Reviews of Mental Health Services, Health Services for People with Learning Disabilities, Dementia Services and Care of Vulnerable Adults in Acute Hospitals Dudley & Walsall Health Economy th

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Visit Date: 9 – 13 May 2011

Report Date: August 2011

Images courtesy of NHS Photo Library and Sandwell & West Birmingham NHS Trust

VERSION NUMBER

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CHANGE FROM PREVIOUS VERSION

V1

August 2011

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V1.1

September 2011

Appendix 2: Table 1 Percentage of Quality Standards met Learning Disabilities health economy percentage met amended

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INDEX

Introduction.......................................................................................................................................................... 4 Key Points .......................................................................................................................................................... 4 Health Economy.................................................................................................................................................... 6 Mental Health Services ......................................................................................................................................... 7 Dudley and Walsall Mental Health Partnership NHS Trust (Trust-wide) .................................................................... 10 Dudley Enhanced Primary Care & IAPT and Walsall Primary Care & IAPT ................................................................... 9 Dudley and Walsall Early Intervention Services ......................................................................................................... 11 Dudley and Walsall Community Mental Health Teams .............................................................................................. 12 Dudley and Walsall Acute Care Services (Crisis Resolution Home Treatment Teams) ............................................... 13 Dudley and Walsall Assertive Outreach and Recovery Services ................................................................................. 14 Commissioning ........................................................................................................................................................... 15 Health Services for People with Learning Disabilities ...........................................................................................16 Walsall Specialist Learning Disabilities Service (Black Country Partnership NHS Foundation Trust) ......................... 16 Commissioning ........................................................................................................................................................... 18 Dementia Services ...............................................................................................................................................19 Commissioning ........................................................................................................................................................... 19 Care of Vulnerable Adults in Acute Hospitals .......................................................................................................20 Dudley Group NHS Foundation Trust ......................................................................................................................... 20 Walsall Healthcare NHS Trust ..................................................................................................................................... 21 Commissioning ........................................................................................................................................................... 21 Appendix 1 Membership of Visiting Team ...........................................................................................................23 Appendix 2 Compliance with Quality Standards .................................................................................................25

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INTRODUCTION West Midlands Quality Review Service (WMQRS) was set up as a collaborative venture by NHS organisations in the West Midlands to help improve the quality of health services by developing evidence-based Quality Standards, carrying out developmental and supportive quality reviews - often through peer review visits, producing comparative information on the quality of services and providing development and learning for all involved. Expected outcomes are better quality, safety and clinical outcomes, better service user and carer experience, organisations with better information about the quality of clinical services, and organisations with more confidence and competence in reviewing the quality of clinical services. More detail about the work of WMQRS is available on http://www.wmqi.westmidlands.nhs.uk/wmqrs/. This report presents the findings of the review of mental health services, health services for people with learning th

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disabilities, dementia services and care of vulnerable adults in acute hospitals which took place on 9 , 10 , 11 , th

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12 and 13 May 2011. The visit reviewed compliance with, and identified related issues, for the following WMQRS Quality Standards: Mental Health Services, Version 1, February 2011 Health Services for People with Learning Disabilities, Version 1.1, December 2010 Dementia Services, Version 1, February 2011 Care of Vulnerable Adults in Acute Hospitals, Version 1.1, December 2010 These visits were organised by WMQRS on behalf of the following Care Pathway Groups: West Midlands Mental Health Care Pathway Group, West Midlands People with Learning Disabilities Care Pathway Group and West Midlands Dementia Care Pathway Group. The report gives external assurance of the care within the Health Economy which can be used as part of organisations’ Quality Accounts. For commissioners, the report gives assurance of the quality of services commissioned and identifies areas where developments may be needed. The report reflects the situation at the time of the visit. The text of this report identifies the main issues raised during the course of the visit. Appendix 1 lists the visiting ream which reviewed the services at Dudley and Walsall health economy. Appendix 2 contains the details of compliance with each of the standards and the percentage of standards met.

ACKNOWLEDGEMENTS West Midlands Quality Review Service would like to thank the service users and carers and staff of the Dudley and Walsall health economy for their hard work in preparing for the review and for their kindness and helpfulness during the course of the visit. Thanks are also due to the visiting team and their employing organisations for the time and expertise they contributed to this review.

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KEY POINTS 1

This report presents the findings of the WMQRS review visit to mental health services, health services for people with learning disabilities and care of vulnerable adults in acute hospitals in the Dudley and Walsall health economies. The review did not cover Dudley’s health services for people with learning disabilities, and primary care, in-patient mental health services and services for people with dementia in both localities, for a variety of reasons which are explained in this report.

2

In general, the review found services provided by staff who were committed to responding to the needs of service users and carers. All services had been working hard to improve the quality of care offered and reviewers saw significant evidence of progress and change.

3

Reviewers were concerned that collaborative working arrangements across the health economies were not robust enough to enable service user and carer, commissioner, partner organisations’ and staff input into the programme of redesign of mental health services. The Dudley and Walsall Mental Health Partnership NHS Trust (Trust-Wide) programme of transformation of mental health services will address several of the issues identified in this report, including redesigning emergency access to mental health services.

4

Addressing some of the issues identified in this report, including documentation of clinical guidelines and operational policies will flow from the service transformation work being pursued by the health economy. These issues are mostly classified as for ‘further consideration’. They do, however, need to be addressed and should be considered as ‘concerns’ if reasonable progress is not made over the next year.

5

Many examples of good practice were identified, including the Dudley and Walsall Mental Health Partnership NHS Trust (Trust-Wide) work on infection control and on valuing the nursing workforce. At a Trust-wide level, reviewers were concerned about staff training on the Mental Capacity Act and Deprivation of Liberty Safeguards and about arrangements for document control.

6

The Walsall Specialist Learning Disabilities Service (Black Country Partnership NHS Foundation Trust) provided good care for people with learning disabilities with many examples of very good practice.

7

NHS Dudley was planning to commission a memory service on a pilot basis from June 2011. Reviewers had some concerns about the model being proposed.

8

Care of vulnerable adults was reviewed at both Dudley Group NHS Foundation Trust and Walsall Healthcare NHS Trust. Both Trusts had appropriate policies and procedures and were working to ensure full implementation of these. There was no mental health liaison service at Dudley Group NHS Foundation Trust but this was being commissioned from June 2011.

9

This was the first WMQRS review visit to mental health services, health services for people with learning disabilities and care of vulnerable adults in acute hospitals. This report should be read with this in mind. Some issues may have been resolved had the review taken place later and compliance with the Quality Standards may have been higher.

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Return to Index

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HEALTH ECONOMY General Comments and Achievements The quality review visit to Dudley and Walsall was the first of the 2011/12 WMQRS reviews of mental health services, health services for people with learning disabilities, dementia services and care of vulnerable adults in acute hospitals. The review team was impressed by the positive approach to the review from everyone they met. Both commissioners and provider organisations were working hard to improve the quality of services and several examples of good practice were identified. (These are listed in the relevant Trust or service section of this report.) The reviews did not visit any general practices and general practitioners were not available to meet the review team. The health economies may wish to use the WMQRS Quality Standards for primary care (general practice) for each pathway in order to give assurance of the quality of these services. WMQRS Quality Standards for long-term care of people with dementia can be used in the same way. Concerns

1

Collaboration on transformation of mental health services At a health economy level, reviewers were concerned about the arrangements for collaborative working on proposals for transformation mental health services. There was a Commissioner Programme Board which agreed redesign principles. Proposals were discussed and developed at a senior level within the Dudley & Walsall Mental Health Partnership NHS Trust. It appeared that service transformation proposals were then presented as nearly ‘finished products’. Reviewers did not find robust arrangements for involving service users and carers, staff, partner organisations, third sector and commissioners in the development of the proposals. A more inclusive approach may lead to more robust proposals which better meet users’ and carers’ needs and align with the plans of other organisations and resources available. This work needs to include clarifying referral and acceptance criteria, the role and function of each service and the care clusters which are offered. At the time of the review, several services could not clearly articulate their role and function and both commissioners and provider organisations were concerned about some clients who were ‘falling between the gaps’.

2

Walsall Adult Safeguarding Board The Walsall Adult Safeguarding Board met in April 2011 but had not met for a year before this. Reviewers were concerned that this was not frequent enough to ensure that all safeguarding issues were being appropriately addressed. (A Safeguarding Board within Walsall Healthcare NHS Trust had continued to meet regularly with representation from the Adult Safeguarding Unit.)

Return to Index

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MENTAL HEALTH SERVICES DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST (TRUST-WIDE) General Comments and Achievements All Trust staff who the reviewers met were committed to providing high quality services and keen to improve the care they offered. Leadership was strong, including clear Board commitment to improving quality. Care Programme Approach documentation was clear and easy to complete. A newly appointed Trust pharmacist had undertaken an audit of medicines management, was aware of the issues to be addressed and had plans to increase pharmacy staffing. Good Practice

1

Infection control Sixty one link nurses had been trained to champion good practice in infection control within Trust. This enabled very good coverage across the Trust.

2

Nursing leadership The Trust had an excellent programme of valuing the nursing workforce and nurses’ contribution and commitment to providing high quality care. A ‘PRIDE in Nursing’ folder and bag was being distributed to all nurses in the Trust through local champions, emphasising Professional, Respect, Innovation, Dignity, and Effective. The folder gave a range of information about national and local nursing issues.

Immediate Risks:

None

Concerns

1

Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) training The Trust was not able to evidence that staff had up to date training in the Mental Capacity Act and Deprivation of Liberty Safeguards appropriate to their role. These areas were covered on Trust induction and a DVD and information pack was available for staff interested in updates. MCA and DOLS were not mentioned in the competence framework and training plan for individual services and so it was not clear which staff had done refresher training. The Trust was reviewing the need for refresher training and was planning to target specific service areas. Reviewers suggested that MCA and DOLS should be included in the competence frameworks and training plans so that implementation of the new arrangements can be monitored.

2

Document control

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Several of the policies seen by the reviewers were not dated or were out of date. (More detail is given in Appendix 2: compliance with QS G*-799). There was a Trust ‘policy on policies’ but this was not yet being robustly implemented across all the services reviewed. Further Consideration

1

Service user and carer involvement The Trust had a variety of mechanisms for service user and carer involvement in improving services. The mechanisms for ensuring input to decisions at a strategic level did not appear well-developed. Further work on the mechanisms for involvement of service users and carers in strategic decisions may be helpful so that full advantage is taken of users’ and carers’ expertise and experiences.

2

Service users - Copy of Care Plan and relevant information Several of the service users who met the reviewing team said they had not received a copy of their Care Plan. The OASIS system has a field where staff record that the Care Plan has been given but there is no record that the patient has received this. It may be useful to institute a regular audit to give assurance that service users have actually received their Care Plan (unless the IT system could be adapted to include a service user signature to indicate this). This issue may be made more difficult by the different names given by staff to the Care Plan documentation in the clinical notes and the version given to service users. It was also not clear that service users and carers were always being offered the range of information that was available.

3

Skill mix and multi-disciplinary working Reviewers considered that the skill mix in the services reviewed was generally ‘top heavy’ with senior nursing staff and this may benefit from review. The services generally had few occupational therapy staff and few social workers as integrated members of the teams. The medical staffing structure was separate from the service structure, although there were good operational relationships, and some staff commented that medical staff had considerable influence on decision-making within the Trust. Reviewers saw little evidence of enhanced roles and ‘new ways of working’, for example, only two of the 12 trained nonmedical prescribers were using these skills. Reviewers also commented that, in some services, the Dudley team had more staff, especially more senior staff, than the Walsall team and it was not clear that this was justified by differences in caseload. This may also benefit from review.

4

Safeguarding training Safeguarding training (covering children and vulnerable adults) was undertaken on induction and then every three years, in line with the Dudley Adult Safeguarding Board policy. The Trust may wish to consider the need for more frequent updates on safeguarding issues for some staff.

5

Sharing between Walsall and Dudley services In general, the Walsall and Dudley services had different strengths and different areas for development. Reviewers did not find evidence of sharing between the services. Further development of appropriate

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shared working may help both services to improve and avoid duplication. There may also be times when they could help each other operationally, for example, cover for unexpected staff absences.

6

Professional leadership arrangements The Trust was changing to a model whereby all professional leadership was through a matrix arrangement rather than direct line management. Some professional leads who met the visiting team were unclear about roles and how the new arrangements would work. Some leads also said that they would welcome a multi-disciplinary professional forum which involved medical staff. It may be helpful to evaluate the new arrangements at an appropriate time to ensure that they are working as expected.

7

Clinical Guidelines Work had started on documenting clinical guidelines relating to care clusters and this work needs to continue. This issue is identified as for ‘further consideration’ at this stage but will be of concern at any future review visits as progress should have been made by then. Guidelines will need to link with the service transformation work (see health economy section of this report).

8

IT system The Trust had implemented the IT system OASIS as a clinical system and for data collection. Some clinicians in the Trust were concerned that this was not intuitive to use, not easy to see all the relevant information and required repeated data entry – with associated potential for information to be missed or incorrect. The Trust was aware of these problems and had plans to make changes to the system.

9

Audit The Trust had a programme of clinical audit and a ‘lessons learnt’ newsletter was circulated. There was also an ‘embedding lessons’ folder which aimed to spread learning from audit and incidents. The Trust had a small governance team and it may be worth reviewing whether mechanisms for ensuring changes become embedded into practice are sufficiently robust.

The ‘Green Light Toolkit’ had not yet been fully

implemented in the Trust.

10

Services for people with eating disorders were not part of the scope of this review. Reviewers noticed, however, that the two members of staff with specific expertise in this area (one in Walsall and one in Dudley) had a large number of referrals and high caseload. Return to Index

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PRIMARY CARE-BASED PSYCHOLOGICAL THERAPIES DUDLEY ENHANCED PRIMARY CARE & IMPROVED ACCESS PSYCHOLOGICAL THERAPY (IAPT) AND WALSALL PRIMARY CARE & IMPROVED ACCESS PSYCHOLOGICAL THERAPY General Comments and Achievements These teams had made considerable progress and were offering a good range of services. There was committed and energetic leadership. The teams seemed keen to embrace change and continually improve the services offered. There were good relationships between the Dudley and Walsall teams as well as between professional groups. The services had good links with partner organisations in the health economy. Good Practice

1

The services had worked with general practices and community centres to reduce the stigma associated with accessing mental health services.

2

The services were achieving recovery rates of 59% which was considerably above the national target.

Immediate Risks:

None

Concerns

1

The Dudley service was collecting some of the expected data on referrals, times to treatment, discharges and outcomes of therapeutic interventions. The Walsall service was about to collate the expected data. Mechanisms for using data in order to monitor and improve the quality of services offered were therefore not robust. It may also be helpful to undertake further work on outcomes for different groups of service users.

2

MCA and DOLS training:

See Trust-wide section of this report.

Further Consideration

1

Information for service users was available but there was no clear system for ensuring and auditing that all service users were offered this information.

2

The operational policy was in draft form (2010) and needed to be finalised.

3

Improving sharing between Walsall and Dudley services:

4

Staffing levels were below the nationally recommended levels. The service was, however, achieving good

See Trust-wide section of this report.

outcomes (see good practice) despite this.

5

Clinical guidelines: Work had started on documenting clinical guidelines relating to psychological therapies and referral to referral to specialist mental health services and this work needs to continue. Return to Index

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SPECIALIST MENTAL HEALTH SERVICES DUDLEY AND WALSALL EARLY INTERVENTION (EI) SERVICES General Comments and Achievements These teams were clearly committed to providing good services. Each service had a clear vision and priorities for their future development. Working relationships within the teams appeared good and there was good leadership. Good Practice

1

The Allotment Project was actively involving service users in running an allotment. This was also leading on to volunteering, training and employment opportunities.

2

Thirty four per cent of service users were in education, training or employment. The trust-wide individual placement support should increase this level even further.

3

The Early Intervention Service information folder is a good concept, including clear identification and contact details for the care coordinator. It may be helpful to involve service users in the development of the information within the folder.

Immediate Risks:

None

Concerns

1

Young people aged under 18 were sometimes admitted to in-patient beds because a Tier 4 CAMHS bed was not available. The Trust risk-assessed and risk-managed each client, including ensuring CAMHS consultant input into the young person’s care and treating each case as a Serious Incident. Reviewers were told that length of stay was normally 24 to 48 hours but could be up to seven or eight days, because arrangements for moving young people to a more appropriate environment were not working effectively. Reviewers were seriously concerned about this issue.

