1
Addressed to: The health board
No Response Published
Link to recommendation 1
Recommendation · source text
The health board must ensure that full and comprehensive mental health assessments and physical health assessments are always being completed in a timely manner, in line with the Mental Health (Wales) Measure 2010 under the Mental Health Act 1983.
2
Addressed to: The health board
No Response Published
Link to recommendation 2
Recommendation · source text
The health board must ensure that when staff complete patient risk assessments, the method should reflect the requirements set out within national guidance.
3
Addressed to: The health board
No Response Published
Link to recommendation 3
Recommendation · source text
The health board must ensure that mental capacity assessments are undertaken by relevant staff, which reflect the criteria set within the relevant legislation and national guidance.
4
Addressed to: The health board
No Response Published
Link to recommendation 4
Recommendation · source text
The health board must ensure that carers assessments are routinely offered and where required, undertaken for relevant individuals, in line with The Mental Health Act 1983 Code of Practice.
5
Addressed to: The health board
No Response Published
Link to recommendation 5
Recommendation · source text
The health board must ensure that patient care and treatment plans:
a) Reflect the requirements set out within the Mental Health (Wales) Measure 2010.
b) Are routinely signed and dated following review or update, to allow for the identification of relevant staff members.
6
Addressed to: The health board
No Response Published
Link to recommendation 6
Recommendation · source text
The health board should review the ward round structure and arrangements in place, to ensure that sufficient time is permitted to adequately discuss all patients.
7
Addressed to: The health board
No Response Published
Link to recommendation 7
Recommendation · source text
The health board must ensure that arrangements are in place to enable prompt communication and information sharing between inpatient and community teams during the discharge process.
8
Addressed to: The health board
No Response Published
Link to recommendation 8
Recommendation · source text
The health board must ensure that all relevant staff complete appropriate training for timely and effective communication and information sharing relating to the discharge process.
9
Addressed to: The health board
No Response Published
Link to recommendation 9
Recommendation · source text
The health board must ensure that minutes are completed for inpatient MDT meetings. This is to ensure an accurate record of attendance, key discussion points and agreed actions are available to all staff.
10
Addressed to: The health board
No Response Published
Link to recommendation 10
Recommendation · source text
The health board must provide an update to HIW on the action taken and outcome, to address the administrative support issues within POWH mental health unit.
11
Addressed to: The health board
No Response Published
Link to recommendation 11
Recommendation · source text
The health board must ensure that patients and, where appropriate, their family, carer and/or advocate are able to provide their views to inform inpatient care and discharge planning. These views and any subsequent actions should be recorded within the patients’ notes.
12
Addressed to: The health board
No Response Published
Link to recommendation 12
Recommendation · source text
The health board must ensure that crisis or contingency plans and relapse indicators are routinely developed and documented as part of the discharge planning process. This information should be discussed, agreed and shared with relevant teams, the patient and where appropriate, their family or carer, prior to or on discharge.
13
Addressed to: The health board
No Response Published
Link to recommendation 13
Recommendation · source text
The health board must ensure that patient records are routinely being updated by staff, to detail what, when and to whom information is being shared with as part of the discharge process.
14
Addressed to: The health board
No Response Published
Link to recommendation 14
Recommendation · source text
The health board must ensure arrangements are in place to mitigate against the risks associated with expedited patient discharges, ensuring that timely information is shared with relevant community teams.
15
Addressed to: The health board
No Response Published
Link to recommendation 15
Recommendation · source text
The health board must provide an update to HIW on the actions taken or are outstanding, to mitigate the risks associated with the availability of inpatient beds.
16
Addressed to: The health board
No Response Published
Link to recommendation 16
Recommendation · source text
The health board should consider the benefits of reinstating the huddle meetings to help manage the issues with patient flow in and out of the inpatient units.
17
Addressed to: The health board
No Response Published
Link to recommendation 17
Recommendation · source text
The health board must consider the causes and subsequent options to minimise the number of delayed discharges occurring within inpatient mental health wards.
18
Addressed to: The health board
No Response Published
Link to recommendation 18
Recommendation · source text
The health board must ensure that the management and storage of paper patient records used within POWH inpatient mental health unit, and across the health board as a whole, is reviewed:
a) to ensure a standardised approach to allow for more efficient access to patient information;
b) to maintain the security of patient data and clinical information.
19
Addressed to: The health board
No Response Published
Link to recommendation 19
Recommendation · source text
The health board must continue to provide HIW with updates on the plans to implement the unified patient clinical records system. This must also include consideration for its inpatient and community services for Child and Adolescent Mental Health Services across the health board.
20
Addressed to: The health board
No Response Published
Link to recommendation 20
Recommendation · source text
The health board must implement actions to mitigate against risks associated with staff access to clinical records in different teams to patient information in a timely manner.
