Independent investigation: Terrance Hall, Weston Super Mare (2008)

Given the changes in access to Specialist Drug and Alcohol Services the Trust should put in place mechanisms to demonstrate and monitor this improvement. • The Trust should develop a reliable and valid methodology for monitoring: o access to the service; o commencement of treatment. In the first instance this methodology might collect performance activity in relation to identified goals on an episodic basis. This should be done as a matter of some urgency. The Trust should then look at how it might develop the monitoring of access to and treatment by this service on a more continuous basis.

Commissioners should ensure that they are commissioning services in a manner that is consonant with the latest NICE Guidance on the commissioning of alcohol services253

Given the initiatives and service improvements that have been put in place in the Specialist Drug and Alcohol Services the Trust should put in place mechanisms to assure itself and its commissioners that: • all relevant staff undergo appropriate training which is updated on a regular basis; • staff receive appropriate support and regular supervision to enable them to implement their newly acquired skills in a consistent manner. The Trust should put in place regular monitoring, including regular audits, to assure itself and its commissioners that: • assessments are undertaken and care and risk management plans are reviewed both on a regular pre-determined basis and in response to changes in the services user’s life; • care plans include a clear formulation: o enabling those providing care and treatment for the service user to have a common understanding of his/her needs; o which provides the basis for treatment interventions; • there is appropriate multi-agency involvement in assessment and care and risk management planning; • care and risk plans are disseminated in a timely manner.

The Specialist Drug and Alcohol services have put in place a number of initiatives relating to the availability and quality of psychological interventions. The Trust should put in place mechanisms, including regular audit, to assure itself and its commissioners that: • all relevant staff receive appropriate training to deliver these interventions and that this training is updated on a regular basis; • all staff receive regular supervision at an identified minimum frequency; • the psychological interventions delivered are of a consistent and acceptable quality; • the need for psychological intervention is assessed for each individual on a regular basis and that delivery of this is included in an agreed care plan; • where a service user has need of psychological assessment or intervention which is beyond the skills of the care worker or clinical team this need is met by ensuring that the individual is referred to appropriate services for this aspect of their care.

The Trust, in conjunction with its partner agencies and commissioners, should ensure that the local Children’s Safeguarding policies and procedures are being implemented in a consistent manner. It should ensure that: • assessments and risk assessments routinely identify contact with and concerns regarding children; • this information is communicated to relevant agencies in an agreed and timely manner. The assurance mechanism should look at both the quality of the assessments and any related plans and not merely that these are being undertaken.

The Specialist Drug and Alcohol Service has put in place a number of initiatives to improve the likelihood that carers and significant others are involved in the assessment of the service user’s needs and the planning of his/her care. The Trust should put in place clear deadlines and reporting and monitoring mechanisms to assure itself that the Specialist Drug and Alcohol Services Quality Improvement programme is being realised in a timely manner. While the Quality Improvement programme is being implemented the Trust should establish priorities to ensure that, for example, carers and families are informed of relevant aspects of the risk management plan and have up to date information on how to access the Specialist Drug and Alcohol Service, or other relevant services, in times of crisis. It would be good practice to involve families and carers in the reviewing and monitoring of their involvement in risk assessment, risk and crisis management planning and access to relevant information.

Given the improvements that the Trust has put in place in SDAS it should now put in place mechanisms to assure itself that: • there is effective and timely communication between its clinical staff and other relevant agencies; • other agencies and professionals who are, or ought to be, involved in the support, care and/or treatment of a service user are routinely identified as part of the service user’s assessments; • the other relevant agencies are routinely, appropriately, involved the assessment of the service user’s needs and any risk s/he poses and in the planning of care; • there are mechanisms in place which are being used in an effective manner to ensure that support, care and treatment are being delivered in a coherent and co-operative fashion.

The Trust should put in place mechanisms to ensure that its revised Dual Diagnosis policy is being implemented in a consistent manner; it should conduct audits to ensure that the mental heath needs of those individual’s under the care of the Specialist Drugs and Alcohol Services are being effectively identified and addressed in a timely and effective manner; it should ensure that: • it is clear who, in the clinical team, is responsible for identifying that the service user’s mental health needs are identified and met; • a mechanism is in place to ensure that this function is carried out in an effective and consistent manner.

Bristol PCT and North Somerset PCT should ensure that they have in place policies and procedures which ensure that: • they are informed of any serious adverse incident in a timely manner; • standards for the quality and time scale of investigations are in place; • the role of Bristol PCT and North Somerset PCT in assuring that the recommendations of the investigation are translated into meaningful and effective action plans which are consonant with the quality standards identified for the commissioned services, is identified; • the role of Bristol PCT and North Somerset PCT in assuring that the action plan is implemented in a timely manner, is identified; • all relevant staff in Bristol PCT and North Somerset PCT are aware of the policy and protocol; • information concerning serious adverse incidents is fed into the governance and quality and performance monitoring structures of the PCTs in such a way that they can assure themselves that local mental health services are safe and of an acceptable quality; • they conduct regular assurance exercise, including audits, to assure themselves that their policies are being implemented in a consistent and effective manner.