A thematic review of six independent investigations

The Trust’s Crisis Resolution and Community Mental Health Team services should satisfy themselves that:
• The systems and support in place to ensure regular Care Programme Approach reviews take place are adhered to in accordance with Trust policy.
• When Care Programme Approach reviews are recorded as having taken place, the reviews take place in accordance with the Trust’s Care Programme Approach policy and guidance.
• For those individuals subject to Care Programme Approach who are arrested and subsequently held in prison, liaison takes place with the appropriate prison services as soon as is possible in order to ensure continuity of care takes place.

In addition to the above recommendations, the Trust should ensure that:
• The processes in place to retrieve externally archived manual clinical notes and associated records are fit for purpose.

The Trust should consider the options available to refine and develop its electronic record systems and thereby ensure greater integration of systems in regard to safeguarding, care planning and care delivery.

To ensure the efficacy of the EIP team and the appropriateness of care delivery to patients, the Trust should routinely audit case files to ensure that the EIP team is focused on those patients with psychosis, or at risk of psychosis. Those patients with a presentation suggestive of personality disorder should be transferred to other trust services such as the CMHT or psychological therapies.

The trust should seek further to refine and develop its electronic record systems to ensure greater integration of systems in regard to safeguarding, care planning and care delivery.

The Trust should review its dual diagnosis policy and capacity to ensure appropriate access to specialist knowledge and drug screening when services are responding to presentations that include both a mental disorder and active substance misuse.

The Trust should seek to provide assurance to commissioning bodies of compliance with NICE Guidance in the treatment and management of personality disorder (appendix C) through an audit process.

The Trust should maintain and improve on current performance in delivery of psychological therapies to ensure that 18 weeks is the maximum waiting time rather than, as at present, the average.

The Trust in conjunction with its commissioning bodies should conduct as part of its ongoing clinical audit programme an audit to consolidate the implementation of all of its new policies and procedures. The audit should be conducted either one year following the policy implementation changes, or within six months of the publication of this report, whichever comes first. The audit should include:
• the take up of CPA and risk assessment training across all disciplines;
• compliance with the risk assessment policy;
• the effectiveness of referral and discharge processes;
• clinical supervision compliance;
• the quality of clinical supervision processes;
• a compliance and quality review of the new electronic clinical record system; and
• a feedback process from all staff who have been involved in serious untoward incident procedures.

“The CRHTT, or equivalent service, needs to ensure that for people who have ongoing contact with the services there is a system by which following assessment the appropriateness of cluster of the patient and other key decisions are audited and confirmed.”

When working with service users, the EIP team should fully utilise the range of specialist assessments which are readily accessible on the RiO system and form part of the service user electronic patient record; they are thus available to all practitioners and support the safe and effective management of care and risk.

“The CRHTT, or equivalent staff, should make routine enquiries with A&E staff at the time of the initial assessment to ensure that as full a history and risk profile as possible is obtained.”

The EIP team should review its discharge process and practice to ensure that the administrative caseload record is an accountable and accurate reflection of clinical caseload at all times.

“The Inpatient Service Manager should ensure that the ward MDT understands the requirements for formally completing the required risk assessments and that there are appropriate systems in place to facilitate this.”

Clear guidelines and specific timeframes on the use of the Sainsbury level 1 and level 2 risk assessment should be embedded in the CPA policy and the clinical risk assessment, management and training policy. Team managers should review practitioners’ understanding of these requirements and ensure the appropriate use and consistency with the required standards thus promoting best practice and providing the opportunity to review risk and draw together various professional perspectives.

“Staff at each interface or transfer to a new service throughout the patient journey will review the existing assessment and finish the parts not completed previously. This applies to both risk assessment and other parts of the assessment process.”

Practitioners in EIP could benefit from the opportunity to reflect upon and review their approach to working with people with substance misuse issues who do not present with dual diagnosis but who may have needs in this area which, if openly established, could be receptive to intervention to preclude antisocial or illegal behaviour. Reflection and review may also promote staff safety and wellbeing when working with such service users and could form part of a team development session or be facilitated by the Trust’s dual diagnosis specialists or nurse consultants.

“Ward staff should routinely seek further criminal information from the police in relation to inpatients if the person had indicated during assessment that they had a criminal history.”

