Recommendation
The Trust should provide training and develop guidance to ensure that there is a greater focus on, and value attached to, the building of a therapeutic relationship between inpatient and community staff and their service users.
Recommendation
The Trust should test for effectiveness their implementation of the internal investigation’s recommendations, and ensure that the new model of care is operating fully and effectively by conducting some qualitative audits of the whole care pathway including for someone with …
Read more
The Trust should test for effectiveness their implementation of the internal investigation’s recommendations, and ensure that the new model of care is operating fully and effectively by conducting some qualitative audits of the whole care pathway including for someone with personality disorder.
Show less
Recommendation
The Trust should ensure that any reports from service users about violent behaviour are fully logged in the patient’s notes and reported in detail to the police.
Recommendation
The Trust should ensure that, when there are reports of actual or possible violence, a detailed history is compiled and an appropriate risk assessment tool is used.
Recommendation
The Trust should ensure that their risk management strategy outlines a clear link between risk assessment, care planning, care co-ordination and the application of CPA.
Recommendation
The Trust should ensure that any requests for a specific medication are fully explored with the service user and the possibility of dependency is considered and discussed.
View response
• Quality Practice Alert to be shared with medical staff emphasizing the need to explore addiction issues Steve Morgan, Director of Patient Safety May 2015 That prescribing clinicians will have an increased awareness of dependency issues that may be otherwise masked.
• Drug and Therapeutic Committee asked to consider including this issue in its training programmes Lee Knowles, Chief Pharmacist June 2015 The training programmes are amended to reflect the need for staff to explore dependency issues.
• Risk assessment guidance to be checked/amended to ensure it requires staff to consider dependency issues and the affect on their mental health and safety Jane Boland, Project Lead June 2015 Risk processes will include dependency on illicit substances and alcohol and where necessary be incorporated into risk management plan
• To be included in the new Dual Diagnosis Training sessions to be delivered directly into Clinical Areas by Dual Diagnosis Specialist Practitioners . Steve Morgan, Director of Patient Safety May 2015 The training programmes are amended to reflect the need for staff to explore dependency issues.
• Addictions services will be actively involved in considering their knowledge and accountability re patients with a mental illness and a dual diagnosis and how they relate with adult mental health services Dr Al-abasi, Clinical Lead September 2015 Addictions services have clear guidance that directs how staff relate to adult services when they are working with a patient with a mental illness and a dual diagnosis and how they relate with adult mental health services
Recommendation
The Trust should consider whether, when a service user is known to have a particularly peripatetic lifestyle and there are significant concerns about risk, contact should be made with appropriate mental health trusts to share information (with due regard to …
Read more
The Trust should consider whether, when a service user is known to have a particularly peripatetic lifestyle and there are significant concerns about risk, contact should be made with appropriate mental health trusts to share information (with due regard to guidance on confidentiality).
Show less
View response
• Risk assessment guidance to be checked/amended to ensure it considers the need for staff to liaise with other agencies to gain or share information about involvement in care • Updates/amendments to be provided when required. Jane Boland, Project Lead June 2015 Risk assessment guidance will include direction for staff regarding the importance of liaising with other services
• A quality Practice Alert will be sent to all Clinical Teams emphasizing the importance of sharing information with neighbouring organisations where appropriate. Director of Patient Safety June 2015 Staff are aware of the need to consider the stability of a persons living accommodation and potential involvement of other services
• Quality Practice Alerts will be audited on a bi-annual basis to ensure that they are an effective way of disseminating information and changing practice. This issue will be used as one of the QPAs that are audited as part of a percentage process Director of Patient Safety October 2015 The efficacy of using Quality Practice Alerts will be reviewed and amendments made where coverage or effectiveness are challenged
Recommendation
The Trust should ensure that, when there has been reported violence to a family member, there should be robust efforts to establish some contact with the victim and other family members to discuss the issue, and to consider an assessment …
Read more
The Trust should ensure that, when there has been reported violence to a family member, there should be robust efforts to establish some contact with the victim and other family members to discuss the issue, and to consider an assessment of carers’ needs, in line with Trust 1’s CPA policy.
Show less
Recommendation
The Trust should review progress made against the internal review’s recommendation for mental health staff to assist service users to register with a local GP, and establish systems for effective communication between GPs and mental health services regarding patient care.
Read more
The Trust should review progress made against the internal review’s recommendation for mental health staff to assist service users to register with a local GP, and establish systems for effective communication between GPs and mental health services regarding patient care.
Show less
Recommendation
The Trust should revise their drug detection policy to include procedures around the use of drug detection dogs, and specifically a process for making service users aware that drug detection dogs may visit acute inpatient areas.