing/AHP
Deputy Director of Nursing/ Head of AHPs
6 Hounslow
(6.33) SDU wide review of PDR’s and training including medical appraisal
Dec 31 2010
(6.33.1) SDU will effect detailed manual PDR uptake map for comprehensive training need and gap analysis 
informed by training issues from I8 cycle
Service Director / Service Manager
6 Hounslow
(6.30) Own and plan delivery to SDU allocated recruitment target (10%)
Dec 31 2010
(6.30.1) Standing item on SMT agenda with monthly reports by care group.  Review on monthly basis Clinical 
Director, Director and HR consultant.
Service Director/ Service Managers
6 Hounslow
(6.30) Own and plan delivery to SDU allocated recruitment target (10%)
Dec 31 2010
(6.30.2) 95% staff in post across 5 wards at LMHU
Head of Nursing/ Service Manager
6 All SDU's
(6.3) Recruitment strategies linked to recruiting staff with the right skills
Jan 31 2011
DOCUMENT 
(6.3.1) Skills escalator developed for nursing staff
EVIDENCE 
ATTACHED

Deputy Director of Nursing/Heads of Nursing
6 All SDU's
(6.16) To continue to proactively manage sickness absence through the use of the Bradford Score and the 
Dec 31 2011
on line attendance management system, targeting hotspots to reduce sickness absence rates.

(6.16.1) To monitor on a monthly basis sickness absence rates across the SDUs and agree actions to target 
hotspots.
HR Consultancy Team/SDU managers
6 All SDU's
(6.16) To continue to proactively manage sickness absence through the use of the Bradford Score and the 
Dec 31 2011
on line attendance management system, targeting hotspots to reduce sickness absence rates.
(6.16.2) To manage individual sickness absence cases in line with the processes and timescales of the Managing 
Health and Attendance Policy.
HR Consultancy Team/SDU managers
6 All SDU's
(6.16) To continue to proactively manage sickness absence through the use of the Bradford Score and the 
Dec 31 2011
on line attendance management system, targeting hotspots to reduce sickness absence rates.
(6.16.3) To continue to deliver training on the management of sickness absence and the on line tool as need 
identified.
HR Consultancy Team/SDU managers
6 All SDU's
(6.19) To ensure NMC Standards for Practice Placement are met.
Jan 31 2012
(6.19.1) To work with all relevant clinical staff and areas to ensure NMC standards for practice placements are met.
Carol Scott – Dep. Director for Nursing
6 Broadmoor
(6.35) Increase recruitment to allow the reconfiguration of wards with additional nursing staff as per the 
Oct 31 2015
Clinical Services Improvement Plan.
(6.35.2) Completion of recruitment strategy including the use of recruitment agency Pyramid 8
SDU Director, CSIP Programme Manager
6 Broadmoor
(6.35) Increase recruitment to allow the reconfiguration of wards with additional nursing staff as per the 
Oct 31 2015
Clinical Services Improvement Plan.
(6.35.3) Continued Trust wide recruitment – for all directorates to ensure projected workforce turnover is factored in.
Service Directors

6 H&F
(6.24) To have constant overview of recruitment and recruitment
Oct 31 2015
(6.24.7) Monthly monitoring of vacancies as a KPI
Service Directors/ Service Managers
6 Ealing
(6.22) Specific targeted campaigns where we experience difficulty in recruiting in Ealing
Oct 31 2015
(6.22.2) SDU CAMHs post- working with Deputy Director of Nursing
External Facilitator
6 Ealing
(6.21) To have regular review of vacancies and recruitment needs
Oct 31 2015
(6.21.1) Standing agenda item at SMT and Monthly performance meetings with EDs - happens and on-going
Service and Clinical Director
6 Ealing
(6.21) To have regular review of vacancies and recruitment needs
Oct 31 2015
(6.21.2) Monitor and evaluate on-going recruitment campaigns through recruitment and retention trust-wide 
meetings in place - happening and on-going
Service Director/ Deputy Director of HR
6 All SDU's
(6.12) Continue to develop proactive approach to employment of people with mental health issues
Oct 31 2015
(6.12.1) Work of Employment sub-group continues to promote the recruitment and retention of people with 
experience of mental health problems
Head of AHPs Social Inclusion Lead/Deputy Director of HR

7 All SDU's
(7.9) Launch E-learning Trust Wide
Aug 31 2009
DOCUMENT 
(7.9.1) E-Learning launched Trustwide on 24th August 2009.
EVIDENCE 
ATTACHED

Head of Staff Development
7 All SDU's
(7.10) Implement On-line PDR
Aug 31 2009
(7.10.1) Carry out local tests of PDR system within L&D and produce screen shot training guides.
Head of Staff Development
7 All SDU's
(7.7) Improve communication about report facility on exchange and review what is needed and would be 
Sep 30 2009
useful to managers
DOCUMENT 
(7.7.1) Produce Advert and How to Guide on Using report and communicate via Training Matters.
EVIDENCE 
ATTACHED

Head of Staff Development
7 All SDU's
(7.7) Improve communication about report facility on exchange and review what is needed and would be 
Sep 30 2009
useful to managers
DOCUMENT 
(7.7.2) Offer/Set up training on training activity reports to managers, as required.
EVIDENCE 
ATTACHED

Head of Staff Development
7 All SDU's
(7.2) Review uptake and methods of mandatory training, including recording and feedback loop. Develop 
Sep 30 2009
report by staff group and SDU.
DOCUMENT 
(7.2.2) Review training places attended by each group against numbers in group to ascertain requirements and 
EVIDENCE 
training requirements at each of the LDCs.
ATTACHED
Head of Staff Development/ Workforce and Info Manager
7 All SDU's
(7.2) Review uptake and methods of mandatory training, including recording and feedback loop. Develop 
Sep 30 2009
report by staff group and SDU.