Further Consideration

1

Some of the service users who met the visiting team said that they had not received the care that they had been promised. Reviewers looked at a sample of notes to see whether the Care Plan had, broadly, been delivered but were not able to verify this adequately due to a lack of documentation of the Care Plan. An audit of this topic is recommended as this issued would have been a ‘concern’ if confirmed.

2

Community Development Workers told reviewers that they were not able to access interpreter services for their clients.

3

Increasing use could be made of nurse prescribers in both teams.

4

Clinical Guidelines:

5

Service users - Copy of Care Plan and relevant information:

See Trust-wide section of this report. See Trust-wide section of this report. Return to Index

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DUDLEY AND WALSALL COMMUNITY MENTAL HEALTH TEAMS (CMHTS) General Comments and Achievements Nine community mental health teams across Dudley and Walsall were reviewed. All CMHTs had nurses, social workers, occupational therapists, medical staff, psychologists, support workers and administrative staff. At the time of the visit, the five Dudley teams cared for 903 service users and the four Walsall teams 953. These teams were working steadily to address the issues that they faced. There were good relationships between senior management and the leaders of each team. There was strong commitment to ensuring changes were embedded into practice. Reviewers were told that sickness levels had reduced and morale had improved. Good Practice

1

There was clear evidence of close working with other health and social care agencies and sharing of practice between the Walsall and Dudley teams.

Immediate Risks:

None

Concerns

1

There was no operational policy governing the work of the CMHTs. The role and function of the services was not clearly described in the documentation available or by staff themselves and pathways of care were not clear. For example, reviewers were told that whether the teams accepted a referral depended on who was on duty, with social workers accepting on a postcode basis and nursing staff accepting on a GP practice basis. Reviewers were also told that service users who were receiving consultant out-patient care only, and who did not have a care coordinator, CPA Care Plan and risk assessment, were not able to access Rethink and MIND. Reviewers queried why these service users were still under the care of specialist mental health services.

2

According to the Electronic Staff Records, training was out of date for several members of staff.

3

Reviewers were told of variable access to psychological therapies with users waiting for 18 weeks and for some service users, up to 18 months to see a psychologist.

4

During working hours access to crisis resolution services for patients not previously known to secondary care was through the CMHTs. This was being addressed through implementation of the Emergency Assessment Access Team from June 2011.

Further Consideration

1

The CMHTs did not have an identified lead professional although the managers for each CMHT were all health or social care professionals. It may be helpful to clarify the clinical leadership responsibilities of the team managers (for example, for ensuring clinical guidelines are developed, implemented and audited) and the links with professional leadership arrangements (see Trust-wide section of this report).

2

Clinical guidelines:

See Trust-wide section of this report. Return to Index

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DUDLEY AND WALSALL ACUTE CARE SERVICES CRISIS RESOLUTION HOME TREATMENT TEAMS (CRHT) In-patient services at both Dudley and Walsall had been reviewed by the Royal College of Psychiatrists ‘AIMS’ review programme and so were not reviewed as part of this visit. Reports of the AIMS reviews are available at [email protected] General Comments and Achievements The Crisis Resolution Home Treatment teams had been through a time of uncertainty and change and were embracing these changes positively. Each team was working well, although there appeared little sharing between the two teams. Both teams were located close to in-patient services. Good Practice

1

The assessment tool included clear time-lines for feedback to service users.

2

The Walsall service had access to a good range of respite alternatives to admission. Six beds at Broadway North were staffed 24 hours a day, of which three were respite beds. Reviewers were told that there were good working relationships with this service and the beds were easily accessible at any time.

3

A good, comprehensive service user feedback form was being used.

Immediate Risks:

None

Concerns

1

Crisis visits to people at home were available only 9am to 5pm Monday to Friday. Outside of these hours, clients were seen only at Bushey Fields or Dorothy Pattison Hospitals or in the Emergency Departments at Russells Hall, Dudley and the Manor Hospital, Walsall.

2

For clients who were not previously in contact with specialist mental health services, access to the crisis team was through Community Mental Health Teams or one of the Emergency Departments. The Trust was planning to implement an Emergency Assessment Team from June 2011 which would address this issue.

3

There were no social care staff in either team and staff had to contact social services for access to an Approved Mental Health Practitioner if a client needed to be detained. This added several steps to the pathway and could lead to delays in the client reaching appropriate care.

4

Multi-disciplinary input to the Walsall service was insufficient. As well as no social care staff, the team had an occupational therapist during term-time only.

Further Consideration

1

The only alternative to admission available to the Dudley service was one respite bed at the Wordsley respite facility. There were no formal links with day services to support admission avoidance.

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2

Clients in crisis who were asked to come to Bushey Fields / Dorothy Pattison Hospitals or the Emergency Departments for an assessment were brought by relatives or advised to get a taxi. It may be helpful to review the indications for ambulance transport and ensure all staff are aware of these.

3

The skill mix of the services may benefit from review. The services worked to fairly traditional staff roles and ‘New Ways of Working’ did not appear well-developed. For example, no use was being made of nurse prescribing or Patient Group Directives, and medical staff reviewed all service users every seven days. The current skill mix may not empower the development of new roles and innovative ways of working.

4

Clinical guidelines: See Trust-wide section of this report. This should include guidelines on physical health care (GN-504).

5

The Dudley service accepted referrals from age 14 years and the Walsall service from age 16 years. Young people could therefore have different care pathways and experiences depending on their address. There were examples of different documentation in use, however new Trust-wide CPA forms were being ratified for use and implementation would start to address this anomaly.

6

Sharing between Walsall and Dudley services: See Trust-wide section of this report. Return to Index

DUDLEY AND WALSALL ASSERTIVE OUTREACH (AO) AND RECOVERY SERVICES General Comments and Achievements These teams were committed to providing good services. Some good policies were available which were being followed in practice. Clinical and managerial roles were clearly identified in the team structure with time allocated for leadership of the services. Links with voluntary sector organisations seemed good and the services were trying proactively to involve service users and carers. Following the merger of the rehabilitation and recovery teams, the recovery focus had been maintained and a good service was being provided. Good Practice

1

One consultant had a particular interest in autistic spectrum disorder and was developing this aspect of the service.

Immediate Risks:

None

Concerns:

None

Further Consideration

1

The work on care clusters, guidelines and outcome measures should continue so that the services have a clear vision of their role and expected outcomes. Data presented to the reviewers indicated that only 21% of service users were in the care clusters where an Assertive Outreach Team would be expected to make a major contribution. Reviewers were also told that 20% of the services’ clients were in in-patient care, which appeared very high. Staff who met the reviewers were not able clearly to articulate the role and function of the services and their specific contribution to different care pathways. As part of this work, the balance between the teams’ assertive outreach and rehabilitation / recovery functions may also benefit from review.

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2

Further work on outcomes for different groups of service users, for example, those from black and ethnic minority groups, may be helpful.

3

Sharing between Walsall and Dudley services: See Trust-wide section of this report. Return to Index

COMMISSIONING – MENTAL HEALTH SERVICES General Comments and Achievements NHS DUDLEY MENTAL HEALTH COMMISSIONING No specific commissioning issues were identified. Commissioners had a good balance of health and social care skills. The health economy section of this report discusses the need for more collaboration on plans for transformation of specialist mental health services. The Acute Care Services (Crisis Resolution Home Treatment) report suggests further consideration is given to increasing the range of alternatives to admission for service users in crisis. The Dudley Group NHS Foundation Trust section of the report discusses the proposed mental health liaison service. NHS WALSALL MENTAL HEALTH COMMISSIONING No specific commissioning issues were identified. The health economy section of this report discusses the need for more collaboration on plans for transformation of specialist mental health services. The Walsall Healthcare NHS Trust section of the report discusses the mental health liaison service at Walsall Manor Hospital. Return to Index

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HEALTH SERVICES FOR PEOPLE WITH LEARNING DISABILITIES Dudley’s specialist learning disabilities services were in the process of transfer to the management of the Black Country Partnership NHS Foundation Trust and were not reviewed as part of this visit. The provision and commissioning of health services for people with learning disabilities in Dudley will be reviewed later in 2011 and a supplementary report will be issued.

WALSALL SPECIALIST LEARNING DISABILITIES SERVICE (BLACK COUNTRY PARTNERSHIP NHS FOUNDATION TRUST) General Comments and Achievements The Walsall Specialist Learning Disabilities Service (Black Country Partnership NHS Foundation Trust) was an impressive service which provided a good range of care including two in-patient units and community teams. The community teams consisted of learning disability community nurses, a health facilitation team, a behavioural support team, physiotherapy, occupational therapy, speech and language therapy, a re-provision nurse, psychiatry team, psychology, a forensic nursing team, a transition community nurse, a dementia community nurse, a long term conditions education and development clinical nurse specialist, an acute liaison nurse, a community nurse support worker, clinical team leader, clinical service manager and two administrators. The team worked closely with social care staff although social workers were no longer integrated in the service’s structure. Staff were highly committed to responding to the needs of service users and carers. The service had strong, dynamic leadership and staff were passionate about improving the care which they offered. There were good relationships with commissioners of services for people with learning disabilities. A visioning event had been held, looking at priorities for the future. Good Practice:

1

This service had many examples of very good practice, including the speed of response to changing needs of service users and carers. Of particular note were: a.

The Health Action Plan was an excellent document and was given to all service users and clearly used by many.

b.

Specific information had been developed for service users with diabetes and epilepsy and to help clients access national screening programmes.

c.

Access to health and social care services for people with learning disabilities was through a single telephone number.

d.

A good range of surveys of users’ and carers’ experiences had been carried out.

e.

The health facilitation team had a very proactive approach to working with primary care, including ensuring information was available for carers in the ‘Carers’ Corner’ (available in some general practices).

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f.

The transition team had developed very good information for young people moving to adult services. There was a good transition pathway and a network group which linked children’s and adult services. All young people transferring to adult care had a Health Action Plan and also received th

an 18 birthday card. g.

Speech and language therapy staff had offered ‘Makaton’ training to carers. A staff training programme on recognising and intervening in dysphasia had been developed and there were plans for this to be offered free to carers.

h.

Community teams were actively involved in preventative health interventions.

i.

A good range of augmented communication systems was available.

j.

The refurbished Orchard Hill Assessment and Treatment facility was able to care for people with additional physical and complex needs. The reviewing team was impressed by the environment and the accessible information for service users and families that was available on the unit.

Immediate Risks:

None

Concerns

None

Further Consideration

2

Maintaining service quality The service was facing several changes: management responsibility had moved to the Black Country Partnership NHS Foundation Trust, social care staff were no longer integrated with the service and the office base for the Clinical Service Manager was moving away from the building where commissioners were based. It will be important to ensure that the quality of services and the close working relationships are preserved despite these changes, and that all staff continue to have access to the information that they need to provide good quality care.

3

Some of the Easy Read information included words which the service user reviewers considered were too long and complex. It may be helpful to involve local service users in reviewing the information available. It may also be useful to acknowledge the user input on the information which is developed.

4

A good range of advocacy services was available for service users and carers with different needs. A simple guide for staff and for those trying to access advocacy may help to avoid confusion.

5

The Suttons Drive service provided a forensic step-up / step-down service. Reviewers heard several different views about the role and function of this service. A booklet about the service had been developed but was not clear about the admission and discharge criteria (see also Further Consideration 5). Staff were available to provide therapeutic interventions but the expected interventions were not documented in Care Plans. The bathroom was rather ‘clinical’. It may be helpful to review the role, function and plans for the future development of this service.

6

Admission and discharge criteria and discharge planning arrangements may benefit from review to ensure timely transfers occur across services.

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7

The reviewers met with a small number or service users and carers but it was not clear to the reviewing team the level of input of carers had into service consultation.

Return to Index

COMMISSIONING – SERVICES FOR PEOPLE WITH LEARNING DISABILITIES WALSALL HEALTH SERVICES FOR PEOPLE WITH LEARNING DISABILITIES General Comments and Achievements A small integrated health and social care team commissioned all services for people with learning disabilities, led by the Local Authority and with a pooled budget with a Section 75 Partnership Agreement. Commissioners worked closely with the specialist learning disability service and long-standing working relationships were strong. Commissioners were well aware of the issues which needed to be tackled and had clear plans to address them. Good progress had been made on personalisation with some service users and carers holding personal budgets and employing staff themselves. Commissioners had also recognised the need for changes to the Partnership Board and a revised structure had been implemented, including focus groups for service users and carers to enable input from a wider range of people. Good Practice:

See general comments and achievements.

Immediate Risks:

None

Concerns

1

Commissioner capacity was insufficient for the range of services commissioned. Two people commissioned health and social care services for people with disabilities, including those with learning disabilities, physical, sensory and neurological disabilities. Reviewers were concerned that this did not give sufficient resources for quality monitoring and for ensuring effective service user and carer involvement in commissioning arrangements.

Further Consideration

1

Maintaining service quality:

2

Commissioners were aware of a lack of services for adults with Autistic Spectrum Disorder (with or without

See Specialist Learning Disabilities Service section of this report.

learning disabilities) and were developing an ‘Autism Strategy’ with plans to address this. This work needs to continue. Return to Index

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DEMENTIA SERVICES The memory service at Walsall was not reviewed as it had already been reviewed by the Royal College of Psychiatrists ‘Memory Services National Accreditation Programme’.

COMMISSIONING – SERVICES FOR PEOPLE WITH DEMENTIA NHS DUDLEY - SERVICES FOR PEOPLE WITH DEMENTIA Concerns

1

At the time of the review, NHS Dudley did not commission a Memory Service (covering diagnosis and assessment and / or follow up and ongoing care). Reviewers were told that a nurse-led service, with clinical supervision from South Staffordshire and Shropshire Healthcare NHS Foundation Trust, was to start in June 2011, on a pilot basis for one year. The dementia pathway shown to reviewers did not appear to be based on the National Dementia Strategy. Reviewers were also concerned that links between this service and services previously provided by Dudley and Walsall Mental Health Partnership NHS Trust (Trust-Wide) were not clear.

NHS WALSALL - SERVICES FOR PEOPLE WITH DEMENTIA No commissioning issues were identified as this service was not reviewed (see above) Return to Index

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CARE OF VULNERABLE ADULTS IN ACUTE HOSPITALS DUDLEY GROUP NHS FOUNDATION TRUST During this visit, reviewers looked at Trust-wide guidelines and policies and tested their implementation in the following clinical areas: Emergency Department, Emergency Admissions Unit and three medical wards. General Comments and Achievements Reviewers were impressed by several aspects of the care of vulnerable adults at Dudley Group NHS Foundation Trust. Trust policies and procedures were generally clear and available, although a few were out of date. Nonexecutive Director and PALS involvement in monitoring and improving care of vulnerable adults was strong. White boards, through which patients needing additional care were identified, were robustly implemented and appeared to be in regular use. A team specialising in the care of people with acute confusion was in place. A nutritional support worker had recently been appointed on a pilot basis. Good Practice

1

A ‘Take the Time’ campaign, produced by the Dudley and Walsall Mental Health Partnership NHS Trust (Trust-Wide) was being implemented with the aim of improving staff understanding of the needs and wishes of vulnerable adults.

2

The Emergency Department had a good checklist used with patients aged over 65s and other vulnerable adults to ensure staffed consider all relevant issues when caring for these patients.

3

The Trust had implemented a very good campaign on tissue viability and reducing hospital-acquired pressure sores. This campaign was embedding good care at all levels in the Trust, including training staff, providing information on wards, ensuring Board members were aware of progress and a process of ‘ward to Board’ assurance.

4

PALS was working with a group of people with learning disabilities to provide training to staff on care of people with learning disabilities with emphasis on the skills needed to negotiate care planning.

Immediate Risks:

None

Concerns

1

Mental health liaison No mental health support / liaison team was available at the time of the visit. A liaison team had been commissioned from June 2011. Several staff who met the reviewers were unclear about the starting date and scope of the new service and, in particular, whether it would include the care of patients with dementia.

2

Mental Capacity Act and Deprivation of Liberty Safeguards Training A Board report on safeguarding stated that 45% staff had had training in the Mental Capacity Act and Deprivation of Liberty Safeguards. Reviewers were concerned that this was too low and that, from the

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information provided, achievement of the expected training in safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards was not being robustly monitored.

