Independent investigation: Alan Clarke, Salisbury (2008)

Training:
• the Trust must ensure that all clinical staff receive training, which is updated on a regular basis, on working with and involving families and carers of service users in the assessment of needs and planning of care of the service user;
• where appropriate the ‘Working in Partnership with Families and Carers’ workshop should continue to be offered as part of this training;
• the Trust Care Programme Approach (CPA) and Risk Management training should continue to use Carer Trainers to model partnership working;
• a mechanism to disseminate good practice in this area should be put in place.
Practice:
• the expectation that, wherever possible and appropriate, families and carers should be involved in the assessment of needs and planning of care of the service user should be enshrined in Trust policy and procedure;
• that this best practice is being followed should be reviewed on a regular basis in supervision;
• the Trust should ensure that there is easy access to advice and support in this area of clinical practice.
Monitoring and assurance:
• the Trust should put in place mechanisms, including regular audits, to assure itself that its policies and protocols in this area are being consistently implemented;
• building on the good practice the Trust has already developed, carers should be involved, appropriately, in these assurance exercises;
• the Trust should put in place a mechanism, for example audits and surveys, to assure itself that the involvement of carers and families is meeting the identified needs of this policy of improving the care and treatment of service users and appropriately involving carers and providing them with relevant information and support;
• the Trust should continue its good practice of consulting carers; it should obtain the views of carers and families on how they can most efficiently and effectively be involved in the planning and delivery of care for those they care for. This information should be used in the development of future policies and protocols.

The Trust is currently concluding the review of its Risk Procedures.
Policy and Protocols:
The Trust should ensure that the new policy and associated procedures:
• promote robust risk assessment in line with the best practice guidance (e.g. Department of Health Best Practice in Managing Risk, 2007);
• as in previous Trust policies the revised policy should emphasise that risk assessment is an ongoing exercise, builds on previous assessments and historical information, wherever possible is multi-disciplinary and, where appropriate, is a multi-agency exercise;
• wherever possible and appropriate corroboration should be sought;
• the risk assessment should result in a clear formulation which enables all those providing care, treatment and support to make informed decisions;
• following a risk assessment a risk management plan should be drawn up:
o this should set out how the identified risks are to be responded to and managed;
o this plan should be more than a list of actions and more than a list of people who should be contacted in times of crisis;
• As the Trust is now employing the RiO electronic records system it must ensure that any changes in policy and protocols are reflected in the RiO system;
• following the updating of the risk management policy and protocols the Trust must ensure that all clinical staff are provided with appropriate training in a timely manner and this training should be repeated on a regular basis;
• the Trust might consider continuing its established good practice and involving carers in this training.
Practice:
• The Trust must ensure that families and carers are appropriately involved in both the risk assessment and risk management planning and that they are appropriately informed of risk management plans;
• the Trust should consider putting in place mechanisms to ensure that risk assessments and risk management plans are carried out on a planned and regular basis as well as at times of crisis and at points of change in the service user’s life;
• the Trust should ensure that risk management plans are disseminated in a timely manner.
Monitoring and Assurance:
• The Trust should put in place mechanisms to assure itself that its policies are being implemented in a consistent manner, this might include surveys of service users and carers and others involved in the care of service users e.g. GPs, as well as clinical audits;
• the assurance exercises should address issues of quality, of assessment and planning, as well as the occurrence of assessment and the recording of plans;
• risk assessment and planning should be regularly addressed in supervision and clinical staff should have ready access to advice and support in this area.

• The Trust should ensure that all clinical staff receive regular, up-dated training addressing the assessment of substance misuse and dual diagnosis;
• the Trust should put in place a mechanism to assure itself that its policies relating to the assessment of substance misuse and dual diagnosis are being implemented in a consistent manner; this exercise should included an evaluation of the quality of the assessments as well as identifying that relevant information is recorded;
• The Trust should ensure that staff in Adult Mental Health services have ready access to advice, consultation, and support from Specialist Substance Misuse services and that protocols are in place and being employed to foster joint working to address the needs of the service user.

