NHS Nottinghamshire Healthcare
NHS / Health Body
Action Planned
Nottinghamshire Healthcare is undertaking a comprehensive review of its Crisis Resolution and Home Treatment service, which is currently underway and will lead to an improvement plan by 30 November 2022. (AI summary)
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Dear Mr. Clow,
Please find below the organisational response to the recently received Preventing Future Deaths Report, following the unfortunate death of Mr. Nottle. In responding, we have worked closely in conjunction with Turning Point. The Matters of concern raised within the report:
1. Clarifying the role of telephone workers and the steps necessary to ensure that the government guidance regarding access to mental health services is followed so far as is possible within the available resources.
Nottinghamshire Healthcare and Turning Point are jointly commissioned by Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) to provide a 24-hour Urgent Access Mental Health telephone service. The purpose of the telephone line is to provide support, advice and triage across Nottingham and Nottinghamshire to people requesting help with any aspect of mental health. This includes practical immediate support and guidance or assistance to navigate any further support needed; and immediate transfer to Crisis Resolution and Home Treatment (CRHT) staff if required. The first point of contact are Recovery Workers employed by Turning Point and co-located in the City Crisis Resolution and Home Treatment (CRHT) team office at Highbury Hospital. The staff are co- located so that they may have immediate assistance from CRHT staff if required. The Turning Point Team Leader and CRHT staff have the ability to listen in to calls if necessary. This is carried out via a dual listening device that allows a second set of headphones to be plugged in. The UK Mental Health Triage Scale (Appendix 1) is utilised to guide staff as to when a call should be transferred directly to a CRHT member of staff During the evidence at the inquest the Turning Point staff member stated that Turning Point staff may be placed on the line within their first week of starting work, after shadowing a small number of shifts. It was also stated that there are frequent times when calls are not transferred to CRHT in line with the UK Mental Health Triage Scale Private and Confidential
Mr. Clow HM Assistant Coroner for Nottingham and Nottinghamshire Nottinghamshire Coroner’s Office The Council House Old Market Square Nottingham NG1 2DT Reference:
E-mail:
Date: 3 August 2022.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chair: , Chief Executive:
In order to respond to the PFD senior members of Adult Mental Health and the Deputy Director for Mental Health Services have met with national and local senior staff from Turning Point. We have sought assurance from Turning Point regarding the training that staff receive. All staff complete the Turning Point Mental Health Foundation Programme which includes mandatory e-learning modules alongside face-to-face training sessions facilitated by the Turning Point Learning and Development Team. The Recovery Workers also undertake a competency assessment to ensure they have a high level of competence in managing calls, using correct systems and utilising appropriate escalation protocols in relation to risk and safety management. The competency assessment has been updated in light of this inquest. The updated competency assessment is attached (Appendix 2). As well as the Turning Point training, staff also receive a face-to-face training session from the CRHT staff as part of their induction. This is based on the Trust’s e-learning package for risk assessment and management. We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff member was referring to June 2021 when the Urgent Access line was first set up, where there were some initial issues with the transfer of calls. The local guidance for the UK Mental Health Triage Scale has been reviewed with a more robust escalation process should there be any difficulty encountered in transfer of a call. The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed and shared with all relevant staff via email and also during supervision and team meetings. A new digital telephony system is being introduced into the Trust which will provide greater insight into call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that the telephony system will be operational by Mid-August 2022. An audit system is being introduced whereby telephone recordings of a sample of telephone calls will be listened to monthly and utilised for audit and training purposes. This will include monitoring if the calls are being handled in accordance with the SOP and taking remedial action if needed.
2. Steps to ensure that, for individuals with complex mental health needs involving a range of providers, there is co-ordination of care to ensure that appropriate care is in place and, where necessary, a consistent approach is taken to patients by different organisations or teams working with the patient; and
3. Review of the multi-disciplinary team’s decision-making process in light of the issues identified by Mr Nottle’s circumstances.