3

Actions to mitigate the risk of pressure sores for patients on trolleys for long periods of time had been implemented following the WMQRS review in October 2010, which identified this as an immediate risk to clinical safety and clinical outcomes. Some of the actions, including ‘Waterlow’ scoring for patients waiting on trolleys in the Emergency Department, had been implemented only recently. It was not clear that mattresses were now easily available. The Trust Board should assure themselves that the action plan from the October 2010 review has been implemented in full in all relevant departments.

Further Consideration

1

Specialist clinical support for people with learning disabilities within the Trust was not available. A business case for a Learning Disabilities Support Worker had been prepared.

2

There was some inconsistency in the way care planning was undertaken by ward staff. Some were using set care plans and in some areas no care plans could be evidenced.

3

The Trust Board received several reports on vulnerability and safeguarding. The key performance indicators for these issues were not clear to reviewers. It may be helpful to review Board reporting of these issues. Return to Index

WALSALL HEALTHCARE NHS TRUST During this visit, reviewers looked at Trust-wide guidelines and policies and tested their implementation in the following clinical areas: stroke rehabilitation ward, acute medicine ward, general medical ward and surgical ward. General Comments and Achievements Walsall Healthcare NHS Trust had excellent leadership for the development of adult safeguarding and care of vulnerable adults.

Policies and procedures were evident in clinical areas. Non-executive Director, PALS and

patient involvement in monitoring and improving care of vulnerable adults was strong. Reviewers were particularly impressed by the arrangements for governance of safeguarding and care of vulnerable adults. Good Practice

1

The Trust had very good processes for identifying vulnerable adults which included a clear proforma for admissions and for patients attending out-patients and a ‘trigger tool’. The ‘trigger tool’ ensured that information about patients with additional needs was sensitively communicated in order to avoid stigma.

2

The monthly safeguarding report was good, with clear key performance indicators. The report was in a standard format so that trends could be clearly seen.

Immediate Risks:

None

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Concerns

1

Assessments of need were taking place but, apart from the stroke rehabilitation ward, there was little evidence in patients’ notes that these assessments were being followed through to care planning and clear actions.

2

Arrangements for monitoring locum and agency staff were not sufficiently robust to identify whether locum and agency staff had up to date safeguarding, MCA and DOLS training.

Further Consideration

1

The Trust was heavily dependent on one Adult Safeguarding Lead and arrangements for cover for unexpected absences were not robust. The Adult Safeguarding Lead also had significant operational and training responsibilities. When addressing this issue, reviewers suggest that the Trust consider a model whereby the undoubted expertise of the Adult Safeguarding Lead is ‘rolled out’ and others are encouraged to develop their expertise. This may help changes to become embedded and part of routine practice.

2

A mental health liaison service for younger adults was in place. Two mental health nurses in the discharge team specialised in the care of people with dementia and an acute liaison learning disabilities nurse was available. The arrangements for liaison on the care of older adults with mental health problems before discharge were not formalised and may benefit from review.

3

The Trust had plans to link the ‘trigger tool’ (see good practice) to the Fusion IT system. If possible, this would help communication about the care of vulnerable adults in the Trust.

4

The flow chart in the Trust safeguarding policy did not reflect what is happening in practice, especially about arrangements during absences of the Adult Safeguarding Lead. Reviewers suggested that the policy is amended to reflect current practice.

5

A new medical lead for adult safeguarding had been appointed but had no time allocated for this role. The need for time within the job plan should be kept under review.

6

It was not clear that all documents had been ratified through the expected Trust processes. Return to Index

COMMISSIONING – CARE OF VULNERABLE ADULTS IN ACUTE HOSPITALS NHS DUDLEY Concerns

1

Mental health liaison:

See Dudley Group NHS Foundation Trust section of this report.

NHS WALSALL Concerns

1

Adult Safeguarding Board:

See health economy section of this report. Return to Index

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APPENDIX 1

MEMBERSHIP OF VISITING TEAM

Rosemary Brown

Senior Nurse/Modern Matron

North Staffordshire Combined Healthcare NHS Trust

Simon Collett

Self Advocate

Choice Checkers

John Copping

Carer

Carers in Partnership

Phillip Cullen

Team Leader

Coventry & Warwickshire Partnership NHS Trust

Felix Davies

Director of Psychological Services

South Staffordshire & Shropshire Healthcare NHS Foundation Trust

Dr Martin Deahl

Consultant Psychiatrist

South Staffordshire & Shropshire Healthcare NHS Foundation Trust

Mary Elliffe

Service Manager

Birmingham & Solihull Mental Health NHS Foundation Trust

Dr Alan Farmer

Consultant Psychiatrist/Lead Consultant Community Business Unit

Worcestershire Mental Health Partnership NHS Trust

Amanda Hill

Operational Manager

Coventry & Warwickshire Partnership NHS Trust

David Hitchen

MH Commissioning Manager

Worcestershire County Council

Dr Kathryn Horsler

Clinical Psychologist

Solihull Care Trust

Philomena Humphries

Strategic Health Facilitator

Solihull Care Trust

Janice Johnson

Adult Safeguarding Nurse

University Hospital of North Staffordshire NHS Trust

Dawn Leese

Chief Nurse Safeguarding)

Marisa Murphy

Self Advocate

Choice Checkers

Gillian Mobbs

CMHT Manager

Coventry and Warwickshire Partnership Trust

Carol Molloy

Service Lead for Assertive Outreach

South Staffordshire & Shropshire Healthcare NHS Foundation Trust

Dr Behruz Nabavi

Consultant Psychiatrist

Birmingham & Solihull Mental Health NHS Foundation Trust

Oliver Orr

Service User

Worcestershire Mental Health Partnership NHS Trust

Ann Parry

Deputy Director Governance Quality and Risk

Sandwell Mental Health & Social Care NHS Foundation Trust

Alison Price

Carer

Choice Checkers

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(Executive

Lead

for

Burton Hospitals NHS Foundation Trust

23

Janette Price

Community Learning Disability Nurse

North Staffordshire Combined Healthcare NHS Trust

Catherine Quekett

Support Worker

Worcestershire Supporting People (Choice Checker Team)

Lynne Reep

Consultant Psychologist

Jo-Anne Rickets

Learning Disabilities Specialist Nurse

Royal Wolverhampton Hospitals NHS Trust

Fiona Ritchie

Associate Director

Worcestershire Mental Health Partnership NHS Trust

Claire Rylands

Deputy Clinical Governance, Audit & Risk Manager

University Hospital of North Staffordshire NHS Trust

Dawn Wardell

Director of Nursing Quality & Workforce

George Eliot Hospital NHS Trust

Kuli Kaur Wilson

Mental Health Manager

Wolverhampton PCT Mental Health Services

Lesley Wood

Service User

Worcestershire Mental Health Partnership NHS Trust

Jane Eminson

Acting Director

West Midlands Quality Review Service

Sarah Broomhead

Quality Manager

West Midlands Quality Review Service

John Levy

Mental Health, Dementia & Learning Disabilities Lead.

West Midlands Quality Review Service

Samina Arshad

Mental Health Model of Care Improvement & Development Project Manager

Birmingham East & North PCT

Patrick Keady

Quality Review Lead

Coventry & Warwickshire Partnership NHS Trust

Chartered

Strategic

Counselling

Redesign

Worcestershire Mental Health Partnership NHS Trust

WMQRS members:

Observers:

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APPENDIX 2

COMPLIANCE WITH QUALITY STANDARDS

Analyses of percentage compliance with the Quality Standards should be viewed with caution as they give the same weight to each of the Quality Standards. Also, the number of Quality Standards applicable to each service varied depending on the nature of the service provided. Percentage compliance takes no account of ‘working towards’ a particular Quality Standard. Reviewers often comment that it is better to have a ‘No but’, where there is real commitment to achieving a particular standard, than a ‘Yes but’ – where a ‘box has been ticked’ but the commitment to implementation is lacking. With these caveats, table 1 summarises the percentage compliance for each of the services reviewed. Dudley and Walsall health economy percentage compliance should be viewed with particular caution because this was the first visit of the review programme.

Table 1 - Percentage of Quality Standards met No. Applicable QS

No. QS Met

% met

No. services / clinical areas

Dudley Primary Care General Practice

10

3

30

-

Walsall Primary Care General Practice

10

3

30

-

Dudley and Walsall Mental Health Partnership NHS Trust (Trust-wide)

11

9

82

-

Dudley Enhanced Primary Care & IAPT and Walsall IAPT

30

19

63

2

Dudley & Walsall Early Intervention Services

52

36

69

2

Dudley & Walsall Community Mental Health Teams

52

29

56

3 of 9

Dudley & Walsall Acute Care Services (Crisis Resolution Home Treatment Teams)

56

33

59

Dudley & Walsall Assertive Outreach Services

54

35

65

2

Commissioning - NHS Dudley

14

8

57

-

Service Mental Health Services

Commissioning - NHS Walsall

14

6

43

-

Health Economy

303

181

60

-

Walsall Primary Care General Practice

8

6

75

-

Walsall Specialist Learning Disabilities Service (Black Country Partnership NHS Foundation Trust)

49

36

73

3

Commissioning - NHS Walsall

17

9

53

-

Health Economy

74

51

69

-

Dudley Primary Care

-

-

-

Dudley – Memory Service

-

-

-

Commissioning – NHS Dudley

-

-

-

Walsall Primary Care

-

-

-

17

9

53

Dudley Group NHS Foundation Trust (Trust-wide)

24

18

75

Dudley Group NHS Foundation Trust (Clinical areas)

17

14

82

Walsall Healthcare NHS Trust (Trust-wide)

24

20

83

Health Services for People with Learning Disabilities

Dementia Services

Commissioning – NHS Walsall

-

Care of Vulnerable Adults in Acute Hospitals

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No. Applicable QS

No. QS Met

% met

No. services / clinical areas

Walsall Healthcare NHS Trust (Clinical areas)

17

11

65

4

Commissioning – NHS Dudley

3

3

100

-

Commissioning – NHS Walsall

3

2

67

-

Health Economy

88

68

77

-

Dudley and Walsall Mental Health Partnership NHS Trust

255

161

63

-

Black Country Partnership NHS Foundation Trust: Walsall Specialist Learning Disabilities Service

49

36

73

-

Dudley Group NHS Foundation Trust

41

32

78

-

Walsall Healthcare NHS Trust

41

31

76

-

NHS Dudley

27

14

52

-

NHS Walsall

69

35

51

-

Health Economy

482

309

64

-

Service

Totals

Return to Index

MENTAL HEALTH TRUST-WIDE DUDLEY & WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST Ref

Quality Standard

Met?

Comments

Y

Reviewers were told that the Community Development Workers were required to apply for funding if they needed access to interpretation services for clients.

Support for Service Users and Carers GD-101

GD-199

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information Involving Users and Carers The Trust should have: a. Mechanisms for receiving feedback from service users and carers about the treatment and care they received b. A rolling programme of audit of a random sample of service users’ experiences of their treatment and care c. Mechanisms for involving service users and, where appropriate, their carers in decisions about individual treatment and care d. Mechanisms for involving service users and carers in decisions about the organisation of services.

Y

Staffing

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Ref GD-298

Quality Standard Clinical and Managerial Supervision The Trust should have a policy on clinical and managerial supervision for clinical staff.

Met?

Comments

Y

Guidelines and Protocols GD-510

GD-511

GD-594

GD-595

Care Coordination Policy The Trust should have a policy on Care Coordination (including the Care Programme Approach). Community Treatment Orders The Trust should have a policy on the use of Community Treatment Orders.

Y

Mental Capacity Act and Deprivation of Liberty Safeguards The Trust should have a policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards. General Policies The Trust should have policies on: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

Y

Y

N

The lone worker policy was in draft. All other policies were in place.

GD-596

Safeguarding Policy A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for investigation and, if necessary, referral of complaints and incidents relating to the care of vulnerable adults b. Expected staff training c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy).

Y

The frequency of the training was three yearly as agreed by the Dudley safeguarding partnership board.

GD-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

There was an information sharing agreement but only one out of the seven members listed had signed the agreement.

Service organisation and liaison with other services GD-601

Service Coordination and Liaison The Trust should have appropriate arrangements for ensuring effective communication and liaison between services including: a. An Acute Care Forum b. A mechanism covering community-based non-acute services with links to primary care, social care and voluntary sector organisations.

Y

GD-602

Partnership Board Attendance The Trust should participate in the local Partnership Board (or equivalent) with responsibility for improving services for people with mental health problems (QS GZ701).

Y

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MENTAL HEALTH PRIMARY CARE – NHS DUDLEY Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers GA-101

Self-referral to psychological therapy Information on self-referral to primary care-based psychological therapies should be clearly displayed.

N

GA-102

Advocacy Information Information on advocacy services available for patients should be clearly displayed. Annual Health Check Each general practice should offer a comprehensive annual health check to all people with serious mental illness registered with their practice, covering: a. all relevant national screening programmes b. keeping healthy and preventing diseases c. contraception and sexual health d. review of medication e. details of main carer/s and carer support needs (if appropriate) The outcome of the annual health check should be summarised in writing to the service user and, if appropriate, their carer, and should be recorded in their notes.

Y

Y

Most practices were offering annual health checks to people with serious mental illness

Training and development General practice staff should participate in the programme of training and development of primary care staff in the prevention, recognition, screening, early intervention, user and carer experience and ongoing care of people with mental health problems (QS GZ-299).

N

There was some involvement but no formal input into an ongoing programme.

GA-103

No information was available about the Dudley service.

Staffing GA-299

Guidelines and Protocols GA-501

Screening and Initial Assessment Screening and initial assessment tools should be in use covering, at least: a. Psychosis b. Depression c. Risk of suicide d. Ante-natal and post-natal mental health screening

N

Assessment tools covered all except 'd'.

GA-502

Clinical guidelines Clinical guidelines should be in use covering, at least: a. Anxiety b. Depression c. Psychosis d. Other serious mental illnesses Clinical guidelines should cover diagnosis, therapeutic options, medication and prescribing, and expected frequency of review. Referral Guidelines - Psychological Therapies Guidelines on seeking advice from and referral to primary care-based psychological therapies should be easily available.

N

No evidence of compliance with this QS was available.

N

Work to develop referral guidelines was in progress.

GA-503

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Ref

Quality Standard

Met?

Comments

GA-504

Referral Guidelines – Specialist Mental Health Services Guidelines on seeking advice from and referral to specialist mental health services should be easily available.

N

Processes were in place but not written guidelines.

GA-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Y

An information sharing protocol was in place for Dudley.

Practice Register Each general practice should have a register which identifies people with serious mental illness registered with the practice, including: a. Demographic details b. Appropriate Read codes This information should be shared with Commissioners on an annual basis.

N

Data showing compliance with this QS were not available.

Governance GA-701

MENTAL HEALTH PRIMARY CARE – NHS WALSALL Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers GA-101

Self-referral to psychological therapy Information on self-referral to primary care-based psychological therapies should be clearly displayed.

Y

GA-102

Advocacy Information Information on advocacy services available for patients should be clearly displayed.

Y

GA-103

Annual Health Check Each general practice should offer a comprehensive annual health check to all people with serious mental illness registered with their practice, covering: a. all relevant national screening programmes b. keeping healthy and preventing diseases c. contraception and sexual health d. review of medication e. details of main carer/s and carer support needs (if appropriate) The outcome of the annual health check should be summarised in writing to the service user and, if appropriate, their carer, and should be recorded in their notes.

Y

Most practices were offering annual health checks to people with serious mental illness.

Training and development General practice staff should participate in the programme of training and development of primary care staff in the prevention, recognition, screening, early intervention, user and carer experience and ongoing care of people with mental health problems (QS GZ-299).

N

Details of training and development programmes for primary care staff were not available.

Staffing GA-299

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Ref

Quality Standard

Met?

Comments

Guidelines and Protocols GA-501

Screening and Initial Assessment Screening and initial assessment tools should be in use covering, at least: a. Psychosis b. Depression c. Risk of suicide d. Ante-natal and post-natal mental health screening

N

Assessment tools covered all except 'd'.