DOCUMENT 
(7.2.4) Work with Hounslow SDU to provide local facilities to enabling mandatory training to be provided on site and 
EVIDENCE 
increase uptake of training.
ATTACHED
7 All SDU's
(7.3) On-line bookings to be tracked and monitored monthly to help early identification of capacity issues
Sep 30 2009
DOCUMENT 
(7.3.2) Ensure that staff and managers are made aware of action being taken.  Where courses are showing as full – 
EVIDENCE 
Pop Ups will be implemented to state that additional courses are being scheduled.
ATTACHED
Mandatory training coordinator
7 All SDU's
(7.4) Automated reminder of booking 1 week prior to course
Sep 30 2009
DOCUMENT 
(7.4.2) Admin Team to send duplicate DNA e-mails to managers until a response is received.
EVIDENCE 
ATTACHED

Admin Team
7 All SDU's
(7.5) Process implemented to chase response from managers following DNA letter.
Sep 30 2009
DOCUMENT 
(7.5.2) Ensure reasons for DNA are recorded and reported in both Exchange and ESR.
EVIDENCE 
ATTACHED

Admin Team
7 Ealing
(7.14) Mandatory training is linked to Trustwide actions and implementation programmes
Sep 30 2009
(7.14.1) Standing item on SMT agenda, governance meetings and monthly performance meetings with EDs -Month 
on month target to be agreed with HR to access incentive payments for backfill to release staff for training
Service Director/Managers
7 H&F
(7.15) To improve compliance with mandatory training
Sep 30 2009
DOCUMENT 
(7.15.1) Communicate revised mandatory training matrix
EVIDENCE 
ATTACHED


Service and Clinical Director
7 H&F
(7.15) To improve compliance with mandatory training
Sep 30 2009
DOCUMENT 
(7.15.2) Communicate on-line E learning system
EVIDENCE 
ATTACHED

Service and Clinical Director
7 H&F
(7.15) To improve compliance with mandatory training
Oct 31 2009
DOCUMENT 
(7.15.3) Ask all members of SDU management team to ensure that mandatory training is a standing item in 
EVIDENCE 
supervision.  For that instruction to be cascaded to all supervision
ATTACHED
Service and Clinical Director
7 All SDU's
Removed
Oct 31 2009
Removed
7 Broadmoor
(7.22) Additional focus on mandatory training availability & uptake by SMT
Oct 31 2009
(7.22.1) In view of concerns re failure to meet mandatory training targets – SDU HR consultant to presentation 
information currently available on bookings, availability & uptake of mandatory training.  SMT members to agree 
upon any remedial action required and to ensure solutions are put in place .
HR Consultant
7 All SDU's
(7.5) Process implemented to chase response from managers following DNA letter.
Oct 31 2009
DOCUMENT 
(7.5.3) From responses obtained from new DNA monitoring process review reasons and feedback where necessary 
EVIDENCE 
to SDU.
ATTACHED
L&D centre manager/Head of staff Development

7 All SDU's
(7.5) Process implemented to chase response from managers following DNA letter.
Oct 31 2009
DOCUMENT 
(7.5.1) Where no responses are received at month end, this will be escalated to the Service Manager by Head of 
EVIDENCE 
Staff Development.
ATTACHED
Head of Staff Development/Admin Team
7 All SDU's
(7.4) Automated reminder of booking 1 week prior to course
Oct 31 2009
DOCUMENT 
(7.4.1) Action being taken forward with Exchange Team
EVIDENCE 
ATTACHED

Internet System Manager
7 All SDU's
(7.2) Review uptake and methods of mandatory training, including recording and feedback loop. Develop 
Oct 31 2009
report by staff group and SDU.
DOCUMENT 
(7.2.3) Work with H&F SDU to provide local training facilities to enable mandatory training to be provided on site 
EVIDENCE 
and increase uptake of training.
ATTACHED
Head of Staff Development
7 All SDU's
(7.3) On-line bookings to be tracked and monitored monthly to help early identification of capacity issues
Oct 31 2009
DOCUMENT 
(7.3.1) Produce weekly ‘Future Training Bookings Report’ on the exchange to monitor places available and identify 
EVIDENCE 
where additional courses are required.
ATTACHED
Ass Dir HR L&D/ Head of Staff Development
7 All SDU's
(7.8) Develop competency tracking via ESR when available later this year to show staff status regarding in 
Oct 31 2009
date with training out of date with training.
DOCUMENT 
(7.8.3) Input all localised training attendance sheets onto Exchange to ensure system includes all training data.
EVIDENCE 
ATTACHED

Admin Teams

7 All SDU's
(7.8) Develop competency tracking via ESR when available later this year to show staff status regarding in 
Nov 30 2009
date with training out of date with training.
DOCUMENT 
(7.8.1) Develop competency tracking in Exchange in view of ESR competency tracking not being fully functional.
EVIDENCE 
ATTACHED

Head of Staff Development/Internet system manager
7 All SDU's
(7.8) Develop competency tracking via ESR when available later this year to show staff status regarding in 
Nov 30 2009
date with training out of date with training.
DOCUMENT 
(7.8.2) Develop mandatory tracking as a priority  in Exchange to show mandatory training activity against passport 
EVIDENCE 
group and launch via HR 1 Stop.
ATTACHED
Internet System manager
7 All SDU's
(7.10) Implement On-line PDR
Nov 30 2009
DOCUMENT 
(7.10.3) Set up Pilot Groups for On-line PDRs
EVIDENCE 
ATTACHED

Director of HR L&D/Head of Staff Development
7 All SDU's
(7.1) Further Review mandatory training matrix and communication to staff
Nov 30 2009
DOCUMENT 
(7.1.1) Schedule meetings with all internal training providers to review the content of the mandatory training matrix 
EVIDENCE 
and review frequency and appropriate method of delivery
ATTACHED
Review e-learning courses that meet mandatory requirements and confirm usage with subject matter experts.
Associate Director of HR L&D/ Head of Staff Development
7 All SDU's
(7.2) Review uptake and methods of mandatory training, including recording and feedback loop. Develop 
Nov 30 2009
report by staff group and SDU.
DOCUMENT 
(7.2.5) Work with SDUs to ascertain report requirements.
EVIDENCE 
ATTACHED

