Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 33
Essex Partnership University NHS Foundation Trust Adapt governance arrangements through collaborative learning involving care leadership, quality and safety specialists, and patient safety partners.
View source
Essex Partnership University NHS Foundation Trust Provide Food and Fluid Refresher training to inpatient nursing staff.
View source
Essex Partnership University NHS Foundation Trust Develop system-based Safety Improvement Plans from themes identified through historical incident learning.
View source
Essex Partnership University NHS Foundation Trust Commission PSIRF training, learning and development activities for staff, including senior leaders overseeing the process.
View source
Essex Partnership University NHS Foundation Trust Operate a PSIRF Improvement Oversight Project Board reporting to the Safety of Care Committee.
View source
Essex Partnership University NHS Foundation Trust Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
View source
Essex Partnership University NHS Foundation Trust Develop and circulate a learning briefing on restricted items and other high-risk items.
View source
Essex Partnership University NHS Foundation Trust Update records-management and adverse-incidents policies and distribute inpatient guidance on preserving records and post-incident actions.
View source
Essex Partnership University NHS Foundation Trust Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
View source
Essex Partnership University NHS Foundation Trust Roll out electronic observations across all wards with daily audit functionality and project-board oversight.
View source
Essex Partnership University NHS Foundation Trust Develop and roll out a digital application providing access to standard operating procedures.
View source
Essex Partnership University NHS Foundation Trust Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
View source
Essex Partnership University NHS Foundation Trust Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
View source
Essex Partnership University NHS Foundation Trust Introduce post-incident protocols for collating staff statements and triangulating written evidence with CCTV, Oxevision and body-worn-camera data.
View source
Essex Partnership University NHS Foundation Trust Refine patient-safety incident processes and reporting templates.
View source
Essex Partnership University NHS Foundation Trust Provide ward security leads and numbered, traceable security passes for staff, including temporary staff, with shift sign-in and sign-out controls.
View source
Essex Partnership University NHS Foundation Trust Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
View source
Essex Partnership University NHS Foundation Trust Implement an inpatient care framework with named-nurse responsibilities and personalised leave plans reviewed by clinical teams.
View source
Essex Partnership University NHS Foundation Trust Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
View source
Essex Partnership University NHS Foundation Trust Review multidisciplinary safety huddles and improve handovers through a nurse-in-charge checklist and task allocation.
View source
Essex Partnership University NHS Foundation Trust Update and disseminate restrictive-practice guidance, prohibited-item lists and handover forms using individualised risk assessment.
View source
Essex Partnership University NHS Foundation Trust Appoint a Matron lead and embed Registered General Nurses and physical-health champions across inpatient wards.
View source
Essex County Council Develop a directly managed short-term service in South Essex for neuro-divergent young people.
View source
Essex County Council Provide home-based care packages through local agencies or direct payments following social care assessment.
View source
Essex County Council Work with statutory partners, service providers and service users to identify housing needs and develop specialist care and support models.
View source
Essex County Council Repurpose Colchester accommodation into a four-bed short-term group home staffed by a multidisciplinary team.
View source
Essex County Council Develop a third solo children’s home through planning and a full rebuild.
View source
Essex County Council Operate an internally delivered solo bespoke children’s home in Colchester for young people with high needs.
View source
Essex County Council Submit capital bids for additional services for complex autistic young people with significant mental health issues, including single-person homes, move-on housing and preventative respite.
View source
Essex County Council Seek governance approval and capital funding to purchase a property for a fourth solo children’s home.
View source
Essex County Council Establish a second Colchester solo children’s home through a tendered provider, subject to Ofsted registration.
View source
Essex County Council Improve relationships with residential providers to increase access to local placements.
View source
Essex County Council Commission community-based short-break provision, including activities, mental-health training, autism publications, adapted holidays and subsidised local attractions.
View source
× 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 Delays and premature sign-off in Trust investigations
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed . Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” 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 of investigations to identify and document material issues and limitations
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations .
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” Is this part of a recurring concern? Yes — Inadequate safety incident investigations .
