1
Addressed to: Trust Board
Accepted
Link to recommendation 1
Recommendation · source text
Our team recommends that a Non-Executive Director be nominated to carry specific responsibility at Trust Board level to support dissemination of learning from incidents.
View response
A Non-Executive Director will be nominated to carry specific responsibility at Trust Board Level to support the dissemination of learning from incidents. A Non-Executive Director has been identified to carry specific responsibility for supporting the dissemination and learning from incidents. Completed Dec. 2020. Endorsed by the Board.
1
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 1
Recommendation · source text
Clinicians should make every effort to draw together the psychosocial circumstances and diagnoses of all service users. Whenever possible a full psychiatric history should be taken and used to construct a comprehensive diagnostic formulation. This should be recorded in full in the service user’s clinical record and used to inform care and treatment and all risk assessment and management plans. The Trust should: ensure that this expectation is embedded in all policy documentation; ensure formal mental state examinations are conducted; make training and supervision available to all clinicians to develop these skills further; ensure clinical audit builds diagnostic formulation into the annual review cycle.
2
Addressed to: Trust
Accepted
Link to recommendation 2
Recommendation · source text
Our team recommends that a care pathway be developed by the Trust for submission to the CCG to elaborate treatment and onward referral for patients with complex mental ill health and comorbid substance misuse. The purpose would be to ensure that it is clear to all Trust staff how and to whom to refer people who fail to reach the threshold for access to CGL (or `Change, Grow, Live’), the independent drugs and alcohol service for adults over 18 who live in the Borough.
View response
a) The SLaM dual diagnosis policy contains clear pathways for supporting people with substance misuse issues. These will be disseminated to all complex care services in Southwark, including updated contact details of dual diagnosis specialists. b) All teams in the complex care pathway have at least one dual diagnosis lead (champion) who has/will complete the level two training and be supported to attend bimonthly leads’ development forum. c) Monthly dual diagnosis clinical support sessions to be established for the complex care pathway, to be facilitated by dual diagnosis specialists and Senior Clinical Psychologist. a) The Trust promotes an approach that encourages staff to ask people about their drugs and alcohol use, no matter what organisation is contacted. Drug and alcohol care pathways have been circulated to complex care services, including contact details of dual diagnosis specialists. Completed Nov. 2020. b) All teams have at least one dual diagnosis lead that has completed the level 2 training and attends leads’ development forum. Completed Dec 2020. c) Monthly clinical sessions commenced in January 2021, led by dual diagnosis specialists and Senior Clinical Psychologist. Additional Information: 1) In order to increase the rates of drug and alcohol assessment and intervention: i- Drugs and alcohol assessment tools are easily accessible in the electronic patients’ journey system ii- Admission checklists include time frames for assessing drug and alcohol use iii- Pathways for the management of drug and alcohol use are easily accessible via the Trust intranet iv- A centralised data monitoring system provides real-time feedback to teams about rates of drug and alcohol assessment & intervention. 2) The Trust promotes an integrated treatment model whereby most service users will have both their mental health and substance misuse needs addressed at the same time, by one worker or team. In some cases however, MH and substance misuse services work collaboratively to meet service users’ needs. The Trust has joint working agreements with CGL, the local addictions service. 3) Local mental health and addictions interface meetings have been established and take place monthly. These provide a space for workers from both services to discuss better ways of working with dual diagnosis issues. 4) The trust has several dedicated dual diagnosis specialist roles that work alongside staff teams and support service users to access better dual diagnosis care. 5) The Quality Centre in SLAM now has a programme of work aimed at improving dual diagnosis care standards in the trust. This includes improving the quality and consistency of simple psychological interventions that can be delivered by all staff and increasing prescribing of relapse prevention and harm reduction medication.
2
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 2
Recommendation · source text
Guidelines should be developed to assist in the development of diagnostic formulations for Somali service users. The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular.
3
Addressed to: Trust
Accepted
Link to recommendation 3
Recommendation · source text
We recommend that the Trust provide training for staff working with patients with complex needs and co-morbid substance misuse problems. This should be designed to ensure that those staff can themselves provide support to such patients, and/or to ensure that they know how, and to whom, to refer.
View response
a) At least 60% of staff in the complex care pathway to complete the level one dual diagnosis course. b) At least two staff in each team in the complex care pathway to complete the level two training. a) Leaders have assessed the level of completion of the level one training within their teams and the baseline data is informing training targets. Completed Feb 2021. b) All teams have at least two staff that have completed the level two training. Completed March 2021. The Trust has a range of training and development opportunities for dual diagnosis: • A level 1 e-learning course teaches basic drugs and alcohol knowledge which provides an introduction to the nature of the relationship mental health and substance use. All registered, non-medical clinical staff are required to complete this course within 6 months of joining the Trust. • A level 2 course which provides the foundations for working with people with more complex needs. For example, it teaches staff how to support people build motivation for change, how to support people to reduce the negative impacts of use if they aren’t ready to stop. People with lived experienced are involved in the design and delivery of this course. • During the pandemic, several bite-size courses have been designed and are being delivered flexibly online to teams.