Ass Dir HR L&D/ Head of Staff Development

7 All SDU's
(7.1) Further Review mandatory training matrix and communication to staff
Dec 31 2009
DOCUMENT 
(7.1.2) Re-launch matrix with existing/new e-learning courses.
EVIDENCE 
ATTACHED

Associate Director HR L&D/ Head of Staff Development
7 All SDU's
(7.10) Implement On-line PDR
Dec 31 2009
(7.10.2) Input all KSF data onto the Exchange PDR on-line System
Admin Team Associate
7 All SDU's
removed
Dec 31 2009
removed
7 WLFS
(7.16) Ensure systems are in place to monitor attendance at SMT, DMT and team level
Dec 31 2009
(7.16.1) Implement systems to record and monitor attendance of mandatory training. Attendance to be incorporated 
in the SDU performance management process.
HR Consultant and Head of Business Mgt
7 WLFS
(7.17) Ensure adequate spaces are available to meet the demand
Dec 31 2009
(7.17.1) Identify SDU demand and work with training providers to optimise capacity, including increasing capacity of 
PMVA training as priority
HR Consultant  and Directorate Managers
7 Hounslow
(7.19) Learning & Development meetings in place across all care groups
Dec 31 2009
DOCUMENT 
(7.19.1) Revised ToR in the Training and Education Committee  and the local training meetings (Adult/OPS (SB), 
EVIDENCE 
CAMHS (TC), Cassel (LD)) to ensure routine review of PDR uptake and mandatory training
ATTACHED
Service Managers

7 Hounslow
(7.19) Learning & Development meetings in place across all care groups
Dec 31 2009
DOCUMENT 
(7.19.2) Re-launch mandatory training passport through Learning and Development across all care groups
EVIDENCE 
ATTACHED

HR Consultant/ Service Manager
7 Broadmoor
(7.21) Agreement for local systems for monitoring and managing mandatory training of staff
Dec 31 2009
DOCUMENT 
(7.21.1) All managers to have up to date training matrix in place for staff in their areas.
EVIDENCE 
ATTACHED

Clinical Nurse Managers & Heads of Service
7 All SDU's
(7.10) Implement On-line PDR
Jan 31 2010
DOCUMENT 
(7.10.4) Review and update PDR policy to reflect on-line system, using information from pilot groups.
EVIDENCE 
ATTACHED

Director of HR L&D/ Head of Staff Development
7 All SDU's
(7.2) Review uptake and methods of mandatory training, including recording and feedback loop. Develop 
Jan 31 2010
report by staff group and SDU.
DOCUMENT 
(7.2.1) Request staff/workforce figures against staff groups in the Mandatory Matrix by site.
EVIDENCE 
ATTACHED

Associate Director HR L&D/ Head of Staff Development
7 All SDU's
(7.10) Implement On-line PDR
Feb 28 2010
(7.10.5) Train staff on new PDR system.
Head of Staff Development/ Employee Development Advisor/ L&D Manager

7 Hounslow
(7.20) Strengthen SDU-wide  coordination of mandatory and developmental training, monitor DNA’s, ensure  Mar 31 2010
focussed administrative support.

(7.20.1) Relevant Service Managers for SDU
Director / Clinical Director / Service Manager
7 Broadmoor
(7.21) Agreement for local systems for monitoring and managing mandatory training of staff
Mar 31 2010
(7.21.3) Consideration for mandatory training to be delivered in ‘block’ week – review trial being carried out in 
Estates and Facilities.
Associate Directorate of Estates and Facilities
7 Ealing
(7.14) Mandatory training is linked to Trustwide actions and implementation programmes
Mar 31 2010
(7.14.2) Managers will utilise new trust mandatory training matrix and recording system
Service Director
7 H&F
(7.15) To improve compliance with mandatory training
Mar 31 2010
(7.15.4) Construct dedicated E Learning room in H & F
Service Director/Service Manager/ Director of Capital Development
7 H&F
(7.15) To improve compliance with mandatory training
Mar 31 2010
(7.15.5) Work with Staff side to develop learning reps
Staff side convenor/Service Managers
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.1) Short Term measures agreed to mitigate risks
Associate Director of HR L&D/ Head of Staff Development

7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.2) The need to urgently increase compliance rates between Nov 2009/10 to ensure sustainability during 
2010/11 Actions already being taken
Associate Director of HR L&D/ Head of Staff Development
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.3) Additional course capacity created Nov 2009- March 2010.
Associate Director of HR L&D/ Head of Staff Development
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.4) Additional funding to backfill staff release Nov 2009 – March 2010
Associate Director of HR L&D/ Head of Staff Development
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.5) Flexible provision of training including Saturday provision and better use of e-learning.
Associate Director of HR L&D/ Head of Staff Development/ SDU Directors
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.6) Closer monitoring of uptake and attendance with monthly targets
Associate Director of HR L&D/ Head of Staff Development/ SDU Directors

7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.7) Increased reporting of DNA and follow-up.
Associate Director of HR L&D/ Head of Staff Development/ SDU Directors
7 All SDU's
(7.11) Risks to not achieving Desired Outcome. Inability to release staff from workplace to attend training 
Mar 31 2010
due to staff shortages (vacancies and Sickness) interdependency with Recommendation 6. Risk due to 
extreme circumstances i.e. Flu Pandemic

(7.11.8) Prioritisation of mandatory training over all other training especially at times of staff shortages.
Associate Director of HR L&D/ Head of Staff Development/ SDU Directors
7 All SDU's
(7.6) Review DNA position and look at ways of reducing
Apr 30 2010
(7.6.1) Consider implementing charging/penalty for DNAs discussion paper to EDs/ODG.
Associate Director HR L&D
7 WLFS
(7.18) Development of mandatory annual security update in accordance with medium secure standards
Apr 30 2010
(7.18.1) Development of annual security update for staff, including system for ensuring compliance
Service Director  & Head of Security
7 Hounslow
(7.19) Learning & Development meetings in place across all care groups
Oct 31 2015
(7.19.3) Link with HR/Learning and Development to support Trustwide implementation of strategy
HR Consultant/ Service and Clinical Directors
7 Broadmoor
(7.21) Agreement for local systems for monitoring and managing mandatory training of staff
Oct 31 2015
(7.21.2) All staff to have training passports reviewed by supervisor at monthly supervision.

