An independent investigation into the care and treatment of Mr S: Published September 2017

Agencies who are currently responsible for undertaking carer’s assessment and providing carers services need to review their current protocols for:
 Responding to disclosures of actual or potential risk of abuse of carers.
 Identifying in what circumstances would there be an escalation of information sharing.
 A review of the allocation and role of the care coordinator to identify their responsibilities for liaising with other involved services as part of both the initial assessment and during the review process.

In order to standardise and improve the quality of assessments and reviews of carer’s needs and risks, consideration should be given to introducing one set of assessment and review proformas that are used by all carer’s services within Lancashire.

Consideration should be given to introducing a “keeping safe plan” within all support plans which also addresses the carer’s possible fears around care alternatives for the person they are caring for and the consequences that may arise if action is taken.

In order to improve information sharing between primary care and Lancashire Care NHS Foundation Trust’s community mental health services consideration should be given to strengthening a joint information sharing protocol. Such a protocol should identify both agencies’ responsibilities for:
 Information sharing following a patient’s discharge from an acute inpatient admission.
 Joint responsibility for on-going communication between a patient’s primary care and care coordinator.
 Involvement of primary care in a patient’s care planning reviews by mental health services.

In order to evaluate whether the issues and deficits highlighted within this report are systemic within Lancashire Care NHS Foundation Trust’s Complex Care and Treatment Team and/ or the N Compass service; both should consider undertaking an audit of a number of patients involved with both services. This audit should also include a review of the current interagency information sharing protocol and involvement in care planning and care planning reviews.

Lancashire Care NHS Trust should consider introducing an alert system on their Electronic Care Record System which alerts the clinician when new correspondence has been unloaded onto a patient’s records.

A quality audit should be undertaken of care plans and safety profiles and reviews completed by the Complex Care and Treatment Team to ascertain if practitioners are accurately identifying and assessing the levels of risk(s). Where deficits are identified with specific practitioners then the appropriate training and management guidance should be provided.

Lancashire Care NHS Foundation Trust should review its current guidelines within their Safeguarding Policy to ensure that it provides clear directives as to when and in what circumstances staff should be consulting the Trust’s safeguarding team to seek advice and guidance.

The members of both the Complex Care and Treatment Team and psychologist who were involved in this case should receive additional training on their role, responsibilities and actions that is expected to be taken when there has been a disclosure and/or report from another service of either historical and/or recent incidents of domestic abuse.

An audit should be undertaken within the Complex Care and Treatment Team, including the psychologist team, to highlight any current cases where domestic abuse maybe a feature to ensure that staff are:
 Taking the appropriate and proportionate action is being taken.
 Seeking the appropriate guidance from Lancashire Care NHS Foundation Trust’s safeguarding team and their senior managers and supervisors.
 Awareness of when to utilise assessments, such as CAADA DASH.

In order to ensure that there is a process utilised to evaluate, maximise and demonstrate the value of its training programme to both the trainee and the organisation Lancashire Care NHS Trust should consider adopting a recognised training evaluation tool such as the Kirkpatrick Model.