Independent investigation: Eddie Thorpe, Dewsbury (2008)

In line with current CPA guidance and the Trust’s own current CPA policy the Trust should undertake regular quality audits to ensure: all those referred to its secondary mental health services have a comprehensive assessment of their needs; there is a clear formulation of the individual’s difficulties and needs; care plans are informed by appropriate assessment and formulation; all care plans have clear goals or outcomes; service users and, with their consent, their families and carers, are involved in the assessment of need, the planning of care, and any changes to either the care plan or the care co-ordinator; the agreement of families and carers is obtained before care plans are finalised which involve actions on their part; families and carers, with the agreement of service users, are provided with current care plans, including crisis management plans; where there is multidisciplinary or multi-agency involvement all those involved in delivering care and support are appropriately involved in the assessment and planning process with the knowledge and consent of the service user.

Having revised its risk assessment, mangement and training policy the Trust should institute a regular quality audit to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk; that robust and meaningful care plans are put in place; that the service user and other relevant individuals are involved in the assessment and planning process; that the risk management plan is appropriately disseminated.

South West Yorkshire Partnership NHS Foundation Trust should review, with its commissioners, the provision of services for individuals with a diagnosis of personality disorder. This review should identify how a comprehensive service, complying with the relevant NICE guidelines, will be established. Any plans should ensure that there is equity of access to services for individuals from all the localities served by the Trust. In line with the Trust’s current plans there should be an ongoing audit, agreed with the Trust’s commissioners, to ensure that the Trust is complying, or moving towards compliance in a planned and agreed manner, with the relevant NICE guidelines on personality disorders.

In line with the recent developments in the provision and delivery of Psychological Therapies in the Trust, together with its commissioners, the Trust should review this provision to ensure that it complies with the recommendations of relevant NICE guidelines. In particular the Trust should ensure that those individuals with more serious, complex and enduring mental health problems have access to psychological interventions in a timely manner as recommended by the relevant NICE guidelines. Having agreed appropriate standards with its commissioner the Trust should institute a regular cycle of audits to establish that, especially, those individuals with serious, complex and enduring mental health problems have appropriate access to Psychological Therapies.

The Trust has identified that progress has been made in the delivery of substance misuse services. It should now put in place a system, including an audit cycle, to assure itself and its commissioners that these developments are realising the intended and identified outcomes. The Trust has identified a number of issues which need to be addressed. Together with its partner organisations the Trust should agree an action plan to address the issues it has identified and put in place a monitoring system to assure itself and its commissioners that the identified actions have been completed and the agreed goals realised. An audit cycle should be put in place to ensure the ongoing improvements of this service.

South West Yorkshire Partnership NHS Foundation Trust should ensure that the aims of its Equality and Diversity policy are translated into practice in the clinical arena by: ensuring that cultural and religious issues are included in the assessment of need in a routine manner; ensuring that staff receive appropriate training to enable them to address cultural and religious issues as part of the assessment process; ensuring that staff receive appropriate and regular supervision in this area; undertaking regular audits to monitor the implementation of the Trust’s Equality and Inclusion Strategy in clinical practice.

South West Yorkshire Partnership NHS Foundation Trust should take action to ensure that the Spiritual and Pastoral Care Team, or another suitable resource, is available to raise awareness of cultural and religious issues within the clinical arena and that clinical staff have timely access to appropriate advice, consultation and supervision on these matters

The Trust should assure itself and its Local Authority partners that the Safeguarding policies and procedures which it has put in place and supported with training are being implemented. It should include audits of compliance with its Safeguarding policies in its regular audit cycle.

Access to appropriate family interventions should be available to services users under the care of the CMHT. CMHT staff should receive training and supervision in appropriate family work and interventions. The Trust should monitor the provision of this service, including using regular audits, to ensure that those individuals who might benefit from family interventions are able to access them in a timely fashion.

The PCT should put in place a system to ensure that there is timely communication between primary care and secondary care services. This should include: a mechanism to ensure that Secondary Services are informed, in a timely manner, who has clinical responsibility in Primary Care, for a service user where this person is different from the original referrer or when responsibility changes/is transferred; the requirement that information and/or advice from secondary mental health services is acted on in a timely manner and where it is not then the secondary services are informed so that the clinicians can make informed decisions about the service user’s care; the requirement that this system should be audited within six moths of its implementation to ensure that it is working effectively.

Given that new protocols have now been put in place the local Housing Associations, the Trust and the commissioners of mental health services should institute a monitoring system to ensure that: the proper roles and responsibilities of these organisation are adhered to; the protocol for sharing information is adhered to; staff are properly trained and supported to carry out their agreed roles; there is a clear mechanism for identifying unmet need.