7 H&F
(7.15) To improve compliance with mandatory training
Oct 31 2015
(7.15.6) Work with training & development in relation to the production of  reports which monitor compliance with 
MT across SDU
SMT
7 All SDU's
removed
Oct 31 2015
removed

11 H&F
(11.5) The SDU will continue to support recovery principles
Aug 31 2009
DOCUMENT 
(11.5.1) The underpinning principles within the service redesign set up in August 09, are recovery and social 
EVIDENCE 
inclusion
ATTACHED
Service Director/Clinical lead
11 H&F
(11.6) The development of new business to be considered
Sep 30 2009
DOCUMENT 
(11.6.3) Bid for Assertive Outreach services; initial expression of interest
EVIDENCE 
ATTACHED

Service Director/ Deputy Chief Executive
11 All SDU's
(11.1) To achieve excellence against CQC criteria
Oct 31 2009
DOCUMENT 
(11.1.1) St Bernard’s: SOC approved by  Trust Board and awaiting approval by NHS London
EVIDENCE 
ATTACHED

11 H&F
(11.6) The development of new business to be considered
Oct 31 2009
DOCUMENT 
(11.6.1) Successful in obtaining IAPT pilot site status from October 09
EVIDENCE 
ATTACHED

Head of Psychological Therapies
11 H&F
(11.6) The development of new business to be considered
Oct 31 2009
DOCUMENT 
(11.6.2) Development of a business case to expand Gender Identity services
EVIDENCE 
ATTACHED

Director for Strategy and Performance/ Service manager/ Director Gender Identity 
clinic

11 Hounslow
(11.8) CD and D, with other Trustwide SDU directors, develop shared direction towards excellence.
Oct 31 2009

(11.8.3) Strong promotion of Social Inclusion with key partners. Social inclusion strategy to be signed off 10th 
December 09
Service Director
11 Ealing
(11.4) Service Director and Clinical Director to develop shared direction towards excellence
Nov  2 2009
(11.4.3) Strong promotion of Social Inclusion with key partners.    In partnership with Twinings developing work 
based opportunities across borough
11 H&F
(11.6) The development of new business to be considered
Dec 31 2009
DOCUMENT 
(11.6.4) Explore potential for the development of ante natal services
EVIDENCE 
ATTACHED

Service Director
11 Broadmoor
(11.9) Improving day to day practice and the patient experience in all areas.
Jan 31 2010
DOCUMENT 
(11.9.1) To produce an operational strategy to improve on the quality of care received by our patients.
EVIDENCE 
ATTACHED

Deputy Director of Nursing
11 Hounslow
(11.8) CD and D, with other Trustwide SDU directors, develop shared direction towards excellence.
Feb 28 2010
(11.8.2) Strong promotion of positive risk assessment and management
Service Director
11 Ealing
(11.4) Service Director and Clinical Director to develop shared direction towards excellence
Feb 28 2010
DOCUMENT 
(11.4.2) Commitment to and promotion of positive risk assessment and management.
EVIDENCE 
ATTACHED

Service and Clinical Director

11 All SDU's
(11.2) The Trust must continue to support and promote Social Inclusion and the Recovery Approach
Feb 28 2010
(11.2.4) Full data completeness to facilitate effective performance management (focussing on key aspects such as 
MH Minimum data set)
SDU Directors
11 All SDU's
(11.2) The Trust must continue to support and promote Social Inclusion and the Recovery Approach
Mar 31 2010
(11.2.3) Recovery Strategy developed
Social Inclusion Lead/Associate Medical Director
11 All SDU's
(11.3) Trustwide and three borough work to achieve excellence in clinical care
Mar 31 2010
(11.3.2) Engage service users and carers to support and drive service improvements
Five SDU x SDU Directors/Clinical Directors
11 H&F
(11.6) The development of new business to be considered
Mar 31 2010
(11.6.5) Explore the potential for the development of court diversion services following pilot
Service Directors H&F and WLF SDU/ service manager
11 All SDU's
(11.3) Trustwide and three borough work to achieve excellence in clinical care
Apr 30 2010
(11.3.1) "Think Family” services - Trust wide five SDUs
Five SDU x SDU Directors/Clinical Directors
11 Broadmoor
(11.11) Extend a positive reputation for Forensic Care through greater academic output via research
Apr 30 2010
(11.11.1) A coordinated programme of external publications and presentations to be agreed with greater publicity of 
events
Specialist Consultant

11 All SDU's
(11.3) Trustwide and three borough work to achieve excellence in clinical care
Apr 30 2010
(11.3.4) Develop services with shared strong focus on Social Inclusion and Recovery
Five SDU x SDU Directors
11 Ealing
(11.4) Service Director and Clinical Director to develop shared direction towards excellence
Apr 30 2010
(11.4.1) Commitment to and promotion of Recovery Approach in all care groups.
Service and Clinical Director
11 All SDU's
(11.3) Trustwide and three borough work to achieve excellence in clinical care
May 31 2010
(11.3.3) Use Patient Experience data for quality assurance - pilot date slipped
Five SDU x SDU Directors/clinical directors
11 WLFS
(11.7) Develop culture of publicising /  promoting the innovative work within the SDU & across the 
Sep 30 2010
organisation
(11.7.1) Engage partnership organisations and seek opportunities to publicise and promote work within the SDU 
and beyond. Encourage research, participation in external training and contributions to conferences.
Business manager
11 All SDU's
To achieve excellence against CQC criteria
Dec 31 2013
11 All SDU's
(11.2) The Trust must continue to support and promote Social Inclusion and the Recovery Approach
Nov 30 2015
(11.2.1) Support Trustwide prioritisation of Social Inclusion and Recovery in all SDU and Corporate related work 
streams

