Source · Investigations in the NHS

An independent external quality assurance review (published August 2019) can be viewed here

North West Published 01 Aug 2019 Trust Lancashire and South Cumbria NHS Foundation Trust

Recommendations

5 total
1a Addressed to: Lancashire County Council, the Local Pharmaceutical Council, NHS England and services involved in the provision of shared care services in the Lancashire area. No Response Published

Link to recommendation 1a

Recommendation · source text
The revised contract for the provision of substance misuse services should identify how patients’ records are to be transferred to a new provider.
1b Addressed to: Lancashire County Council, the Local Pharmaceutical Council, NHS England and services involved in the provision of shared care services in the Lancashire area. No Response Published

Link to recommendation 1b

Recommendation · source text
Lancashire County Council should convene regular Shared Care meetings, with representation from prescribing agencies, primary and secondary health services and community pharmacies. These meetings should provide a forum to:
• Monitor and evaluate performance of agencies against their Shared Care contracts.
• Highlight and resolve any commissioning, contractual and agency concerns.
• Review any serious incidents, near misses and complaints.
• Oversee joint serious incident investigations.
1c Addressed to: Lancashire County Council, the Local Pharmaceutical Council, NHS England and services involved in the provision of shared care services in the Lancashire area. No Response Published

Link to recommendation 1c

Recommendation · source text
The Local Pharmaceutical Council, substance misuse services, and NHS England should consider undertaking a review to ascertain the value of making an adjustment to the PharmOutcomes system so that it notifies all the involved shared care services when a supervised consumption patient has missed a single methadone collection. This review should take place within six months.
2 Addressed to: Lancashire Health and Wellbeing Board, Lancashire County Council (Public Health), Lancashire Clinical Commissioning Groups, Lancashire Care NHS Foundation Trust and provider(s) of substance misuse, housing and judicial services. No Response Published

Link to recommendation 2

Recommendation · source text
Lancashire Health and Wellbeing Board should assume responsibility for the coordination of a forum to develop and implement a local dual-diagnosis protocol that provides:
• A coordinated and collaborative whole system integrated pathway to support individuals who misuse substances so that they have access to high-quality physical and mental healthcare, housing and employment.
• A senior strategic board that oversees and monitors the implementation of the dual-diagnosis protocol across all of the health and social care sectors.
• Clarity with regard to interagency information sharing and the management of risk, shared care arrangements, including care coordination.
• Biannual meetings with representatives from all involved sectors with the aim of developing robust interagency relationships, to share lessons learned from serious incidents and to proactively identify and manage interagency issues.
3 Addressed to: Lancashire Care NHS Foundation Trust No Response Published

Link to recommendation 3

Recommendation · source text
Lancashire Care NHS Foundation Trust should consider developing a new risk assessment tool that includes both risk management and crisis plans, and which involves both the patient and all other involved agencies.

Acceptance status

Per recommendation
No Response Published
5

Total recommendations
5
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.