GA-502

Clinical guidelines Clinical guidelines should be in use covering, at least: a. Anxiety b. Depression c. Psychosis d. Other serious mental illnesses Clinical guidelines should cover diagnosis, therapeutic options, medication and prescribing, and expected frequency of review.

N

No evidence of compliance with this QS was available.

GA-503

Referral Guidelines - Psychological Therapies Guidelines on seeking advice from and referral to primary care-based psychological therapies should be easily available.

N

Work to develop referral guidelines was in progress.

GA-504

Referral Guidelines – Specialist Mental Health Services Guidelines on seeking advice from and referral to specialist mental health services should be easily available.

N

Processes were in place but not written guidelines.

GA-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

The Walsall information sharing protocol was under review.

Practice Register Each general practice should have a register which identifies people with serious mental illness registered with the practice, including: a. Demographic details b. Appropriate Read codes This information should be shared with Commissioners on an annual basis.

N

Data showing compliance with this QS were not available.

Governance GA-701

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MENTAL HEALTH - DUDLEY ENHANCED PRIMARY CARE & IMPROVED ACCESS PSYCHOLOGICAL THERAPY AND WALSALL IMPROVED ACCESS PSYCHOLOGICAL THERAPY Ref

Quality Standard

Met?

Comments

Support for service users and carers GP-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

GP-102

Psychological Therapy Service Information Service users and their carers should be offered information about the Psychological Therapy Service covering, at least: a. Brief description of the service b. How to contact the service for help and advice c. Staff of the service d. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns e. How to get involved in improving services (QS GP199)

Y

Good examples were available for the Dudley service.

GP-103

Care Package Information Each service user and, where appropriate, their carer should agree, and should be offered information about, their Care Package. This information should cover the: a. Description and implications of different types of mental health problem b. Case Worker c. Arrangements for liaison with Case Worker d. Therapeutic interventions and expected outcomes e. Review date f. Discharge from the Psychological Therapy Service

N

From the examples available, documented evidence of implementation appeared limited

GP-199

Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service.

Y

Engagement with service users and carers was limited but both services were considering ways of improving this.

Staffing

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Ref

Quality Standard

Met?

Comments

GP-201

Lead Practitioner and Manager The Psychological Therapy Service should have a nominated lead practitioner and lead manager.

Y

GP-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. NICE-indicated therapeutic interventions for depression and anxiety b. Employment support and advice Staffing levels should be based on a competence framework (QS GP-203) covering skill mix, staffing levels and competences expected.

N

Staffing levels were less than those recommended in the IAPT guidance, but outcomes were good and staff had a good range of competences.

GP-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS GP-202). GP Lead The service should have a local GP lead who has responsibility for ensuring effective liaison with local general practices.

N

It was not clear if all staff were regularly updated for MCA and DoLS.

GP-297

General Competences All staff should have up to date training appropriate to their role in: a. equal opportunities b. racial awareness c. gender awareness d. disability awareness e. religious awareness f. sexual safety awareness g. safeguarding children and young people h. safeguarding vulnerable adults i. Involving service users and carers in the planning, delivery and review of services.

Y

GP-298

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role.

Y

GP-299

Administrative and Clerical Support Administrative and clerical support should be available.

Y

GP-204

Y

Facilities and Equipment GP-401

Appropriate Facilities Appropriate facilities for providing NICE-indicated therapeutic interventions for depression and anxiety should be available.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GP-402

IT System An IT system capable of care package monitoring should be available.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

Guidelines and Protocols

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Ref

Quality Standard

Met?

GP-501

Assessment Tool An assessment tool which ensures involvement of service users and, where appropriate, their carers should be in use. The outcome of the assessment should be communicated to the service user, their carer (where appropriate) and general practitioner and should be recorded in their case notes.

Y

GP-502

Clinical Guidelines Clinical guidelines should be in use for each therapeutic intervention offered by the service. These guidelines should include the expected frequency of review, indications for referral back to the general practitioner and indications for seeking advice from and referral to specialist mental health services.

N

GP-594

Mental Capacity Act and Deprivation of Liberty Safeguards A policy covering adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

GP-595

General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

Y

GP-596

Safeguarding Policy A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for investigation and, if necessary, referral of complaints and incidents relating to the care of children or vulnerable adults b. Expected staff training c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy).

Y

GP-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

Comments

Care cluster guidelines were available but these did not include the expected frequency of review.

An information sharing protocol was in place for Dudley. The Walsall information sharing protocol was under review.

Service organisation and liaison with other services

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Ref

Quality Standard

Met?

GP-601

Operational Policy An operational policy should be in use which ensures: a. Assessment is started within two weeks of referral b. Service users are offered a range of NICErecommended therapeutic interventions c. A Care Package is agreed with the service user d. Therapeutic interventions are started within four weeks of referral e. Service users are given information (QS GP-102) about the service and about their Care Package (QS GP103) f. The Care Package and any revisions following review is documented and communicated to the service user, their carer (where appropriate) and general practitioner, and is recorded in their case notes. g. A discharge plan is agreed with the service user and communicated to the service user, their carer (where appropriate) and general practitioner, and is recorded in their case notes.

N

The operational policy available was still in draft (2010).

GP-602

Information for Primary CareInformation on the service’s referral criteria and arrangements should have been circulated to all local general practices and other appropriate organisations. Primary Care Liaison Appropriate arrangements should be in place to ensure effective liaison with primary care services.

N

Information about care clusters was available but not details of distribution to all local practices.

Y

Primary care consultation events had taken place.

GP-604

Mental Health Services Liaison The service should have arrangements for liaison with other local mental health services.

N

Evidence of arrangements for liaison was not available.

GP-605

Partnership Board Attendance The service should attend the local Partnership Board (or equivalent) with responsibility for improving services for people with mental health problems.

N

The minutes available did not appear to include attendance by a member of the services.

GP-606

Mental Health Promotion Programme The service should contribute to the local programme on mental health promotion and reducing stigma (QS GZ-102).

Y

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Clients not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘sign-posting’ c. Clients not accepted by the service for some other reason d. Times from referral to assessment and from referral to start of treatment e. Discharges, including expected care after discharge f. Outcomes of therapeutic interventions g. IAPT minimum dataset or other Key Performance Indicators agreed with commissioners.

N

GP-603

Comments

Governance GP-701

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A limited amount of data was collected by the Dudley service. The Walsall system was not able to collate the information required by the Quality Standard.

34

Ref

Quality Standard

Met?

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each therapeutic intervention offered by the service (QS GP502). Comparison with Other Services At least annually, the service should review its compliance with Key Performance Indicators with those of other services and, if necessary, agree an action plan to improve performance.

N

A rolling programme of audit for all areas was not yet in place.

Y

The Dudley IAPT service was compared with services regionally and nationally. The Walsall service had not been in operation for more than 12 months.

GP-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, incidents and ‘near misses’.

Y

A Quality and Standards Group was in place.

GP-799

Document Control All policies, procedures and guidelines should comply with Trust (or equivalent) document control procedures.

Y

GP-702

GP-703

Comments

MENTAL HEALTH – SPECIALIST SERVICES – DUDLEY & WALSALL EARLY INTERVENTION SERVICES Ref

Quality Standard

Met?

Comments

Support for service users and carers GN-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

Generic information was available. It was not clear that the information was easily available to service users and carers.

GN-102

Information about the Service Service users and, where appropriate, their carers should be offered information about the service covering, at least: a. Brief description of the service b. How to contact the service for help and advice, including out of hours c. Staff of the service d. Belongings, visiting times and daily routine (in-patient services only) e. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns f. How to get involved in improving services (QS GN199)

Y

The Early Intervention psychosis leaflet may benefit from review. Reviewers considered that it was not in a format that was suitable for all service users.

D&W V1.1 20110914 Final Report.Doc

35

Ref

Quality Standard

Met?

Comments

GN-103

Care Plan Each service user and, where appropriate, their carer should agree their Care Plan and Care Cluster. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Overall aim and Care Cluster b. Care coordinator c. Arrangements for allocation / liaison with Care Coordinator d. Therapeutic interventions and medication e. Expected outcomes of the therapeutic interventions f. Early warning signs of problems and what to do if these occur g. Risk management plan h. Planned review date and how to access a review more quickly, if necessary.

Y

An initial assessment was undertaken and then a recovery plan (care plan) developed and shared with the service users.

GN-198

Carer Assessment Each carer should be offered an assessment of their own needs and information and advice on services available to provide support. Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service.

Y

Carers' needs assessments were completed in Dudley by the EIP team and in Walsall by an independent carers team. a and b were met but not c. There was a Trust -wide group but this was not service-specific and Early Intervention issues may not be fully explored. From discussions with the team it was not apparent that service users and carers were being actively involved in decisions about the organisation of Early Intervention Services.

GN-199

N

Staffing GN-201

Lead Practitioner and Manager The service should have a nominated lead practitioner and lead manager.

Y

GN-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. the assessments and Care Clusters activities for the usual number of service users on each Care Cluster and the usual level of need / complexity of care required; b. the service’s role in the identification and management of service users’ physical health needs (QS GN-504). Staffing levels should be based on a competence framework covering skill mix, staffing levels and competences expected. The relationship between the competence framework and the usual number of service users, their needs / complexity and Care Cluster activities should be clearly identified. For Acute Care Services this applies only to the acute care aspects of each Care Cluster which should be able to be delivered in either a community or in-patient setting.

Y

D&W V1.1 20110914 Final Report.Doc

Consultant sessions were allocated to the Dudley Early Intervention Service. Walsall had 'patch' consultants and a dedicated middle grade doctor. Some practitioners had advanced skills in care of people with learning disabilities, supplementary prescribing, physical health clinics and administration of medicines.

36

Ref

Quality Standard

Met?

Comments

GN-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS GN-202).

N

An essential training matrix covered the mandatory and essential training needs but did not cover the Mental Capacity Act other than at induction. It was not clear that the policy covered both services. E learning was available but not recorded on the matrix.

GN-204

Case Management Competences All staff involve in case management should have up to date competences in: a. Individualised recovery planning with goals and milestones b. Discharge/transition planning c. Coordinating service users’ care d. Discharge planning e. Working with primary care and other services to ensure continuity of care across multiple agencies f. Working with people who have mental illness and substance use problems g. Mental Health Act (2007) and the Mental Capacity Act (2005) and the interaction between them.

N

Some staff in the Walsall service had not completed the areas detailed in the framework. Overall it appeared that only four out of 12 staff had up to date training in the MCA.

GN-205

Approved Mental Health Act Practitioner An Approved Mental Health Practitioner should be available at all times, either as a member of the team or through access to another service.

Y

GN-206

Lead Consultant Psychiatrist The service should have a lead consultant psychiatrist responsible for coordinating medical input to the service.

Y

GN-207

CRHT Registered Practitioner Acute Care Services (CRHT) only: At least one registered practitioner should be on duty at all times.

N/A

GN-208

CRHT Doctor Available Acute Care Services (CRHT) only: A doctor of grade ST4 or above (or equivalent nontraining grade doctor) should be available to the Acute Care Service, and able to do home visits, at all times. Nominated Links – Specialist Services The service should have a nominated lead practitioner for liaison with each of the following services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services. The nominated leads should take a lead role in relation to liaison with the specialist service, guidelines and staff development.

N/A

GN-209

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There was an overall clinical lead for both services and a lead based at Dudley.

Y

37

Ref GN-210

GN-297

GN-298

GN-299

Quality Standard

Met?

Nominated Links – Local Services The service should have a nominated lead practitioner for the care of service users with: a. dual diagnoses b. substance misuse problems c. complex needs, including personality disorders d. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD e. age 16 to 18, including those who have not previously been in contact with mental health services f. dementia The nominated leads should take a lead role in relation to liaison with specialist services, guidelines and staff development. General Competences All staff should have up to date training appropriate to their role in: a. equal opportunities b. racial awareness c. gender awareness d. disability awareness e. religious awareness f. sexual safety awareness g. safeguarding children and young people h. safeguarding vulnerable adults i. Involving service users and carers in the planning, delivery and review of services.

Y

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role. Administrative and Clerical Support Administrative and clerical support should be available.

N

Comments

From the training records available it was not clear that ' i' was addressed.

Y

Y

Support Services GN-301

General Support for Service Users and Carers See QS GN-101

GN-302

Pharmacy Pharmacy advice and pharmacological supplies should be available at all times the service is operational. In normal working hours pharmacy advice with mental health specific expertise should be available.

GN-303

Residential and Day Opportunities Acute Care Services and Assertive Outreach Services only: The service should have access to a range of residential and day opportunities as alternatives to admission to inpatient care.

GN-304

Access to Venepuncture and ECG The service should have timely access to venepuncture and ECG services, including interpretation of ECGs.

Y

N/A

Y

Facilities and Equipment

D&W V1.1 20110914 Final Report.Doc

38

Ref

Quality Standard

Met?

Comments

GN-401

Facilities for Seeing Service Users All community-based services: Access to facilities for seeing service users away from their own home should be available at all times the service is operational.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-402

Team Accommodation community-based services: Accommodation for the service should be sufficient for the whole team, including space for team meetings.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-403

Mobile Phones and Cars All community-based services: All clinical staff should have access to a mobile phone and a car.

Y

GN-404

Storage of Drugs All community-based services : Appropriate storage for drugs should be available including: a. Secure storage within the team’s base including provision of cold storage (where applicable) b. Cases for transporting drugs c. Disposal facilities. d. Pharmacy approval of storage facilities should have been given.

Y

GN-405

Storage of Case Notes All community-based services : A facility for secure storage of case notes and access to service users’ historic notes should be available at all times.

Y

GN-406

IT System An IT system capable of care plan and care pathway monitoring should be available. This system should be capable of electronic communication with the service user’s GP and with Local Authority IT systems, in order to facilitate comprehensive assessments.

Y

GN-407

In-patient Facilities Acute Care Service (IP) only: In-patient services should comply with relevant guidance on facilities and equipment for in-patient mental health services.

The medicines management policy was seen. The team was working with the newly appointed Trust pharmacist to develop the community competency framework.

Facilities were not visited but assurances were given by the teams that appropriate storage was available.

N/A

Guidelines and Protocols

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39

Ref

Quality Standard

Met?

Comments

GN-501

Assessment Tool An assessment tool which ensures involvement of service users and, where appropriate, their carers should be in use. The outcome of the assessment should be communicated to the service user, their carer (where appropriate) and general practitioner and should be recorded in their case notes. (Appendix 6 summarises the areas which should be covered by the assessment tool.)

Y

GN-502

Clinical Guidelines Clinical guidelines should be in use for each Care Cluster offered by the service. These guidelines should cover therapeutic activities, medication and prescribing for each Care Cluster, and the expected frequency of review.

N

A comprehensive system was in place. An initial assessment was undertaken and then a recovery plan (care plan) developed and shared with the service users was in place and updated. A CPA review was undertaken six monthly. The Sainsbury risk assessment tool was on OASIS but was not suitable for use with children. The CAMHS and EI teams had worked together and implemented the Maudsley Children's Risk Assessment tool. The Trust was planning to adopt the FACE assessment tool to replace the Sainsbury risk assessment tool. Clinical guidelines were not completed for all the care clusters offered by the service.

GN-503

Clinical Guidelines – Detail Clinical guidelines (QS GN-502) should be explicit about alterations to the Care Cluster expected for service users with: a. a risk of harm to themselves or others (including consideration of safeguarding children and vulnerable adults) b. dual diagnoses c. substance misuse problems d. complex needs, including personality disorders e. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD f. dementia.

N

As GN-502. In addition the pathway for Cluster 10 had not yet been fully integrated with the operational policy.

Clinical guidelines should also be explicit about i. Criteria for admission to in-patient care and for access to alternatives to admission (QS GN-303) ii. Care and management of pregnant and lactating women iii. Service users with young children.

D&W V1.1 20110914 Final Report.Doc

40

Ref

Quality Standard

Met?

GN-504

Physical Health Care Guidelines should be in use covering the identification and management of service users’ physical health needs, including: a. Prevention programmes b. Access to national screening programmes and c. Management of commonly occurring long-term conditions. d. Ensuring a physical health check was carried out in the last year. Where care is shared with the service user’s general practitioner, guidelines should be clear about responsibilities, including responsibility for prescribing.

