Independent investigation: Steven Janczuk, Arlesey, Beds (2006)

The Trust should demonstrate that they have put in place a suite of measures to ensure that all staff are aware of the importance of the therapeutic relationship in allowing an effective care plan to be delivered. This should include ensuring that supervision discussions include a review of the therapeutic alliance between each service-user and member of staff. The Trust should put in place measures to provide assurance that a therapeutic alliance between service-users and practitioners is being achieved in practice. These measures will need to draw on a range of data sources. The Trust should ensure that Care Coordinators are provided with clear guidance on the action to take where they identify that a therapeutic relationship has not been adequately developed or sustained, including the requirement to develop a time-bound plan of action when appropriate. The Trust should collate 'Did Not Attend' (DNA) data on a quarterly basis for all service-users on CPA. The Trust should also consider monitoring the number of different psychiatrists and care coordinators a service-user sees over a quarter to minimise service fragmentation.

Robust and timely supervision needs to be provided to all nursing, social work and clinical staff. Compliance with this activity should be monitored on a quarterly basis, and the results should be communicated formally and informally across the Trust. The organisational causes (for example, workload) of significant non-compliance should be identified and addressed.

The Trust should continue to develop and refine a training management system, covering all staff, that builds in mandatory training requirements with refresher courses and other courses around key themes. The system should prompt the staff member and their line manager in advance of a training requirement, and should record attendance and monitor compliance levels. The Trust should monitor mandatory and refresher attendance by staff on a quarterly basis.

The Trust should continue to work on the cultural and organisational issues to increase the sustainability of the above recommendations. The Trust should therefore consider undertaking a safety culture audit to identify further areas for improvement within the next 12 months. Such an audit should take into account service-user, carer and staff perceptions, and include, for example, measurement of: • The culture of involving carers in management plans and decision making; • Risk assessment processes; • Processes for handovers between care coordinators and cross agency communication; • Systems in place for managing appointment ‘Did Not Attend’ (DNAs) and disengagement of service-users, and for monitoring fragmentation of contacts between healthcare professions and across professional disciplines.

The Trust should ensure that adequate liaison arrangements are in place between the providers of addiction services and Community Mental Health Teams (CMHTs) to ensure that a holistic view is taken of a service-user’s alcohol and/or drug use, and that this is used to inform the risk assessment

The Primary Care Trust (PCT) should put in place measures to assess the effectiveness of the interactions between Primary and Secondary care for service-users on CPA, for example by auditing the attendance of GPs at service-user’s CPA review meetings held by the Trust. The PCT should use the results of such assessments to drive improvements.

The Trust should coordinate SMART and targeted strategies to strengthen the support staff receive following serious untoward incidents, including participation in an external, independent investigation.

The Trust should communicate with the victim’s and service-user’s families immediately following an incident to offer condolences, explain the Trust’s investigative processes and where appropriate offer an apology and provide support options. The Trust should consider, where contact with the family has not been established, that action is taken to apologise and retrospectively offer support services to the family.

The Trust should seek to determine whether the current arrangements to internally investigate serious untoward incidents would identify whether a child or other vulnerable witnesses were present, in order to determine whether psychological support should be provided by the Trust.