Investigation into the care and treatment of Ms L

Unit X must reassess its processes for identifying and managing clinical risk. This should address training in risk assessment and management, multi-professional input to risk assessment and improvements to documentation on interventions to reduce risk.

Unit X must review policies on observation and ensure that they comply with national guidelines.

Unit X should conduct a full examination of its governance of adverse incident reporting. This should address thresholds for incident reporting, examination of patterns and trends, feedback to staff and procedures for implementing action needed to reduce risk locally and across the organisation. Documentation on reporting of incidents may need to be amended as a result.

Unit X should, from time to time, audit completion of incident reports to ensure that appropriate information is captured and shared with the Care Commission and the Mental Welfare Commission.

Unit X must review their policy on restraint with regard to the status of patients where care plans include the regular or planned use of physical restraint or other measures which may lead to a deprivation of liberty.

Local authority A, NHS Board A and Unit X should ensure that there is appropriate and ongoing input at all case conferences and planning meetings for people who are placed out of area. There should always be a representative from the local authority who is carrying care management responsibilities for the case. This recommendation is also applicable to all local authorities and NHS Boards who place people out of area.

We note that the Care Commission had issued previous enforcement notices in 2006 to Unit X which addresses 4 of our 5 recommendations. The Care Commission should continue to review the service in respect of these recommendations

In continuing to implement “The Same as You?” the Scottish Government should review the need for regional or national planning to support people with learning disability whose needs for care and support are not presently being met on a local basis.