Barking and Dagenham review

All agencies working with those with long-term illnesses should ensure that each review routinely includes an assessment of a person's psychological and mental resilience and wellbeing, the up to date management of any adverse symptoms, and information about informal sources of specialist support.

All practitioners should ensure that their case recording is detailed and clear and all assessments are reflective and state reasons for assessment decisions backed up by examples which provide evidence for professional judgement. Quality should be addressed by management in supervision and via annual file audits.

All agencies must ensure their staff are fully trained and compliant with safeguarding procedures and that concerns and alerts are fully and accurately recorded including time, date, who made the contact and name of person contacted, discussions with managers and actions agreed. Consultation with all involved agencies must take place before closure of the safeguarding alert. Auditing of staff training and compliance with procedures to be built into supervision, and annual staff development plans.

The formation of a multidisciplinary team as recommended by NICE Guidance (NG27) December 2015 should be put in place for those with complex needs and life limiting illness who are living at home to ensure an holistic approach is taken to risk assessment and their needs, which includes the identification of a named coordinator, and a structure of regular multi-disciplinary reviews. It is recommended that the Camden High Risk model is investigated.

Agencies should ensure that staff are aware of the local authority hoarding policy, of the issues around hoarding including its impact on mental health, day to day functioning, and home safety, and the steps to take where hoarding is identified.

All staff who have responsibility for adult assessments or visiting patients/service users in their own homes must have in-depth domestic abuse training which also includes elder abuse by partners and family carers, and high risk groups such as those with disabilities and/or mental illness. It is recommended that this training is mandatory.

Up to date and easily accessible information and resources available for front line practitioners around hoarding, domestic abuse, and coercive and controlling behaviour should be reissued and publicised to staff.

A scanned copy of all service user signed documents should be uploaded onto their electronic record within 7 days of signing to ensure clarity and confirmation of agreements and provision of services.

Assumptions or not of mental capacity must be clearly recorded as well as the reasoning behind the assumption. Where capacity is doubted then formal assessment should take place and be recorded.

All staff to have regular training with regards to safeguarding, risk assessment and issues of mental capacity. London Borough of Barking & Dagenham to consider setting a mandatory timescale for refresher courses.

The new electronic data base planned by the Borough needs to have the functionality that enables key information, current or previous safeguarding alerts, and risks to be identified quickly by social workers not familiar with the case.

Checks with all professionals involved with a service user should be part of all case closure processes as standard, recorded clearly, and checked for completion before management sign-off. Auditing of this process to be built into management supervision and an annual compliance audit implemented.

Reassessments at the time of case closure must be fully entered onto the Adult Social Care database ensuring that the rationale for closure is recorded, risk assessed and how any risks will be managed in future. Procedures to be updated and auditing of this process to be built into management supervision and an annual compliance audit implemented.

Training should be provided to enhance the skills of all staff involved in undertaking carer assessments to ensure the willingness and ability of a potential carer and to encourage the uptake of carer training as recommended by NICE Guidelines. The staff must have previously undertaken domestic abuse training to qualify for this.

Where a vulnerable tenant has been identified by a housing officer they should discuss this with their manager as to the required frequency of the next tenancy audit. Discussion should focus upon at least annual visits unless evidence suggest that this is not required.

All housing officers should complete Adult Safeguarding Training and Domestic Abuse Training.

Social worker and other support staff's details are to be recorded on the contact screen by housing officers and rent officers within 24 hours of capturing this information.

Where a request for garden cultivation is requested the housing officer should complete the application form with the tenant at their property to ensure that the home is also inspected.

All first Tenancy Audits to be completed for all Council properties by the existing deadline of 30 November 2016. (Not fully completed by this date - being monitored by Action Plan).

At the time contractors carrying out repairs, or at the annual inspection made by gas engineers, the housing officer should be updated within 24 hours where a property is found to be in an unacceptable condition.

Advice notes are to be loaded by housing officers with details of tenants' disability as per the new 2016 procedures.

A record of all services with whom a patient is in engaged (i.e. MS society, Integrated Care Team, Social Services, etc) and the interactions these services have with the patient, must be routinely recorded on the patient's medical record. If the patient's home has a key safe, all agencies must be informed that the key safe code lies with the GP.

The GP practice should ensure that they hold a register of patients who have caring responsibilities to inform any need for additional support. The register should be reviewed annually to ensure its accuracy.

Where a patient known to have a debilitating or life limiting illness fails to attend hospital appointments more than once there should be follow up including a home visit, to ensure that the patient knows they have an appointment, has the means to attend, and are not being prevented from attending for any reason.

In addition to ensuring all patients with multiple sclerosis are referred to the community MS specialist nurse, the practice should ensure that patients are referred to a suitable support agency such as the MS Society or MS Trust UK.

The practice should put in place a clear strategy for managing patients with multiple sclerosis in line with best practice which includes multidisciplinary reviews of their mental wellbeing as well as their physical symptoms, and consideration of how their carer is coping.

A system of regular updates on a patient with long term illness should be established between the GP practice and the District Nursing Service and Community Treatment Team.

The District Nursing Service should review their recording system to ensure that there is electronic back-up to handheld patient notes which can be shared by nurses prior to and after visiting patients and to record any safeguarding concerns or alerts.

The Trust should publicise the Community Specialist Multiple Sclerosis Nursing Service within Barking & Dagenham among GPs, Adult Social Care, Occupational Therapy, and allied professionals, and patients and families affected by the disease as soon as possible. This should be completed no later than December 2016. (This has been completed -See Action Plan)

Details of the allocated MS Nurse for each Directorate within NELFT should be identified to the relevant District Nursing teams to ensure timely referrals may be made when additional support may be required to an individual patient.

There should be a strengthening of the Think Family approach when nursing staff are providing services for adults with care and support needs. Staff should use professional curiosity regarding carers, being aware of the carer’s needs assessment and outcome as this affects patient care.

To continue the roll-out across all NELFT directorates, agile working to allow staff to remotely access electronic patient records and update accordingly.

Barking, Havering & Redbridge University Hospitals NHS Trust to strengthen their Patient Access Policy section on Did Not Attend with the addition of issues to consider when vulnerable adults Do Not Attend, and guidance to staff of steps to take when they have concerns.