PFD report

Mahamoud Hussain Ali · Prevention of Future Deaths report

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Issued 10 Jul 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
36

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Failure to conduct required observations
    Part of recurring concern: Unreliable observation of patients in specialist mental health unitsPart of recurring concern: Unreliable patient observation arrangements
  2. Failure to accurately record required observations
    Part of recurring concern: Deliberate falsification of clinical and care recordsPart of recurring concern: Unreliable recording of required observations in care and custody
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.22

  1. Action

    Develop and deliver Honesty in Documentation training face to face across all inpatient services.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
  2. Action

    Develop a learning system linking internal incident and improvement learning with national observation-practice work.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  3. Action

    Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to conduct required observations

Wider context from the report

“(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep. East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable. Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained. Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022. I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…” Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur. ”

Is this part of a recurring concern?

Yes — Unreliable observation of patients in specialist mental health units; Unreliable patient observation arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to accurately record required observations

Wider context from the report

“(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep. East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable. Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained. Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022. I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…” Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur. ”

Is this part of a recurring concern?

Yes — Deliberate falsification of clinical and care records; Unreliable recording of required observations in care and custody.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and deliver Honesty in Documentation training face to face across all inpatient services.

Verbatim wording from the response

“Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a learning system linking internal incident and improvement learning with national observation-practice work.

Verbatim wording from the response

“Learning system To develop a learning system that includes learning from incidents and improvement work internally, but that also links in with national work in relation to observations practice.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.

Verbatim wording from the response

“Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.

Verbatim wording from the response

“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location

Response from ELFT
Page 4 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.

Verbatim wording from the response

“Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct senior-staff night visits with spot-check audits and observation of practice.

Verbatim wording from the response

“Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.”

Source location

Response from ELFT
Page 5 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.

Verbatim wording from the response

“Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement zonal observations to support continuous patient engagement and monitoring across wards.

Verbatim wording from the response

“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location

Response from ELFT
Page 4 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.

Verbatim wording from the response

“Audit and monitoring The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.”

Source location

Response from ELFT
Page 5 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.

Verbatim wording from the response

“Staffing/resource availability Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.

Verbatim wording from the response

“To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.

Verbatim wording from the response

“Standardised processes To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.

Verbatim wording from the response

“A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.”

Source location

Response from ELFT
Page 4 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.

Verbatim wording from the response

“Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement observation board relay to reduce missed observations and improve handover between staff.

Verbatim wording from the response

“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location

Response from ELFT
Page 4 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.

Verbatim wording from the response

“Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.”

Source location

Response from ELFT
Page 4 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.

Verbatim wording from the response

“Overarching theme | Therapeutic engagement and observation improvement work undertaken Staffing/resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.”

Source location

Response from ELFT
Page 2 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.

Verbatim wording from the response

“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue work on honesty in documentation.

Verbatim wording from the response

“Continued work on honesty in documentation.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the Human Factors Analysis findings and suggested improvements through senior leadership.

Verbatim wording from the response

“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.

Verbatim wording from the response

“Communication To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.

Verbatim wording from the response

“Professional practice Review and relaunch use of SOM tool and outputs to impact on practice.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.14

  1. 1

    Introduce the Loop App to restrict bank-shift bookings to staff with required clinical-area competencies.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  2. 2

    Seek service-user perspectives to strengthen safety-culture intelligence.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  3. 3

    Improve governance of temporary and bank nursing staff through training-compliance oversight, supervision and reflective practice.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  4. 4

    Recruit toward zero registered vacancies and review the unregistered workforce’s correct banding and skills.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
  5. 5

    Review findings from the service-user experience of observations qualitative audit tool.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  6. 6

    Develop a second Trust-wide quality-improvement phase with multidisciplinary collaboration to identify alternatives to working-hours observations.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  7. 7

    Maintain participation in the Cavendish Square community of practice to develop approaches and adopt learning on observation practice.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
  8. 8

    Conduct annual inpatient safety-culture assessments, share team reports and discuss findings to target improvements.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
  9. 9

    Use developed escalation protocols to guide staff when resources are insufficient to meet care needs.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
  10. 10

    Pilot Trust-wide clinical induction with consistent core learning and protected study access for substantive and bank staff.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
  11. 11

    Monitor improvement actions and agreed plans through an Executive-led improvement board.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  12. 12

    Run Trust-wide learning seminars on incident learning, improvement and good practice.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
  13. 13

    Review night-shift culture with staff and service users and design practice standards and assurance mechanisms, including senior night visits.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  14. 14

    Maintain monthly Time to Think forums for inpatient staff to reflect on practice, data and clinical examples and inform improvements.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce the Loop App to restrict bank-shift bookings to staff with required clinical-area competencies.

