Independent investigation: Robert Newby, Sticklepath (2007)

The Trust and the PCT need to develop and implement a dual diagnosis strategy based on their needs assessment, National Policy and best practice. This needs to include: the appointment of a Clinical Lead who should be either a Team Leader or Consultant who is prepared to persevere and drive treatment on both substance misuse and mental illness; the development of a Dual Diagnosis Steering Committee to include the key stakeholders from statutory, including the PCT, and voluntary sector to take this work forward; the development of a dual diagnosis network to provide protected time for case discussion and group supervision; develop the care pathway to include those presenting to accident and emergency; prioritise the need for effective training so that all staff members utilise evidence-based interventions when delivering treatment (assertive outreach, crisis team, liaison team and PICU staff); the committee should report directly to the Director of Operations and the PCT on progress and the work should be considered as “core” to adult services development; visits to nationally respected Dual Diagnosis services may be helpful (e.g. Haringey and Birmingham) in determining the model most appropriate for Devon.

A care pathway, based on the 2009 NICE guidelines for treatment of depression, is developed across the well being and access, and recovery teams to incorporate the interface with primary care psychology/IAPT service. Work in partnership with the PCT, GPs with special interest and the voluntary sector to develop the stepped care model for the treatment and management of depression. Introduce an evidenced based assessment such as Beck’s Depression Inventory or the Hamilton Rating Scale for Depression for all adults presenting to mental health services with a low mood or depression.

The ‘emergency services’ and those conducting on call services need to have priority for dual diagnosis training regarding assessment. Research indicates that assertive outreach, crisis teams and PICU staff, will have the highest density of patients who have a dual diagnosis. They should therefore be expected and supported to undertake training at a minimum of level 3. Liaison psychiatry staff and home treatment/crisis staff are more likely to have contact with people in crisis. They need to be able to distinguish between those who have an underlying chronic problem as opposed to those who are using substances as a means of coping. They should therefore be expected and supported to undertake training at a minimum of level 2. In order to ensure that training is put into practice a supervision network needs to be developed.

The Professions Directorate develop and put in place an action plan to strengthen, support and empower the role of the Clinical Team Leaders across the Trust to support the professional leadership structure at Board level through: the creation of action learning sets; the use of executive coaching; clinical master classes; 360 appraisals; considering the merits of developing an in-house leadership programme.

The Trust must commission/complete a review of clinical records and their storage against the standards cited in the Data Protection Act. All clinical areas must ensure that records have been returned to the central archive when patients are discharged or move through services. An audit needs to be conducted in relation to the most recent 10 near misses or serious incidents to ensure that the clinical records have been correctly archived following an internal investigation. Trust personnel must be reminded of their duties and obligations to maintain clinical records to professional standards during clinical supervision. Random spot audits of clinical case files should be conducted across all clinical teams to ensure correct ordering and storage of clinical records.

Following the introduction the electronic record system RiO, the Trust must, ensure using regular audit and supervision, that: all relevant clinical information is stored in a manner that is readily accessible to all clinicians working with a client; that information is appropriately cross referenced; that the quality of clinical notes is of an acceptable standard and complies with best practice guidance and professional standards.

The Trust CPA policy is clear about the roles and responsibilities of professionals and managers. These responsibilities should be restated at all staff development reviews and appraisals. These responsibilities should be presented to all new members of staff as part of the formal induction process. The CPA process should be a standing item within management supervision with case files being checked for: up to date holistic assessment of health and social care needs; a CPA care plan that is reflective of the identified needs; a review date has been set; supervisors and managers need to complete the Practice Audit during supervision and be able to demonstrate adherence to the CPA policy; the Trust needs to ensure that the current policy is compliant with the Refocusing the CPA guidance 2008.

The risk policy needs to be reviewed to more closely align the risk screening tool (level 1) with the in depth risk assessment (level 2). The policy needs to specify that where a risk is identified at the screening stage then an in-depth assessment focusing on that particular risk needs to be conducted and a management plan developed. Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services (Department of Health, 2007) should be used as guidance to underpin the revised risk assessment and management policy. The policy should be structured to reflect the functions of the various teams e.g. Crisis Team, CMHT etc. The Trust needs to ensure that risk management plans are drawn up following risk assessments where either significant risk is identified or where current trigger Factors, which might increase risk, are present. Random spot audits need to be carried out to support the annual audit plan. Risk assessment is a component of the CPA process and is to be included in management and clinical supervision. A service audit needs to be completed six months after the implementation of the revised policy to ensure that it has been acted upon.

The Trust must issue a short protocol, within six months of the publication of this report, clarifying how relatives of staff will be treated within the Trust. This recommendation was made following the Internal Investigation but had at the time of writing the report not been actioned. It is therefore repeated.

Clear concise Operational Policies are developed to enable staff to understand their core function and responsibilities. These should include reference to core policies such as CPA and the key Clinical Practice Standards. Operational service managers need to develop a core operational policy for the area they manage highlighting the area of practice such as age range, geographical area covered and services available. Clinical team leaders need to plot out the systems and processes that operate within their team such as referral criteria, assessment method, liaison with primary care/specialist services, allocation, supervision, discharge criteria and team meetings. Operational policies must be consonant with best practice guidelines such as the national Policy Implementation Guides, CPA policy or NIHCE guidelines A mechanism for the disseminating policies and policy revisions needs to be devised and implemented by the Clinical Governance Committee. Adherence to operational policies needs to be regularly monitored as part of an on-going audit programme. This will in effect create a service map and the beginnings of a service care pathway.

The implementation of the Clinical Practice Standards and the Practice Quality Audit needs to be strengthened across the Trust. Clinical audit participation needs to be developed through: being a standing item on all clinical team meeting agendas; being included in individual annual appraisal and personal development plans; being monitored through supervision; forming part of all employees core job description.

A robust annual audit plan, reflecting the Clinical Practice Standards and the standards specified in ‘Services Good Enough for My Family’, needs to be developed and widely disseminated. This will need to detail the roles and responsibilities of team leaders and managers not just in terms of data collection but also their involvement in action planning to rectify shortfalls. The support services that are available across the Trust, such as coaching and Patient Safety Officers need to be targeted at those teams that struggle to complete the audit cycle. Clear time scales need to be incorporated into the annual audit plan to enable individual practitioners and teams to manage their time.

The Trust need to review the SUI Policy to include: the introduction of reflective feedback sessions following serious incidents and near misses; the involvement of clinical teams in the development of recommendations; how learning and recommendations are to be shared across the Trust; greater clarity about the involvement of the family of victim and perpetrator in Internal Investigations and how they will be supported thorough out the process.