Independent Thematic Pathway Review: In a North West England Foundation Trust

Action is required to ensure evidence-based practice is delivered by the Trust, this to minimise the risks associated with less optimal care and treatment being delivered associated with poorer clinical outcomes. The Clinical Senate and Trust-based Practice Groups should:
1. Undertake a mapping review of the findings and conclusions of this report against the Trust’s newly embedded care pathways. This to ensure the care pathways cross-match with the areas identified for improvement as a result of this Investigation.
2. Undertake a selection of case study reviews against the standards proforma used for this investigation process. This will provide an early indication to evaluate the effectiveness of the new care pathways when mapped against the provision of basic building blocks of care’ issues.

The transformation process comprises a five-year strategic plan. At the time of writing this report the Trust and its partners had been working on service change for 18 months. Action is required to focus on the progress made to-date in order to minimise the risk of a reoccurrence of the access issues identified by this Review. The Trust, its commissioners, partners and stakeholders should:
1. Review the strategic plan to ensure that all of the identified areas for improvement identified in this report have been addressed and have been incorporated. Particular focus should be placed on access to community forensic services, substance misuse services, crisis intervention and recovery-based services.
2. Review progress in relation to implementation as set against the findings and conclusions of this report. A mapping exercise should be conducted to ensure there are no omissions in the strategic plan.
3. Review the costs (and other implications) of any additional service additions and changes that might be required.

During the Review process it was evident that multi-agency collaboration was improving and that there was a strong willingness for partnership working. What was not so evident was how the inputs of the past four years could be evidenced in a practical manner when it came to examining an actual Service User pathway (such as those for the Service Users in this study). Strategic thinking needs to be implemented ‘on the ground’ and in a practical manner to minimise the risk of service users receiving fragmented service provision. The Trust, its commissioners and multi-agency partners should consider:
1. Realigning all relevant policies and protocols to include: information sharing, safeguarding, MAPPA and collaborative working. Short information leaflets short be made available to facilitate usage.
2. Realigning incident investigation and lessons for learning work in order to promote a whole-systems learning and improvement approach.
3. Evaluating the findings of this Review report in order to understand whether the Service User experiences detailed within it could be mapped onto present day services. The question should be asked ‘are the problems identified with their pathways still a real possibility for other service users today’?

Steady progress against the findings and conclusions of this report appears to have been made by the Trust in conjunction with its multi-agency partners. In order to embed new processes, to minimise the risk of child and adult safeguarding issues going undetected and unmanaged, consideration should be given to the following:
1. Child and adult safeguarding policies and procedures need to be re-aligned between agencies – with particular regard to information sharing protocols.
2. In order to promote a culture where robust communication takes place the Trust and its multi-agency partners need to agree how safeguarding alerts should be made without relying so heavily on the use of emails.
3. There should be an examination of current safeguarding recording systems across all agencies (education, health, police, probation, Social Services). This to ensure that they align and all alerts and concerns are managed in a synchronised manner.
4. Child safeguarding training should be re-visited to also incorporate wellness and child developmental and psychological safety. A multi-agency and multi-disciplinary approach should be taken to this.
5. An evaluation of the findings of this report should be considered in order to understand whether the experiences of the service users in this review (and their families) could be mapped onto present-day service provision. The question should be asked ‘are the problems identified still a real possibility for other service users and their families today’?