Verbatim wording from the response

“The introduction of the Loop App will ensure that only staff with the required competencies for each clinical area are able to book onto bank shifts.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Seek service-user perspectives to strengthen safety-culture intelligence.

Verbatim wording from the response

“All of our mental health inpatient wards have been participating in this process, with good engagement and over 800 responses have been collected from across all directorates and wards. Next steps are to seek service user perspectives to triangulate and strengthen the safety culture intelligence available to the teams.”

Source location

Response from ELFT
Page 5 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve governance of temporary and bank nursing staff through training-compliance oversight, supervision and reflective practice.

Verbatim wording from the response

“Staff knowledge and capability To improve the robustness and governance of systems for the temporary/bank nursing workforce. This would include better oversight of training compliance and support offered (supervision and reflective practice).”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit toward zero registered vacancies and review the unregistered workforce’s correct banding and skills.

Verbatim wording from the response

“A proactive recruitment campaign has been ongoing with services moving to zero registered vacancies and a review of the unregistered workforce (correct band and skill).”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review findings from the service-user experience of observations qualitative audit tool.

Verbatim wording from the response

“A review of findings from the service user experience of observations qualitative audit tool.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a second Trust-wide quality-improvement phase with multidisciplinary collaboration to identify alternatives to working-hours observations.

Verbatim wording from the response

“Developing the second phase of quality improvement work to include collaborative work with the whole Multi-Disciplinary Team to identify alternatives to observations during working hours. This would require a significant cultural shift away from observations, which will require a significant project to be undertaken Trust-wide.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain participation in the Cavendish Square community of practice to develop approaches and adopt learning on observation practice.

Verbatim wording from the response

“The Trust is involved in the London-wide Cavendish Square community of practice attended by Chief Nurses (Observation practice is one of its yearly objectives) and have applied to enroll in a new NHS England 90-day collaborative around Enhanced Therapeutic observations.”

Source location

Response from ELFT
Page 5 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct annual inpatient safety-culture assessments, share team reports and discuss findings to target improvements.

Verbatim wording from the response

“Inpatient Ward Safety Culture Improvement Work Since 2023 a new safety culture self-assessment process has been incorporated into the Quality Assurance annual review process for each in-patient team across ELFT. Annually, staff complete an anonymous survey based on each component safety culture element. A bespoke team report on the safety culture results is then shared back to directorates and teams (where enough responses are received) with advice/signposting to where steps can be taken to strengthen safety culture. The survey tool results are then discussed in team away-days and meetings with teams, enabling local leaders to focus on areas where improvements need to be made.”

Source location

Response from ELFT
Page 5 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use developed escalation protocols to guide staff when resources are insufficient to meet care needs.

Verbatim wording from the response

“Escalation protocols have been developed for use to guide staff when there are not sufficient resources in place to meet care needs.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Pilot Trust-wide clinical induction with consistent core learning and protected study access for substantive and bank staff.

Verbatim wording from the response

“A pilot of Trust-wide clinical induction started in August 2024. Prior to this, comprehensive clinical inductions were being done in directorates. This Trust-wide approach supports consistency of material and ensures core learning on commencement of clinical roles. Non substantive staff (bank staff) are booked to attend and have access to protected study time to achieve the same competencies as substantive staff.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor improvement actions and agreed plans through an Executive-led improvement board.

Verbatim wording from the response

“An Executive-led improvement board will monitor actions and agreed plans.”

Source location

Response from ELFT
Page 7 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Run Trust-wide learning seminars on incident learning, improvement and good practice.

Verbatim wording from the response

“Trust-wide learning lessons seminars open to all staff focus on areas of learning and improvement from incidents or identified areas of good practice.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review night-shift culture with staff and service users and design practice standards and assurance mechanisms, including senior night visits.

Verbatim wording from the response

“A review of night-shift culture engaging staff and service users and observing work as done. Design standards for night shift practice and a mechanism for assurance including senior night visits.”

Source location

Response from ELFT
Page 6 · response
Published 31 July 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain monthly Time to Think forums for inpatient staff to reflect on practice, data and clinical examples and inform improvements.

Verbatim wording from the response

“Time to Think forums in directorates are well established. These are held monthly in directorates, led by lead nurses and are open to all staff within the inpatient service. They are a protected resource for teams to reflect on their practice, understand work as it happens using data and clinical examples, and generate discussions to inform learning and next steps.”

Source location

Response from ELFT
Page 3 · response
Published 31 July 2024

Open published response
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