Independent investigation: Sharon Stokes, Exmouth (2007)

The Devon Partnership NHS Trust should undertake a review of its policies and practices to ensure that families and carers, where appropriate, are involved in assessment and care planning. The current CPA 2 Assessment should be revised to identify the expectation that families and carers are involved in assessment and care planning. This should provide information suitable for audit. The Devon Partnership NHS Trust should undertake an audit to establish whether families and carers are involved in an appropriate and timely manner. They might consider consulting carers directly as part of the audit and not rely exclusively on clinical notes. The Devon Partnership NHS Trust should look at best practice in involving carers exemplified elsewhere. The involvement of families and carers should routinely be monitored during supervision.

The Devon Partnership NHS Trust should establish, via audit or survey, that the referral routes into and eligibility criteria for the Mental Health services are clear and easily accessible, and advice is readily available to referrers.

Using both audit and regular supervision the Devon Partnership NHS Trust must ensure that its CPA policy and the guidance provided in Refocusing the Care Programme Approach – policy and positive practice guidance, (2008) are followed regarding the transfer of information when a client/patient is transferred between teams.

The Devon Partnership NHS Trust should draw up guidelines, in line with best practice, on case formulation. Amongst other things this should cover the importance of trait-like characteristic as well as more transient symptomatology, the involvement of the patient and his/her family/carers, and the regular reviewing of the formulation. In line with current policy formulations should be consonant with the recovery model and the promotion of well being. Where appropriate training should be provided. Compliance with the policy should be monitored/audited on a regular basis.

The Devon Partnership NHS Trust Clinical Risk policy should be reviewed. It should be brought more in line with the principles outlines in “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). The risk policy should 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 the identified risk needs to be conducted and a management plan developed. The Devon Partnership NHS Trust should ensure that staff understand when a comprehensive risk assessment is to be undertaken and apply this knowledge consistently. This might be achieved through either improvements in the policy document or in the associated training. The Devon Partnership NHS Trust‟s Risk Management policy should be structured to reflect the functions of the various teams e.g. Crisis Team, CMHT etc. The Devon Partnership NHS 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. The Devon Partnership NHS Trust needs to ensure that the individual and, where appropriate, his/her family or carers are meaningfully involved in the risk assessment and management planning. The Devon Partnership NHS Trust should ensure that its Risk Management policy is being adhered to through a programme of regular monitoring and audit. Risk assessment is a component of the Care Programme Approach (CPA) process and is to be included in management and clinical supervision. Random audits need to be carried out to support the annual audit plan. A service audit needs to be completed six months after the implementation of the revised policy to ensure that it is being consistently acted on.

The Devon Partnership NHS Trust should review the availability of psychological therapy service. The adequacy of the overall level of resourcing of this service with reference to current National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of mental health problems commonly encountered in secondary mental health services. How psychological therapy resources are allocated across services and functional teams. The timely access to psychological services. Access to psychological services for consultation, advice and support.

The Devon Partnership NHS Trust should ensure that its policies and practices relating to care co-ordination conform to the standards identified in Refocusing the Care Programme Approach – policy and positive practice guidance, (2008). It should ensure that its operational policies and CPA policies are clear as to the allocation of a care co-ordinator. It must ensure that care co-ordinators have appropriate training. It must ensure that patients are not retained in the Well-Being and Access team and provided with “informal” or ad hoc care co-ordination because of a shortage of resources in the Recovery Team.

Following the introduction the electronic record system RiO, the Devon Partnership NHS 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; information is appropriately cross referenced; the quality of clinical notes is of an acceptable standard and complies with best practice guidance and professional standards.

The Devon Partnership NHS Trust must 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 a professional standard during clinical supervision Random audits of clinical case files should be conducted across all clinical teams to ensure correct ordering and storage of clinical records.

Clear concise Operational Policies should be developed for each functional team to enable staff to understand their core function and responsibilities and the function of their team. These should include reference to core policies such as the Care Programme Approach (CPA) and key Clinical Practice Standards. Operational service managers need to develop a core operational policy for the area they manage identifying the age range of the population to be served, the 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 and eligibility criteria, assessment methods, liaison with primary care and 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 NICE guidelines. A mechanism for the disseminating of 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 Devon Partnership NHS Trust should: review its strategies for engaging its staff; review the efficacy of its dissemination strategies; involve staff in identifying the likely impact of new initiatives; put in place clear management of change strategies.

The implementation of the Clinical Practice Standards and the Practice Quality Audit needs to be strengthened across the Devon Partnership NHS Trust. Clinical audit participation needs to be developed through: being a standing item on all 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 Devon Partnership NHS Trust, such as Coaching and Patient Safety Officers need to be targeted at those teams that struggle to complete the audit cycle. Clear timescales need to be incorporated into the annual audit plan to enable individual practitioners and teams to manage their time.

The Devon Partnership NHS Trust needs to review its Serious Untoward Incident (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 Devon Partnership NHS Trust; greater clarity about the involvement of victims‟ and perpetrators‟ families.