Recommendation
Both PCFT and GMMH should clarify the MAPPA status at the point of transfer to other services for patients with forensic histories. This should also include identification and involvement of probation/ NOMS for appropriate patients.
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PCFT • The Trust is proposing to include a paragraph relating to the MAPPA status of patients at the point of transfer to other services within the CPA Policy; however, the Community Mental Health Teams (CMHTs) are under review. The Trust has recognised that this may have a direct relationship on the content of policy so revisions will be made once complete. Interim arrangements (e.g. through safeguarding adults training) have not been stated.
• No evidence of action implementation provided.
Niche comments and gaps on assurance
• In the absence of a revised CPA Policy incorporating MAPPA guidance, the Trust will need to determine the timelines for the changes proposed to the policy, immediate contingency plans, and how these will be communicated to relevant staff and tested to ensure compliance.
• The Trust will need to clarify how the actions referenced are aligned to those of GMMH.
NIAF rating: PCFT have provided some reassurances on actions to be taken but there is limited evidence of implementation. Further, the action developed to address the recommendation may be insufficient to promote sus8tainable change. Further work is required.
Overall rating for this recommendation for PCFT: 1
Recommendation
The Trust AWOL policy should be amended to ensure that any decision to discharge an AWOL patient in their absence is explicitly risk assessed, supported by a detailed decision making tool, and reported on centrally to ensure practice is monitored.
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Trust response and evidence submitted
• The Trust AWOL Policy has been harmonised and strengthened to ensure that service users who are informal and return from leave have their MHA status reviewed on return from AWOL. Although it would not be deemed best practice to discharge service users in their absence, the GMMH AWOL Policy highlights that any decisions made by a team in relation to this should be supported by a detailed risk assessment and recorded within the service users records’. The Policy has provided flow charts for staff to provide at a glance guidance and assist in the decision making of teams in these instances.
• Further review of compliance against the Policy has been carried out via a Trust wide audit. This audit took place over a 12-month period, included 277 service user records and was completed by the Strategic Lead for Patient Flow. The aim of the audit was to review if staff were fully implementing the policy and also decision making by MDTs following an individual going AWOL. The outcome of this audit demonstrated that overall staff were implementing the Policy correctly and MDTs were recording decisions where service users were discharged in their absence. A repeat of this audit has been scheduled in the Trust 19/20 audit programme in Quarter 3.
Niche comments and gaps on assurance
• The audit that is referenced confirmed good practice in many aspects of the AWOL Policy. In relation to this recommendation it also identified 12 patients who were discharged in their absence. The 48 hour / 7 day follow-up was completed in all but two cases.
• The scheduling of a repeat audit is good practice to confirm whether compliance is being sustained.
NIAF rating: This recommendation has been completed and testing has evidenced that it is largely embedded in practice. Further testing is planned to ensure changes in practice have been sustained. In order to fully meet this recommendation the Trust should demonstrate sustained improvements to practice.
Overall rating for this recommendation: 4
Recommendation
The Trust should assure themselves and commissioners that arrangements are in place to provide appropriate medical cover on the acute adult in-patient wards to ensure medical oversight and continuity of care.
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Trust response and evidence submitted
• The Trust has implemented a proactive recruitment strategy and have reviewed job plans and support for consultant posts within Park House. They have been successful in the recruitment of good calibre substantive consultant posts into vacancies. All acute in-patient wards across Bolton, Salford, Trafford and South Manchester areas now have full Consultant establishments.
• The Trust recognise that this position is an ongoing risk for the organisation and this is being closely monitored by the Workforce Development Strategy Group and the Medical Workforce Sub-Group. A further recruitment campaign is ongoing with enhanced consultant support and sessional allocation for adult in-patient consultants. In the interim, Lead Consultants have worked proactively with Human Resource colleagues and any vacancies have been successfully recruited into by locum cover. The locum consultants appointed have been of a high calibre and have been providing a consistent service to Park House.
• A key role also being introduced as part of the recruitment strategy includes the role of Advanced Practitioner (AP) posts to support multi-disciplinary teams. A lead AP commenced in post in June 2019 with other substantive posts being considered. The aim is to have an AP on each ward.
Niche comments and gaps on assurance
• A number of actions have been progressed in order to implement this recommendation and there is ongoing reporting as described. The Board is also sighted on areas of risk through, for example, quarterly safe working hours reports for doctors in training.
NIAF rating: This recommendation has been completed and on-going compliance is being monitored at Board and Committee levels. This is an area of on-going risk which is recognised by the Trust.
Overall rating for this recommendation: 4
Recommendation
The Trust must ensure that discharge planning arrangements on the adult acute in-patient wards comply with Trust policy, and that arrangements are made to appropriately grade those patients with complex needs and often forensic and/or substance misuse histories who are …
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The Trust must ensure that discharge planning arrangements on the adult acute in-patient wards comply with Trust policy, and that arrangements are made to appropriately grade those patients with complex needs and often forensic and/or substance misuse histories who are at high risk of disengagement from mental health services, and who should receive assertive and proactive care to prevent them being lost to services, even if discharged whilst AWOL.