Social Inclusion Lead/SDU Directors/Professional Leads
11 All SDU's
(11.2) The Trust must continue to support and promote Social Inclusion and the Recovery Approach
Nov 30 2015
(11.2.2) Recovery and social inclusion training continues across Trust, and is included in the Refocusing the CPA 
work stream
Social Inclusion Lead/Associate Medical Director
11 All SDU's
(11.2) The Trust must continue to support and promote Social Inclusion and the Recovery Approach
Nov 30 2015
(11.2.5) Service users and carers “recruited” to support more Trust work, and to develop greater integration with 
Patient Experience work
Director of Nursing and Patient Experience
11 Broadmoor
(11.10) Deliver the transitional plan from current arrangements to reprovided hospital and full 
Nov 30 2015
implementation of the Clinical Model
(11.10.1) SMT agree implementation schedule and regularly monitor delivery.
SDU Director Clinical Director
11 WLFS
(11.7) Develop culture of publicising /  promoting the innovative work within the SDU & across the 
Nov 30 2015
organisation
(11.7.2) Train staff in the recovery model. Promote and support the integration of the recovery approach, social 
inclusion and the patient experience
Head of Nursing/ Head OT
11 Hounslow
(11.8) CD and D, with other Trustwide SDU directors, develop shared direction towards excellence.
Nov 30 2015
(11.8.1) Strong promotion of Recovery Approach in all care groups.
Clinical Director

3 All SDU's
(3.1) Ensure system in place so PCT and LA are involved with progress  and review of level 1 – 3 incidents 
Sep 14 2009
linked to SDU Integrated Management Boards
DOCUMENT 
(3.1.1) Needs agreement with PCT CEOs – agenda for next 3 way PCT meeting.
EVIDENCE 
ATTACHED

Dep Chief Executive/ PCT CEOs
3 All SDU's
(3.1) Ensure system in place so PCT and LA are involved with progress  and review of level 1 – 3 incidents 
Sep 14 2009
linked to SDU Integrated Management Boards
(3.1.2) PCTs to be represented on all local incident monitoring groups in each SDU.
Dep Chief Executive/ PCT CEOs
3 WLFS
(3.6) Lead Commissioner to engage in SDU IRG meetings
Sep 30 2009
(3.6.1) To invite Lead Commissioner and support attendance - LEAD COMMISSIONER ATTENDS
3 Broadmoor
(3.7) Formalise positive working relationships with Commissioners and NHS London.
Oct 29 2009
(3.7.3) Performance manager (NHS London) and CQC formally MHAC continue as members of IMRG
SDU Director
3 Broadmoor
(3.7) Formalise positive working relationships with Commissioners and NHS London.
Oct 29 2009
(3.7.4) Continued full compliance with High Secure Reporting policy
SDU Director
3 Broadmoor
(3.7) Formalise positive working relationships with Commissioners and NHS London.
Oct 29 2009
(3.7.5) (NB We have just been made aware that there will be a change to our Lead Commissioner)
Arrange meeting with new Lead Commissioner upon appointment to agree future working arrangements and 
systems for communication
SDU Director/Clinical Director

3 All SDU's
(3.2) Commissioning PCT to attend monthly Incident Monitoring Groups
Oct 29 2009
Attend
SDU Directors/Clinical Directors
3 WLFS
(3.4) Ensure clear arrangements are in place with the NWL Forensic Consortium relating to the reporting 
Oct 31 2009
and reviewing of incidents, including reporting against action plans
DOCUMENT 
(3.4.1) To discuss & formalise agreement with Lead Commissioner
EVIDENCE 
ATTACHED

Service Director
3 Broadmoor
(3.7) Formalise positive working relationships with Commissioners and NHS London.
Oct 31 2009
(3.7.2) Quarterly Cluster and SLA meetings with Commissioners
SDU Director
3 WLFS
(3.5) Ensure similar arrangements are clarified with other commissioners (NCG, WEMSS and cost-per-case) Nov 30 2009
DOCUMENT 
(3.5.1) SDU Director to ensure arrangements & expectations are clear for each commissioner
EVIDENCE 
ATTACHED

Service Director
3 All SDU's
(3.3) Commissioning PCT to attend interagency Trustwide learning events (currently bi-annual)
Dec 31 2009
Attend and complete
3 All SDU's
(3.1) Ensure system in place so PCT and LA are involved with progress  and review of level 1 – 3 incidents 
Dec 31 2009
linked to SDU Integrated Management Boards

DOCUMENT 
(3.1.3) To formalise Trust – Commissioner relationships around the process for monitoring, reviewing and learning 
EVIDENCE 
from incidents
ATTACHED
Dep chief Executive
3 Broadmoor
(3.7) Formalise positive working relationships with Commissioners and NHS London.
Oct 31 2015
(3.7.1) Monthly hospital visits by Performance Manager with feedback sessions to SDU Director.
SDU Director

4 Broadmoor
(4.8) Develop FBC and submit for Approval
Sep 16 2009
DOCUMENT 
(4.8.1) Revised OBC submitted to NHS London in Dec 2009. St. Bernards redevelopment OBC due for completion 
EVIDENCE 
Jan 2011
ATTACHED
Programme Director / Director of capital development
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Oct 21 2009
(4.8.2) Approval of OBC by NHS London CIC
Programme Director
4 All SDU's
(4.2) Implementation of the transitional plan as the next stage as part of Redevelopment programme.
Oct 29 2009
DOCUMENT 
(4.2.1) This transitional plan will be submitted to the Senior Management Team and Programme Board in 
EVIDENCE 
September - NOVEMBER PROGRAMME BOARD WAS CANCELLED - TO GO TO DECEMBER MEETING FOR 
ATTACHED
RATIFICATION
Programme Director
4 WLFS
(4.7) Ensure Commissioners are fully engaged in the process
Oct 31 2009
DOCUMENT 
(4.7.1) Copy all relevant documentation to Commissioners and ensure they are invited to relevant meetings 
EVIDENCE 
regarding the redevelopment.
ATTACHED
Service Director
4 WLFS
(4.7) Ensure Commissioners are fully engaged in the process
Oct 31 2009
DOCUMENT 
(4.7.2) To ensure formal communication of support takes place (including discussion regarding revenue) prior to 
EVIDENCE 
Gateway review - this is delayed
ATTACHED
Service Director
4 All SDU's
(4.4) The Trust has commenced the process of engaging a range of advisors for the detailed design stage 
Oct 31 2009
of the Broadmoor Hospital Redevelopment Programme.