21
Addressed to: The health board
No Response Published
Link to recommendation 21
Recommendation · source text
The health board must ensure that discharge letters provide sufficient information to patients and where appropriate family or carers, to help manage patient care following discharge. Where applicable, this should include information on the patients’ rights to self-refer to the service, in line with the Mental Health (Wales) Measure 2010.
22
Addressed to: The health board
No Response Published
Link to recommendation 22
Recommendation · source text
The health board must ensure that discharge letters are sent to patients, family, their GP and other applicable services within 24 hours of their discharge date. This should also be documented within the relevant patient records.
23
Addressed to: The health board
No Response Published
Link to recommendation 23
Recommendation · source text
The health board must ensure that discharge summaries are completed and sent out to the patients’ GP and other relevant services involved in the post discharge care and treatment, within a week of the discharge.
24
Addressed to: The health board
No Response Published
Link to recommendation 24
Recommendation · source text
The health board must ensure that patients are followed up within three days post discharge from mental health units, in line with national guidance.
25
Addressed to: The health board
No Response Published
Link to recommendation 25
Recommendation · source text
The health board must take action to manage the risks of insufficient staff numbers and temporary staffing needs on inpatient mental health wards.
26
Addressed to: The health board
No Response Published
Link to recommendation 26
Recommendation · source text
The health board should undertake a community workforce capacity and demand review, to ensure relevant community teams are sufficiently resourced to manage their patient caseloads.
27
Addressed to: The health board
No Response Published
Link to recommendation 27
Recommendation · source text
The health board must provide an update on the status of the Merthyr Cynon CRHT assessment facilities within PCH.
28
Addressed to: The health board
No Response Published
Link to recommendation 28
Recommendation · source text
The health board must ensure communication arrangements are embedded, to allow for essential sharing of information between teams regarding patient care and treatment planning during the hospital stay and after discharge.
29
Addressed to: The health board
No Response Published
Link to recommendation 29
Recommendation · source text
The health board must take action to ensure there is sufficient medical capacity across all mental health teams.
30
Addressed to: The health board
No Response Published
Link to recommendation 30
Recommendation · source text
The health board must consider how it can work with therapies staff:
a) to act on the concerns raised;
b) to enable them to undertake their role to adequately manage the needs of patients during their recovery phase prior to discharge.
31
Addressed to: The health board
No Response Published
Link to recommendation 31
Recommendation · source text
The health board must consider the need to undertake a review of the capacity and demand of the mental health therapy services, and whether the establishment is correct to meet the demand.
32
Addressed to: The health board
No Response Published
Link to recommendation 32
Recommendation · source text
The health board must consider the staff feedback highlighted in this report and consider undertaking a training needs analysis for inpatient and community staff, to identify any training gaps and help ensure all staff have the appropriate knowledge and skills to effectively undertake their role.
33
Addressed to: The health board
No Response Published
Link to recommendation 33
Recommendation · source text
The health board must ensure that all staff across the mental health services are aware of how to access support, and that timely access to occupational health and well-being support is available to staff when required.
34
Addressed to: The health board
No Response Published
Link to recommendation 34
Recommendation · source text
The health board should ensure there is adequate and consistent engagement with all staff around the audit arrangements in place across its mental health services, and that staff are made aware of all audit result and any actions required for improvement.
35
Addressed to: The health board
No Response Published
Link to recommendation 35
Recommendation · source text
The health board must ensure that the audit process is reviewed within its mental health services, and that a robust and sustainable audit action management plan is implemented (as applicable), to ensure actions are monitored and to assure itself that implemented improvements are being sustained.
36
Addressed to: The health board
No Response Published
Link to recommendation 36
Recommendation · source text
The health board must provide HIW with an update on the progress of the ongoing work to review and update the mental health service policies and procedures, and when the health board wide documents will be implemented. This must include how this will be shared with all staff across the mental health services as a whole.
37
Addressed to: The health board
No Response Published
Link to recommendation 37
Recommendation · source text
The health board must ensure that risk registers are reviewed, and that consideration is given to risk identification and risk management processes. This must include assuring itself that key staff are adequately trained in identifying risks and their management.
38
Addressed to: The health board
No Response Published
Link to recommendation 38
Recommendation · source text
The health board must consider how it can audit the process in place for social worker identified incidents, which are documented within Datix, and that feedback, learning and actions are shared with them as applicable.
39
Addressed to: The health board
No Response Published
Link to recommendation 39
Recommendation · source text
The health board must ensure that any staff who report incidents via Datix are provided with feedback, including any actions taken and learning identified.
40
Addressed to: The health board
No Response Published
Link to recommendation 40
Recommendation · source text
The health board must ensure that there is a process in place to share learning or actions identified following incidents are cascaded across all teams within its mental health services.