Recommendation
NHS Morecambe Bay CCG must • Ensure that General Practitioners are reminded to consider a referral for a carer’s assessment when carer responsibilities are indicated. • Ensure that General Practitioners add safety alerts to relevant patient notes where an individual …
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NHS Morecambe Bay CCG must
• Ensure that General Practitioners are reminded to consider a referral for
a carer’s assessment when carer responsibilities are indicated.
• Ensure that General Practitioners add safety alerts to relevant patient
notes where an individual is known or suspected to pose a risk to others.
• Explore whether there are systems available to assess the safety of
family members and informal care providers who are supporting patients
with mental health issues in the community and advise GP practices
accordingly. Encourage GPs to audit against this recommendation.
• Work with providers and medicines management teams to develop a
process by which the GP / Practice Pharmacist are notified of patients
failing to collect prescriptions and communicate this effectively to relevant
parties, particularly where a shared care agreement is in place.
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Recommendation
The Trust must ensure that families and carers are appropriately involved in
care planning and risk assessment.
Recommendation
The Trust must ensure that it is recognised that supportive families may also be
at risk of harm, and that comprehensive assessments and supportive plans are
developed.
Recommendation
The Trust must seek assurance that safeguarding supervision is accessible and
provided to staff within ward environments in accordance with NHS England
Safeguarding Accountability and Assurance Framework 2019.
Recommendation
The Trust must seek assurance that the Trust Safeguarding Service is made
aware of Trust incidents where there is harm caused to a service user to ensure
appropriate safeguarding oversight.
Recommendation
Trust and Adult Social Care staff must consider how best to communicate information to Nearest Relatives, so they can be assured that the Nearest Relative clearly understands their role and rights under the Mental Health Act. Simplified versions of written …
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Trust and Adult Social Care staff must consider how best to communicate
information to Nearest Relatives, so they can be assured that the Nearest
Relative clearly understands their role and rights under the Mental Health Act.
Simplified versions of written materials are recommended, where they are not
already in use.
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Recommendation
NHS England should share learning identified with the First Tier Tribunal (Mental
Health) regarding providing guidance to families about how any confidential
information they share may be used.
Recommendation
The Trust must ensure that serious incident investigations are carried out at the
appropriate levels, within expected timescales and that they provide evidence of
action plan implementation.
Recommendation
Cygnet Health Care must ensure that serious incident investigations are carried
out at the appropriate levels, within expected timescales and that they meet
expected NHS England national standards.
Recommendation
Cygnet Health Care policies should clearly demonstrate the sign off and
governance process.
Recommendation
Cygnet Health Care must demonstrate and provide assurance to commissioners
that their admission, discharge and Care Programme Approach (CPA) policies
are adhered to.
Recommendation
Cumbria and Lancashire Rehabilitation Company must provide assurance that: • Risk assessments are updated at expected intervals and communicated to other agencies. • There is a policy that applies where the individual is open to multiple agencies, clarifying when information …
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Cumbria and Lancashire Rehabilitation Company must provide assurance that:
• Risk assessments are updated at expected intervals and communicated
to other agencies.
• There is a policy that applies where the individual is open to multiple
agencies, clarifying when information and risk assessments must be
shared with the other agencies involved.
This should relate to the Probation Service from June 2021.
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Recommendation
NHS England should gain assurance about the quality of private PICU provision following the principles of host commissioning arrangements. This is to ensure that the local CCG/ICS monitors and has quality oversight for providers in their locality. Quality issues should …
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NHS England should gain assurance about the quality of private PICU provision
following the principles of host commissioning arrangements. This is to ensure
that the local CCG/ICS monitors and has quality oversight for providers in their
locality. Quality issues should be raised via the quality system oversight groups.
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Recommendation
Safer Cumbria and the local Community Safety Partnership should develop
systems to ensure there is oversight of the implementation of action plans from
domestic homicide reviews.
Recommendation
The Trust must ensure that risk to families is considered as part of risk
assessment and management, with collateral information from family members.
Recommendation
Safer Cumbria must develop and implement a comprehensive domestic abuse
action plan which includes the learning from this review.
Recommendation
The Trust must incorporate the understanding of potential risk of harm to
parents into risk assessment training, policy and procedures.
Recommendation
NHS England should share learning identified about parricide with the Home
Office.
Recommendation
NHS England should share the learning with the First Tier Tribunal (Mental
Health) about parricide and risk to family members, and how sensitive third-party
information is managed.
Recommendation
Prison health care providers must ensure that systems are in place to share
secondary prison health care consultations and information with GPs on
discharge or release.
Recommendation
The Trust must ensure that there is clear guidance to be followed for the care of
patients who present as sexually disinhibited, which adheres to national
guidance on same sex accommodation.
Recommendation
The Trust must ensure the use of Section 17 leave is supported by robust risk
assessment and clear care plans that are agreed by the multidisciplinary team
(MDT) and families as appropriate.
Recommendation
The Trust must demonstrate that referrals for Psychiatric Intensive Care Unit
(PICU and/or out-of-area treatment include clinical assessment and
recommendations.
Recommendation
The Trust must ensure that evidence-based treatment plans are in place, that
are in line with NICE treatment guidance ‘Psychosis and schizophrenia in adults:
prevention and management’ (2014).
Recommendation
Any changes to the risk assessment tools used by the Trust should be informed by current research and recommendations from independent bodies. Any newly developed tools should be based on current knowledge and informed by independent experts in risk assessment …
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Any changes to the risk assessment tools used by the Trust should be informed
by current research and recommendations from independent bodies. Any newly
developed tools should be based on current knowledge and informed by
independent experts in risk assessment in mental health services. They should
also be subject to independent evaluation by experts in risk assessment before
they are implemented.
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Recommendation
Cygnet Health Care must ensure that the risks identified by local services are
clearly visible in any risk assessment completed by Bearsted Ward, and that
when risks are identified they are recorded and mitigation plans developed.