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 ensure complete therapeutic engagement records in patient observation sheets
Wider context from the report “(5) Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate by nurses and senior staff during evidence, yet had been signed off:
a. Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement
b. Omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder.
c. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff
” 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 Omissions in required food and fluid chart recording
Wider context from the report “(5) Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate by nurses and senior staff during evidence, yet had been signed off:
a. Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement
b. Omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder.
c. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff
” 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 maintain clear and consistent rules on patient belts
Wider context from the report “(2) There was a dispute in evidence over whether it was or was not permitted for patients to have belts on Chelmer Ward, that has not been resolved .
a. Morgan-Rose was on 1:1 observation due to her high risk of self-harm that including ligaturing and a belt was in her possession
b. The Responsible Clinician and a Ward Manager providing support to staff gave evidence that at time that belts were not permitted
c. The Trust senior management stated that belts were permitted and referenced the policy. The Updated ward documentation ‘Handover Checklist’ approved in October 2023 contains belts on a list of prohibited items . The Trust has stated that this is not correct although this was part of the After-Action Review and is in current use.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 Shortfall of appropriate inpatient and community placements for autistic people with mental health and self-harm risks
Wider context from the report “(7) There is a significant shortfall of appropriate placements for people with Autism who have mental health and self-harm risks in Essex both inpatient and the community .
” 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 escalate changes in leave risk
Wider context from the report “(3) Escalation of risk – Morgan-Rose attempted to secure unescorted leave on the morning of her death, her Responsible Clinician had only authorised escorted leave. This was not escalated to the nurse in charge and the Responsible Clinician was not informed .
” 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 Lack of accurate records of staff pass allocation and access
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct.
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation . The Trust investigation did not establish that staff borrowed each other's security passes . On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 ensure in-person checks after bathroom alerts
Wider context from the report “(4) Bathroom alerts – Evidence was heard that an Oxevision alert is triggered if a person is in the bathroom for more than 3 minutes and staff are required to complete an in-person check . Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes . It was not clear from the evidence how the Trust proposes to ensure compliance in respect of this duty .
” 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 Insufficient scrutiny of CCTV and staff observation records
Wider context from the report “(1) The Trust investigation was materially incomplete and there was a lost an opportunity to:
a. Understand concerns of the Family
b. Acknowledge errors and learn lessons from the circumstances of the death. The Director of Operations and Matron informed the Trust Senior Management that the PSII Report had omissions. The Trust evidence was that it was an early adopter of the new NHS investigation process. The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed. Evidence was there was a pressure to sign the report off although it remained incomplete and did not contain a note about the limitations.
c.
d. Escalate concerns about staff observations - About 2 weeks after the death the Matron received a report that staff observations had not been appropriately conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s death. There was insufficient scrutiny of the CCTV that showed that multiple observations entries made on 6 July 2022 after 14:06 hours could not be correct .
e. Understand security issues on a locked mental health ward - It has not been possible to establish the identity of the person that reset the bathroom alert triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an accurate records of Trust staff pass allocation. The Trust investigation did not establish that staff borrowed each other's security passes. On the day of Morgan-Rose’s death a visitor pass issued had had access to the nursing office. The Trust was unable to provide the identity of this person.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 use Oxevision only as an adjunct to face-to-face observations
Wider context from the report “(6) Staff entries in patient observations sheets should have given rise to a concern that some staff may have been using Oxevision not just as an adjunct to face-to-face observations, but instead of them . This remains a concern .
” 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 Adapt governance arrangements through collaborative learning involving care leadership, quality and safety specialists, and patient safety partners.
Verbatim wording from the response “▪ Governance arrangements have been reviewed and currently being adapted which includes identification of early learning through collaborative approach with the care unit leadership, deputy directors of quality and safety subject matter expert and people with lived experience for example our patient safety partners, who are actively involved in the review process.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Provide Food and Fluid Refresher training to inpatient nursing staff.
Verbatim wording from the response “All inpatient nursing staff are completing the Food and Fluid Refresher training delivered by the Professional Development Team.” Source location Response from Essex Partnership University NHS Foundation Trust
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 system-based Safety Improvement Plans from themes identified through historical incident learning.
Verbatim wording from the response “Improvement activities include:” Source location Response from Essex Partnership University NHS Foundation Trust
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 Commission PSIRF training, learning and development activities for staff, including senior leaders overseeing the process.
Verbatim wording from the response “▪ We have commissioned a series of training, learning and development activities both internal and external to ensure staff are trained in the new PSIRF guidance approach including senior leaders who provide oversight for PSIRF process.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Operate a PSIRF Improvement Oversight Project Board reporting to the Safety of Care Committee.
Verbatim wording from the response “The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Oxevision use through ward spot checks, DATIX review and maintained training records.