Y

GN-505

Referral Guidelines – Local Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, other local services should be easily available. These should cover at least: a. Primary care –based psychological therapy services b. Early intervention services c. Community mental health services d. Acute care services (CRHT and in-patient) e. Assertive outreach services f. Substance misuse services g. Memory services h. Services for people with learning disabilities i. Child and adolescent mental health services

Y

Comments Trust-wide guidelines were available. The electronic CPA prompted recording of physical health needs but did not cover further management.

The referral criteria for CRHT should include: i. all clients where hospital admission is being considered ii. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals. GN-506

Discharge to Services Providing Less Intensive Intervention Early Intervention, Acute Care and Assertive Outreach Services only: Guidelines on referral or discharge to services providing less intensive interventions should be in use.

Y

GN-507

Referral Guidelines – Specialist Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, the following specialist services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

Y

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41

Ref

Quality Standard

Met?

GN-508

Transition to Adult Care Guidelines should be in use covering transition from CAMHS to adult care which should include: a. Age guidelines for the timing of the transfer b. Involvement of the young person and, where appropriate, their carer in the decision about transfer c. Involvement of the young person’s general practitioner in planning the transfer d. Joint CAMHS / adult service meeting/s in order to plan transfer to adult care e. Allocation of a named coordinator for the transfer of care f. A preparation period and education programme prior to transfer to adult care g. Arrangements for monitoring during the time immediately after transfer to adult care. h. These guidelines should have been agreed with the CAMH service/s from which service users are usually transferred.

Y

GN-509

Transition to Memory Services Guidelines should be in use covering transition to the care of the local Memory Service/s which should include: a. Involvement of the service user and, where appropriate, their carer in the decision about transfer b. Involvement of the service user’s general practitioner in planning the transfer c. Joint meeting with the Memory Service in order to plan transfer d. Allocation of a named coordinator for the transfer of care e. A preparation period prior to transfer f. Arrangements for monitoring during the time immediately after transfer.

N/A

Comments

These guidelines should have been agreed with the Memory Service to which service users are usually transferred. GN-510

Care Coordination The Trust Policy on Care Coordination (including the Care Programme Approach) should be in use.

Y

GN-511

Community Treatment Orders A policy on the use of Community Treatment Orders should be in use. This policy should be clear about the service’s role in decisions on the use of Community Treatment Orders.

Y

GN-593

Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes.

Y

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42

Ref

Quality Standard

Met?

Comments

GN-594

Mental Capacity Act and Deprivation of Liberty Safeguards A Trust policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

See comments in main report (Trust-wide section).

GN-595

General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

N

The lone worker policy was in draft form. All other policies were in place.

GN-596

Safeguarding Policy The Trust Safeguarding Policy should be in use.

Y

GN-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

There was an information sharing agreement but only one out of the seven members listed had signed the agreement.

Service organisation and liaison with other services GN-601

Operational Policy An operational policy should be in use which ensures: a. Each stage of the service user ‘journey’ takes place within expected time scales. b. Each service user agrees a care plan. c. The care plan and any revisions following review is documented and communicated to the service user, their carer (where appropriate) and general practitioner and is recorded in their case notes. d. Each service user and, where appropriate, their carer is offered information about their Care Plan and Care Cluster.

N

The operation policy did not detail expected timescales. There was no evidence of monitoring key performance indicators on a regular basis.

GN-602

Liaison with Other Mental Health Services The service should link effectively with the Trust-wide and Partnership Board (or equivalent) mechanisms for coordination and liaison between services through attendance at meetings or through arrangements for influencing and getting feedback on its work.

N

Liaison between services and forums was not proactive. The services did meet within the EI business unit.

GN-603

Liaison with Other Services Arrangements for liaison with the following services should be in place: a. Housing b. Benefits advice c. Employment support d. Education e. Probation and police f. Relevant voluntary organisations g. Youth offending teams h. Children’s services (Early Intervention Services and Acute Care Services) i. Local authorities

Y

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43

Ref

Quality Standard

Met?

Comments

GN-604

Review Meetings – Specialist Services At least one representative of the service should meet at least annually with each service to which clients are referred in order to review links between services and identify shared learning: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N

Formal meetings were not yet in place.

GN-605

Mental Health Promotion Programme The service should contribute to the local programme on mental health promotion and reducing stigma (QS GZ-102).

Y

GN-606

Primary Care Liaison The service should have arrangements for liaison with primary care services including the service user’s general practitioner. The arrangements should cover operational issues, advice and feedback.

Y

GN-607

Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with mental health problems in the local general acute hospitals and should contribute to acute hospital training and development programmes

N

Links were in place with Walsall Manor Hospital but not with Dudley Group Commissioning of a liaison service for Dudley Group was to take place later in 2011.

GN-699

Primary Care Training and Development The service should contribute to primary care training and development programmes (QS GZ-299).

N

Reviewers were told that a range of training had been delivered but there was no evidence to support this.

GN-701

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘signposting’ c. Individuals not accepted by the service for some other reason d. Key indicators of user journey (Appendix 7) e. Discharges, including expected care after discharge f. Minimum data set, including Health of the Nation Outcome Scores at assessment and discharge.

N

Some data were collected but there was no evidence of systematic collection of data covering all aspects of the QS. Work was in progress to address this via the OASIS system.

GN-702

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each Care Cluster offered by the service (QS GN-502).

N

Evidence demonstrating a rolling programme of audit was not available. Not all the clinical guidelines for the care clusters were complete.

GN-703

Monitoring of Staff Retention and Turnover The service should monitor and regularly review staff retention and turnover.

Y

Governance

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44

Ref

Quality Standard

Met?

GN-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, incidents and ‘near misses’.

Y

GN-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

N

Comments

Some documents were not in the Trust format.

MENTAL HEALTH - DUDLEY & WALSALL COMMUNITY MENTAL HEALTH TEAMS Ref

Quality Standard

Met?

Comments

Support for service users and carers GN-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

GN-102

Information about the Service Service users and, where appropriate, their carers should be offered information about the service covering, at least: a. Brief description of the service b. How to contact the service for help and advice, including out of hours c. Staff of the service d. Belongings, visiting times and daily routine (in-patient services only) e. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns f. How to get involved in improving services (QS GN199)

Y

D&W V1.1 20110914 Final Report.Doc

Reviewers did not find any documentation about the choice of locations where clients could be seen (for example, home, GP surgery, other location). It may also be helpful to produce a simpler version of the carer's strategy for carers themselves.

45

Ref

Quality Standard

Met?

Comments Reviewers were given different answers on the document that would be given to service users. From discussions with service users it was not clear that all were receiving a copy of their care plan. The documents seen included little information about relapse and what to do.

GN-103

Care Plan Each service user and, where appropriate, their carer should agree their Care Plan and Care Cluster. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Overall aim and Care Cluster b. Care coordinator c. Arrangements for allocation / liaison with Care Coordinator d. Therapeutic interventions and medication e. Expected outcomes of the therapeutic interventions f. Early warning signs of problems and what to do if these occur g. Risk management plan h. Planned review date and how to access a review more quickly, if necessary.

Y

GN-198

Carer Assessment Each carer should be offered an assessment of their own needs and information and advice on services available to provide support.

Y

GN-199

Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service.

Y

Service users and carers were heavily outnumbered by professionals in some of the meetings. The service may wish to consider whether this is the best way to enable service user and carer input.

GN-201

Lead Practitioner and Manager The service should have a nominated lead practitioner and lead manager.

Y

Managers for these teams were also the professionals

GN-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. the assessments and Care Clusters activities for the usual number of service users on each Care Cluster and the usual level of need / complexity of care required; b. the service’s role in the identification and management of service users’ physical health needs (QS GN-504). Staffing levels should be based on a competence framework covering skill mix, staffing levels and competences expected. The relationship between the competence framework and the usual number of service users, their needs / complexity and Care Cluster activities should be clearly identified. For Acute Care Services this applies only to the acute care aspects of each Care Cluster which should be able to be delivered in either a community or in-patient setting.

N

Some CMHTs did not have staff with competences in undertaking the service’s role in the identification and management of service users’ physical health needs. The skill mix within the teams may benefit from review. The teams appeared relatively 'top heavy' with senior staff. There were few occupational therapists and little use of Support and Recovery Workers. Differences in grading of staff between the Dudley and Walsall teams did not appear to be related to the roles which the staff were carrying out.

Staffing

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46

Ref

Quality Standard

Met?

Comments An essential training matrix covered the mandatory and essential training needs but did not cover the Mental Capacity Act other than at induction. According to the Electronic Staff Records, training was out of date for several members of staff. Evidence was available for individual recovery and discharge planning. There was little evidence of c to g. See also comments on GN-204.

GN-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS GN-202).

N

GN-204

Case Management Competences All staff involve in case management should have up to date competences in: a. Individualised recovery planning with goals and milestones b. Discharge/transition planning c. Coordinating service users’ care d. Discharge planning e. Working with primary care and other services to ensure continuity of care across multiple agencies f. Working with people who have mental illness and substance use problems g. Mental Health Act (2007) and the Mental Capacity Act (2005) and the interaction between them.

N

GN-205

Approved Mental Health Act Practitioner An Approved Mental Health Practitioner should be available at all times, either as a member of the team or through access to another service.

Y

GN-206

Lead Consultant Psychiatrist The service should have a lead consultant psychiatrist responsible for coordinating medical input to the service.

Y

GN-207

CRHT Registered Practitioner Acute Care Services (CRHT) only: At least one registered practitioner should be on duty at all times.

N/A

GN-208

CRHT Doctor Available Acute Care Services (CRHT) only: A doctor of grade ST4 or above (or equivalent nontraining grade doctor) should be available to the Acute Care Service, and able to do home visits, at all times.

N/A

GN-209

Nominated Links – Specialist Services The service should have a nominated lead practitioner for liaison with each of the following services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services. The nominated leads should take a lead role in relation to liaison with the specialist service, guidelines and staff development.

N

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Nominated leads for liaison from within the CMHTs had not yet been identified.

47

Ref

Quality Standard

Met?

Comments

GN-210

Nominated Links – Local Services The service should have a nominated lead practitioner for the care of service users with: a. dual diagnoses b. substance misuse problems c. complex needs, including personality disorders d. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD e. age 16 to 18, including those who have not previously been in contact with mental health services f. dementia The nominated leads should take a lead role in relation to liaison with specialist services, guidelines and staff development.

N

Nominated leads were identified for a and b.

GN-297

General Competences All staff should have up to date training appropriate to their role in: a. equal opportunities b. racial awareness c. gender awareness d. disability awareness e. religious awareness f. sexual safety awareness g. safeguarding children and young people h. safeguarding vulnerable adults i. Involving service users and carers in the planning, delivery and review of services.

N

Most areas were covered by Equality and Diversity training. This did not appear to cover f and i. (See also GN-203 concerning safeguarding training.)

GN-298

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role.

Y

GN-299

Administrative and Clerical Support Administrative and clerical support should be available.

Y

The example notes of supervision sessions shown to reviewers did not include any reference to Personal Development Reviews. The teams had good levels of administrative and clerical support.

Support Services GN-301

General Support for Service Users and Carers See QS GN-101

GN-302

Pharmacy Pharmacy advice and pharmacological supplies should be available at all times the service is operational. In normal working hours pharmacy advice with mental health specific expertise should be available.

GN-303

Residential and Day Opportunities Acute Care Services and Assertive Outreach Services only: The service should have access to a range of residential and day opportunities as alternatives to admission to inpatient care.

GN-304

Access to Venepuncture and ECG The service should have timely access to venepuncture and ECG services, including interpretation of ECGs.

D&W V1.1 20110914 Final Report.Doc

Y

N/A

Y

Arrangements were variable. Some teams were based in GP surgeries.

48

Ref

Quality Standard

Met?

Comments

Reviewers were not able to visit facilities but were told that the QS was met in all facilities except Castle Court in Dudley town centre. See also GN-102 about information for service users on choice of location. Reviewers were not able to visit facilities but were told that the QS was met in all facilities except Castle Court in Dudley town centre.

Facilities and Equipment GN-401

Facilities for Seeing Service Users All community-based services: Access to facilities for seeing service users away from their own home should be available at all times the service is operational.

N

GN-402

Team Accommodation community-based services: Accommodation for the service should be sufficient for the whole team, including space for team meetings.

N

GN-403

Mobile Phones and Cars All community-based services: All clinical staff should have access to a mobile phone and a car.

Y

GN-404

Storage of Drugs All community-based services: Appropriate storage for drugs should be available including: a. Secure storage within the team’s base including provision of cold storage (where applicable) b. Cases for transporting drugs c. Disposal facilities. d. Pharmacy approval of storage facilities should have been given.

Y

GN-405

Storage of Case Notes All community-based services : A facility for secure storage of case notes and access to service users’ historic notes should be available at all times.

Y

GN-406

IT System An IT system capable of care plan and care pathway monitoring should be available. This system should be capable of electronic communication with the service user’s GP and with Local Authority IT systems, in order to facilitate comprehensive assessments.

Y

GN-407

In-patient Facilities Acute Care Service (IP) only: In-patient services should comply with relevant guidance on facilities and equipment for in-patient mental health services.

Facilities were not visited but assurances were given by the teams and the pharmacist that appropriate storage was available.

Some staff were not yet confident with the new IT system. It had not been rolled out to all CMHTs yet and some legacy systems were still being used.

N/A

Guidelines and Protocols GN-501

Assessment Tool An assessment tool which ensures involvement of service users and, where appropriate, their carers should be in use. The outcome of the assessment should be communicated to the service user, their carer (where appropriate) and general practitioner and should be recorded in their case notes. (Appendix 6 summarises the areas which should be covered by the assessment tool.)

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Y

There was a good CPA form and HONOS was used.

49

Ref

Quality Standard

Met?

Comments

GN-502

Clinical Guidelines Clinical guidelines should be in use for each Care Cluster offered by the service. These guidelines should cover therapeutic activities, medication and prescribing for each Care Cluster, and the expected frequency of review.

N

Clinical guidelines were being developed based on care clusters.

GN-503

Clinical Guidelines – Detail Clinical guidelines (QS GN-502) should be explicit about alterations to the Care Cluster expected for service users with: a. a risk of harm to themselves or others (including consideration of safeguarding children and vulnerable adults) b. dual diagnoses c. substance misuse problems d. complex needs, including personality disorders e. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD f. dementia.

N

As GN-502

Y

Trust-wide guidelines were available. The electronic CPA prompted recording of physical health needs but did not cover further management.

Clinical guidelines should also be explicit about i. Criteria for admission to in-patient care and for access to alternatives to admission (QS GN-303) ii. Care and management of pregnant and lactating women iii. Service users with young children. GN-504

Physical Health Care Guidelines should be in use covering the identification and management of service users’ physical health needs, including: a. Prevention programmes b. Access to national screening programmes and c. Management of commonly occurring long-term conditions. d. Ensuring a physical health check was carried out in the last year. Where care is shared with the service user’s general practitioner, guidelines should be clear about responsibilities, including responsibility for prescribing.

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50

Ref GN-505

Quality Standard

Met?

Comments

Referral Guidelines – Local Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, other local services should be easily available. These should cover at least: a. Primary care –based psychological therapy services b. Early intervention services c. Community mental health services d. Acute care services (CRHT and in-patient) e. Assertive outreach services f. Substance misuse services g. Memory services h. Services for people with learning disabilities i. Child and adolescent mental health services

N

Referral processes were in place but not always documented. Further work was taking place as part of the service transformation project.

Referral processes were in place but not always documented. Further work was taking place as part of the service transformation project.

The referral criteria for CRHT should include: i. all clients where hospital admission is being considered ii. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals. GN-506

Discharge to Services Providing Less Intensive Intervention Early Intervention, Acute Care and Assertive Outreach Services only: Guidelines on referral or discharge to services providing less intensive interventions should be in use.

N

GN-507

Referral Guidelines – Specialist Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, the following specialist services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N/A

GN-508

Transition to Adult Care Guidelines should be in use covering transition from CAMHS to adult care which should include: a. Age guidelines for the timing of the transfer b. Involvement of the young person and, where appropriate, their carer in the decision about transfer c. Involvement of the young person’s general practitioner in planning the transfer d. Joint CAMHS / adult service meeting/s in order to plan transfer to adult care e. Allocation of a named coordinator for the transfer of care f. A preparation period and education programme prior to transfer to adult care g. Arrangements for monitoring during the time immediately after transfer to adult care. h. These guidelines should have been agreed with the CAMH service/s from which service users are usually transferred.