Where child protection issues exist and practitioners agree to take responsibilities and actions, these should be incorporated into the service user’s care plan with explicit, specific and timed actions underpinned by a shared risk assessment which clarifies each agency’s expectations and thresholds for action. All issues regarding the wellbeing of children and potential risk should be included in the Sainsbury risk assessment and passed on to the appropriate agencies immediately and a record made of this in accordance with the appropriate trust and inter-agency policies and procedures relating to safeguarding.

“The CRHTT should obtain contact and other key information about patients prior to discharge.”

There should be clarification of expectations, roles, responsibilities and purpose when planning case transfers between teams. This should be achieved by the effective delivery of the principles, practice and processes of CPA. Team managers should be reminded of the need to ensure that transfers between teams are effective and purposeful.

“Ward staff should provide information on treatment and support options to people who experience drug and alcohol problems as a routine intervention and a system should be in place to support this.”

Appropriate access to the APTS for service users in EIP should be clarified and any pathway issues or barriers to individuals having the opportunity to receive a suitable service for their needs should be addressed.

“All carers of people on inpatient wards should be given the opportunity to have a discussion with members the MDT in the absence of the patient.”

Guidance should be provided to practitioners in relation to intervention in and management of situations where service users have weapons, including the safe and accountable removal, storage and disposal of weapons. A trust-wide protocol is currently being developed to inform practice in relation to service users who are known to own or have access to firearms; this should be made available to all teams.

“CPA and discharge policies should be reviewed to clarify the following:
• CPA status and discharge arrangements for inpatients who have had a brief admission to hospital.
• The 7 day follow-up process including the rationale for this and how it should be implemented.”

The EIP team should review the process regarding the offer of carers’ assessments. All eligible carers should be offered a carer’s assessment and a carer’s plan if appropriate, and a record of this having been done should be made. This record and associated documentation should form part of the service user electronic patient record to ensure optimum and effective communication of service user need and risk.

“Trust policy requirement to complete a Level 2 risk assessment for all inpatients should be reviewed with specific reference to short admissions.”

The EIP operational policy should include clear standards for ongoing monitoring of service users’ physical wellbeing and the side-effects of medication.

“Trust policy should be amended to include ‘Domestic Abuse Policy – service users’ guidance for staff in relation to service users as perpetrators of domestic abuse.”

The EIP operational policy in its reference to expectations around blurring professional boundaries should be reviewed and its wording offer a safe and accountable framework for practice.

“Information relating to domestic abuse and support should be readily available on the wards for service users and for carers.”

Consideration should be given to producing practice guidance for communication with service users by mobile phone and by text, and should incorporate the disclosure of individual’s numbers and the safety and accountability implications of this. This could also include email communication.

Practitioners should be reminded of the Trust’s expectations with regard to record-keeping standards and the need for timely and comprehensive entries to be made in the electronic patient record. All processes and interventions around the service user pathway should be fully recorded and reflected including those of psychology practitioners.

The Trust should take steps to ensure that patients are reviewed by the multidisciplinary team on a regular basis so that timely discharge and relapse plans are put in place.

In line with current CPA guidance and the Trust’s own current CPA policy the Trust should undertake regular quality audits to ensure that:
• all those referred to its secondary mental health services have a comprehensive assessment of their needs;
• there is a clear formulation of the individual’s difficulties and needs;
• care plans are informed by appropriate assessment and formulation;
• all clear plans have clear goals or outcomes;
• service users and, with their consent, their families and carers, are involved in the assessment of need, the planning of care, and any changes to either the care plan or the care co-ordinator;
• the agreement of families and carers is obtained before care plans are finalised which involve actions on their part;
• families and carers, with the agreement of service users, are provided with current care plans, including crisis management plans; and
• where there is multidisciplinary or multi-agency involvement all those involved in delivering care and support are appropriately involved in the assessment and planning process with the knowledge and consent of the service user.

In line with current CPA guidance and the Trust’s own current CPA policy the Trust should undertake regular quality audits to ensure that:
• all those referred to its secondary mental health services have a comprehensive assessment of their needs;
• there is a clear formulation of the individual’s difficulties and needs;
• care plans are informed by appropriate assessment and formulation;
• all clear plans have clear goals or outcomes;
• service users and, with their consent, their families and carers, are involved in the assessment of need, the planning of care, and any changes to either the care plan or the care co-ordinator;
• the agreement of families and carers is obtained before care plans are finalised which involve actions on their part; and
• families and carers, with the agreement of service users, are provided with current care plans, including crisis management plans.
Where there is multidisciplinary or multi-agency involvement all those involved in delivering care and support are appropriately involved in the assessment and planning process with the knowledge and consent of the service user.