DOCUMENT 
(4.4.1) The ITT was issued in early August and shortlisting will occur in late September 2009. Interviews will take 
EVIDENCE 
place during October. This will enable design work to commence upon OBC approval without any delay.
ATTACHED
Programme Director / Dir High Secure Services / Interim successor
4 Ealing
(4.5)
Oct 31 2009
DOCUMENT 
(4.5.1) Working with partner agencies to identify new sites for Adult CMHT’s. Process Started .
EVIDENCE 
ATTACHED

SDU Director/ Director of Capital Development
4 Ealing
(4.5) New Therapy centre and PICU development in train, work commencing October.
Oct 31 2009
Fit for purpose business cases being submitted for Community sites
(4.5.2) Working with corporate services to identify what services may be provided off site in the future. New PICU 
and Therapy service due for completion July 2010  (4.5.3) St Bernards redevelopment process to reach a preferred 
option will take into account the medium to long term trust Strategy for the future provision of local services
Service Director Estates and Facilities
4 WLFS
(4.6) SDU to ensure effective engagement with the SOC process and beyond
Oct 31 2009
(4.6.1) Interim project manager appointed – to appoint to substantive post if required beyond SOC stage  - Pam 
Scott in post
Service Director and Director of Capital Development
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Nov 16 2009
DOCUMENT 
(4.8.3) Preferred Team of Advisors approved by Trust Board
EVIDENCE 
ATTACHED

Programme Director
4 All SDU's
(4.3) Completion of capital improvement works as scheduled aimed at improving the safety of the 
Nov 30 2009
environment at Broadmoor Hospital.
(4.3.1) The transitional plan also includes all capital improvement works. This includes a major review of furnishings 
following risk incidents, and a further programme of identification and removal of ligatures

Director of Capital Development
4 All SDU's
(4.1) Strategic Outline Business Case for St. Bernard’s site to be presented to Trust Board
Nov 30 2009
(4.1.1) Presented to Board
4 WLFS
(4.6) SDU to ensure effective engagement with the SOC process and beyond
Apr 30 2010
(4.6.2) Agree & resource project structure to optimise clinical & service user involvement for OBC stage.
St bernards Redevelopment SOC agreed by Trust Board and is now awaiting approval from NHS LONDON - March 
2010
Service Director/ Director of Capital Development
4 Broadmoor
(4.8) Develop FBC and submit for Approval
May 31 2010
(4.8.4) Design work commenced
Programme Director
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Jul 31 2010
(4.8.5) Environmental Impact Assessment Complete
Programme Director
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Aug 31 2010
(4.8.6) Contractor appointed
Programme Director
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Aug 31 2011

(4.8.7) Full Planning Submitted
Programme Director
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Mar 29 2012
(4.8.8) Commissioner Support finalised
Programme Director
4 Broadmoor
(4.8) Develop FBC and submit for Approval
Jul 31 2012
(4.8.9) FBC Approval
Programme Director
4 Broadmoor
(4.8)Develop FBC and submit for Approval
Oct 31 2012
(4.8.10) FBC: DH/Treasury Approval
Programme Director

12 All SDU's
(12.1) Patient Experience Project established
Sep 30 2009
(12.1.4) Director of Nursing and Patient Experience post advertised
Chief Executive/Deputy Chief Executive
12 H&F
(12.3) To encourage and develop effective working relationships with key non-executive directors to link 
Sep 30 2009
with SDU as a means of improving patient experience
DOCUMENT 
(12.3.1) To give priority to Non executive Director visits
EVIDENCE 
ATTACHED

Service Director and Clinical Director
12 Ealing
(12.2) To encourage and develop effective working relationships with key non-executive directors to link 
Nov  2 2009
with SDU
DOCUMENT 
(12.2.1) A series of visits to service areas to be planned so that Non Executive Directors can understand the service 
EVIDENCE 
provision. Programme starting Jan feb 2010
ATTACHED
Service Director
12 WLFS
(12.4) Develop effective working relationships with key non-executive directors.
Nov  2 2009
(12.4.1) Organise programme of visits for Non-executive Directors to familiarise them with the various components 
of the SDU. Being organised currently - and centrally by Board Secretary
Service Director and Clinical Director
12 WLFS
(12.5) Improve service user experience
Nov  2 2009
DOCUMENT 
(12.5.1) Join pilot for PET in the ward and community forensic settings . PILOT COMMENCED
EVIDENCE 
ATTACHED

Head of Nursing
12 Ealing
(12.2) To encourage and develop effective working relationships with key non-executive directors to link 
Nov 30 2009
with SDU

DOCUMENT 
(12.2.2) Invites to Inpatient Forum and CIGs for opportunities to hear service users issues first hand.
EVIDENCE 
ATTACHED

Inpatient Service Manager
12 All SDU's
(12.1) Patient Experience Project established
Nov 30 2009
(12.1.5) Appointment
Chief Executive
12 H&F
(12.3) To encourage and develop effective working relationships with key non-executive directors to link 
Nov 30 2009
with SDU as a means of improving patient experience
DOCUMENT 
(12.3.2) H & F to be part of the pilot for PET. To develop governance arrangements for the use of information
EVIDENCE 
ATTACHED

Service Director and Clinical Director
12 Broadmoor
(12.7) SDU to provide a schedule of meetings, fora etc and ensure that Non Exec Directors are encouraged  Nov 30 2009
to attend either on a regular or ad hoc basis

DOCUMENT 
(12.7.1) Provide schedule to Board secretary for dissemination.
EVIDENCE 
ATTACHED