N

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Guidelines were available for b, c and d but not for a and e.

51

Ref GN-509

Quality Standard

Met?

Comments

Transition to Memory Services Guidelines should be in use covering transition to the care of the local Memory Service/s which should include: a. Involvement of the service user and, where appropriate, their carer in the decision about transfer b. Involvement of the service user’s general practitioner in planning the transfer c. Joint meeting with the Memory Service in order to plan transfer d. Allocation of a named coordinator for the transfer of care e. A preparation period prior to transfer f. Arrangements for monitoring during the time immediately after transfer.

N

This QS was met in Walsall. At the time of the visit there was no memory service in Dudley to which service users could be transferred and no guidelines for referral to another memory service.

These guidelines should have been agreed with the Memory Service to which service users are usually transferred. GN-510

Care Coordination The Trust Policy on Care Coordination (including the Care Programme Approach) should be in use.

Y

GN-511

Community Treatment Orders A policy on the use of Community Treatment Orders should be in use. This policy should be clear about the service’s role in decisions on the use of Community Treatment Orders.

Y

GN-593

Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes.

Y

GN-594

Mental Capacity Act and Deprivation of Liberty Safeguards A Trust policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

GN-595

General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

Y

GN-596

Safeguarding Policy The Trust Safeguarding Policy should be in use. Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Y

GN-597

N

See GN-203 (CMHT) about safeguarding training. Information sharing guidelines were available for Dudley. The Walsall guidelines were being updated. Staff did not seem to be aware of either guideline.

Service organisation and liaison with other services

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Ref

Quality Standard

Met?

GN-601

Operational Policy An operational policy should be in use which ensures: a. Each stage of the service user ‘journey’ takes place within expected time scales. b. Each service user agrees a care plan. c. The care plan and any revisions following review is documented and communicated to the service user, their carer (where appropriate) and general practitioner and is recorded in their case notes. d. Each service user and, where appropriate, their carer is offered information about their Care Plan and Care Cluster.

N

There was not an up to date policy. A draft 2008 Walsall policy was available. See also main report.

GN-602

Liaison with Other Mental Health Services The service should link effectively with the Trust-wide and Partnership Board (or equivalent) mechanisms for coordination and liaison between services through attendance at meetings or through arrangements for influencing and getting feedback on its work.

N

Links within the Trust were good, with good two-way communication with senior management. Mechanism for liaison with the Partnership Board were not apparent.

GN-603

Liaison with Other Services Arrangements for liaison with the following services should be in place: a. Housing b. Benefits advice c. Employment support d. Education e. Probation and police f. Relevant voluntary organisations g. Youth offending teams h. Children’s services (Early Intervention Services and Acute Care Services) i. Local authorities

Y

Contact details were available. Referral processes were documented for Walsall but not for Dudley.

GN-604

Review Meetings – Specialist Services At least one representative of the service should meet at least annually with each service to which clients are referred in order to review links between services and identify shared learning: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N

There was no evidence that these review meetings had taken place. Links with eating disorders, secure services and a member of staff with particular interest in care of people with Autistic Spectrum Disorder were in place.

GN-605

Mental Health Promotion Programme The service should contribute to the local programme on mental health promotion and reducing stigma (QS GZ-102).

N

Mental health promotion was undertaken on an individual basis but there was no evidence of input into local programmes.

GN-606

Primary Care Liaison The service should have arrangements for liaison with primary care services including the service user’s general practitioner. The arrangements should cover operational issues, advice and feedback.

Y

CMHTs had identified primary care link workers.

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Comments

53

Ref

Quality Standard

Met?

Comments

GN-607

Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with mental health problems in the local general acute hospitals and should contribute to acute hospital training and development programmes

N

This QS was met in Walsall but not in Dudley. A liaison service was to be commissioned for Dudley in June 2011.

GN-699

Primary Care Training and Development The service should contribute to primary care training and development programmes (QS GZ-299).

N

There was no evidence of regular input into primary care training programmes.

GN-701

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘signposting’ c. Individuals not accepted by the service for some other reason d. Key indicators of user journey (Appendix 7) e. Discharges, including expected care after discharge f. Minimum data set, including Health of the Nation Outcome Scores at assessment and discharge.

N

Data were being collected by OASIS but did not include the minimum data set, including HONOS. There was also no evidence that CMHTs were regularly monitoring this information.

GN-702

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each Care Cluster offered by the service (QS GN-502).

N

Some audits were taking place but not against the clinical guidelines for the care clusters offered by the service.

GN-703

Monitoring of Staff Retention and Turnover The service should monitor and regularly review staff retention and turnover.

Y

Retention and sickness had improved. Staff reported that the recruitment process was complex.

GN-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, incidents and ‘near misses’.

Y

GN-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

Y

Governance

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MENTAL HEALTH SPECIALIST SERVICES - DUDLEY AND WALSALL ACUTE CARE SERVICE CRISIS RESOLUTION HOME TREATMENT TEAMS Ref

Quality Standard

Met?

Comments

Leaflets were interesting and informative. The PALS leaflet was over three years old and may benefit from review. Information on British Sign Language was not easily available.

Support for service users and carers GN-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

GN-102

Information about the Service Service users and, where appropriate, their carers should be offered information about the service covering, at least: a. Brief description of the service b. How to contact the service for help and advice, including out of hours c. Staff of the service d. Belongings, visiting times and daily routine (in-patient services only) e. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns f. How to get involved in improving services (QS GN199)

Y

GN-103

Care Plan Each service user and, where appropriate, their carer should agree their Care Plan and Care Cluster. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Overall aim and Care Cluster b. Care coordinator c. Arrangements for allocation / liaison with Care Coordinator d. Therapeutic interventions and medication e. Expected outcomes of the therapeutic interventions f. Early warning signs of problems and what to do if these occur g. Risk management plan h. Planned review date and how to access a review more quickly, if necessary.

Y

GN-198

Carer Assessment Each carer should be offered an assessment of their own needs and information and advice on services available to provide support.

Y

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Ref

Quality Standard

Met?

Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service.

Y

GN-201

Lead Practitioner and Manager The service should have a nominated lead practitioner and lead manager.

Y

The teams had different seniority of management support.

GN-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. the assessments and Care Clusters activities for the usual number of service users on each Care Cluster and the usual level of need / complexity of care required; b. the service’s role in the identification and management of service users’ physical health needs (QS GN-504). Staffing levels should be based on a competence framework covering skill mix, staffing levels and competences expected. The relationship between the competence framework and the usual number of service users, their needs / complexity and Care Cluster activities should be clearly identified. For Acute Care Services this applies only to the acute care aspects of each Care Cluster which should be able to be delivered in either a community or in-patient setting.

Y

The skill mix of the services may benefit from review. Both services had generous levels of senior staffing. There were no social care staff in either team. One team had an occupational therapist during term-time only.

GN-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS GN-202).

N

An essential training matrix covered the mandatory and essential training needs but did not cover the Mental Capacity Act other than at induction.

GN-204

Case Management Competences All staff involve in case management should have up to date competences in: a. Individualised recovery planning with goals and milestones b. Discharge/transition planning c. Coordinating service users’ care d. Discharge planning e. Working with primary care and other services to ensure continuity of care across multiple agencies f. Working with people who have mental illness and substance use problems g. Mental Health Act (2007) and the Mental Capacity Act (2005) and the interaction between them.

N

a to e were met but not f and g.

GN-199

Comments

Staffing

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Ref

Quality Standard

Met?

GN-205

Approved Mental Health Act Practitioner An Approved Mental Health Practitioner should be available at all times, either as a member of the team or through access to another service.

Y

GN-206

Lead Consultant Psychiatrist The service should have a lead consultant psychiatrist responsible for coordinating medical input to the service.

Y

GN-207

CRHT Registered Practitioner Acute Care Services (CRHT) only: At least one registered practitioner should be on duty at all times.

Y

GN-208

CRHT Doctor Available Acute Care Services (CRHT) only: A doctor of grade ST4 or above (or equivalent nontraining grade doctor) should be available to the Acute Care Service, and able to do home visits, at all times.

N

GN-209

Nominated Links – Specialist Services The service should have a nominated lead practitioner for liaison with each of the following services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services. The nominated leads should take a lead role in relation to liaison with the specialist service, guidelines and staff development.

N

Consideration was being given to identifying nominated liaison leads.

GN-210

Nominated Links – Local Services The service should have a nominated lead practitioner for the care of service users with: a. dual diagnoses b. substance misuse problems c. complex needs, including personality disorders d. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD e. age 16 to 18, including those who have not previously been in contact with mental health services f. dementia The nominated leads should take a lead role in relation to liaison with specialist services, guidelines and staff development.

N

Consideration was being given to identifying nominated leads for liaison with these services.

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Comments

The rota gave first names only and so it was not easy for reviewers to establish if this QS was always met. Given the relatively 'top heavy' skill mix, the QS could be met. Crisis visits to people at home were available only 9am to 5pm Monday to Friday.

57

Ref

Quality Standard

Met?

Comments Most areas were covered by Equality and Diversity training. This did not appear to cover f and i. (See also GN-203 concerning safeguarding training.)

GN-297

General Competences All staff should have up to date training appropriate to their role in: a. equal opportunities b. racial awareness c. gender awareness d. disability awareness e. religious awareness f. sexual safety awareness g. safeguarding children and young people h. safeguarding vulnerable adults i. Involving service users and carers in the planning, delivery and review of services.

N

GN-298

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role.

Y

GN-299

Administrative and Clerical Support Administrative and clerical support should be available.

Y

Support Services GN-301

General Support for Service Users and Carers See QS GN-101

Y

GN-302

Pharmacy Pharmacy advice and pharmacological supplies should be available at all times the service is operational. In normal working hours pharmacy advice with mental health specific expertise should be available.

Y

GN-303

Residential and Day Opportunities Acute Care Services and Assertive Outreach Services only: The service should have access to a range of residential and day opportunities as alternatives to admission to inpatient care.

N

GN-304

Access to Venepuncture and ECG The service should have timely access to venepuncture and ECG services, including interpretation of ECGs.

Y

The Walsall service had excellent access to respite beds (see main report - good practice). The Dudley service had access to one respite bed only. Formal links with day services to support admission avoidance were not in place.

Facilities and Equipment GN-401

Facilities for Seeing Service Users All community-based services: Access to facilities for seeing service users away from their own home should be available at all times the service is operational.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-402

Team Accommodation community-based services: Accommodation for the service should be sufficient for the whole team, including space for team meetings.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-403

Mobile Phones and Cars All community-based services: All clinical staff should have access to a mobile phone and a car.

Y

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Ref

Quality Standard

Met?

GN-404

Storage of Drugs All community-based services: Appropriate storage for drugs should be available including: a. Secure storage within the team’s base including provision of cold storage (where applicable) b. Cases for transporting drugs c. Disposal facilities. d. Pharmacy approval of storage facilities should have been given.

Y

GN-405

Storage of Case Notes All community-based services : A facility for secure storage of case notes and access to service users’ historic notes should be available at all times.

Y

GN-406

IT System An IT system capable of care plan and care pathway monitoring should be available. This system should be capable of electronic communication with the service user’s GP and with Local Authority IT systems, in order to facilitate comprehensive assessments.

Y

GN-407

In-patient Facilities Acute Care Service (IP) only: In-patient services should comply with relevant guidance on facilities and equipment for in-patient mental health services.

Comments

See main report (Trust-wide section).

N/A

Guidelines and Protocols GN-501

GN-502

Assessment Tool An assessment tool which ensures involvement of service users and, where appropriate, their carers should be in use. The outcome of the assessment should be communicated to the service user, their carer (where appropriate) and general practitioner and should be recorded in their case notes. (Appendix 6 summarises the areas which should be covered by the assessment tool.) Clinical Guidelines Clinical guidelines should be in use for each Care Cluster offered by the service. These guidelines should cover therapeutic activities, medication and prescribing for each Care Cluster, and the expected frequency of review.

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Y

The assessment tool included clear time-lines for feedback to service users.

N

Clinical guidelines were being developed.

59

Ref GN-503

Quality Standard

Met?

Comments

Clinical Guidelines – Detail Clinical guidelines (QS GN-502) should be explicit about alterations to the Care Cluster expected for service users with: a. a risk of harm to themselves or others (including consideration of safeguarding children and vulnerable adults) b. dual diagnoses c. substance misuse problems d. complex needs, including personality disorders e. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD f. dementia.

N

Clinical guidelines were being developed.

Clinical guidelines should also be explicit about i. Criteria for admission to in-patient care and for access to alternatives to admission (QS GN-303) ii. Care and management of pregnant and lactating women iii. Service users with young children. GN-504

Physical Health Care Guidelines should be in use covering the identification and management of service users’ physical health needs, including: a. Prevention programmes b. Access to national screening programmes and c. Management of commonly occurring long-term conditions. d. Ensuring a physical health check was carried out in the last year. Where care is shared with the service user’s general practitioner, guidelines should be clear about responsibilities, including responsibility for prescribing.

Y

Trust-wide guidelines were available. Medical staff reviewed all service users every seven days. Physical health was included in the assessment documentation. GPs were faxed about psychotropic prescribing.

GN-505

Referral Guidelines – Local Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, other local services should be easily available. These should cover at least: a. Primary care –based psychological therapy services b. Early intervention services c. Community mental health services d. Acute care services (CRHT and in-patient) e. Assertive outreach services f. Substance misuse services g. Memory services h. Services for people with learning disabilities i. Child and adolescent mental health services

N

Referral guidelines were present but were not clear. The arrangements for referral were documented but indications for referral were not.

The referral criteria for CRHT should include: i. all clients where hospital admission is being considered ii. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals.

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Ref

Quality Standard

Met?

Comments

GN-506

Discharge to Services Providing Less Intensive Intervention Early Intervention, Acute Care and Assertive Outreach Services only: Guidelines on referral or discharge to services providing less intensive interventions should be in use.

N

The services were aspiring to achieve this QS but there was little documentation of guidelines. Both operational policies were under review and there were plans to address this.

GN-507

Referral Guidelines – Specialist Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, the following specialist services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N

This QS was met except for e.

GN-508

Transition to Adult Care Guidelines should be in use covering transition from CAMHS to adult care which should include: a. Age guidelines for the timing of the transfer b. Involvement of the young person and, where appropriate, their carer in the decision about transfer c. Involvement of the young person’s general practitioner in planning the transfer d. Joint CAMHS / adult service meeting/s in order to plan transfer to adult care e. Allocation of a named coordinator for the transfer of care f. A preparation period and education programme prior to transfer to adult care g. Arrangements for monitoring during the time immediately after transfer to adult care. h. These guidelines should have been agreed with the CAMH service/s from which service users are usually transferred.

N

The Dudley policy was available but it was dated 2007 and did not have a review date or originator information. Walsall PCT policy was available but this was due for review in 2009.

GN-509

Transition to Memory Services Guidelines should be in use covering transition to the care of the local Memory Service/s which should include: a. Involvement of the service user and, where appropriate, their carer in the decision about transfer b. Involvement of the service user’s general practitioner in planning the transfer c. Joint meeting with the Memory Service in order to plan transfer d. Allocation of a named coordinator for the transfer of care e. A preparation period prior to transfer f. Arrangements for monitoring during the time immediately after transfer.

N

This QS was met in Walsall. At the time of the visit there was no memory service in Dudley to which service users could be transferred and no guidelines for referral to another memory service.

These guidelines should have been agreed with the Memory Service to which service users are usually transferred. GN-510

Care Coordination The Trust Policy on Care Coordination (including the Care Programme Approach) should be in use.

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Y

61

Ref

Quality Standard

Met?

Comments

GN-511

Community Treatment Orders A policy on the use of Community Treatment Orders should be in use. This policy should be clear about the service’s role in decisions on the use of Community Treatment Orders.

N/A

GN-593

Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes.

Y

GN-594

Mental Capacity Act and Deprivation of Liberty Safeguards A Trust policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

GN-595

General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

Y

GN-596

Safeguarding Policy The Trust Safeguarding Policy should be in use.

Y

See GN-203 (EI) about safeguarding training.

GN-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

There was an information sharing agreement but only one out of the seven members listed had signed the agreement.

