Independent investigation: Rosemary Armstrong, Bournemouth (2010)

The Trust will provide training to Community Mental Health Team staff on Medicines Management Planning; this will cover compliance and non-adherence and will incorporate motivational interviewing skills. The Trust will instruct clinicians of the importance of documenting the reason behind … Read more The Trust will provide training to Community Mental Health Team staff on Medicines Management Planning; this will cover compliance and non-adherence and will incorporate motivational interviewing skills. The Trust will instruct clinicians of the importance of documenting the reason behind decisions to change treatment, either medication or psychological and social intervention, so that not only is the decision recorded but the reasons underpinning the decision are recorded. Show less

The Safeguarding Adult Board (SAB) and the Trust at Board/leadership level to understand and define the relationship between adults at risk by reason of their mental health issues and those at risk within the broader definition and therefore oversight of … Read more The Safeguarding Adult Board (SAB) and the Trust at Board/leadership level to understand and define the relationship between adults at risk by reason of their mental health issues and those at risk within the broader definition and therefore oversight of adult safeguarding. The SAB to communicate and train relevant staff when that understanding has been reached and agreed. Show less

The SAB to debate and agree the extent to which adult safeguarding protocols and procedures are/should be the backstop for service failures elsewhere in the system.

The Trust will develop and implement a Care Pathway for Psychosis that will include the provision of family interventions in accordance with NICE guidance. As part of this the Trust will continue to promote and publicise the role of the … Read more The Trust will develop and implement a Care Pathway for Psychosis that will include the provision of family interventions in accordance with NICE guidance. As part of this the Trust will continue to promote and publicise the role of the Recovery Education Centre in supporting Carers and Families. Show less

The Trust will review the Care Programme Approach Policy including the specific requirements for Patients on Community Treatment Orders. The Trust will provide training to all staff of Community Mental Health Teams on the revised policy. The Trust will conduct … Read more The Trust will review the Care Programme Approach Policy including the specific requirements for Patients on Community Treatment Orders. The Trust will provide training to all staff of Community Mental Health Teams on the revised policy. The Trust will conduct an audit to ensure compliance with the revised policy within 12 months of the publication of this report to provide assurance that: holistic needs assessments are conducted; care plans are developed, monitored and reviewed; carers and service users are involved fully (where appropriate) in the process; primary care practitioners are sent copies of all relevant documentation; specific management plans are in place when a person is placed on a Community Treatment Order. Show less

All staff from Community Mental Health Teams will be trained in the revised Clinical Risk Policy. The Trust will review and ensure that clear guidance and protocols are in place with partner agencies to ensure that information pertaining to increased … Read more All staff from Community Mental Health Teams will be trained in the revised Clinical Risk Policy. The Trust will review and ensure that clear guidance and protocols are in place with partner agencies to ensure that information pertaining to increased risk and significant change is communicated in a robust manner and documented in the RiO record. The Trust will conduct an audit to ensure compliance with the revised policy within 12 months of the publication of this report to provide assurance that: risks are assessed at a frequency in accordance with Trust risk and CPA policy documentation; all identified risks are managed by comprehensive risk plans; relapse and crisis and contingency plans are updated in accordance with service user need and are communicated widely to all members of secondary and primary care-based care and treating teams. Show less

The Trust will ensure that each Community Mental Health Team has a Carer’s Lead to champion the needs of Carers and their families. The Trust will develop and implement a Care Pathway for Psychosis that will include the provision of … Read more The Trust will ensure that each Community Mental Health Team has a Carer’s Lead to champion the needs of Carers and their families. The Trust will develop and implement a Care Pathway for Psychosis that will include the provision of family interventions in accordance with NICE guidance. As part of this the Trust will continue to promote and publicise the role of the Recovery Education Centre in supporting Carers and Families. Show less

The Trust will work with the Local Authority to participate in a scoping exercise of housing need, reviewing need against current provision. The Trust will work with the Local Authority to use this information to develop a Mental Health Housing … Read more The Trust will work with the Local Authority to participate in a scoping exercise of housing need, reviewing need against current provision. The Trust will work with the Local Authority to use this information to develop a Mental Health Housing Strategy to include a strong focus on individuals with severe and ensuring mental health needs. Show less

The Trust will develop new Information Sharing Protocols for each Third Sector Organisation that jointly provides care with the Trust. These protocols to be audited for effectiveness as part of an ongoing audit process.

The Trust will review its systems for informing teams of new/revised Policies and Procedures. The Trust will develop a revised management and clinical supervision policy that takes account of adherence to new Policies and Procedures.

The Trust will ensure that all Community Mental Health Teams are instructed of the referral routes to the Crisis and Home Treatment Team and of the role that Duty Workers have in managing patients who require urgent assessment or intervention. … Read more The Trust will ensure that all Community Mental Health Teams are instructed of the referral routes to the Crisis and Home Treatment Team and of the role that Duty Workers have in managing patients who require urgent assessment or intervention. The Trust will ensure that all Service Users on Community Treatment Orders are discussed as a minimum on a monthly basis within Team Meetings and that a record of the discussion is recorded in the RiO system. The Trust will also review all Operational Policies and care pathways to ensure that referral and access to Crisis Team is made explicit to: primary care workers; secondary care workers; third sector workers; services users; carers and families. Show less