Verbatim wording from the response “DATIX data reflects that staff are using Oxevission in adherence to policy and responding to alerts which has resulted in no harm. The Inpatient Leadership team continue to spot check ward practice and review DATIX data.” Source location Response from Essex Partnership University NHS Foundation Trust
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 and circulate a learning briefing on restricted items and other high-risk items.
Verbatim wording from the response “The EPUT Culture of Learning Lessons Team are developing and circulating a learning briefing to clarify correct process and share learning regarding restricted items and highlight other high risk items not included on the list. The learning brief is to be informed by existing policy.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Update records-management and adverse-incidents policies and distribute inpatient guidance on preserving records and post-incident actions.
Verbatim wording from the response “○ The requirement to preserve records is being re-enforced by the Trust. The Trust’s Records Management Policy is being updated, with the addition of a poster for inpatient services which outlines records/data which need to be retained and the process to follow within the initial 24 hour period. This will be distributed to mental health inpatient services. The updated policy contains further details of records retention the Trust will take after the initial 24 hours post-incident and within non-inpatient services. In addition, the Trust’s Adverse Incidents Policy is being updated to include the actions to be taken following an unexpected death wider” Source location Response from Essex Partnership University NHS Foundation Trust
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 Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
Verbatim wording from the response “▪ The PSIRF Policy is being updated to reflect best practice. The policy includes time scale for completion of a learning response review and timely sign off. The policy also includes process for the management of safety action plan and cascading of learning across the trust.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Roll out electronic observations across all wards with daily audit functionality and project-board oversight.
Verbatim wording from the response “We have rolled out ‘e-observations’, across all wards, which is a mobile tablet (IPAD) electronic observation recording system; which records the patient observation with detail of patient presentation and engagement in the moment. There is an audit function within the system to enable ward managers to audit the quality of recording and engagement on a daily basis. There is an Oxehealth E-observations Project Board that has oversight of implementation, delivery and outcomes.” Source location Response from Essex Partnership University NHS Foundation Trust
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 and roll out a digital application providing access to standard operating procedures.
Verbatim wording from the response “A new digital app providing instant and easy access to Standard Operating Procedures has been developed. Implementation is in progress, with the rollout commencing in May 2024.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
Verbatim wording from the response “The review of the Therapeutic Engagement and Supportive Observation policy has been completed and circulated to all staff.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
Verbatim wording from the response “Configuration changes to the Oxevission system have been implemented. This will ensure that bathroom alerts continue at 3 minute intervals until an individual has exited the bathroom. This includes the reset functionality of a repeatable and audible and tile illumination of an alert with timer continuation after each successive reset of the alert in 3-minute intervals.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Introduce post-incident protocols for collating staff statements and triangulating written evidence with CCTV, Oxevision and body-worn-camera data.
Verbatim wording from the response “▪ Further, following a patient safety incident the following new ‘post incident immediate actions protocol’ will ensure that security measures in relation to the signing in and out of patient related records are immediately collated:” Source location Response from Essex Partnership University NHS Foundation Trust
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 Refine patient-safety incident processes and reporting templates.
Verbatim wording from the response “Improvement activities include:” Source location Response from Essex Partnership University NHS Foundation Trust
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 Provide ward security leads and numbered, traceable security passes for staff, including temporary staff, with shift sign-in and sign-out controls.
Verbatim wording from the response “○ All wards have an allocated security lead/nurse 24/7 on each shift to support the Nurse in Charge and ensure that all ward staff have their own security passes (ACT), at the beginning of a shift.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
Verbatim wording from the response “A clinical review of the SOPs for Oxevission and Oxevission Observations to align terminology and produce updated versions of the SOPs has been implemented. This includes ensuring the continuity of terminology in the SOP and all communications mirroring system based terms and wording.” Source location Response from Essex Partnership University NHS Foundation Trust
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 an inpatient care framework with named-nurse responsibilities and personalised leave plans reviewed by clinical teams.
Verbatim wording from the response “EPUT are adopting and implementing an evidence based framework within inpatient services to support engagement, care planning and therapeutic intervention. This is an internationally recognised framework which will support a positive cultural change across all our ward environments around therapeutic engagement, holistic care planning (including leave plans), whilst considering the context of care. This will include re-establishing the ‘named nurse’ function and responsibilities.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Verbatim wording from the response “All clinical staff are being retrained or trained in the use of Oxevission and observations. In line with the Oxevission SOP and the Therapeutic engagement and supportive observation policy.” Source location Response from Essex Partnership University NHS Foundation Trust
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 multidisciplinary safety huddles and improve handovers through a nurse-in-charge checklist and task allocation.