Our response to issues 2 and 3 will be taken together as these represent issues in regard to the decision making within the LMHT. We acknowledge that the team conflated the two issues of Mr Nottle living remotely and a clinical decision as to whether secondary care services were the right place for Mr Nottle to receive his care. There was not a comprehensive care plan, there was a lack of
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chair:
Chief Executive:
liaison with the GP, with Mr Nottle’s parents and with Mr Nottle himself. In addition, multiple re- referrals of Mr Nottle to the team were not acted upon. These concerns highlighted that expected systems and protocols had not been complied with and therefore indicated that a poor culture has developed within the team which has led to poor decision making and, at times, a loss of compassion. In order to address these issues of culture and practice within the team a programme of Quality Assurance work is planned. This will consist of a Culture Review and a Quality Standards review. The Culture Review will be based on the closed culture indicators set out by the Care Quality Commission (CQC) (Appendix 4). This commences on 3rd August 2022 over a 3-month period. During this period there will be regular contacts by the Quality Assurance team to monitor improvement. The Quality Standards review, led by the Quality Assurance Team, will take place on 19th September
2022. This will look at the 5 key areas and fundamental standards of the CQC, namely is the service Safe, Effective, Caring, Responsive and Well Led. Both of these reviews will include:
• a thematic review of serious incidents and complaints involving the team
• live observation of Multi-Disciplinary team meetings and decisions which are made with in the meetings. This will involve how referrals are managed and how discharge decisions are taken
• review of care plans including involvement of patients and carers, and where multiple out of hours calls are made to the CRHT
• Views of staff, service users and carers about the service
The Person-Centred Care audit tool (Appendix 5) will be another key element of this review. Following both these reviews an improvement plan will be developed to assist the team in making required changes in a supportive and achievable manner. The improvement plan will be monitored to completion on a monthly basis, overseen by the local management team (Service Manager, Operational Manager and Matron). Once considered complete, the improvement plan will be presented at the Quality and Risk meeting and signed off by the General Manager. An audit will then be developed and carried out twelve months later in order to understand the efficacy of changes made. I hope the information above provides the assurance that we have and continue to consider your recommendations seriously, that we are actively seeking to clarify and improve the services we provide by implementing the actions outlined. The Trust will be able to share the findings of the review and initial improvement plan with you by 30 November 2022 and agreement made at that point in relation to any further updates on progress of the implementation of the plan you may wish to receive.
Please find below the organisational response to the recently received Preventing Future Deaths Report, following the unfortunate death of Mr. Nottle. In responding, we have worked closely in conjunction with Turning Point. The Matters of concern raised within the report:
1. Clarifying the role of telephone workers and the steps necessary to ensure that the government guidance regarding access to mental health services is followed so far as is possible within the available resources.
Nottinghamshire Healthcare and Turning Point are jointly commissioned by Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) to provide a 24-hour Urgent Access Mental Health telephone service. The purpose of the telephone line is to provide support, advice and triage across Nottingham and Nottinghamshire to people requesting help with any aspect of mental health. This includes practical immediate support and guidance or assistance to navigate any further support needed; and immediate transfer to Crisis Resolution and Home Treatment (CRHT) staff if required. The first point of contact are Recovery Workers employed by Turning Point and co-located in the City Crisis Resolution and Home Treatment (CRHT) team office at Highbury Hospital. The staff are co- located so that they may have immediate assistance from CRHT staff if required. The Turning Point Team Leader and CRHT staff have the ability to listen in to calls if necessary. This is carried out via a dual listening device that allows a second set of headphones to be plugged in. The UK Mental Health Triage Scale (Appendix 1) is utilised to guide staff as to when a call should be transferred directly to a CRHT member of staff During the evidence at the inquest the Turning Point staff member stated that Turning Point staff may be placed on the line within their first week of starting work, after shadowing a small number of shifts. It was also stated that there are frequent times when calls are not transferred to CRHT in line with the UK Mental Health Triage Scale Private and Confidential
Mr. Clow HM Assistant Coroner for Nottingham and Nottinghamshire Nottinghamshire Coroner’s Office The Council House Old Market Square Nottingham NG1 2DT Reference:
E-mail:
Date: 3 August 2022.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chair: , Chief Executive:
