Recommendation
The Trust must ensure that NICE guidance for the care and treatment of patients with psychosis is adhered to, including specific reference to structured family education.
Recommendation
The Trust must revise their clozapine administration guidance to include the education of patients and families, and the management of risk if clozapine is stopped suddenly.
Recommendation
The Trust must ensure that community teams have structures and processes to ensure that the CPA policy is adhered to, and systems in place to monitor compliance.
Recommendation
The Trust must provide clarity about protocols and responsibilities with respect to responding to increased need for interventions, zoning, and the process for considering and effecting inpatient admissions from the community.
Recommendation
Standards for note keeping must be monitored by the Trust, to include how medical consultations are recorded.
Recommendation
When going through large-scale service changes, the Trust must ensure that risks to patient care are assessed, documented and mitigated.
Recommendation
Serious incident investigation reports must meet the timeliness standards expected by NHS England guidance.