Service organisation and liaison with other services GN-601

Operational Policy An operational policy should be in use which ensures: a. Each stage of the service user ‘journey’ takes place within expected time scales. b. Each service user agrees a care plan. c. The care plan and any revisions following review is documented and communicated to the service user, their carer (where appropriate) and general practitioner and is recorded in their case notes. d. Each service user and, where appropriate, their carer is offered information about their Care Plan and Care Cluster.

N

An operational policy was present but did not cover b and d, or expected timescales, although reviewers were told that this happened in practice.

GN-602

Liaison with Other Mental Health Services The service should link effectively with the Trust-wide and Partnership Board (or equivalent) mechanisms for coordination and liaison between services through attendance at meetings or through arrangements for influencing and getting feedback on its work.

N

Links with the acute care forums were in place. There was no evidence of links with the Partnership Board.

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Ref

Quality Standard

Met?

Comments

GN-603

Liaison with Other Services Arrangements for liaison with the following services should be in place: a. Housing b. Benefits advice c. Employment support d. Education e. Probation and police f. Relevant voluntary organisations g. Youth offending teams h. Children’s services (Early Intervention Services and Acute Care Services) i. Local authorities

Y

GN-604

Review Meetings – Specialist Services At least one representative of the service should meet at least annually with each service to which clients are referred in order to review links between services and identify shared learning: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N

These meetings had not yet taken place.

GN-605

Mental Health Promotion Programme The service should contribute to the local programme on mental health promotion and reducing stigma (QS GZ-102).

N

Mental health promotion was undertaken on an individual basis but there was no evidence of input into local programmes.

GN-606

Primary Care Liaison The service should have arrangements for liaison with primary care services including the service user’s general practitioner. The arrangements should cover operational issues, advice and feedback.

Y

GN-607

Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with mental health problems in the local general acute hospitals and should contribute to acute hospital training and development programmes

N

Links were in place with Walsall Manor Hospital but not with Russells Hall Hospital, Dudley. A liaison service for Dudley was being commissioned later in 2011.

GN-699

Primary Care Training and Development The service should contribute to primary care training and development programmes (QS GZ-299).

N

There was no evidence of regular input into primary care training programmes. Reviewers were told of informal links, especially in Walsall. Information about input on the care of people with dementia was available.

Governance

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Ref

Quality Standard

Met?

Comments

GN-701

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘signposting’ c. Individuals not accepted by the service for some other reason d. Key indicators of user journey (Appendix 7) e. Discharges, including expected care after discharge f. Minimum data set, including Health of the Nation Outcome Scores at assessment and discharge.

N

Some data were collected but there was no evidence of systematic collection of data covering all aspects of the QS.

GN-702

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each Care Cluster offered by the service (QS GN-502).

N

There was no evidence of audit of clinical guidelines.

GN-703

Monitoring of Staff Retention and Turnover The service should monitor and regularly review staff retention and turnover.

Y

GN-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, incidents and ‘near misses’.

Y

GN-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

Y

Staff reported that they received good feedback on incidents and complaints.

MENTAL HEALTH SPECIALIST SERVICES – DUDLEY & WALSALL ASSERTIVE OUTREACH SERVICES Ref

Quality Standard

Met?

Comments

Y

Generic information was available. It was not clear that the information was easily available to service users and carers.

Support for service users and carers GN-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

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Ref

Quality Standard

Met?

Comments

GN-102

Information about the Service Service users and, where appropriate, their carers should be offered information about the service covering, at least: a. Brief description of the service b. How to contact the service for help and advice, including out of hours c. Staff of the service d. Belongings, visiting times and daily routine (in-patient services only) e. How to give feedback on the service, including how to make a complaint and how to report adult safeguarding concerns f. How to get involved in improving services (QS GN199)

Y

Information was available via the internet but difficult for all service users to access.

GN-103

Care Plan Each service user and, where appropriate, their carer should agree their Care Plan and Care Cluster. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Overall aim and Care Cluster b. Care coordinator c. Arrangements for allocation / liaison with Care Coordinator d. Therapeutic interventions and medication e. Expected outcomes of the therapeutic interventions f. Early warning signs of problems and what to do if these occur g. Risk management plan h. Planned review date and how to access a review more quickly, if necessary.

Y

Documents in different formats were available and use of these appeared to vary.

GN-198

Carer Assessment Each carer should be offered an assessment of their own needs and information and advice on services available to provide support.

N

There was no evidence that carer assessments were undertaken by the Dudley AO team. This Quality Standard was met by the Walsall AO team.

GN-199

Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, their carers in decisions about the organisation of the service.

N

This QS was met for Walsall but not for Dudley.

Lead Practitioner and Manager The service should have a nominated lead practitioner and lead manager.

Y

Staffing GN-201

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Ref

Quality Standard

Met?

GN-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. the assessments and Care Clusters activities for the usual number of service users on each Care Cluster and the usual level of need / complexity of care required; b. the service’s role in the identification and management of service users’ physical health needs (QS GN-504). Staffing levels should be based on a competence framework covering skill mix, staffing levels and competences expected. The relationship between the competence framework and the usual number of service users, their needs / complexity and Care Cluster activities should be clearly identified. For Acute Care Services this applies only to the acute care aspects of each Care Cluster which should be able to be delivered in either a community or in-patient setting.

Y

GN-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service, including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences (QS GN-202).

Y

GN-204

Case Management Competences All staff involve in case management should have up to date competences in: a. Individualised recovery planning with goals and milestones b. Discharge/transition planning c. Coordinating service users’ care d. Discharge planning e. Working with primary care and other services to ensure continuity of care across multiple agencies f. Working with people who have mental illness and substance use problems g. Mental Health Act (2007) and the Mental Capacity Act (2005) and the interaction between them.

Y

GN-205

Approved Mental Health Act Practitioner An Approved Mental Health Practitioner should be available at all times, either as a member of the team or through access to another service.

Y

GN-206

Lead Consultant Psychiatrist The service should have a lead consultant psychiatrist responsible for coordinating medical input to the service.

Y

GN-207

CRHT Registered Practitioner Acute Care Services (CRHT) only: At least one registered practitioner should be on duty at all times.

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Comments

N/A

66

Ref

Quality Standard

Met?

Comments

GN-208

CRHT Doctor Available Acute Care Services (CRHT) only: A doctor of grade ST4 or above (or equivalent nontraining grade doctor) should be available to the Acute Care Service, and able to do home visits, at all times.

N/A

GN-209

Nominated Links – Specialist Services The service should have a nominated lead practitioner for liaison with each of the following services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services. The nominated leads should take a lead role in relation to liaison with the specialist service, guidelines and staff development.

N

Informal links only were in place via the team managers.

GN-210

Nominated Links – Local Services The service should have a nominated lead practitioner for the care of service users with: a. dual diagnoses b. substance misuse problems c. complex needs, including personality disorders d. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD e. age 16 to 18, including those who have not previously been in contact with mental health services f. dementia The nominated leads should take a lead role in relation to liaison with specialist services, guidelines and staff development.

N

Evidence was not available for personality disorder or CAMHS.

GN-297

General Competences All staff should have up to date training appropriate to their role in: a. equal opportunities b. racial awareness c. gender awareness d. disability awareness e. religious awareness f. sexual safety awareness g. safeguarding children and young people h. safeguarding vulnerable adults i. Involving service users and carers in the planning, delivery and review of services.

Y

GN-298

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role.

Y

GN-299

Administrative and Clerical Support Administrative and clerical support should be available.

Y

Support Services GN-301

General Support for Service Users and Carers See QS GN-101

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Ref

Quality Standard

Met?

GN-302

Pharmacy Pharmacy advice and pharmacological supplies should be available at all times the service is operational. In normal working hours pharmacy advice with mental health specific expertise should be available.

Y

GN-303

Residential and Day Opportunities Acute Care Services and Assertive Outreach Services only: The service should have access to a range of residential and day opportunities as alternatives to admission to inpatient care.

Y

GN-304

Access to Venepuncture and ECG The service should have timely access to venepuncture and ECG services, including interpretation of ECGs.

Y

Comments

Opportunities were available but it was not clear how they were accessed.

Facilities and Equipment GN-401

Facilities for Seeing Service Users All community-based services: Access to facilities for seeing service users away from their own home should be available at all times the service is operational.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-402

Team Accommodation community-based services: Accommodation for the service should be sufficient for the whole team, including space for team meetings.

Y

Facilities were not visited. Compliance was based on the service's self-assessment.

GN-403

Mobile Phones and Cars All community-based services: All clinical staff should have access to a mobile phone and a car.

Y

GN-404

Storage of Drugs All community-based services : Appropriate storage for drugs should be available including: a. Secure storage within the team’s base including provision of cold storage (where applicable) b. Cases for transporting drugs c. Disposal facilities. d. Pharmacy approval of storage facilities should have been given.

Y

Facilities were not visited but assurances were given by the teams and the pharmacist that appropriate storage was available.

GN-405

Storage of Case Notes All community-based services : A facility for secure storage of case notes and access to service users’ historic notes should be available at all times.

Y

Facilities were not visited but assurances were given by the teams that appropriate storage was available.

GN-406

IT System An IT system capable of care plan and care pathway monitoring should be available. This system should be capable of electronic communication with the service user’s GP and with Local Authority IT systems, in order to facilitate comprehensive assessments.

Y

Facilities were not visited but assurances were given by the teams that appropriate storage was available.

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Ref GN-407

Quality Standard In-patient Facilities Acute Care Service (IP) only: In-patient services should comply with relevant guidance on facilities and equipment for in-patient mental health services.

Met?

Comments

N/A

Guidelines and Protocols GN-501

Assessment Tool An assessment tool which ensures involvement of service users and, where appropriate, their carers should be in use. The outcome of the assessment should be communicated to the service user, their carer (where appropriate) and general practitioner and should be recorded in their case notes. (Appendix 6 summarises the areas which should be covered by the assessment tool.)

Y

GN-502

Clinical Guidelines Clinical guidelines should be in use for each Care Cluster offered by the service. These guidelines should cover therapeutic activities, medication and prescribing for each Care Cluster, and the expected frequency of review.

N

Clinical guidelines were not completed for all the care clusters offered by the service.

GN-503

Clinical Guidelines – Detail Clinical guidelines (QS GN-502) should be explicit about alterations to the Care Cluster expected for service users with: a. a risk of harm to themselves or others (including consideration of safeguarding children and vulnerable adults) b. dual diagnoses c. substance misuse problems d. complex needs, including personality disorders e. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD f. dementia.

N

As GN- 502

Y

Trust-wide guidelines were available. The electronic CPA prompted recording of physical health needs but did not cover further management.

Clinical guidelines should also be explicit about i. Criteria for admission to in-patient care and for access to alternatives to admission (QS GN-303) ii. Care and management of pregnant and lactating women iii. Service users with young children. GN-504

Physical Health Care Guidelines should be in use covering the identification and management of service users’ physical health needs, including: a. Prevention programmes b. Access to national screening programmes and c. Management of commonly occurring long-term conditions. d. Ensuring a physical health check was carried out in the last year. Where care is shared with the service user’s general practitioner, guidelines should be clear about responsibilities, including responsibility for prescribing.

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Ref GN-505

Quality Standard

Met?

Comments

Referral Guidelines – Local Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, other local services should be easily available. These should cover at least: a. Primary care –based psychological therapy services b. Early intervention services c. Community mental health services d. Acute care services (CRHT and in-patient) e. Assertive outreach services f. Substance misuse services g. Memory services h. Services for people with learning disabilities i. Child and adolescent mental health services

N

Written guidelines were not available though processes were in place for referral to local services.

The referral criteria for CRHT should include: i. all clients where hospital admission is being considered ii. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals. GN-506

Discharge to Services Providing Less Intensive Intervention Early Intervention, Acute Care and Assertive Outreach Services only: Guidelines on referral or discharge to services providing less intensive interventions should be in use.

Y

GN-507

Referral Guidelines – Specialist Services Guidelines should be in use covering the indications and arrangements for seeking advice from, and referral to, the following specialist services: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

N

Guidelines were not available for 'a' or 'e'. Referrals to 'b' and 'd' were managed via commissioners.

GN-508

Transition to Adult Care Guidelines should be in use covering transition from CAMHS to adult care which should include: a. Age guidelines for the timing of the transfer b. Involvement of the young person and, where appropriate, their carer in the decision about transfer c. Involvement of the young person’s general practitioner in planning the transfer d. Joint CAMHS / adult service meeting/s in order to plan transfer to adult care e. Allocation of a named coordinator for the transfer of care f. A preparation period and education programme prior to transfer to adult care g. Arrangements for monitoring during the time immediately after transfer to adult care. h. These guidelines should have been agreed with the CAMH service/s from which service users are usually transferred.

N

The Dudley policy was available but it was dated 2007 and did not have a review date or originator information. Walsall PCT policy was available but this was due for review in 2009.

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Ref GN-509

Quality Standard

Met?

Transition to Memory Services Guidelines should be in use covering transition to the care of the local Memory Service/s which should include: a. Involvement of the service user and, where appropriate, their carer in the decision about transfer b. Involvement of the service user’s general practitioner in planning the transfer c. Joint meeting with the Memory Service in order to plan transfer d. Allocation of a named coordinator for the transfer of care e. A preparation period prior to transfer f. Arrangements for monitoring during the time immediately after transfer.

N

Comments No referral guidelines were available covering the transition of care of the local memory service at Walsall. There was no local memory service in Dudley and no guidelines for referral to another memory service.

These guidelines should have been agreed with the Memory Service to which service users are usually transferred. GN-510

Care Coordination The Trust Policy on Care Coordination (including the Care Programme Approach) should be in use.

Y

GN-511

Community Treatment Orders A policy on the use of Community Treatment Orders should be in use. This policy should be clear about the service’s role in decisions on the use of Community Treatment Orders.

Y

GN-593

Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes.

N

GN-594

Mental Capacity Act and Deprivation of Liberty Safeguards A Trust policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

GN-595

General Policies The following Trust Policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

N

GN-596

Safeguarding Policy The Trust Safeguarding Policy should be in use.

Y

GN-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

N

From the evidence available the discharge policy did not appear to have been implemented.

The lone worker policy was in draft form. All other policies were in place.

There was an information sharing agreement but only one out of the seven members listed had signed the agreement.

Service organisation and liaison with other services

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Ref

Quality Standard

Met?

GN-601

Operational Policy An operational policy should be in use which ensures: a. Each stage of the service user ‘journey’ takes place within expected time scales. b. Each service user agrees a care plan. c. The care plan and any revisions following review is documented and communicated to the service user, their carer (where appropriate) and general practitioner and is recorded in their case notes. d. Each service user and, where appropriate, their carer is offered information about their Care Plan and Care Cluster.

N

GN-602

Liaison with Other Mental Health Services The service should link effectively with the Trust-wide and Partnership Board (or equivalent) mechanisms for coordination and liaison between services through attendance at meetings or through arrangements for influencing and getting feedback on its work.

Y

GN-603

Liaison with Other Services Arrangements for liaison with the following services should be in place: a. Housing b. Benefits advice c. Employment support d. Education e. Probation and police f. Relevant voluntary organisations g. Youth offending teams h. Children’s services (Early Intervention Services and Acute Care Services) i. Local authorities

Y

GN-604

Review Meetings – Specialist Services At least one representative of the service should meet at least annually with each service to which clients are referred in order to review links between services and identify shared learning: a. Peri-natal mental health services b. Eating disorder services c. Intensive care and secure services d. Forensic services e. Neuro-psychiatry services

Y

GN-605

Mental Health Promotion Programme The service should contribute to the local programme on mental health promotion and reducing stigma (QS GZ-102).

N

A formal programme was not in place.

GN-606

Primary Care Liaison The service should have arrangements for liaison with primary care services including the service user’s general practitioner. The arrangements should cover operational issues, advice and feedback.

Y

Informal arrangements were in place.

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Comments The operational polices dated from before the Trust was formed (2009) and had not yet been updated. This work was planned.

72

Ref

Quality Standard

Met?

Comments

GN-607

Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with mental health problems in the local general acute hospitals and should contribute to acute hospital training and development programmes

N

Links were in place with Walsall Manor Hospital but not at Dudley Group. Commissioning of a liaison service for Dudley Group was to take place later in 2011.

GN-699

Primary Care Training and Development The service should contribute to primary care training and development programmes (QS GZ-299).