In the here-and-now the Trust should examine the numerous findings contained within this report (and detailed in the Standards Proforma). A mapping exercise should be undertaken to minimise the continued risk of clinical service omissions and the subsequent potential for risk to service users and their families. The following should be undertaken.
1. A mapping exercise should be undertaken comprising frontline staff and those managers leading the care pathway and transformation agenda. The findings from this Review should be used as a discussion tool in order to assess how practical considerations and frontline service insights can be run alongside high-level strategic thinking and planning. This would also provide an evidence-based progress monitoring opportunity.
2. The Trust should review clinical supervision attendance, content, frequency and purpose. Clinical supervision should be aligned to the Trust’s clinical audit cycle and have a clear evidence-based focus. Competency-based training and supervision should be available for newly qualified staff and those returning to the workplace after a long break away from the workplace. Clinical supervision should make quite clear the responsibilities of each registered practitioner within the Trust to adhere to best practice policy guidance and how to raise an alert if it is not possible to do so.
3. The medical workforce should be provided with clear expectations about conduct, practice and adherence to both NICE guidance and local policy expectation. Expectations should be clarified and built into development and performance management processes. This process should make quite clear the responsibilities of each medical practitioner within the Trust to adhere to best practice policy guidance and how to raise an alert if it is not possible to do so.
4. The Trust should review its key clinical policies to ensure they align and that there are no omissions (e.g. safeguarding, clinical risk management, CPA and care planning). The Trust should also ensure its policies are easy to read, and where they comprise numerous pages (some are in excess of 80 pages) easy to follow. Flow charts and information leaflets are also be considered for ease of access and reading. The Trust should also ensure that template assessment documents capture all of the information required; especially in the areas of risk and safeguarding.
5. The Trust should review its ‘alert’ system so that frontline staff can raise concerns about anything (such as staffing levels, lack of training, ineffective documentation templates etc.) that might inhibit the adherence to either good or safe practice.

Whilst progress has been achieved with the introduction of RiO there are still several areas that need to be addressed in order to minimise the risks associated with poor professional communication. The Trust should ensure the points below are incorporated into its transformation agenda.
1. Discussions should be held with multi-agency partners to see if improved access to Service User information can be facilitated (see recommendations 3 and 4 above).
2. Process modeling in relation to practical multi-agency working should be considered as part of the transformation process. An analysis needs to be worked through regarding what multi-agency working actually means in practice and how it can be made to happen in real time on the front line.
3. Clinical Information gathering should be re-examined in relation to RiO-based templates, and other Trust-based documentation, to check for compatibility with Trust policy guidance. This should include risk assessment, safeguarding and care planning electronic templates.
4. The practice of ‘cut and paste’ should be strongly discouraged and form part of clinical supervision discussions, clinical audit activity and clinical policy guidance.
5. Additional support and training should be provided for those clinicians still struggling to navigate the new RiO system. Checks should also be undertaken to ensure historic information has been reliably transferred from the old system to the new.

The Review Team recognises the work that has been undertaken by the Trust over a period of years to improve its governance issues. However evidence suggests the organisation would benefit from a regular longitudinal care pathway review of selected cases managed by the Trust; this to understand better how policies and clinical guidance work together in the delivery of care and whether optimal care and treatment is being delivered in an evidence-based manner.
1. The Trust should conduct a review of selected case studies against the Standards Proforma used for this Investigation (or a bespoke one to address specific issues); this to be conducted as part of an annual audit cycle. This review should take a longitudinal stance and ensure that all systems, policies and clinical guidelines are working together in an optimal manner. This approach will highlight areas for service improvement and provide an early alert to systems that are under stress and not working in an optimal manner.

While the embedding process continues the Trust should consider monitoring its current practice on a regular basis and should ensure the following:
1. Terms of Reference are written on a case-by-case basis to ensure the basic building blocks of care are always reviewed as part of a quality assurance process.
2. Investigations should be supported by suitably skilled and trained staff who have protected time to complete the work.
3. Detailed investigation archives should be kept on a centralised Trust system designed for this purpose.
4. Treating Teams should have the opportunity to be interviewed and/or met with whenever possible during the course of an investigation. Emphasis should be placed on good investigation principles that support Trust staff to ensure their full engagement and maximise opportunities for learning. Recommendations should be developed with treating teams to ensure they are both relevant and achievable.
5. Duty of Candour principles and guidance should be made explicit in the Trust’s investigation policy guidance.