Independent investigation: Robert CrookElsie Crook, Swindon (2007)

The Trust, in conjunction with NHS Lincolnshire and NHS East Midlands, should develop a formal memorandum of understanding with the Lincolnshire Police Force to establish information sharing protocols.

The new Records Management System will require audit in order to ensure compliance with pre-existing Trust policy and procedure.

All Trust policies and procedures should make explicit the responsibility of the individual professional, the team and the statutory corporate body in the implementation of all local and national best practice guidance. These responsibilities should be restated at all annual staff development reviews and appraisals. These responsibilities should also be presented to all new staff as part of a formal induction process.

New Policies should be disseminated in a formal and systematic manner. The following actions should be undertaken:
formal training events should be conducted for both new policies providing guidance
for significant clinical frameworks and major policy revisions (mandatory training
should be considered for CPA and risk);
policies and procedures should be provided in both electronic and hard copy formats
for access by all clinical staff;
team briefings and team meetings should highlight new policies and procedures;
team briefings and team meetings should highlight issues arising from internal Trust
investigations that have occurred directly due to the non-adherence to policy and
procedure guidance;
team leaders should notify either the Director of Nursing or the Medical Director if
they have reason to believe that extant Trust policy and procedure cannot be
implemented effectively.
new staff should have sufficient time made available to them to read and understand
Trust policy and procedure requirements.

The clinical risk assessment and management policy should be revised in accordance with national best practice guidance. The revised policy should integrate fully with the Trust Integrated Care Pathway Approach and Care Programme Approach procedures. The new policy should make explicit the requirements for:
a professional standard of documentation;
interagency/service liaison;
safeguarding;
carer communication and safety alerts (if indicated);
dynamic care, contingency and crisis planning;
plans for timed and specific intervention, should relapse indicators be evident;
the responsibilities of all Trust personnel at all levels in ensuring that policy is appropriately implemented.

The Trust should continue to provide training across the Trust with regard to the new MAPPA guidance arrangements, changes to information sharing and safeguarding arrangements. This training should be monitored and its effectiveness audited and reviewed on a regular basis. Opportunities to review the effectiveness and uptake of training should be taken:
following any referral from the Police Service, Probation Service or Social Services;
following any safeguarding process;
following any related serious untoward incident;
following any related near miss.

On the publication of this report a Lincoln-based service user and carer satisfaction survey should be conducted to ascertain the perceived effectiveness of the Integrated Care Pathway Approach. This survey to establish whether:
good quality, relevant information was provided in a timely manner;
the wishes and preferences of service users were taken into consideration;
the service user was introduced to a named nurse;
conversations on recovery occurred and were recorded;
the service user, and where appropriate the carer, were involved in all aspects of assessment and care planning;
carer assessments were offered;
copies of relevant information were shared appropriately.

The Trust must audit the use of the Risk Assessment Template currently being used by the Crisis and Home Treatment Teams. This audit will review:
adherence to the Trust policy ensuring that every person referred to Crisis and Home
Treatment Teams has been assessed appropriately;
the interval of time taken between initial referral and the Risk Assessment Template
being completed;
evidence that the Risk Assessment Template has been discussed by the multi
disciplinary team;
evidence that either appropriate triage/referral occurred within an acceptable
timeframe, or a comprehensive and dynamic plan of care and treatment was
developed.

The Trust should undertake a full and comprehensive audit against its current clinical and caseload supervision practice. This audit should review:
the rate of compliance of clinicians undertaking clinical supervision;
whether the grade of clinician affects the uptake of supervision;
sessions per annum undertaken by supervisees;
how many supervisors have been appropriately trained;
how clinical supervision is recorded;
how supervision impacts positively on clinical outcomes.

The Trust must disseminate the findings of this Independent Investigation across the organisation as a case study to explore the implications of not producing contemporaneous records. These implications need to underline:
the risks to the service user and their carers;
the risks to the individual professional/worker;
the risks to the corporate body.

All key junctures of the „Multi Disciplinary Integrated Care Pathway Acute Care‟ should be subject to a comprehensive audit on the publication of this report. This audit to be Lincoln-based and to ensure compliance with:
the appropriate completion of all pathway documentation within the preset timescales;
variance tracking, cause of variance and action taken;
the views of carers having been sought and recorded.

