Independent investigation: Sidney Waller, Manchester (2008)

The Trust should ensure that the revised CPA Policy is implemented robustly throughout the organisation. The implementation should include the monitoring of: continual clinical review, particularly with regards to the role of the Care Coordinator; the personalisation of the care … Read more The Trust should ensure that the revised CPA Policy is implemented robustly throughout the organisation. The implementation should include the monitoring of: continual clinical review, particularly with regards to the role of the Care Coordinator; the personalisation of the care plan; work with carers and carer assessments; 117 aftercare planning (where appropriate); the transfer of care and the communication that happens between teams when the transfers have taken place. Show less

Quality indicators must be monitored closely and it must be ensured that they are delivered in relation to CPA, governance, supervision and the model of care. It is recommended that a tailor-made audit be completed with the Assertive Outreach Service … Read more Quality indicators must be monitored closely and it must be ensured that they are delivered in relation to CPA, governance, supervision and the model of care. It is recommended that a tailor-made audit be completed with the Assertive Outreach Service to assess the service and the delivery of the outlined areas above. Quality indicators should also include care planning, care coordination and the delivery of safe, effective services and the recommendation is that the PCT monitor this within the Trust’s audit processes. Show less

The Trust needs to consider how best to work with staff during future internal investigations. The following should be considered as basic best practice by providing: a full stenography service for the interview process; a period for witness review and … Read more The Trust needs to consider how best to work with staff during future internal investigations. The following should be considered as basic best practice by providing: a full stenography service for the interview process; a period for witness review and amendment of transcriptions following an interview; an opportunity for witnesses to see any report sections that may be critical of their practice, prior to the report being finalised and circulated, so that factual accuracy can be confirmed; individual witness/team feedback should be considered if findings are critical; continued support and counselling services to be made available if required; learning and dissemination events that should focus on the learning and the required action plans. Care should be taken during these events not to allocate blame to individuals in a public forum. Show less

The Trust should develop some good practice guidance on how to involve carers and relatives in investigations, based on the good practice that occurred in this case.

The Trust should instigate quarterly review meetings to encompass the monitoring of care plans, which should: include a peer evaluation against agreed standards; ensure care planning, and the treatment and management of patients be informed and based on a comprehensive … Read more The Trust should instigate quarterly review meetings to encompass the monitoring of care plans, which should: include a peer evaluation against agreed standards; ensure care planning, and the treatment and management of patients be informed and based on a comprehensive risk assessment. Show less

In relation to risk management and risk assessment, the PCT will require assurances that all individuals have clear risk assessments and risk management plans in relation to Assertive Outreach and these are up-to-date and have appropriate reference to crisis management. … Read more In relation to risk management and risk assessment, the PCT will require assurances that all individuals have clear risk assessments and risk management plans in relation to Assertive Outreach and these are up-to-date and have appropriate reference to crisis management. The PCT will build this into performance management processes. Show less

The Trust should ensure that there is an appropriate level of adherence to policy and procedure through systematic audit processes. Where adherence is not happening, remedial action should be taken. The Trust will conduct clinical audits for CPA and risk … Read more The Trust should ensure that there is an appropriate level of adherence to policy and procedure through systematic audit processes. Where adherence is not happening, remedial action should be taken. The Trust will conduct clinical audits for CPA and risk assessment on the completion of the publication of this report that will: ensure clinical compliance across the entire service provision, e.g. completion of clinical records and maintenance of regular reviews; ensure the quality of the content of CPA and risk assessment documentation by conducting a randomised sampling across the Trust of 30 cases; revise existing policies and protocols if they are no longer fit for purpose; support the formulisation of training and development programmes for clinical staff to support appropriate practice. Show less

Clear performance targets and measurable outcomes need to be included in the monitoring and management of the Assertive Outreach Service. The PCT needs to address these within the routine monthly contract monitoring meetings and be provided with assurances that all … Read more Clear performance targets and measurable outcomes need to be included in the monitoring and management of the Assertive Outreach Service. The PCT needs to address these within the routine monthly contract monitoring meetings and be provided with assurances that all performance targets are being met. Show less

The Trust should develop a clinical guideline that would trigger a clinical case conference when the formulation of a service user’s needs are particularly complex or when there is clinical disagreement about how these needs should be met and managed. … Read more The Trust should develop a clinical guideline that would trigger a clinical case conference when the formulation of a service user’s needs are particularly complex or when there is clinical disagreement about how these needs should be met and managed. This guideline will: be developed in conjunction with Trust senior clinicians; be disseminated widely to all clinical teams; be monitored and reviewed in six month intervals for the first year of its implementation. Show less

