Recommendation 1
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 1
Recommendation · source text
The Trust must ensure that it fully executes its Duty of Candour responsibilities and that where there are parallel investigations by other agencies advice is only sought from senior staff about the most appropriate methods of communicating with affected parties.
Recommendation 2
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 2
Recommendation · source text
If it has not already been actioned, the Trust must ensure that appropriate audits are undertaken regarding the effectiveness of the new protocol for the Complex Care and Dementia Team, taking any remedial action required if the effectiveness is found to be lacking.
Recommendation 3
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 3
Recommendation · source text
The Trust must provide assurance that the expectations of the clinical record keeping policy are met.
Recommendation 4
Addressed to: Kernow Clinical Commissioning Group
Action Plan Published
Link to recommendation Recommendation 4
Recommendation · source text
Kernow Clinical Commissioning Group must ensure that the policy covering the management of serious incidents includes a requirement for oversight of provider investigation action plans, and appropriate and documented dialogue between the commissioner and relevant provider/s.
Recommendation 5
Addressed to: Outlook South West
Action Plan Published
Link to recommendation Recommendation 5
Recommendation · source text
Outlook South West must consider what actions it can take to mitigate the risk of patients choosing not to share relevant clinical information with their therapist, now that therapists no longer have access to the GP clinical record system.
Recommendation 6
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 6
Recommendation · source text
The Trust must ensure that SBARD (Situation, Background, Assessment of individual, Recommendation, Decision) is introduced to community mental health teams, ensuring that relevant learning from implementation in inpatient services is transferred.
Recommendation 7
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 7
Recommendation · source text
The Trust must ensure that staff are able to identify and recognise the different types of supervision set out in the Supervision Policy ratified in March 2016, in order that staff can use supervision sessions appropriately.
Recommendation 8
Addressed to: The Trust
Action Plan Published
Link to recommendation Recommendation 8
Recommendation · source text
The Trust must ensure that staff explore patients’ literacy abilities and then communicate information in a way that is accessible and personalised.
Recommendation 9
Addressed to: The Trust and Kernow Clinical Commissioning Group
Action Plan Published
Link to recommendation Recommendation 9
Recommendation · source text
The Trust and Kernow Clinical Commissioning Group must assure themselves that the therapy strategy sufficiently addresses the provision and use of qualified therapy staff across the Trust, ensuring that gaps in access to appropriate therapy are properly addressed.