The Trust should undertake a comprehensive audit six months after the publication of this report/one year on from the implementation of the new revised Priority Pathways (whichever is first). This audit should be developed in conjunction with local stakeholders. As well as auditing adherence to policy and procedure it should review:
sources of referral;
reasons for not accepting referrals;
service user and carer satisfaction with ease of referral to a service;
stakeholder (e.g. General Practice, Police Service, third sector) satisfaction with ease
of referral to a service.

On the publication of this report the Trust should conduct an audit against its 2009 Discharge and Transfer Policies and Procedures to ascertain their effectiveness. These arrangements are relatively new and good practice would require that they are appraised and any appropriate revisions made as necessary.

The Trust and the Swindon-based Police Service should formalise a Safeguarding Vulnerable Adults protocol to ensure a rapid response process is formulated. This protocol should be made available to all clinical teams in the Swindon area.

The new clinical risk assessment and management policy should be supported by a mandatory comprehensive training programme for all health and social care staff within the Trust. This training should make explicit the roles and responsibilities of:
each health and social care professional;
each clinical team;
the corporate body.

All Trust health and social care personnel should receive training with regard to their duty of care to both the Trust Safeguarding Adults‟ Policy and the Safeguarding Vulnerable Adults in Swindon and Wiltshire Policy that operates on behalf of all statutory agencies in the County. This training should make explicit:
what constitutes a vulnerable adult;
situations that constitute potential risk to vulnerable adults and that require action;
every individual health and social care workers‟ duty of care as an employee of the
Trust;
each separate Agencies‟ duty of care;
systems and alerts for initiating formal assessment and action.

The Trust should revise its existing clinical supervision policy in the light of the audit findings. Appropriate training should then be provided for individuals acting in a supervisory role. This policy should also make provision for:
Clinical Supervision
Caseload Supervision
Management Supervision
Trust internal Professional Regulatory Management systems

A quantitative and qualitative audit should take place to examine the supervision status of non-qualified staff. The findings of this audit should be used to revise the Clinical Supervision Policy. This audit should review:
the percentage of non-qualified staff receiving clinical supervision;
the number of sessions made available per annum to individuals;
the grade of the person acting as supervisor;
the links to training and development opportunities arising from the needs identified
during supervision;
the recording process utilised for any discussions and decisions made that are service
user focused.

The Operational Policies of the Community Mental Health and Assertive Outreach Teams must be revised in accordance with any service issues raised from the audit of the Integrated Care Pathways. For example these revisions may need to consider:
establishment;
skill mix;
clinical supervision;
record keeping;
joint working with other services;
referral and discharge processes.

In conjunction with NHS Swindon the Trust must review the newly revised Single Point of Entry system including the changes to Standard Operating Procedures within a twelve-month period of its inception.

New Policies should be disseminated in a formal and systematic manner. The following actions should be undertaken:
formal training events should be conducted for both new policies providing guidance
for significant clinical frameworks and major policy revisions (mandatory training
should be considered for CPA and risk);
policies and procedures should be provided in both electronic and hard copy formats
for access by all clinical staff;
team briefings and team meetings should highlight new policies and procedures;
team briefings and team meetings should highlight issues arising from internal Trust
investigations that have occurred directly due to non-adherence to policy and
procedure guidance;
team leaders should notify either the Director of Nursing or the Medical Director if
they have reason to believe that extant Trust policy and procedure cannot be
implemented effectively.
new staff should have sufficient time made available to them to read and understand
Trust policy and procedure requirements.

All key junctures of the „Integrated Care Pathway Assertive Outreach‟ should be subject to a comprehensive audit on the publication of this report. This audit to be Trust-wide and to ensure compliance with:
the appropriate completion of all pathway documentation within the preset timescales;
variance tracking, cause of variance and action taken;
the views of service users having been sought and recorded.

The Trust needs to use the flexibilities contained in the Mental Health Act (2007) to further extend the opportunities to make provisions under The Act. This will assist in ensuring a greater availability of Approved Mental Health Act Practitioners and will ensure a timely implementation of The Act in situations of crisis.