Independent investigation: Alan ScottStella Scott, Allerton, Liverpool (2008)

Professional staff interviewed by the Independent Team identified a gap in their knowledge and understanding of alcohol and drug misuse. Interviewees also highlighted a gap in their knowledge base about the available resource in Liverpool to enhance this. The Independent Team is mindful of the restrictions on public spending, and the impact this will have on education and training budgets. However, Liverpool is well serviced with a range of charitable organisations and self-help groups that would, if approached, provide opportunity for Mersey Care NHS Trust staff working in general adult community services to enhance their knowledge and understanding of addictions. Examples of these organisations are:  Action on Addiction;  Addaction;  Alcoholics Anonymous (AA);  Narcotics Anonymous (NA); and  Cocaine Anonymous (CA). AA, NA and CA will all have „open‟ meetings which professionals can attend, and/or most AA, NA, and CA groups will have members who are willing to attend at local work premises to share their addiction experience, and their recovery. The insights these individuals provide can be very illuminating for health professionals. The family self-help groups of Al-Anon and Families Anonymous will also have members who will come and speak to health professionals so that they can have a better understanding of the impact another‟s addiction has on family life and the type of information and support families might need if caring for a person with a dual diagnosis or addiction. Contact details for all of the above are available on the World Wide Web, and are easily located via a simple internet search.

All clinical business units in Mersey Care NHS Trust need to implement a more dynamic approach to how it audits and reviews the quality of clinical documentation. The quality of documentation was not of the standard expected in Mr SU‟s community mental health records. In particular, there was no depth of information about how his mental state was being assessed, little about communications with other involved agencies such as supported housing, and a complete lack of up-to-date care plans. Although Mersey Care NHS Trust conducts audits of CPA and risk assessment documents via standardised audits, information gathered during the investigation process suggests that it does not sufficiently or consistently interrogate the quality of what has been recorded. Consequently, the Independent Team recommends that a peer review process is implemented where: A randomised selection of CPA and Risk Assessment documents and  progress notes are selected from the professionals participating in the peer review process; The group of peers reviews the documents selected and provides  constructive feedback on their completeness and also usefulness. The Independent Team suggests that a peer review of clinical records could be facilitated on a three- to four-monthly basis. The Independent Team also recommends that each professional‟s supervisor reviews the record-keeping for each of its supervisees across the professional‟s entire caseload on a rolling basis. Because documentation review is time-consuming, the Independent Team anticipates approximately two to three sets of records being reviewed at each monthly supervision session. To make delivery of this recommendation achievable, the following principles will be required: An agreement of what aspects of the clinical record should be  subjected to scrutiny; An agreement as to what proportion of each record needs to be  scrutinised. For example, would it be acceptable to review a contemporary CPA care plan in one set of records, and a risk assessment and crisis intervention plan in a different service user‟s records? To achieve the principle of proactive records review does not mean that for each set of records reviewed in a supervision session, the same documents need to be reviewed for each service user.

Where a long-term service user ceases to have regular contact with his or her Carers, their needs do not simply end. As part of its ongoing commitment to supporting Carers, Mersey Care NHS Trust needs to find a way of ensuring that, if it becomes inappropriate for a care co-ordinator to maintain contact with the Carer for a service user, then the Carers are provided with an alternative source of contact and support, as well as information about how to make direct contact with the Service User‟s care team if there are any concerns. Mersey Care NHS Trust has had in situ a robust approach to meeting the needs of carers with a Carers‟ Support Worker (Officer) working in all community mental health teams. These individuals have developed effective working relationships with local Carer Support agencies. The future of the Carers‟ Support Officer is uncertain following the removal of funding from Liverpool City Council. Mersey Care NHS Trust will need to give careful consideration as to how the support needs of Carers are not forgotten when a service user does not agree to his/her care co-ordinator having contact with his/her family. In the case of Mr SU, such a situation arose which was compounded by the fact that the care co-ordinator did not know that his family continued to provide substantial support to him in the years immediately preceding their deaths. The Independent Team is aware that Mersey Care NHS Trust is already taking measures to resolve the potential service gap should its own funding of the Carers‟ Support Officer post not be sustainable beyond this financial year.