3
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 3
Recommendation · source text
The Trust should review its practice in relation to medical assessment and mental state examination. This will require a robust process that can be routinely assured by clinical governance mechanisms within the Trust.
4
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 4
Recommendation · source text
Clinicians should always conduct medication reductions in a systematic manner and guidelines should be developed to support all such decisions. The following should always be considered prior to medication reduction: the role medication has played in the maintenance of recovery; the service user’s mental health response to previous periods of non-compliance, reductions to, or changes of, medication; the service user’s levels of insight and willingness to seek help/engage when experiencing the first signs of relapse; the levels of support of from carers/friends who can be relied upon to support the service user if relapse occurs. The following should always be conducted prior to medication reduction: psychoeducation (service users and carers); a mental state examination; a risk assessment; discussion/liaison with the rest of the secondary care treating team and/or primary care.
5
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 5
Recommendation · source text
The Trust has a robust CPA policy. In order to maximise its effectiveness a more sensitive clinical audit tool should be developed to ensure adherence to formal CPA milestones - such as: care planning; risk assessment; implementation, monitoring and review of care planning; relapse prevention; primary care liaison. In addition the Trust should consider making these milestones more explicit during: staff induction; regular CPA training and development and updating programmes; clinical supervision.
6
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 6
Recommendation · source text
The RiO-based risk assessment should always be used by clinical teams who should ensure it is updated and comprehensive; all zoning discussions should be recorded formally. In order to support this the current Trust RiO format review should ensure RiO is fit for purpose. As part of the review the RiO system needs to take into account the requirements of clinicians in relation to accessing significant information and should be able to flag high risk service users and incidents in a simple ‘at a glance’ format.
7
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 7
Recommendation · source text
The Trust is establishing a revised programme for assessing and managing clinical risk. There appears to be a significant improvement. The Trust should audit the revised system six months following the publication of this report to establish: the quality of risk assessment and risk formulation; the quality of risk management, crisis and contingency plans; the quality and regulatory monitoring and review processes (in particular the zoning system); the effectiveness of professional communication and liaison systems (with a particular emphasis on that between primary and secondary care).
8
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 8
Recommendation · source text
The Trust should ensure that clinical risk policies make explicit the assessment and management arrangements required for vulnerable adults.
9
Addressed to: Gallions Reach Health Centre
Action Plan Published
Link to recommendation 9
Recommendation · source text
The Gallions Reach Health Centre should adopt a formal risk assessment process when making clinical decisions about patients with severe and enduring mental illness. This should be supported by secondary care (clinical expertise and care pathway support) and CCG input (peformance management).
10
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 10
Recommendation · source text
The Trust has established a new model of service delivery via Primary Care Plus. This appears to be working well. The Trust should audit the revised system six months following the publication of this report; this to be achieved in conjunction with the relevant CCGs. The audit should also ascertain GP and service satisfaction with the new arrangements.
11
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 11
Recommendation · source text
The Trust has fit for purpose policies and processes in relation to protecting vulnerable adults from abuse. However it is recommended that more explicit guidance is developed in relation to: service user on service user abuse; risk assessment and risk management of vulnerable adults which support detailed protection plans; explicit information about which agency leads for each service user (perpetrator and victim of abuse); criteria for police referral and intervention; the Trust risk assessment policy makes more explicit the actions required in relation to Vulnerable Adults.
12
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 12
Recommendation · source text
The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Guidelines should be developed in relation to the culture and identity of Somali people with reference also made to the additional impact of asylum seeker and refugee status on mental health and general wellbeing.
13
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 13
Recommendation · source text
The Trust should ensure that its current audit processes are reviewed so that they are sensitive enough to detect non-compliance in relation to recording clinical information to an appropriate professional standard.
14
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 14
Recommendation · source text
All known patients re-presenting to the Trust will have their archived files checked; if archived between 2005 - 2007, the records will be reviewed to determine whether: a core assessment was conducted at the point of record transition; the psychiatric history was transitioned from one system to the other; key risk information transitioned in an easily accessible format; current care and treatment is appropriate in the light of any identified historic context.
15
Addressed to: Oxleas NHS Foundation Trust
Action Plan Published
Link to recommendation 15
Recommendation · source text
In keeping with Recommendation 13 the Trust should revise its clinical audit tools to ensure they are sensitive enough to detect policy non-compliance. The Trust also utilise training and clinical supervision to reinforce the importance of policy adherence.
16
Addressed to: Oxleas NHS Foundation Trust and NHS England
Action Plan Published
Link to recommendation 16
Recommendation · source text
Following serious incidents involving homicide or suicide the Trust must make every effort to contact families with immediate effect. The Trust and NHS England should discuss how best this can be facilitated (in light of the new arrangements set out directly above) with the Metropolitan Police Service and ensure that dedicated senior officers are deployed within the organisation to maintain support and communication throughout the investigation process.