If clinicians are to conduct robust and reliable assessments of risk and need it is essential that they have access to all relevant historical information. Given that the Trust does not provide CAMH services it cannot, on its own, put in place a protocol or mechanism to ensure that information relating to a services user’s contact with CAMH services is readily available.
Commissioner
• The commissioner should ensure that:
o there are protocols in place to ensure that clinicians have timely access to historical information from Child and Adolescent Mental Health Services (CAMHS) and other relevant services;
o that there are relevant information sharing protocols in place;
o that service providers work in a collaborative manner with the aim of ensuring that service users receive the best possible care and treatment.
• These protocols might build on the protocols already in place relating to the transition from CAMHS to Adult Mental Health services.
The Trust
• The Trust must ensure that, at least, as part of the initial assessment of each service user:
o information regarding the individual’s mental health as a child is sought;
o relevant, corroborative information is sought and, where appropriate, access to clinical notes, assessments and plans is obtained.
Monitoring and Assurance
The commissioners in collaboration with the Trust and other relevant service providers should put in place appropriate mechanisms to ensure these protocols are being implemented in a consistent fashion.

The Trust should ensure that:
• clinical staff have appropriate training in formulation and diagnosis;
• that all patients have a clear formulation of their needs, including a working diagnosis, which informs intervention and treatment, following their initial period of assessment;
• it puts in place a mechanism to assure itself that this policy is being adhered to in a consistent manner, and that diagnostic practices and formulations are of an acceptable quality.

The Trust should put in place mechanisms to assure itself and its commissioners that those service users who have been identified as having a substance misuse or Dual Diagnosis problem are having their needs appropriately addressed, in line with the Trust’s recent initiatives and policies.
• As part of this assurance exercise the Trust might conduct an annual audit of discharge CPA paperwork for those service users who have been identified as having Dual Diagnosis issues to ensure that substance misuse issues have been addressed as part of discharge planning.

• The Trust should ensure that its policy on Safeguarding Adults is reviewed:
• with reference to the South West Safeguarding Adult Threshold Guidance;
• to enshrine emerging locally agreed best practice and ensure that it employs language that is consonant with local multi-agency guidance, policies and protocols.
• The Trust should ensure that clinical staff have regular training on Adult Safeguarding and that advice and consultation are readily accessible.
• The Trust should put in place mechanisms to assure itself, its commissioners and other local agencies that its policies and the local Adult Safeguarding Guidance are being implemented in a consistent manner.

• The Trust should agree a protocol with the Local Authority, which provides the out of hours emergency duty system, to ensure that assessments undertaken out of hours are forwarded in a timely manner to Mental Health teams who will ensure that these assessments are uploaded on to the Trust’s systems within an agreed timescale.
• The Trust should put in place a mechanism to assure itself that information from out of hours assessments is available to clinicians in a timely manner;
• The Trust together with its Local Authority partners should put in place a mechanism to assure themselves and their commissioners that those undertaking out of hours assessments have ready access to relevant clinical information, assessments and plans.

The Trust should:
• complete its development of a its Early Warning Trigger tool in a timely manner;
• ensure that this device and/or associated protocols, together with relevant training, enable particularly those undertaking emergency assessments to understand and formulate why an individual is repeatedly presenting in crisis;
• consider putting in place a protocol to assess and address the needs of those who present in this manner;
• together with commissioners undertake a review of the needs and subsequent care required by such individuals to inform future service development and effective practice.

NHS Wiltshire should ensure that it has in place policies and procedures which ensure that:
• they are informed of any serious adverse incident in a timely manner;
• standards for the quality and time-scale of investigations are in place;
• the role of NHS Wiltshire is identified in assuring that the recommendations of the investigation are translated into meaningful and effective action plans which are consonant with the quality standards identified for the commissioned services;
• the role of NHS Wiltshire in assuring that the action plan is implemented in a timely manner is identified;
• all relevant staff in NHS Wiltshire are aware of the policy and protocol;
• that information concerning serious adverse incidents is fed into the governance and quality and performance monitoring structures in such a way that it can assure itself that local Mental Health services are safe and of an acceptable quality;
• it conducts regular assurance exercises, including audits, to assure itself that its policies are being implemented in a consistent and effective manner.