1
Addressed to: the Trust
Action Plan Published
Link to recommendation 1
Recommendation · source text
Our team noted the steps that have already been taken to strengthen training about risk, but we recommend that the provision of training about risk and be audited by the Trust in six months’ time to ensure that improvements in both the quality of the content as well as the quality of record-keeping has improved.
2
Addressed to: the Trust
Action Plan Published
Link to recommendation 2
Recommendation · source text
We recommend that the Trust ensure that the current Care Plan and Risk Assessment forms for each patient are updated appropriately, related clearly to one another and marked very clearly as current. Attention is needed to ensure that risk assessments and care plans are `joined up’ and that essential information is readily available, particularly to staff who do not know a patient well.
3
Addressed to: the Trust
Action Plan Published
Link to recommendation 3
Recommendation · source text
We recommend that the Trust should ensure that a summary or chronology of health episodes and risk events is provided in the electronic visible to enable practitioners to seek and obtain further information from other health providers to inform their work working.
4
Addressed to: commissioners of the NHS mental health service
Action Plan Published
Link to recommendation 4
Recommendation · source text
We recommend that commissioners of the NHS mental health service give urgent and positive consideration to the improvement of inpatient facilities on the ward where X was a patient; this would ideally include number and location of beds; services for people with Personality Disorder, as well as the appointment of support staff. In this way, we believe that care can be delivered more safely, more appropriately, and in a manner that will impact positively upon care quality, recruitment and retention.
5
Addressed to: clinical leaders with responsibility for inpatient staff teams
Action Plan Published
Link to recommendation 5
Recommendation · source text
We recommend that clinical leaders with responsibility for inpatient staff teams take further steps to foster an inclusive, multi-disciplinary approach to clinical care and decision-making. This should include attention to ensuring that team meetings include staff at all levels and that supervision takes place, as agreed.
6
Addressed to: NHS mental health services and A&E departments
Action Plan Published
Link to recommendation 6
Recommendation · source text
We recommend that attention be given to the question of how to ensure that communication between A & E and mental health services is improved.