Independent investigation: Margaret Ford, Templeton, Pembs (2009)

On a strategic level Hywel Dda Health Board and Pembrokeshire County Council Board should jointly: • Enhance arrangements for joint working at a strategic and joint planning level between mental health services and social services for example, to look at issues such as the size of patches, staffing levels and cover, the roles, relationships and ‘fit’ between the different mental health services provided by the two services. • Embed quality risk assessment and risk management, crisis and contingency planning processes in developing and implementing the care plan in conjunction with the carer and significant others in the service user’s life.12 The contingency and crisis plans should be easy to access for both health and social services staff on a 24 hour basis. • Embed within their practice and policies the ethos that ‘accurate risk assessment relies upon a high quality history taking, sharing of information between individuals and services and locating relevant past information which may indicate areas of current and future risk’. • Undertake a project with carers and mental health users’ organisations, with a view to increasing the uptake and usefulness of carers’ assessments. • Make sure that the services review their CPA policies, to ensure conformity with the interim policy guidelines recently issued by the Welsh Assembly Government (see footnote 12 above) and to implement the recommendations of the 2009 Review of the Care Program Approach in Wales13.

In relation to CPA, Hywel Dda Health Board and where appropriate, due to an involvement in the co-ordination and provision of care, Pembrokeshire County Council need to ensure: • Improved clinical team meeting structures to allow for improved review of new patients and clinical discussion of people with continued contact. • That the philosophy and guiding principles of the CPA are implemented consistently and that the approach is to be holistic, incorporating both clinical and social models of care which assesses and addresses medical, social and family circumstances and needs. This needs to be embedded in practice through training, supervision, documentation and the use of appropriate quality assurance processes to include all practitioners including doctors, care co-ordinators and supervisors. • That when carers’ assessments are offered to a patient’s family member(s), they are advised that by being identified as a carer they can be included in crisis and contingency planning. • That active consideration is given to providing GPs with greater opportunities to be included in the care/treatment of serious mentally ill patients. • That crisis teams be required to take in to account the views and supporting evidence provided by family & carers.

In relation to FACE, Hywel Dda Health Board needs to ensure that: • A thorough evaluation and review of the fitness for purpose of FACE system and thorough training of all staff in its use is undertaken. • Historical paper patient notes should be incorporated into the FACE record in the form of thorough summaries and that care co-ordinators are given sufficient protected time to complete such summaries. However HIW recognises that if the mental health service from which the patient had been transferred from had engaged with the CPA transfer process when they became aware of Mr G's imminent relocation out of their area, the necessity for the actions recommended above would have diminished. For that reason this report will be drawn to the attention of the relevant departments in the Welsh Assembly Government and their counterparts in the department of health for them to take the matter forward as appropriate. • That consideration is given to the incorporation of a ‘front page’ which, alongside the usual details of diagnosis, medication etc. should include triggers and relapse signs, contingency/crisis plans and include details of any vulnerable adults or children living at the same address. • That FACE be made available to both social services staff and if appropriate, GPs.

In relation to the function of the CMHT and CRHT, Hywel Dda Health Board and, where appropriate, Pembrokeshire County Council should: • Review the availability and implementation of clinical and managerial supervision to ensure that staff are appropriately supported. • Look to improve staffing levels in both teams. • Ensure that there are formal arrangements in place to cover long term absences of staff. • Clarify and develop guidance on the respective roles and responsibilities for co-ordinating a response to crises that involve the contribution of both the out of hours service and the CRHT. Specifically they should review and identify the circumstances and indicators to establish when a joint visit involving both CRHT and the out of hours practitioner should be considered and undertaken. • Review the delivery of services within the Narberth patch and South Pembrokeshire CMHT to ensure that these reflect the demands of the geographical area.