Independent investigation: Rae Torbet(Ms E), Hastings, Sussex (2003)

that the managers of the service ensure that plans and clear service standards are developed and implemented in the following areas that match the overall strategic direction of the Trust. • Supervision • Care Programme Approach • Clinical governance • Staff Development • Cross team working • Case review

that the newly formed Crisis Home Treatment Team (CHTT) service policies and procedures are reviewed to ensure that they are consistent with the overall Trust strategy.

that a system is implemented whereby the team formally reviews all case formulation, care plans and multi-disciplinary care review.

That a review of the handover process is undertaken to ensure that all decisions are documented in the individual’s notes and that an ongoing team log of the handovers and review meeting is completed.

That a clearer process is established for the allocation and coordination of each case.

that the mental health services should develop protocols with wider Domestic Violence services to assist in supporting and protecting ex partners.

that Turning Point, the mental health trust and the PCT work together to jointly agree a care pathway which incorporates the Sanctuary service into the wider mental health services in order to: o ensure a shared value base between all parties o identify key staff to liaise between provider services and ensure co-ordinated care planning and delivery

that the Sanctuary funding is reviewed to ensure adequate resourcing to meet the significant demands placed upon them

that crisis services routinely access primary care and other available health and social care information within 24 hours.

that a protocol for handover of clients is developed urgently, which contains information to ensure the safe transfer of patients to ongoing services and includes all patient documentation.

that the Trust should consider whether A&E liaison service should be part of an integrated crisis service.

That Clinical Psychology input is sought by team members to assist with the formulation of care plans and to participate in multi-disciplinary case reviews.

That this is reinforced to team members and Agency staff and that a mandatory annual training session on the formulation of active and dynamic Care Plans from Risk Assessments is introduced.

that a member of the team be identified to receive training in substance misuse from the DAAT, and that they provide a continuing structured link between the DAAT and the CHTT

that the team has sufficiently resourced Consultant Psychiatrist input.

that the Trust reviews the process of dealing with Serious Untoward Incidents to ensure that the SUI policy is implemented consistently and comprehensively; that lessons are learned and cascaded effectively through the Trust; that audit systems are put in place to ensure that recommendations are implemented and that lessons from SUIs are considered by the Trust Board as part of overall Clinical and wider Governance structures.

that a more structured process for supervision is developed to ensure that there is a formal review of care plans for all members of the team including CPNs and psychiatrists as well as developing a multi-disciplinary team based approach to review cases. At these reviews it would be advisable to include other professionals such as substance misuse and housing.

that all agency staff receive proper induction and access to statutory and mandatory training.

that a care coordination system is systematically implemented which clarifies the role.

the Strategic Health Authority, County Council and other relevant health bodies satisfy themselves that arrangements for performance management now in place meet the requirements of statute and best practice