Mental Health Homicides Thematic Review – Quality Assurance Report (volume 1)

Continuing the work being done on co-producing activities such as training, recording, QI and widening the use of co-production wherever possible as this work seems to be improving the standards of training and record-keeping, as well as the experience of service users and carers.

Carrying out a clinical risk assessment and care planning re-audit as soon as conditions permit.

Assuring itself that clinical supervision is used to help staff integrate their learning into their daily practice and that improvements in performance follow.

Monitoring and reducing unwanted differences in the experiences of service users and carers in receipt of the Trust’s services which the Trust’s own data collection, the People Participation Group and our own five per cent sample of service users have identified.

Employing more systematic methods so the Trust can understand the ‘added value’ the resources put into education and training bring to its activities.

The Board of Directors should monitor the implementation of the CDS structure and the use of the Safeguard Serious Incident recording system (Ulysses) to assure itself that investigation management and implementation of action plans are consistent with Trust policies, processes and systems.

The Board of Directors should build upon the work already in place to assure themselves, their stakeholders and the wider public that learning from all recommendations is being fully embedded across the organisation in a timely manner. Currently and in the future, where there is Level 1 evidence, the Board should be expecting the Trust to move towards Level 2 compliance with recommendations; and likewise, where there is Level 2 evidence the expectation of Level 3 evidence should be made clear. If these are not appropriate, then the Trust should be transparent as to the reasons.

The Board of Directors should assure themselves that there are robust systems in place to provide evidence that actions have been implemented in a timely manner and in line with the requirements of each action plan.

The Trust should ensure that clinical staff have dedicated time for recording notes and record-keeping; that staff record the rationale for the clinical decisions they make and use risk assessment and formulation to inform relapse planning.

The Trust should investigate the feasibility of technological solutions to make it easier to complete records and improve productivity. This might include the use of voice recognition technology when recording on the electronic record system.

The Trust should consider developing a checklist of key requirements, based on the themes identified in this report, to be used in all CPA reviews.

When the Trust evaluates training and education, they should evaluate not only the learner experience but also the impact of the training, using a model such as Kirkpatrick: Level 1: Reaction (Staff enjoyed and engaged in the training) Level 2: Learning (Staff acquired the intended knowledge, skills and commitment from the training) Level 3: Behaviour (Staff apply what they learned back in the workplace) Level 4: Results (Achievement of organisational targets or goals as a result of the training).

The Trust should continue to act on its commitment to implementing the ‘Triangle of Care’ approach to involving carers in the care and treatment of service users. The Trust should aim to achieve membership of the national programme within 12 months.