Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009)

Aneurin Bevan Health Board Adolescent Mental Health Services (CAMHS) and Caerphilly County Borough Council Social Services must enhance arrangements for working together effectively, and ensure that there is a clear, shared understanding of each others roles93. Read more Aneurin Bevan Health Board Adolescent Mental Health Services (CAMHS) and Caerphilly County Borough Council Social Services must enhance arrangements for working together effectively, and ensure that there is a clear, shared understanding of each others roles93. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place measures to ensure that their after-care responsibilities for providing adequate accommodation and housing under Section 117 of the Mental Health Act are not discharged through the homelessness … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place measures to ensure that their after-care responsibilities for providing adequate accommodation and housing under Section 117 of the Mental Health Act are not discharged through the homelessness route. Show less

In order to assure itself that it fully meets its Section 117 responsibilities, Caerphilly County Borough Council must revise its housing policies and processes to ensure that suitable, good quality housing is provided to people with mental health issues, particularly … Read more In order to assure itself that it fully meets its Section 117 responsibilities, Caerphilly County Borough Council must revise its housing policies and processes to ensure that suitable, good quality housing is provided to people with mental health issues, particularly those due to be discharged from hospital. Systems should be put in place to enable suitable accommodation to be arranged prior to a patient’s discharge from hospital. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that Mental Health Review Tribunal recommendations are promptly acted upon and that there is clarity about who is accountable for owning such actions. A clear escalation process must be … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that Mental Health Review Tribunal recommendations are promptly acted upon and that there is clarity about who is accountable for owning such actions. A clear escalation process must be in place. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must assure themselves that risk management is embedded in the culture of all mental health services, ensuring that: (cid:131) all staff recognise that accurate risk assessment relies fundamentally on high quality … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must assure themselves that risk management is embedded in the culture of all mental health services, ensuring that: (cid:131) all staff recognise that accurate risk assessment relies fundamentally on high quality history-taking and review of all previous information (including risk assessments)96; (cid:131) all individuals’ risk assessments and risk management plans are up-to-date, of high quality, with appropriate levels of risk tolerance, and are regularly reviewed; (cid:131) due regard is given to national guidance and evidence about common risk factors, including those for patients with complex needs (e.g. co-occurring substance misuse and mental health problems) and for scenarios known to be high risk (e.g. discharge from hospital); (cid:131) risk management is planned and scrutinised effectively at multi-disciplinary team meetings; and (cid:131) Contingency Plans and Crisis Plans are prepared for all patients under CPA, in accordance with Welsh Government Mental Health Policy Guidance97. Plans must be reviewed at multi-disciplinary team meetings when implemented in crisis or contingency scenarios, particularly when actions involve a multi-disciplinary response. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that Carers’ Assessments are used consistently and recognise the impact of patient risk factors on carers’ needs as well as those of the patient.

Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that services’ eligibility criteria do not exclude patients with complex needs. Eligibility criteria must be flexible, with the core emphasis focused on individuals’ needs.

Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that the needs of children and young people with Asperger’s Syndrome, and those with a co-occurring mental health issue, are met comprehensively98.

Aneurin Bevan Health Board and Caerphilly County Borough Council must develop a range of community responses to people with complex needs, to include Crisis Resolution/ Home Treatment alongside Assertive Outreach.

Aneurin Bevan Health Board must ensure that a comprehensive range of local in-patient mental health services is available to all patients.

The Mental Health Programme Board for Wales must ensure that there is sufficient NHS low secure provision in Wales.

Aneurin Bevan Health Board and Caerphilly County Borough Council must work together to strengthen processes for transition from children’s to adults’ services, to include mechanisms for forward planning and multi-agency consideration of needs, identifying clear roles and responsibilities with a … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must work together to strengthen processes for transition from children’s to adults’ services, to include mechanisms for forward planning and multi-agency consideration of needs, identifying clear roles and responsibilities with a period of overlap where possible94. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council should ensure that the Caerphilly Assertive Outreach Team is adequately resourced to provide a service seven days a week where needed.

Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that community mental health services, including CMHTs and AOTs: (cid:131) are managed effectively and equipped with strong leadership; and (cid:131) effective managerial supervision and support mechanisms are in place. Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that community mental health services, including CMHTs and AOTs: (cid:131) are managed effectively and equipped with strong leadership; and (cid:131) effective managerial supervision and support mechanisms are in place. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must strengthen multi-disciplinary team systems to support and ensure effective care planning and decision-making, including escalation arrangements.

Aneurin Bevan Health Board and Cygnet Hospital must undertake a thorough review of the rationale for the clinical decisions made at the time of Mr H’s discharge from Cygnet Hospital and his subsequent care by the CMHT and non-admission to Tŷ Sirhowy.

Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place measures to ensure that: (cid:131) current information sharing arrangements between services exist; (cid:131) individuals’ health and social care records are made available in a timely manner on … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place measures to ensure that: (cid:131) current information sharing arrangements between services exist; (cid:131) individuals’ health and social care records are made available in a timely manner on transfer to a different service; (cid:131) on allocation of a new case, care co-ordinators are required to thoroughly review all previous health and social care records relating to the individual; and (cid:131) all available information relating to diagnosis and risk management is taken into consideration when care planning. Show less

Aneurin Bevan Health Board must ensure that Continuing Healthcare placements are made following full and due consideration of the appropriateness of the placement for the patient and that robust mechanisms are in place to monitor the clinical performance, quality and … Read more Aneurin Bevan Health Board must ensure that Continuing Healthcare placements are made following full and due consideration of the appropriateness of the placement for the patient and that robust mechanisms are in place to monitor the clinical performance, quality and safety of care provided in such facilities. Show less

Aneurin Bevan Health Board must ensure that it sets out a clear pathway for allocating and funding Continuing Healthcare placements and that all parties involved understand their roles and responsibilities.

Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must put in place rigorous procedures to ensure that meetings to plan after-care under Section 117 of the Mental Health Act are held in a … Read more Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must put in place rigorous procedures to ensure that meetings to plan after-care under Section 117 of the Mental Health Act are held in a timely manner and attended by a multi-disciplinary team, using best endeavours to agree an appropriate package of support. A system must be developed to ensure that after-care plans are agreed and signed off by the patient’s RMO, care co-ordinator and third party contractor and where agreement between the three cannot be reached there must be a suitable escalation arrangement. Show less

Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must ensure that after-care planning is systematically undertaken at the start of a patient’s detention under the Mental Health Act, in order to plan for … Read more Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must ensure that after-care planning is systematically undertaken at the start of a patient’s detention under the Mental Health Act, in order to plan for a safe and supported discharge. Show less

Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must ensure that, prior to discharge a multi-disciplinary team agrees after-care, CPA and risk management plans which detail the arrangements for: (cid:131) accommodation which adequately … Read more Aneurin Bevan Health Board, Caerphilly County Borough Council and third parties such as Cygnet Hospital must ensure that, prior to discharge a multi-disciplinary team agrees after-care, CPA and risk management plans which detail the arrangements for: (cid:131) accommodation which adequately meets the needs of the patient, where accommodation is required as part of the after-care package; (cid:131) how medication is to be monitored and supervised if appropriate; (cid:131) mitigating a full range of risk factors including substance misuse and harm to the patient and others; and (cid:131) transport, supervision and care for the day of discharge95. Show less

Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place a mechanism to ensure that after-care plans are timely, consistent, high quality and appropriate to meet the needs of the individual. Aneurin Bevan Health Board, Caerphilly County … Read more Aneurin Bevan Health Board and Caerphilly County Borough Council must put in place a mechanism to ensure that after-care plans are timely, consistent, high quality and appropriate to meet the needs of the individual. Aneurin Bevan Health Board, Caerphilly County Borough Council and Cygnet Hospital should each conduct an audit of relevant patients currently detained under the Mental Health Act to assess the quality, timeliness and consistency of after-care plans. Show less