Independent investigation: Wendy Pashley, Rotherham (2006)

How the Trust treats third party information, especially where it relates to the potential for risk behaviour in a service user, needs to be debated within the Trust’s governance and risk management groups. It is not acceptable for staff to be expected to use their individual judgment on such an important and sensitive issue. Subsequent to this: clear guidance on the use of third party information must be incorporated into the operational policies of all services within the Trust, the issue of managing third party information needs to be incorporated into the Trust’s CPA and risk assessment workshops, consideration should be given to including the issue of the management of third party information in the local team based induction process for new staff members.

Exploring safeguarding issues, both in relation to children and adults, can be challenging. The Trust needs to introduce a section on safeguarding children and adults, to include domestic violence (emotional, verbal and physical) as part of the standardised screening and full risk assessment paperwork.

Although it is not uncommon for mental health service users to have a higher alcohol intake than is recommended, the Trust needs to develop a more proactive approach to the education of its service users about excessive drinking and also information about local support groups if the service user and/or family members and carers are concerned about the service user’s alcohol intake. Standard information that could be provided to service users can be found at : http://www.alcoholicsanonymous.org.uk/newcomer/pack.shtml Information that could be provided to families and carers is at: http://www.al-anonuk.org.uk/alanon/index.asp The Trust could also identify local AA meetings near to its inpatient units, make contact with the local AA group representatives and make an offer of the use of Trust premises for free for their meetings. This would make open AA meetings easily available to staff who want to understand alcoholism and alcohol abuse more, and also make attendance easier for inpatients who accept that their drink habits are damaging their lives.

As part of the Trust’s ongoing commitment to improving its approach to, and standard of client focused risk assessments, the Trust needs to commit to a regular audit of risk assessment documentation that assesses the quality and clinical usefulness of what has been documented. As highlighted on page 20 of this report examples of the types of issues this Investigation Team would expect to see addressed within such an audit are: The frequency with which identified risk behaviours are appropriately described within the current risk assessment documents. For example are the antecedents to the behaviours documented and the previously known consequences of these behaviours? The frequency with which a full risk assessment has been undertaken where indicated on the initial brief assessment. Whether risk assessments are dated and the author(s) of the document is /are clearly documented. The frequency with which a risk management and risk relapse prevention plan is created with service users, and the quality of documentation contained within these plans. Whether staff only use ‘pre-printed’ care plans, or whether there is evidence of individualised care planning In the inpatient admission paper work and the initial medical assessments, how often is information relating to pre-morbid personality recorded?

As part of the Trust’s ongoing commitment to improving its approach to, and standard of client focused risk assessments, the Trust should consider conducting a survey of all of its staff to find out: what works well in the risk assessment process; what elements the staff feel need to be improved and how this could be achieved; and how valuable the staff find the clinically focused risk assessment currently provided, and where it is and is not meeting their needs.

The Trust must produce a detailed project plan with realistic timescales attached to it for the SHA and PCT in relation to its intended developments in relation to its intention to undertake a contemporary review of its risk assessment and CPA paperwork to assess its compliance with current national standards and best practice guidance; implement a common risk assessment process across all of its services; and explore options for more responsive approaches to assessment based on need (including safety), integrated working, communication, effective record keeping and the effective supervision of staff undertaking these assessments.

The service manager for the CRHT recognises that their current service profile document is out of step with the way the CRHT currently operates. He has made a commitment to updating this service profile, incorporating the feedback contained in this report by the end of November 2008.

The thorny issue of how to manage inter-team referrals where the service user is unaware of the referral needs to be properly debated within the context of good governance. It does not seem to be sufficient that the CRHT simply refuse to accept such referrals. Note The assistant directors of in-patient and community services must ensure that this issue is properly addressed through the adult services governance arrangements and ensure that all in-patient ward managers and CMHT leaders and consultant psychiatrists are aware of the outcome of how referrals to teams such as the CRHT are to be managed where the service user and/or family are unaware that a referral has been made.