SDU Director
12 Broadmoor
(12.7) SDU to provide a schedule of meetings, fora etc and ensure that Non Exec Directors are encouraged  Nov 30 2009
to attend either on a regular or ad hoc basis

DOCUMENT 
(12.7.2) Ensure that chairs of meetings, SMT, User Forum, IMR&G, discuss with  members this initiative
EVIDENCE 
ATTACHED

SDU Director
12 H&F
(12.3) To encourage and develop effective working relationships with key non-executive directors to link 
Dec 31 2009
with SDU as a means of improving patient experience

DOCUMENT 
(12.3.3) Proposal being developed about User & Carers being involved in the main SDU operational & governance 
EVIDENCE 
group
ATTACHED
Service Director and Clinical Director
12 WLFS
(12.5) Improve service user experience
Dec 31 2009
DOCUMENT 
(12.5.2) Establish a Service User experience group to ascertain their experience and link this to service 
EVIDENCE 
development and delivery
ATTACHED
Head of Nursing
12 All SDU's
(12.1) Patient Experience Project established
Dec 31 2010
(12.1.1) Patient Experience Tracker pilot agreed to take place in H&F and West London Forensic SDU
Chief Executive/Deputy Chief Executive
12 All SDU's
(12.1) Patient Experience Project established
Dec 31 2010
(12.1.2) “Real time” patient experience reports will be available  - quarterly reports to Trust Board.
Chief Executive/Deputy Chief Executive
12 Hounslow
(12.6) Await outcome of WLMHT H&F and WLFSDU pilot for PET.
Dec 31 2010
(12.6.1) Receive and roll out as appropriate recommendations from the pilot
Clinical Director/Head of Governance
12 All SDU's
(12.1) Patient Experience Project established
Nov 30 2015
(12.1.3) MHA Managers to programme visits to wards and feedback.


10 All SDU's
(10.1) Board Development Programme to be    implemented
Sep 30 2009
(10.1.1) Board agreement to re-start development process (can be linked to FTe development) - AWAITING THE 
FORMULATION OF THE NEW BOARD IN DECEMBER 2009 AND THE NEW DIRECTOR OF ORGANISATIONAL 
DEVELOPMENT IN DIARY 2010. a POSITIVE DISCUSSION WAS TAKEN TO RECAST THIS WISH IN THE NEW 
YEAR WITH THE NEW EXECUTIVE AND NON-EXECUTIVE TEAMS. ALL NEW NEDS WILL BE IN POST AT 
THE END OF NOVEMBER 2009, APPOINTMENTS TO THESE EXECUTIVES MADE IN OCTOBER 2009
Director of workforce and OD
10 Ealing
(10.2) Board Development Programme to be implemented
Sep 30 2009
(10.2.2) Specific work being undertaken re Bullying and Harassment. Head of Nursing and Inpatient service 
manager to deliver training to inpatient wards - training planned
10 Ealing
(10.2) Board Development Programme to be implemented
Sep 30 2009
(10.2.5) Business Case for Ops single rooms - BUSINESS CASE DONE - part of trust  Capital work programme
10 Ealing
(10.2) Board Development Programme to be implemented
Sep 30 2009
(10.2.6) Business Case for J C Wing Restaurant to include new opportunities for visitors. BUSINESS CASE 
COMPLETE - no longer part of capital works programme - meeting imminent
10 All SDU's
(10.1) Board Development Programme to be    implemented
Oct 31 2009
(10.1.2) Appoint OD consultant to lead development program - DETAIL REASON FOR EXCEPTION AS ABOVE 
10.1.1 - agreed with SHA
Director of workforce and OD/Chair
10 All SDU's
(10.1) Board Development Programme to be    implemented
Oct 31 2009

(10.1.3) Present and Agree work plan with Board - DETAIL REASON FOR EXCEPTION AS ABOVE 10.1.1 - 
agreed with SHA
Director of Workforce and OD Chair
10 Ealing
(10.2) Board Development Programme to be implemented
Oct 31 2009
(10.2.3) Project Boards are now more inclusive. PICU project board had service user and carer reps. PICU project 
commenced and due for completion July 2010
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Oct 31 2009
DOCUMENT 
(10.6.4) Respond to and action results from Staff survey
EVIDENCE 
ATTACHED

Service Director/Service Manager
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Nov  2 2009
(10.6.8) Arrange second annual nursing conference
Head of Nursing
10 Broadmoor
(10.7) Need to develop a strategy of positive change culture enhanced by clear and visible leadership.
Nov  2 2009
(10.7.1) Appointment of Executive of High Secure Services based at Broadmoor SDU.
Chief Executive
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Nov  2 2009
DOCUMENT 
(10.6.6) Ensure training group oversees fair access to CPD for all professional groups linking to SDU business plan
EVIDENCE 
ATTACHED

Service Director/Service Manager

10 WLFS
(10.4) To develop mechanisms to improve communication and leadership development
Nov  2 2009
(10.4.1) Communications sub-group established as part of local partnership forum, to better engage and involve 
staff
Service Director
10 All SDU's
(10.1) Board Development Programme to be    implemented
Nov 30 2009
(10.1.5) Initial board workshop and individual interviews with consultant - Away Day happened 8th December 2009, 
individual psychometric assessments for board completed - agreed with SHA to remain amber
Director of workforce and OD
10 Ealing
(10.2) Board Development Programme to be implemented
Nov 30 2009
(10.2.4) Senior Management Team-Away-day to develop Leadership of the SDU.
To agree facilitator and dates with SMT - March 2010
10 All SDU's
(10.1) Board Development Programme to be    implemented
Nov 30 2009
(10.1.8) Implement strategic board agenda management - agreed with SAH to remain amber
10 Ealing
(10.2) Board Development Programme to be    implemented
Nov 30 2009
DOCUMENT 
(10.2.1) All teams in all care groups taking forward issues raised by the staff survey
EVIDENCE 
Clear action plans in place
ATTACHED
Clinical Director, Clinical Leads, Service Director and Operational Managers
10 H&F
(10.3) SDU Development to be considered to support the Board and it’s priorities for this
Dec 31 2009
DOCUMENT 
(10.3.2) Ensure that appraisals & job plans for the management team are up to date
EVIDENCE 
ATTACHED