Verbatim wording from the response “Communication will be improved within the multi - disciplinary team by reviewing the impact of the multi-disciplinary team safety huddles through a Qi methodology. As well as implementing improvements in the handover process with the introduction of the nurse in charge checklist and task allocation.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Update and disseminate restrictive-practice guidance, prohibited-item lists and handover forms using individualised risk assessment.
Verbatim wording from the response “The Trust’s Global restrictive practice Guideline on the use of Global Restrictive Practices in In-Patient Units and the Restricted and Prohibited Items List – Inpatient Units CG92 – Appendix 1 has been updated and the restricted items reviewed through the Trust’s Restrictive Practice Trust Steering Group and Co-Production in December 2022.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Appoint a Matron lead and embed Registered General Nurses and physical-health champions across inpatient wards.
Verbatim wording from the response “We are currently implementing The International Fundamentals of Care Framework which outlines what is involved in the delivery of safe, effective, high-quality fundamental care, and what this care should look like in any healthcare setting and for any care recipient. This programme is being jointly led by the Nursing Directorate and Operations. A Matron lead post has been appointed to support implementation across all inpatient teams.” Source location Response from Essex Partnership University NHS Foundation Trust
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 directly managed short-term service in South Essex for neuro-divergent young people.
Verbatim wording from the response “In South Essex, we are developing a similar short term service as the one referred to in Colchester. These services will be directly run and managed by the Council.” Source location Response from Essex County Council
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 Provide home-based care packages through local agencies or direct payments following social care assessment.
Verbatim wording from the response “Where a need is identified through social care assessment, the Council offer home based care packages with local agencies. This is sourced directly or through direct payments based on the person and family’s needs and preferences.” Source location Response from Essex County Council
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 Work with statutory partners, service providers and service users to identify housing needs and develop specialist care and support models.
Verbatim wording from the response “In addition to the specific developments noted above, the Council works closely with our statutory partners; the Borough & Districts and NHS along with service providers and people who use services to identify future housing needs and to develop specialist models of care and support.” Source location Response from Essex County Council
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 Repurpose Colchester accommodation into a four-bed short-term group home staffed by a multidisciplinary team.
Verbatim wording from the response “Alongside the solo provision, the Council is repurposing another accommodation in Colchester to be a group home. This will provide a 4 bedded short term (up to 6 months) placements, staffed by a multi-disciplinary team, to support neuro-divergent young people to live in the community.” Source location Response from Essex County Council
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 third solo children’s home through planning and a full rebuild.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Operate an internally delivered solo bespoke children’s home in Colchester for young people with high needs.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Submit capital bids for additional services for complex autistic young people with significant mental health issues, including single-person homes, move-on housing and preventative respite.
Verbatim wording from the response “Transforming Care Partnership:” Source location Response from Essex County Council
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 governance approval and capital funding to purchase a property for a fourth solo children’s home.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Establish a second Colchester solo children’s home through a tendered provider, subject to Ofsted registration.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 relationships with residential providers to increase access to local placements.
Verbatim wording from the response “Residential Accommodation Strategy:” Source location Response from Essex County Council
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 Commission community-based short-break provision, including activities, mental-health training, autism publications, adapted holidays and subsidised local attractions.
Verbatim wording from the response “Wider Community Support and Services:” Source location Response from Essex County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Belts need not be added to the prohibited-items list because individualized risk assessments and care plans address self-harm risks.
Verbatim wording from the response “The Trust’s Global restrictive practice Guideline on the use of Global Restrictive Practices in In-Patient Units and the Restricted and Prohibited Items List – Inpatient Units CG92 – Appendix 1 has been updated and the restricted items reviewed through the Trust’s Restrictive Practice Trust Steering Group and Co-Production in December 2022.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for commissioning hospital care rests with the NHS through Integrated Commissioning Boards and NHS England, not the Council.
Verbatim wording from the response “Essex County Council has a joint responsibility with three Integrated Commissioning Boards across Essex for meeting the health and care needs of the residents in Essex. This includes ensuring that there is a sufficient supply and range of specialist community placements and other forms of support for people with autism and co-existing mental health needs.” Source location Response from Essex County Council
Open published response
Pin
Get email alerts
Request correction
Information checked against the published report and official responses