In order to respond to the PFD senior members of Adult Mental Health and the Deputy Director for Mental Health Services have met with national and local senior staff from Turning Point. We have sought assurance from Turning Point regarding the training that staff receive. All staff complete the Turning Point Mental Health Foundation Programme which includes mandatory e-learning modules alongside face-to-face training sessions facilitated by the Turning Point Learning and Development Team. The Recovery Workers also undertake a competency assessment to ensure they have a high level of competence in managing calls, using correct systems and utilising appropriate escalation protocols in relation to risk and safety management. The competency assessment has been updated in light of this inquest. The updated competency assessment is attached (Appendix 2). As well as the Turning Point training, staff also receive a face-to-face training session from the CRHT staff as part of their induction. This is based on the Trust’s e-learning package for risk assessment and management. We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff member was referring to June 2021 when the Urgent Access line was first set up, where there were some initial issues with the transfer of calls. The local guidance for the UK Mental Health Triage Scale has been reviewed with a more robust escalation process should there be any difficulty encountered in transfer of a call. The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed and shared with all relevant staff via email and also during supervision and team meetings. A new digital telephony system is being introduced into the Trust which will provide greater insight into call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that the telephony system will be operational by Mid-August 2022. An audit system is being introduced whereby telephone recordings of a sample of telephone calls will be listened to monthly and utilised for audit and training purposes. This will include monitoring if the calls are being handled in accordance with the SOP and taking remedial action if needed.
2. Steps to ensure that, for individuals with complex mental health needs involving a range of providers, there is co-ordination of care to ensure that appropriate care is in place and, where necessary, a consistent approach is taken to patients by different organisations or teams working with the patient; and
3. Review of the multi-disciplinary team’s decision-making process in light of the issues identified by Mr Nottle’s circumstances.
Our response to issues 2 and 3 will be taken together as these represent issues in regard to the decision making within the LMHT. We acknowledge that the team conflated the two issues of Mr Nottle living remotely and a clinical decision as to whether secondary care services were the right place for Mr Nottle to receive his care. There was not a comprehensive care plan, there was a lack of
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chair:
Chief Executive:
liaison with the GP, with Mr Nottle’s parents and with Mr Nottle himself. In addition, multiple re- referrals of Mr Nottle to the team were not acted upon. These concerns highlighted that expected systems and protocols had not been complied with and therefore indicated that a poor culture has developed within the team which has led to poor decision making and, at times, a loss of compassion. In order to address these issues of culture and practice within the team a programme of Quality Assurance work is planned. This will consist of a Culture Review and a Quality Standards review. The Culture Review will be based on the closed culture indicators set out by the Care Quality Commission (CQC) (Appendix 4). This commences on 3rd August 2022 over a 3-month period. During this period there will be regular contacts by the Quality Assurance team to monitor improvement. The Quality Standards review, led by the Quality Assurance Team, will take place on 19th September
2022. This will look at the 5 key areas and fundamental standards of the CQC, namely is the service Safe, Effective, Caring, Responsive and Well Led. Both of these reviews will include:
• a thematic review of serious incidents and complaints involving the team
• live observation of Multi-Disciplinary team meetings and decisions which are made with in the meetings. This will involve how referrals are managed and how discharge decisions are taken
• review of care plans including involvement of patients and carers, and where multiple out of hours calls are made to the CRHT
• Views of staff, service users and carers about the service
The Person-Centred Care audit tool (Appendix 5) will be another key element of this review. Following both these reviews an improvement plan will be developed to assist the team in making required changes in a supportive and achievable manner. The improvement plan will be monitored to completion on a monthly basis, overseen by the local management team (Service Manager, Operational Manager and Matron). Once considered complete, the improvement plan will be presented at the Quality and Risk meeting and signed off by the General Manager. An audit will then be developed and carried out twelve months later in order to understand the efficacy of changes made. I hope the information above provides the assurance that we have and continue to consider your recommendations seriously, that we are actively seeking to clarify and improve the services we provide by implementing the actions outlined. The Trust will be able to share the findings of the review and initial improvement plan with you by 30 November 2022 and agreement made at that point in relation to any further updates on progress of the implementation of the plan you may wish to receive.