Independent investigation: Kyle Maher, Tooting (2017)

The trust should have a system in place to ensure that the care coordinators within the EIS hold caseloads within the current national recommended number (no more than 15) to promote effective support to service users.

The trust should ensure that the EIS uses a model of working to enable clinical staff to work outside office hours so that service users can be visited, assessed and monitored face to face if necessary.

The trust should carry out an audit to ensure that CPA reviews take place in line with trust policy.

EIS should carry out regular audits to ensure that service users are placed within the correct zone in line with the risks that they present and that they are reviewed, and targeted mental health interventions are delivered in line with the standards within the zoning system.

EIS should consider using urine or saliva testing as part of care planning where it is known that the service user regularly takes drugs.

EIS should ensure that they engage all sources of information including families when trying to visit service users that are hard to engage.

EIS and the housing charity should ensure that all staff are aware of all emergency accommodation options available to them.

EIS should ensure that all incidents that meet the criteria are reported and investigated so improvements can be put in place where necessary.

The trust should ensure that those affected by an incident are offered support in a timely manner.

The trust must ensure that they use the systems in place for complying with duty of candour and carry out regular audits to ensure they are meeting the requirements of the act.