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Trust response and evidence submitted
• A ‘special notes system’ was developed within AMIGOS prior to the acquisition of MHSC and GMW Trust. This system assisted staff in identifying critical information in relation to a service user and highlighted where a forensic assessment had been completed for an individual. Community and in-patient services were audited against use of the special notes criteria and these audits have demonstrated positive results around how staff implemented this system.
• In December 2018, all GMMH Manchester services ceased to use AMIGOS and moved onto PARIS in line with the rest of the organisation. PARIS enables staff to raise individual service user alerts and capture a service users risk information, particularly those with forensic histories who may be in contact with MAPPA.
• Since development of the new organisation, Manchester adult acute wards have a dedicated substance misuse practitioner specifically working with the teams and patients to improve awareness, knowledge and skills in relation to complex patients with serious mental health and substance misuse problems. The Trust has also introduced a dedicated Strategic Lead for Patient Flow role. This role is key in ensuring continuity of care for service users and to ensure service users are placed back with the same consultant and clinical teams as far as possible.
• Adult acute wards have improved pathways for referral for forensic assessments and gateways to beds, and ward managers have an awareness of implementing referrals for forensic assessments.
• There have been examples recently where joint working and referral has meant a smoother and safer transition for the service users requiring medium secure services. Referral pathways have also been highlighted within the Adult Acute Inpatient Ward Managers meeting and recorded within the minutes.
• Wards have been completing audits of the ward discharge checklists that are now in place and results have been positive in relation to how staff are implementing discharge meetings. An audit was recently completed by a senior clinician looking at a sample of 50 patients records where service users have been discharged from wards and whether risk assessments had been completed by staff and the decision making by the team prior to the service users discharge. The audit has revealed good practice with regards to the discharge planning process. The majority of the patients had a discharge CPA meeting and follow-up arrangements at the time of discharge. For patients discharged in their absence, there is clear documentation and discussion of risk management and follow-up arrangements.
• The discharge planning audit results have been presented to the Consultant Senior Leadership Team meeting and is due to be presented to the October In-patient Consultant Forum meeting and to the Trust Clinical and Quality Audit Committee.
Niche comments and gaps on assurance
• A number of actions have been progressed in order to implement this recommendation and the audit referenced overleaf identified good practice in many aspects of discharge planning. However, it has also highlighted some gaps:
‒ 52% of the patients had no mental state examination documented in the electronic records in the 7 days prior to discharge;
‒ 20 out of the 50 patients were identified as having substance misuse difficulties. 8 (40%) of these patients were not referred or signposted to appropriate services during their in-patient admission; and
‒ 28 patients were identified as having a care coordinator who were under the community mental health team during their admission. The care coordinator for 9 (32%) patients had not been involved in the discharge planning process.
• The discharge planning elements of the CPA Policy and learning from the audits has been communicated to senior medical staff and the Clinical Quality and Audit Committee. The Trust will need to ensure that key findings are cascaded to other staff groups with repeat audits to test compliance with Trust policy.
NIAF rating: GMMH has progressed a number of actions to meet this recommendation, however, there are some residual gaps in assurance.
Overall rating for this recommendation: 3
Recommendation
NHS Manchester CCG should assure themselves that the Trust is identifying the cohort of patients at most risk of disengagement from services, who have complex needs and often forensic histories with a background of drug abuse. This identification should then …
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NHS Manchester CCG should assure themselves that the Trust is identifying the cohort of patients at most risk of disengagement from services, who have complex needs and often forensic histories with a background of drug abuse. This identification should then lead to the Trust being able to provide an assertive care pathway for this group with escalation routes into appropriate inpatient beds and access to appropriate clinical and forensic support and advice when needed.
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Manchester CCG response and evidence submitted
• GMMH have a detailed SOP for the CMHT which has been shared with NHS Manchester CCG. This document describes the daily MDT zoning meetings which are a whole team approach to care enabling a targeted clinical response that can adapt quickly to changes in service users’ needs and risk. It encompasses a traffic light system with service users placed in different zones dependant on their level of need and risk; this determines the type of interventions offered. The zoning process allows for daily reviews of care and is inclusive of the whole staff team so enhances a targeting of resources and allows for enhanced communication of service users at risk. The approach provides structured intensive case management of identified service users, safeguarding issues and where vulnerable adults are highlighted. The Trust has a number of services they can utilise depending on service users needs as identified through the zoning meeting.
• The Trust is currently working towards a seven day CMHT service across the GM footprint. Teams are now co-located across central, south and north Manchester sites. With Consultant cover for the MDT to be in place by November 2019 and extensive staff side engagement, this extended service will provide better coverage to patients within Manchester.
• The CCG will be visiting the CMHT on a quality walk-round and sitting in on a zoning meeting to fully understand how the zoning meetings are working.
Niche comments and gaps on assurance
• CMHTs and associated processes are well established in GMMH and NHS Manchester CCG has provided some information on the CMHT SOP. However, there is no evidence to support appropriate implementation of this procedure by the Trust i.e. that patients with complex needs are escalated into appropriate inpatient beds, and can access clinical and forensic support and advice when needed.
NIAF rating: GMMH has progressed a number of actions to meet this recommendation, however, there are some residual gaps in assurance that Manchester CCG will need to pursue.
Overall rating for this recommendation: 3