Independent investigation: William Moss, Newquay (2007)

An audit is conducted within the high risk/high needs services of the Trust including forensic, assertive outreach and eating disorders services; this should take place alongside the current dip sample audits carried out by the Care Process Redesign Group to ensure that: the CPA process is clearly delineated within the clinical record as to when a CPA review or CPA meeting has taken place; care plans are up to date; care plans do not contain information that is out of date; consideration has been given to meeting the needs of the individual in a holistic manner. The results of these audits should be reported to: o the service line leads for actions/developments and areas of improvement; o the Clinical Effectiveness Strategy Group which reports to the Risk, Quality and Standards Committee for the overall governance and monitoring.

there is a multi-agency review of the process for registering an unmet need and a clear policy as to how unmet needs are to be addressed; this review should include Cornwall Council and its relevant departments, in particular Social Services and Housing Departments, and other relevant agencies; this review should be placed within the context of local and National Social Inclusion initiatives; it should be informed by the recovery and well-being models of care and service provision.

The CPA policy and the Clinical Risk Policy are reviewed to ensure: CPA documentation is completed in parallel to the MAPPA process for service users subject to MAPPA; clear criteria are established on a case by case basis for re-referral into the MAPPA process and recorded within the CPA documentation; a CPA meeting is held within four weeks for all patients who have been deregistered from the MAPPA process; a CPA meeting should be held earlier than four week post deregistration: o when a patient is deregistered against the advice of his/her care co-ordinator; o where a pre-MAPPA, CPA and risk review did not occur; o where needs change rapidly after de-registration; prior to MAPPA meetings a structured assessment of risk and needs should be completed.

Cornwall Partnership NHS Foundation Trust should undertake a further review of its Section 117 policy and audit of practice to consider the issues raised in this case. This should be incorporated within the Trust’s clinical governance and performance management arrangements. It should identify how awareness of these issues will be disseminated and how Section 117 awareness can be effectively included in CPA training.

The Strategic Health Authority needs to assure itself that Cornwall Partnership NHS Foundation Trust and the Cornwall and Isles of Scilly PCT monitor that Section 117 is working for the patients under their care and that local services have mechanisms for: identifying patients subject to Section 117; hold CPA/Section 117 care planning meetings to develop care packages for patients covered by Section 117; hold similar meetings to review the progress and care and agree discharge plans for patients who no longer meet the criteria for Section 117.

Local Authorities are jointly responsible with PCTs for the provision of aftercare services under Section 117. Local Authorities therefore need to ensure that social workers, housing officers and others as necessary are available and participate in CPA/Section 117 care planning meetings. Local Authorities need to ensure that any services identified as necessary for a particular patient on Section 117 are provided when the provision of those services are within its responsibilities; Housing Authorities need to take a proactive role in the provision of appropriate accommodation to people who are subject to Section 117. Decisions to end the Section 117 status of a patient are joint Health and Social Service decisions. Local Authorities must therefore ensure that social workers and relevant others are available and participate in CPA/Section 117 meetings to review and if appropriate discharge patients.

The Cornwall and Isles of Scilly Multi-agency Safeguarding Adults Policy is reviewed and audited to consider the interface for: young People who are leaving the care system and on a care order; young people with a diagnosed serious mental illness; people who present with self harm.

in line with best practice and CPA guidance, and the requirements of Section 117 of the Mental Health Act (2007) there should be a clear care plan and risk assessment in place for each service user moving to the catchment area; the receiving team has a responsibility to ensure that an appropriate care plan is put in place; when there is a lack of clarity as to where the individual will be living or which team will provide his/her care the Avon and Wiltshire NHS Partnership Trust should put in place clear guidelines to identify who will take the lead in coordinating the individual care; when an individual is being transferred from a secure unit the Avon and Wiltshire Partnership NHS Trust Forensic Services should play a leading role to ensure that an appropriate care plan is in place and appropriate risk assessments have been carried out and risk management plans put in place; if a service user is transferred to the catchment area from an in-patient facility outside the catchment area the individual should be seen within seven days in line with best practice on discharge; protocol should be agreed with appropriate agencies to ensure that the individual receives a co-ordinated package of care. This is particularly the case for: o young people age between 16 and 21 years; o those being discharged from secure accommodation/services; the Avon and Wiltshire NHS Partnership Trust should ensure that it has in place appropriate audit and other monitoring mechanisms to ensure that these policies and protocols are being effectively implemented.

the Avon and Wiltshire NHS Partnership Trust should review its Section 117 protocols and audit cases against the identified standards. This should be incorporated within the Trust’s clinical governance and performance management arrangements; the Avon and Wiltshire Partnership NHS Trust should disseminate the revised protocol to all relevant Trust staff ensuring that they understand both the protocols and the principles underpinning these: “Aftercare is a vital component in patients’ overall treatment and care. As well as meeting their immediate needs for health and social care, after-care should aim to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital”;15 the Avon and Wiltshire Partnership NHS Trust should undertake an audit to ensure that the revised protocols are being effectively implemented.

The Trust to conduct a risk assessment audit of its Bristol-based Forensic services to ensure: clinical compliance to policy and procedure; that each service user has a dynamic plan based upon a current and comprehensive risk assessment; that each service user has a crisis and contingency plan; that all documentation is shared appropriately with the service users clinical network; to ensure that service users and carers are involved and communicated with as appropriate.

The Avon and Wiltshire NHS Partnership Trust should undertake an audit of completed discharge plan to ensure that the identified standards are being met. The Trust should incorporate a discharge planning audit into its routine clinical governance and performance management arrangements.

The Avon and Wiltshire NHS Partnership Trust should review and audit its prescribing practices, especially with respect to the prescribing of prophylactic and maintenance doses of medication and the regimen for withdrawing medication, to ensure that these comply with Best Practice Guidance

Service Users with complex diagnoses accompanied by challenging behaviours and personality disorders should be subject to a robust mental state examination and be in receipt of a coherent management plan in keeping with NICE guidance for personality disorder.

The Avon and Wiltshire Partnership NHS Trust should undertake regular and routine audits of both the frequency and the quality of supervision. This should be incorporated within the Trust’s clinical governance and performance management arrangements.