Assurance Review

The Trust must review the current pathways in Complex Care and Treatment Teams (CCTTs) to determine if the identified needs of patients who meet the threshold for an assertive outreach approach are being met.

The Trust must provide clear guidance to staff on the identification and management of patients who are not engaging with services, this must include how engagement will be monitored and reviewed.

The Trust must review the action plans for 2015/21744 (Mr W) and 2014/14031 (Mr S) to assess progress and whether actions are still appropriate to meet the original recommendations. Action owners should also be revised and refreshed and revised timelines for delivery of their actions agreed with approval from the CCG and the new Integrated Care System (ICS).

Action plans should be monitored by an appropriate (sub) committee and action owners held to account for action implementation.

NHS England and Improvement should work with the Department of Health and Social Care (DHSC) to agree and ‘sign off’ the revised ‘Memorandum of Understanding’ with the National Police Chiefs’ Council (NPCC) to support investigations into serious incidents in healthcare settings.

In the meantime, the Trust and the local Constabulary should agree a local memorandum of understanding to inform the management of health care incidents that are also subject to criminal investigation.

The trust should urgently review its clinical risk policy to ensure that it accurately describes risk concepts making clear how static risks interact with the current situation to ensure that staff give sufficient weight to static risks when making risk assessments.

The trust should make it explicit in training materials that the formulation of risk must involve consideration of both static and dynamic factors.

The CMHTs should undertake audits or agree methods of monitoring to ensure that its agreed approach (through dynamic risk management) is being used effectively and ensuring clear identification of patients who require an assertive outreach approach.

When the SOP on promoting engagement and access to mental health services is next updated ensure minor errors relating to target implementation dates and monitoring arrangements are corrected.

For NHS England: complete work to agree and introduce the Memorandum of Understanding.