Independent investigation: Jean Darbyshire, Wigan (2009)

It is recommended that the Trust and Local Authority develop a range of key performance indicators to monitor access to care and treatment within the new models of care. These key performance indicators are to be developed: in conjunction with … Read more It is recommended that the Trust and Local Authority develop a range of key performance indicators to monitor access to care and treatment within the new models of care. These key performance indicators are to be developed: in conjunction with the commissioners of mental health services; in accordance with national best practice guidance (to include NICE, DoH and RCP guidelines); available for a full audit to take place within six month of the publication of this report. Show less

The Trust will ensure through the audit process that: all care plans are developed, where possible with service users; all care and service delivery is provided in manner sensitive to the needs and wishes of the service users; all care … Read more The Trust will ensure through the audit process that: all care plans are developed, where possible with service users; all care and service delivery is provided in manner sensitive to the needs and wishes of the service users; all care plans are signed, where possible, by service users; all service users are given a copy of their care plans. Show less

The Trust will ensure through the audit process that: all care plans are developed, where appropriate with carers; collateral information is sought from carers; information pertaining to risk is shared with carers and that, when appropriate, contingency and crisis plan … Read more The Trust will ensure through the audit process that: all care plans are developed, where appropriate with carers; collateral information is sought from carers; information pertaining to risk is shared with carers and that, when appropriate, contingency and crisis plan information is shared in full with them; all carers, where appropriate, to be offered a carer assessment and a funded care package and support package as required; carers who refuse carer assessments should be followed up on a regular basis and health and social care professionals should continue to offer support and remake the offer of an assessment at regular time intervals. Show less

In the long term the Trust must conduct an audit of all service users with the same name, held within the same team, during all record keeping audits. In the short term the Trust must: conduct a record review of … Read more In the long term the Trust must conduct an audit of all service users with the same name, held within the same team, during all record keeping audits. In the short term the Trust must: conduct a record review of the clinical records of the three services users of the same name mentioned in this report to ensure that all records are repatriated appropriately across primary and secondary care; identify systems and processes in conjunction with primary care and the Local Authority to ensure that similar record comingling cannot occur again in the future; conduct an audit into the quality of clinical record keeping within the teams identified within this report to ensure that appropriate professional standards are being upheld. Show less

The Trust and Local Authority should develop a cycle of audit that tests policy to practice for all policies and procedures linked to the delivery of care planning and treatment. These audits must: be developed in conjunction with commissioners; include … Read more The Trust and Local Authority should develop a cycle of audit that tests policy to practice for all policies and procedures linked to the delivery of care planning and treatment. These audits must: be developed in conjunction with commissioners; include NICE treatment guidelines; form links with case, clinical and managerial supervision processes to ensure that sub-audit blind spots are identified; inform the Trust and Local Authority continuing professional development programme; provide regular feedback to the Board, care and treating teams and individuals. Show less

The Trust has accomplished a significant amount of work in relation to clinical governance processes. The Trust should audit progress against the new systems within six months of the publication of this report. This audit should be framed in conjunction … Read more The Trust has accomplished a significant amount of work in relation to clinical governance processes. The Trust should audit progress against the new systems within six months of the publication of this report. This audit should be framed in conjunction with commissioners and should provide assurance in the public interest that implementation stages have been successfully embedded within the Trust. Show less

All patients must receive a diagnosis and diagnostic formulation following assessment. This activity will be monitored through: clinical audit processes; medical appraisal.

The effectiveness of the new medicines management process should be audited to ensure that the system is effective. This should include: an evidence-based audit should be conducted across all five boroughs to provide feedback to prescribing clinicians (Trust and general … Read more The effectiveness of the new medicines management process should be audited to ensure that the system is effective. This should include: an evidence-based audit should be conducted across all five boroughs to provide feedback to prescribing clinicians (Trust and general practice alike) with regard to their prescribing practice; service users with a history of medication non adherence must have a medicines management care plan which is reviewed on a regular basis. Show less

All Trust and Local Authority registered health and social care professionals working in the Wigan area should receive a training update on the Mental Health Act (1983 and 2007). This training should highlight: assessment thresholds; duty of care issues for … Read more All Trust and Local Authority registered health and social care professionals working in the Wigan area should receive a training update on the Mental Health Act (1983 and 2007). This training should highlight: assessment thresholds; duty of care issues for service users in inpatient settings; these to include the differentiation between informal and voluntary admissions; Section 117 aftercare planning and discharge arrangements (NB. This was not a particular issue in relation to Mr. X, but was identified as having been conducted poorly when examining the records, ambient inadvertently, of a service user of the same name during the course of this investigation). Show less

The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. Audit processes should include: Assurance … Read more The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. Audit processes should include: Assurance that all those referred to 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. Show less

The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. The following actions need to … Read more The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. The following actions need to take place: all registered health and social care practitioners in the Borough of Wigan should be subject to a comprehensive risk training programme; all registered health and social care practitioners mentioned in this report should receive clinical risk management training and their caseload should be subject to specialist supervision for a period of six following the publication of this report; risk assessment processes should be audited to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk and can been demonstated to be multidisciplinary in nature; that robust and meaningful risk management plans are put in place and are subject to timely review; that the service user and other relevant individuals are involved in the assessment and planning process; that the risk management plan is appropriately disseminated. Show less

The Trust and Local Authority should develop in conjunction with its commissioners a robust performance management tool to ensure that the new care pathways are effective and are implemented as currently planned. (Please see Recommendation 1).

The Trust and Local Authority should develop a framework of assurance that will measure policy to practice. This framework must: be developed with local commissioners; be based upon national best practice guidance.

All registered health and social care practitioners mentioned in this report should receive an update for safeguarding and Mental Capacity Act training and their caseload should be subject to specialist supervision for a period of six months following the publication … Read more All registered health and social care practitioners mentioned in this report should receive an update for safeguarding and Mental Capacity Act training and their caseload should be subject to specialist supervision for a period of six months following the publication of this report; Show less