Independent investigation: Philip Ellison, Preston (2008)

The Trust should ensure that initial assessment of people with mental health problems takes full account of social care factors: this is particularly relevant when the service user has responsibilities as a carer and there are known child care difficulties. Initial assessments should include thorough analysis of social care factors in mental health presentations.

The Trust should complete an annual audit of compliance with medication standards at residential and supported accommodation schemes for which it has management responsibility.

The Trust should ensure that a full range of therapeutic interventions are available to clinical teams including behavioural approaches (for example Cognitive Behavioural Therapy).

The Trust should take action to ensure that all patients on enhanced CPA will be seen by the Consultant Psychiatrist at least once a year in accordance with the Trust CPA policy.

The Trust should complete the work on a detailed care pathway for the whole of the stepped care model. This should include: arrangements for stepping up and stepping down based on clinical need: testing the current operational policies against this pathway and ensure that for every ‘event’ on the care pathway there is a corresponding reference in the various operational policies clearly outlining the standards and responsibilities associated with that event; identifying throughout the care pathway each administrative action required to support the pathway and identify performance standards to achieve this; this could include identifying all communication events and the development of standard templates for communication; developing a service user and carer version of the care pathway that clearly describes how the service works and establishes a series of customer care outcomes for various stages of the pathway; and developing a stakeholder version for General Practitioners and other organisations with appropriate service standards and contact details for various stages of the pathway.

The Trust should ensure that statutory duties under the Act are met: this is particularly relevant to community treatment and supervision and to meeting obligations to provide aftercare under Section 117 Mental Health Act. There should be systems in place to ensure that staff carrying out these responsibilities meet Trust standards.

The Trust should ensure that the revised Care Programme Approach policy has been fully implemented, including procedures for effective handover and transfer of patients. The trust should monitor implementation through regular audit of the effectiveness of the policy and procedure. This must take place at least annually.

The Trust should review its systems for ensuring that all care coordinators receive regular supervision and that this supervision includes monitoring of caseloads to ensure that both Lancashire Care NHS Foundation Trust and national professional guidance and standards are met.

The Trust must implement a system to ensure that adequate risk assessments are being completed and that regular care planning and multidisciplinary reviews are taking place for people resident in the supported tenancy schemes and similar accommodation where the trust and partner agencies provide services.

The Trust should take action to raise the profile of issues associated with vulnerable adults and safeguarding. In particular the Trust should ensure that staff are aware of the inter-agency Safeguarding Policy and their obligations under it.

The Trust should ensure that there is full information exchange between care coordinators when case responsibility is transferred. There should be a system in place to ensure continuity of care when service users are seen by junior doctors under the supervision of a Consultant Psychiatrist .

The Trust should complete regular audits of case documentation to ensure compliance with standards.

The Trust should ensure that there are systems in place to identify and manage professional communication difficulties. When there are problems the relevant senior manager should be informed and assume responsibility for resolving difficulties.

The Trust should implement its clinical supervision policies to ensure that all activity is carried out to the required standards and is accurately recorded. Where there are issues of poor performance the clinical supervision structure should be used to address these issues. All staff should be clear about the supervision arrangements and their role within them.

The Trust must develop a communications strategy to improve the level of understanding by staff at all grades of the Trust and Lancashire County Council governance and managerial systems. Particular attention must be given to raising concerns and whistleblowing within the partnership.

The Trust should use the findings of this Independent Investigation to inform its work on developing a more open and supportive culture to support high quality clinical practice. Proposed changes to the organisation and delivery of services should be fully discussed with partner agencies.

The Trust should monitor the application of the disciplinary and whistleblowing policies and report regular summary information to the Trust Board.

The Trust should ensure that staff involved in disciplinary or whistleblowing allegations are given timely feedback on the outcome of investigations and are fully supported through the process

The Trust should ensure that when an internal investigation is completed, it leads to an action plan that can be monitored and that the outcomes are communicated to participants and others with a need to know in a timely way.