External Action Plan 2015 / 11721 No* Recommendation / Action Lead Level for Action Monitoring Target date Evidence of action implementation Area of concern (in SMART format) What issue has been How will the issue be addressed? The A single person Is the action How and when In order to demonstrate action point implementation identified? Issues must be action point must directly state how it will should have applicable to: will progress be the evidence must be obtained by the person listed individually with an address the area of concern in a clear and responsibility for An individual measured? E.g. responsible for the action point. A copy of the associated action point measurable way to ensure improvements the implementation member/s of audit, survey. evidence must be sent to the Quality Assurance, assigned. are achieved. of an action point to staff How will you Research and Innovation Unit for corporate avoid confusion and Team demonstrate that reporting. Note: Issues must be ensure clear lines of Service the action point considered from an accountability. Directorate has addressed the individual patient care Note: this must be Borough issue identified? Division perspective, but also from discussed with the a service perspective. nominated Trust individual and agreement obtained 2 PCFT should seek Review the CTO Policy by Task MM (Mental Task and May 2017 Revised policy ☐Individual Team ☐The assurance that the and Finish Groups Health Law Finish Service ☐The current CTO Policy Directorate Manager) ☐The (HMcC) Borough is realistic and fit Audit already implemented for ☐The Division ☐The Revised policy for purpose, and May 2017 care planning and code of KT;MP;HM Policy (MM) Trust ☒The it as required practice compliance Audit results to ensure it is line Q4 Community Audit (LC); Action plan with other relevant Consultant re-measure Trust processes, between and then seek 2016 audit assurance that the results and requirements of Inpatient Q4 2017 the CTO policy are Consultant being adhered to and implemented correctly
External Action Plan 2015 / 11721 No* Recommendation / Area of concern Action (in SMART format) Lead Level for Action Monitoring Target date Evidence of action implementation What issue has been identified? Issues must be listed individually with an associated action point assigned. Note: Issues must be considered from an individual patient care perspective, but also from a service perspective. How will the issue be addressed? The action point must directly state how it will address the area of concern in a clear and measurable way to ensure improvements are achieved. A single person should have responsibility for the implementation of an action point to avoid confusion and ensure clear lines of accountability. Note: this must be discussed with the nominated individual and agreement obtained Is the action applicable to: An individual member/s of staff Team Service Directorate Borough Division Trust How and when will progress be measured? E.g. audit, survey. How will you demonstrate that the action point has addressed the issue identified? In order to demonstrate action point implementation the evidence must be obtained by the person responsible for the action point. A copy of the evidence must be sent to the Quality Assurance, Research and Innovation Unit for corporate reporting. 2 PCFT should seek assurance that the current CTO Policy is realistic and fit for purpose, and it as required to ensure it is line with other relevant Trust processes, and then seek assurance that the requirements of the CTO policy are being adhered to and implemented correctly Review the CTO Policy by Task and Finish Groups Audit already implemented for care planning and code of practice compliance MM (Mental Health Law Manager) KT;MP;HM Community Consultant Inpatient Consultant ☐Individual ☐The Team ☐The Service ☐The Directorate ☐The Borough ☐The Division ☒The Trust Task and Finish (HMcC) Policy (MM) Audit (LC); re-measure between 2016 audit results and Q4 2017 May 2017 May 2017 Q4 Revised policy Revised policy Audit results Action plan
pennine-care-foundation-trust-nhs-action-plan-b.docx