The PCT must receive assurances in relation to the clinical and managerial supervision of all staff and this must be tied in with a robust audit process and an assurance process to demonstrate that the evidence is in place and … Read more The PCT must receive assurances in relation to the clinical and managerial supervision of all staff and this must be tied in with a robust audit process and an assurance process to demonstrate that the evidence is in place and meets all the requirements of supervision. Show less

The revised management arrangements for the Assertive Outreach Team should be reviewed to ensure they are working in line with the recommendations made by the Trust internal review. In order to ensure the success of the previous recommendation an audit … Read more The revised management arrangements for the Assertive Outreach Team should be reviewed to ensure they are working in line with the recommendations made by the Trust internal review. In order to ensure the success of the previous recommendation an audit should be conducted to evaluate progress made against: clinical record keeping practice; provision of adequate administration support; compliance with risk assessment and formulation and CPA expectation; implementation of the risk zoning system; amendments to the operational policy. Show less

The PCT must be given reassurances in relation to the use of the Mental Health Act (07), its appropriateness and in particular pay attention to evidence to monitor Section 117 aftercare to ensure that services are following individuals and that … Read more The PCT must be given reassurances in relation to the use of the Mental Health Act (07), its appropriateness and in particular pay attention to evidence to monitor Section 117 aftercare to ensure that services are following individuals and that individuals are not left at risk when moving through services. Show less

There should be a review of the model of care provided by the Assertive Outreach Team which should include a range of monitoring tools. This review should also examine the stated philosophy of care ensuring that clinical best practice issues … Read more There should be a review of the model of care provided by the Assertive Outreach Team which should include a range of monitoring tools. This review should also examine the stated philosophy of care ensuring that clinical best practice issues are held in balance with those of the service user’s wider social care needs. Show less

The PCT must be provided with assurances in relation to carer assessments and carer involvement and this will involve random audits in relation to carer assessments and family involvement, including user involvement in care planning and treatment.

Specific attention needs to be given to working with carers and listening to the voice of carers. The Trust needs to improve the mechanisms and prompts to practitioners in relation to carer involvement. The Trust needs to: review, and revise … Read more Specific attention needs to be given to working with carers and listening to the voice of carers. The Trust needs to improve the mechanisms and prompts to practitioners in relation to carer involvement. The Trust needs to: review, and revise accordingly, its carer assessment practice; provide clear policy guidance as to the responsibilities of clinical staff relating to the development and maintenance of carer assessments; provide active dissemination of best practice expectation to all clinical and social care staff; incorporate carer assessment compliance into the Trust audit cycle. Show less

In conjunction with the Mental Health Trust the PCT will consider the Assertive Outreach service delivery model and reassess this in relation to its compliance for policy implementation guidance and will consider this in relation to any transformation change programmes … Read more In conjunction with the Mental Health Trust the PCT will consider the Assertive Outreach service delivery model and reassess this in relation to its compliance for policy implementation guidance and will consider this in relation to any transformation change programmes to ensure that the service adheres to national and local policies and procedures; the PCT need to provide evidence to support this recommendation. Show less

The Trust has made significant alterations to its professional management and leadership structures. These arrangements should be reviewed in order to understand their effectiveness with particular regard to: clinical supervision practice, effectiveness and professional regulation; the implementation and development of … Read more The Trust has made significant alterations to its professional management and leadership structures. These arrangements should be reviewed in order to understand their effectiveness with particular regard to: clinical supervision practice, effectiveness and professional regulation; the implementation and development of professional leadership strategies; the integration of designated professional leaders within the Trust clinical governance system. Show less

The PCT will monitor the ongoing progress and implementation of all requirements and recommendations in relation to Assertive Outreach Services in their monthly monitoring meeting and report any issues to the Joint Commissioning Executive and the PCT Board where appropriate. Read more The PCT will monitor the ongoing progress and implementation of all requirements and recommendations in relation to Assertive Outreach Services in their monthly monitoring meeting and report any issues to the Joint Commissioning Executive and the PCT Board where appropriate. Show less

The Trust should ensure that any trends and patterns in relation to incidents, complaints or claims are examined for emerging themes and if there are performance issues, remedial action should be taken.

The PCT in collaboration with the Mental Health Trust should review the commissioning and provision of specialist services for people with Personality Disorder. This review should: consider the effectiveness of current Personality Disorder services against NICE and DH guidelines; consider … Read more The PCT in collaboration with the Mental Health Trust should review the commissioning and provision of specialist services for people with Personality Disorder. This review should: consider the effectiveness of current Personality Disorder services against NICE and DH guidelines; consider the accessibility of current Personality Disorder services against NICE and DH guidelines; ensure that current Trust policy and practice neither excludes nor disadvantages individuals with Personality Disorders; that robust training and clinical guidelines are made available for all those working in general adult psychiatry contexts to support the clinical management of service users with Personality Disorders. Show less