South Worcestershire review

Increase awareness of the Complex Adult Risk Management pathway across all agencies.

Improve practitioners understanding of, and competence in responding to adults who are experiencing or at risk of abuse.

Improve carer awareness and increase signposting to carer services.

For agencies to understand when a disclosure which indicates a ‘risk to others’ is shared and who with

To improve clinicians understanding regarding Carer’s Assessments (as per the Care Act).

To improve knowledge so that clinicians for the GP Practice will understand when/how the Complex Adult Risk Management (CARM) process can be initiated and by whom.

At first contact with services to ensure that all patients are provided with contact details of reception desk should technical issues arise at appointments.

GRIST assessment training to be provided to individual clinicians where there have been omissions in completing the GRIST risk assessment.

Further training and education to be rolled out to all Mental Health staff in assessing patient risk towards others and exploring intensity and frequency of thoughts, asking the question of past behaviours – as an indicator for future behaviours. The requirements to complete GRIST risk assessment accurately and in detail.

If for any reason the medic is not able to attend the initial CARS triage assessment, then for the medic to review the patient notes and treatment plan and document the of outcome of the review in the patients notes and an appointment for a medical review to be arranged.

IPS workers when working with patients to assess the patient’s reading and writing abilities and document this within the patient’s notes.

For all community Mental Health staff to familiarise themselves with the Adult Safeguarding Policy.

For it to be communicated widely across the organisation that if a patient reports thoughts of harming another then for this for be taken extremely seriously and for contact to be made to the safeguarding team for further advice on management of the identified risk.

For individual supervision to take place and discussion and reflection on raising any expressed harm towards others with the safeguarding team for further advice/ support.

A reflective supervision session to be held for CARS team highlighting that if any patient expresses harm towards others this is raised with the safeguarding team for further advice and support.

A reflective supervision session to be held for CARS team highlighting the need to read through all the available information about the patient before the first meeting as allocated care co-ordinator takes place.

All GPs within Worcestershire to be made aware of this incident and that change to medication may have impacted on this patient’s impulsivity and agitation. For GPs to be provided with information of how to access advice from the CARS team for complex patients/frequent changes to anti-depressant medications.

That carer’s are aware of their right to support under the Care Act in respect of a carers assessments. This should be made clear to all patients who disclose that they are carer a carer to someone as this may be causing the considerable distress.

Review current attachment programme to expand and include opportunities for new recruits and CPD training for existing staff / officers for role experience within vulnerability teams and HAUs to enhance understanding of referral requirements and agency requirements

County Manager to disseminate a reminder to the service on the ability for signposting of individuals on how they can access a Carer Assessment should the service user identify as a carer.

An induction process is developed and implemented for new staff that ensures specific skills and knowledge appropriate to role and duties are identified and that progress is recorded.

Formal guidance to be drafted to formalise the current allocation procedure considering level of skill/role of staff.

Supervision guidance do be developed/updated to ensure that quality standards (qualitative and quantitative) are met by existing staff and to support the development of new/less experienced staff.

Staff must be directed in recording impromptu supervision.