The Trust should consider the options available to refine and develop its electronic record systems in order to ensure greater integration of safeguarding, care planning and care delivery systems.

Having revised its risk assessment, management and training policy the Trust should institute a regular quality audit to ensure:
• that the formulation of the individual’s problems and needs informs the understanding of his/her risk;
• that robust and meaningful care plans are put in place;
• that the service user and other relevant individuals are involved in the assessment and planning process; and
• that the risk management plan is appropriately disseminated.

Having revised its risk assessment, management and training policy the Trust should institute a regular quality audit to ensure:
• that the formulation of the individual’s problems and needs informs the understanding of his/her risk;
• that robust and meaningful care plans are put in place;
• that the service user and other relevant individuals are involved in the assessment and planning process;
• that the risk management plan is appropriately disseminated.

South West Yorkshire Partnership NHS Foundation Trust should review, with its commissioners, the provision of services for individuals with a diagnosis of personality disorder. This review should identify how a comprehensive service, complying with the relevant NICE guidelines, will be established. Any plans should ensure that there is equity of access to services for individuals from all the localities served by the Trust.
In line with the Trust’s current plans there should be an ongoing audit, agreed with the Trust’s commissioners, to ensure that the Trust is complying, or moving towards compliance in a planned and agreed manner, with the relevant NICE guidelines on personality disorders.

In line with the recent developments in the provision and delivery of Psychological Therapies in the Trust, together with its commissioners, the Trust should review this provision to ensure that it complies with the recommendations of relevant NICE guidelines. In particular the Trust should ensure that those individuals with more serious, complex and enduring mental health problems have access to psychological interventions in a timely manner as recommended by the relevant NICE guidelines.
Having agreed appropriate standards with its commissioner, the Trust should institute a regular cycle of audits to establish that, especially, those individuals with serious, complex and enduring mental health problems have appropriate access to Psychological Therapies.

The Trust has identified that progress has been made in the delivery of substance misuse services. It should now put in place a system, including an audit cycle, to assure itself and its commissioners that these developments are realizing the intended and identified outcomes.
The Trust has identified a number of issues which need to be addressed. Together with its partner organizations, the Trust should agree an action plan to address the issues it has identified and put it place a monitoring system to assure itself and its commissioners that the identified actions have been completed and the agreed goals realized.
An audit cycle should be put in place to ensure the ongoing improvements of these services.

South West Yorkshire Partnership NHS Foundation Trust should ensure that the aims of its Equality and Diversity policy are translated into practice in the clinical arena by:
Ensuring that cultural and religious issues are included in the assessment of need in a routine manner;
Ensuring that staff receive appropriate training to enable them to address cultural and religious issues as part of the assessment process;
Ensuring that staff receive appropriate and regular supervision in this area;
Undertaking regular audits to monitor the implementation of the Trust’s Equality and Inclusion Strategy in clinical practice.

South West Yorkshire Partnership NHS Foundation Trust should take action to ensure that the Spiritual and Pastoral Care Team, or another suitable resource, is available to raise awareness of cultural and religious issues within the clinical arena and that clinical staff have timely access to appropriate advice, consultation and supervision on these matters.

The Trust should assure itself and its Local Authority partners that the Safeguarding policies and procedures which it has put in place and supported with training are being implemented. It should include audits of compliance with its Safeguarding policies in its regular audit cycle.

Access to appropriate family interventions should be available to service users under the care of the CMHT.
CMHT Staff should receive training and supervision in appropriate family work and interventions.
The Trust should monitor the provision of this service, including using regular audits, to ensure that those individuals who might benefit from family interventions are able to access them in a timely fashion.

The PCT should put in place a system to ensure that there is timely communication between primary care and secondary care services.

Given that new protocols have now been put in place, the local Housing Associations, the Trust and the commissioners of mental health services should institute a monitoring system to ensure that:
• the proper roles and responsibilities of these organisations are adhered to;
• the protocol for sharing information is adhered to;
• staff are properly trained and supported to carry out their agreed roles; and
• there is a clear mechanism for identifying unmet need.