Service Director/Clinical Director
10 WLFS
(10.5) To develop innovative models of Forensic care delivery
Dec 31 2009
DOCUMENT 
(10.5.2) Develop systems to enhance and monitor patient experience to support Trust PET programme
EVIDENCE 
ATTACHED

Head of Nursing
10 All SDU's
(10.1) Board Development Programme to be    implemented
Dec 31 2009
(10.1.6) Development of strategy, LTFM, IBP with Board
Director of Workforce and OD
10 All SDU's
(10.1) Board Development Programme to be    implemented
Dec 31 2009
(10.1.4) Ensure NED and ED appraisals are up to date
10 Broadmoor
(10.7) Need to develop a strategy of positive change culture enhanced by clear and visible leadership.
Jan 31 2010
DOCUMENT 
(10.7.4) Develop regular forums to present case reviews highlighting good practice as well as learning lessons and 
EVIDENCE 
improving practice
ATTACHED
Clinical Director
10 H&F
(10.3) SDU Development to be considered to support the Board and it’s priorities for this
Mar 31 2010
(10.3.1) Away Day to focus on leadership development/skills/SMT strategy
Service Director/Clinical Director

10 WLFS
(10.4) To develop mechanisms to improve communication and leadership development
Mar 31 2010
(10.4.2) Senior Management Team-Away-day to develop Leadership of the SDU
Service Director
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Mar 31 2010
(10.6.3) Managers to attend Trust recruitment  training
Service Director/Service Manager
10 All SDU's
(10.1) Board Development Programme to be    implemented
Apr 30 2010
(10.1.7) Follow up workshop
Director of workforce and OD
10 Broadmoor
(10.7) Need to develop a strategy of positive change culture enhanced by clear and visible leadership.
Jun 30 2010
(10.7.2) SMT to participate in an external Leadership Development Programme
SDU Director
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Oct 31 2010
(10.6.5) Gain re-accreditation of IIP
Service Director/Service Manager
10 WLFS
(10.5) To develop innovative models of Forensic care delivery
Apr 30 2011
(10.5.1) Complete work on future models of long term care, community forensic services and specialist in-patient 
services (WEMSS and Adolescent Forensic)
Service Director/Clinical Director

10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Dec 31 2011
(10.6.1) Hounslow Communications Forum every six weeks to support issues from Staff Survey – will be key 
conduit for sharing findings and actions from CQC report
Service Director/Clinical Director
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Dec 31 2012
(10.6.7) Maintain nurse research group
Head of Nursing
10 Broadmoor
(10.7) Need to develop a strategy of positive change culture enhanced by clear and visible leadership.
Nov 30 2015
(10.7.3) Continue monthly staff forums with a focus of two way communication between the staff and SMT of the 
SDU
SDU Director
10 Hounslow
(10.6) Staff in Hounslow SDU to report high satisfaction and confidence in staff annual survey
Nov 30 2015
(10.6.2) Ensure good recruitment practice linked to trust priorities and strategy
Service Director/Service Manager

13 Broadmoor
(13.5) Review of adequacy clinical information systems proposed at SMT September 2009 in context of Mid  Oct 31 2009
Staffs report

(13.5.2) To agree structure for strengthened SDU SMT clinical assurance at October Away Day
Clinical Director
13 Ealing
(13.1) Operational Delivery Group and Clinical Standards and Strategy Group ceased and new governance 
Oct 31 2009
structure to be developed
(13.1.1) Operational Board to commence October 2009 – Executive Directors and SDU Directors and Clinical 
Directors to meet monthly to oversee governance of the Trust business and services. Operational Board now 
operational
Clinical Director
13 Ealing
(13.1) Operational Delivery Group and Clinical Standards and Strategy Group ceased and new governance 
Oct 31 2009
structure to be developed
DOCUMENT 
(13.1.2) Establish the Clinical Governance Forums within the SDU. Clinical Governance structures being finalised
EVIDENCE 
ATTACHED

Clinical Director
13 Ealing
(13.1) Operational Delivery Group and Clinical Standards and Strategy Group ceased and new governance 
Oct 31 2009
structure to be developed
(13.1.3) Explore opportunities to rationalise. EFS leading for board
Clinical Director
13 Ealing
(13.1) Operational Delivery Group and Clinical Standards and Strategy Group ceased and new governance 
Oct 31 2009
structure to be developed
(13.1.4) Explore opportunities for shared learning across care groups. Learning Lessons Nov 3rd 2009
Clinical Director
13 Broadmoor
(13.5) Review of adequacy clinical information systems proposed at SMT September 2009 in context of Mid  Nov  2 2009
Staffs report


DOCUMENT 
(13.5.1) To ensure Trust arrangements are mirrored at SDU level
EVIDENCE 
ATTACHED

Clinical Director
13 WLFS
(13.3) Review governance structures in line with new Trust-wide clinical governance structure and change 
Dec 31 2009
existing structures if necessary to ensure consistency.
DOCUMENT 
n/a
EVIDENCE 
ATTACHED

Director/ Clinical Director
13 H&F
(13.2) To review the governance structure once the Trust wide structure has been completed
Jan 31 2010
DOCUMENT 
Structure agreed - needs to be approved by Board
EVIDENCE 
ATTACHED

SDU Director
13 Hounslow
(13.4) Governance work streams established locally – to be reviewed accordingly when new Trust 
Dec 31 2011
structures apply
(13.4.1) Audit and performance group reviews audits and monitors performance including against Level 2 and 3 
incident action plans
Clinical Director
13 Hounslow
(13.4) Governance work streams established locally – to be reviewed accordingly when new Trust 
Dec 31 2011
structures apply
(13.4.2) Clinical Effectiveness looks at the interaction between therapies and treatments, care environments and 
pathways, and patient experience
Clinical Director