Y

GN-701

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘signposting’ c. Individuals not accepted by the service for some other reason d. Key indicators of user journey (Appendix 7) e. Discharges, including expected care after discharge f. Minimum data set, including Health of the Nation Outcome Scores at assessment and discharge.

N

Some data were collected but there was no evidence of systematic collection of data covering all aspects of the QS. Work was in progress to address this via the OASIS system.

GN-702

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each Care Cluster offered by the service (QS GN-502).

N

Evidence demonstrating a rolling programme of audit was not available. Not all the clinical guidelines for the care clusters were complete.

GN-703

Monitoring of Staff Retention and Turnover The service should monitor and regularly review staff retention and turnover.

Y

GN-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, incidents and ‘near misses’.

Y

GN-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

N

Governance

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Some documents were not in the Trust format.

73

MENTAL HEALTH – NHS DUDLEY COMMISSIONING Ref

Quality Standard

Met?

Comments

Support for service users and carers GZ-101

Advocacy Services Advocacy services to support people with dementia in their contacts with services should be commissioned. Commissioners should ensure information about these services is available in primary care.

N

Advocacy services were commissioned for those with mental health problems but not specifically for those with dementia.

GZ-102

Mental Health Promotion Programme Commissioners should ensure a programme of mental health promotion and reducing stigma is run. This programme should include input from service users and carers.

Y

A local campaign was in place 'Its good to be you' which included positive steps for mental well being and tackled stigma. There was also access to mental health programme grants commissioning projects to promote mental health, well being and tackle stigma.

Primary Care Development Programme Commissioners should ensure that a programme of training and development of primary care staff in the prevention, recognition, screening, early intervention, user and carer experience and ongoing care of people with mental health problems is available (QS GA-299).

N

A training and development programme for primary care staff was not yet in place.

Staffing GZ-299

Guidelines and Protocols GZ-597

Information Sharing Agreement Commissioners should ensure inter-agency guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life have been agreed.

Y

Service organisation and liaison with other services GZ-601

Commissioning: Mental Health Services An appropriate range of the following services for the local population should be commissioned: a. Primary care-based psychological therapies b. Early Intervention Service c. Community Mental Health Service d. Acute Care Service (Crisis Resolution Home Treatment) e. Acute Care Service (In-patient) f. Assertive Outreach Service g. Mental Health Liaison Service. For each service commissioners should identify the Care Clusters which the service should offer. For each service commissioners should define whether they are expected to care for service users who also have: a. substance misuse problems b. complex needs, including personality disorders c. learning disabilities and /or other neurodevelopmental disorders including Asperger’s

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Y

A matrix available.

of

services

74

was

Ref

GZ-602

Quality Standard

Met?

Syndrome, Autistic Spectrum Condition and ADHD d. other dual diagnoses e. age 16 to 18 who have previously been in contact with child and adolescent mental health services f. age 16 to 18 who have not previously been in contact with mental health services. Commissioning: Mental Health Services – Detail Commissioners should have agreed the indications and arrangements for referral to each service (QS GZ-601). The criteria for acceptance by each service should be explicit about the groups of service users listed in QS GZ-601 (i to vi). The referral criteria for CRHT should include: a. all clients where hospital admission is being considered b. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals.

Comments

Y

GZ-603

Information for Primary Care The indications and arrangements for referring clients to each service should be circulated regularly to GPs, other mental health services, police, social services and Emergency Departments within the catchment area of the service.

N

There was a Multi Agency Operational Policy of Section 136 of the Mental Health Act 1983, but it was not clear what information had been circulated to GPs.

GZ-604

Residential and Day Opportunities Commissioners should ensure a range of residential and day opportunities are available as alternatives to admission to in-patient care

Y

GZ-605

Criminal Justice Liaison Arrangements for criminal justice liaison which take account of the needs of people with mental health problems should have been agreed.

Y

Audit of services for Criminal Justice Liaison was undertaken in 2009.

GZ-701

Partnership Board (or equivalent) Arrangements for coordinating mental health strategy and ensuring effective inter-agency cooperation should be in place. These arrangements should involve users and carers, local providers, social services, voluntary organisations and other relevant organisations.

Y

A Partnership Board took place but was poorly attended by mental health providers.

GZ-702

Needs Assessment An assessment of the need for mental health services should have been undertaken which includes consideration of the needs of people with mental health problems who also have: a. substance misuse problems b. complex needs, including personality disorders c. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD d. other dual diagnoses e. age 16 to 18 who have previously been in contact with child and adolescent mental health services f. age 16 to 18 who have not previously been in contact with mental health services.

Governance

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N

The Needs Assessment did not cover the specific data required for a-f. The Needs Assessment was partially addressed in the Mental Health Strategy using national prevalence data and some locally collected data.

75

Ref

Quality Standard

Met?

Comments

GZ-703

Strategy A strategy for meeting the needs of people with dementia and their carers should have been agreed. This strategy should ensure a holistic pathway of care for people with mental health problems and their carers with an integrated approach across health and social care and the voluntary sector. It should address the specific needs of the groups identified in QS GZ-702.

N

Only the Working Age Strategy was available.

GZ-704

Quality Monitoring – Primary Care Commissioners should ensure that all general practices are: a. Offering a comprehensive, annual health check to all people with serious mental illness registered with their practice (QS GA-103) b. Collecting data on people with serious mental illness registered with their practice (QS GA-701).

Y

All GPs complete QOF and compliance was based on MH9 data

GZ-705

Prisoner Primary Care Commissioners responsible for prison health services should ensure that QS GZ-704 is met by these services

N/A

GZ-706

Quality Monitoring – Mental Health Services For each mental health service commissioned (QS GZ601), arrangements for regular review of the quality of services should be in place, including regular review of: a. number of clients not considered appropriate or not accepted for some other reason, b. key user journey indicators c. compliance with the Quality Standards.

N

Services were all reviewed and for NHS providers this included the Clinical Quality Review meetings and 'appreciative visits'. These did not cover the requirements 'a-c' in the QS.

MENTAL HEALTH – NHS WALSALL COMMISSIONING Ref

Quality Standard

Met?

Comments

Support for service users and carers GZ-101

Advocacy Services Advocacy services to support people with dementia in their contacts with services should be commissioned. Commissioners should ensure information about these services is available in primary care.

Y

GZ-102

Mental Health Promotion Programme Commissioners should ensure a programme of mental health promotion and reducing stigma is run. This programme should include input from service users and carers.

Y

Two projects were in place; Mental Health First Aid and a well -being project targeted at the Black and Minority ethnic community.

Primary Care Development Programme Commissioners should ensure that a programme of training and development of primary care staff in the prevention, recognition, screening, early intervention, user and carer experience and ongoing care of people with mental health problems is available (QS GA-299).

N

A training and development programme for primary care staff was not yet in place.

Staffing GZ-299

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Ref

Quality Standard

Met?

Comments

Guidelines and Protocols GZ-597

Information Sharing Agreement Commissioners should ensure inter-agency guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life have been agreed.

Y

Service organisation and liaison with other services GZ-601

Commissioning: Mental Health Services An appropriate range of the following services for the local population should be commissioned: a. Primary care-based psychological therapies b. Early Intervention Service c. Community Mental Health Service d. Acute Care Service (Crisis Resolution Home Treatment) e. Acute Care Service (In-patient) f. Assertive Outreach Service g. Mental Health Liaison Service. For each service commissioners should identify the Care Clusters which the service should offer. For each service commissioners should define whether they are expected to care for service users who also have: a. substance misuse problems b. complex needs, including personality disorders c. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD d. other dual diagnoses e. age 16 to 18 who have previously been in contact with child and adolescent mental health services f. age 16 to 18 who have not previously been in contact with mental health services.

N

There was no service for 16 to 18 year olds with no previous contact with CAMHS. Care clusters were not yet identified. Services a-g were available though liaison services for older adults were provided through the Walsall Healthcare NHS Trust discharge liaison team.

GZ-602

Commissioning: Mental Health Services – Detail Commissioners should have agreed the indications and arrangements for referral to each service (QS GZ-601). The criteria for acceptance by each service should be explicit about the groups of service users listed in QS GZ-601 (i to vi). The referral criteria for CRHT should include: a. all clients where hospital admission is being considered b. all Mental Health Act Assessments People with dementia should not be excluded from CRHT referrals.

Y

Covered in service specifications

GZ-603

Information for Primary Care The indications and arrangements for referring clients to each service should be circulated regularly to GPs, other mental health services, police, social services and Emergency Departments within the catchment area of the service.

N

Referral information for Primary Care had not been distributed.

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Ref

Quality Standard

Met?

Comments

GZ-604

Residential and Day Opportunities Commissioners should ensure a range of residential and day opportunities are available as alternatives to admission to in-patient care

Y

A range of services was commissioned, including from the Third Sector

GZ-605

Criminal Justice Liaison Arrangements for criminal justice liaison which take account of the needs of people with mental health problems should have been agreed.

N

Agreed arrangements were not in place.

GZ-701

Partnership Board (or equivalent) Arrangements for coordinating mental health strategy and ensuring effective inter-agency cooperation should be in place. These arrangements should involve users and carers, local providers, social services, voluntary organisations and other relevant organisations.

N

The Partnership Board had been reorganised but there were no user and carer representatives.

GZ-702

Needs Assessment An assessment of the need for mental health services should have been undertaken which includes consideration of the needs of people with mental health problems who also have: a. substance misuse problems b. complex needs, including personality disorders c. learning disabilities and /or other neurodevelopmental disorders including Asperger’s Syndrome, Autistic Spectrum Condition and ADHD d. other dual diagnoses e. age 16 to 18 who have previously been in contact with child and adolescent mental health services f. age 16 to 18 who have not previously been in contact with mental health services.

N

The evidence available did not cover 'a to g'.

GZ-703

Strategy A strategy for meeting the needs of people with dementia and their carers should have been agreed. This strategy should ensure a holistic pathway of care for people with mental health problems and their carers with an integrated approach across health and social care and the voluntary sector. It should address the specific needs of the groups identified in QS GZ-702.

N

Work was in progress to develop and agree a strategy.

GZ-704

Quality Monitoring – Primary Care Commissioners should ensure that all general practices are: a. Offering a comprehensive, annual health check to all people with serious mental illness registered with their practice (QS GA-103) b. Collecting data on people with serious mental illness registered with their practice (QS GA-701).

Y

All GPs complete QOF and compliance was based on MH9 data

GZ-705

Prisoner Primary Care Commissioners responsible for prison health services should ensure that QS GZ-704 is met by these services

N/A

Governance

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Ref GZ-706

Quality Standard Quality Monitoring – Mental Health Services For each mental health service commissioned (QS GZ601), arrangements for regular review of the quality of services should be in place, including regular review of: a. number of clients not considered appropriate or not accepted for some other reason, b. key user journey indicators c. compliance with the Quality Standards.

Met?

Comments

N

Services were all reviewed and for NHS providers this included the Clinical Quality Review meetings and 'appreciative visits'. These did not cover the requirements 'a-c' in the QS.

NHS WALSALL DEMENTIA COMMISSIONING Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers KZ-101

Advocacy Services Advocacy services to support people with dementia in their contacts with services should be commissioned. Commissioners should ensure information about these services is available in primary care.

Y

As well as IMHA and IMCA, Age Concern were commissioned for Older Adults, including those with dementia

KZ-102

Dementia Awareness Programme Commissioners should ensure that a ‘dementia awareness’ programme is run, targeted at the public, schools and key voluntary and statutory organisations. This programme should cover prevention, early identification and where to go for further information.

Y

Web-based information was available as well as POD casts. The 'My NHS Parliament' also undertook dementia presentation awareness events.

KZ-201

Primary Care Dementia Liaison Worker A lead primary care professional for people with dementia with responsibilities as described in QS KA601 should be employed or commissioned. There should be arrangements for cover for absences of the lead primary care professional for people with dementia.

N

Plans were in place for this to be addressed in the RATT service

KZ-202

Long-term Care Development Programme Commissioners should ensure that a dementia awareness programme is offered to staff providing longterm care of people with dementia covering dementia prevention, recognition, screening, early intervention, user and carer experience, ongoing care, local services and how to obtain advice in an emergency (QS KP-202).

Y

Train the Trainer programme was in place targeting community staff, social care and hospital staff.

KZ-299

Primary Care Development Programme Commissioners should ensure that a programme of training and development of primary care staff in dementia prevention, recognition, screening, early intervention, user and carer experience, ongoing care, local services and how to obtain advice in an emergency is available (QS KA-299).

N

This was planned to commence in autumn 2011

Staffing

Guidelines and Protocols KZ-501

Circulation of Memory Service Information Commissioners should support and assist local Memory Services in meeting QSs KN-605 and KN-607.

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Y

79

Ref KZ-597

Quality Standard Information Sharing Agreement The Partnership Board (or equivalent) should have agreed guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life.

Met?

Comments

Y

Service Organisation and Liaison with Other Services KZ-601

Commissioning: Memory Service/s The following services should be commissioned: a. Memory assessment and diagnosis service/s b. Follow up and ongoing support service/s for people with dementia These may be commissioned as a combined service or as separate services. For each service there should be: i Agreed criteria and arrangements for acceptance by the service ii Timescales for start and completion assessment (KN-601 or more stringent timescales) iii Agreed therapeutic interventions offered, including prescribing responsibility for pharmacological interventions and any shared care arrangements with general practice iv Agreed criteria and arrangements for discharge.

N

The QS was met apart from 'ii' which was being explored.

KZ-602

Commissioning: Other Services The following services for people with dementia should be commissioned: a. Education and training programme for carers of people with dementia b. Acute care mental health services (including crisis resolution / home treatment) with criteria for acceptance which include people with dementia c. Community palliative care service support for people with dementia who are in long-term care d. Community neuro-rehabilitation services for people with cognitive impairment as a result of alcohol or drug misuse- related brain damage.

N

Areas 'b and d' were commissioned

KZ-603

Commissioning: Long-term Care for People with Dementia Any long-term care commissioned for people with dementia should be commissioned to meet Quality Standards KP-105 to KP-799 (or equivalent standards).

Y

A new unit had been recently commissioned which provided respite, day and long term care.

Partnership Board A Partnership Board (or equivalent) with responsibility for improving services for people with dementia should meet regularly. The Board membership should include, at least, service users and carers, commissioners of health and social care, local Memory Service/s, providers of long-term care for people with dementia, relevant ‘third sector’ organisations, and primary care representatives. The Board should have mechanisms for involving service users and their carers in its work.

N

The Mental Health Board had recently ceased. The Older Adult Partnership Board met which partly covered the dementia agenda

not

Governance KZ-701

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80

Ref

Quality Standard

Met?

Comments

KZ-702

Needs Assessment An assessment of the need for dementia services should have been undertaken covering at least: a. memory assessment and diagnosis services b. support for people with dementia living at home c. support for people with dementia who are in prison d. support for carers of people with dementia e. long-term care for people with dementia f. specific needs of people with young-onset dementia, alcohol-related dementia and people with learning disabilities who have dementia.

Y

KZ-703

Strategy A strategy for meeting the needs of people with dementia and their carers should have been agreed. This strategy should ensure a holistic pathway of care for people with dementia and their family carer/s with an integrated approach across health and social care and the voluntary sector. It should address the specific needs of people with young-onset dementia, alcoholrelated dementia and people with learning disabilities who have dementia.

N

KZ-704

Quality Monitoring – Long Term Care Arrangements for regular review of the quality of services provided by long-term care providers should be in place. Appropriate action should be taken to tackle any issues identified through quality monitoring.

Y

KZ-705

Quality Monitoring – Primary Care Commissioners should monitor local general practices’: a. Proportion of patients diagnosed with dementia b. Compliance with referral guidelines (all primary care services) c. Proportion of patients with dementia who had had a review of their physical health in the last year. Appropriate action should be taken to tackle any issues identified through quality monitoring.

N

Data were unavailable and felt to be the responsibility of primary care commissioning/contracting

KZ-706

Quality Monitoring – Memory Service/s Arrangements for regular review of the quality of services provided by the Memory Service/s should be in place, including regular review of: a. Times from referral to start and completion of assessment (QS KN-601) b. Proportion of patients allocated a ‘key worker’ Appropriate action should be taken to tackle any issues identified through quality monitoring.

N

Data had been requested from Dudley & Walsall Mental Health Partnership NHS Trust but had not yet been received.

KZ-707

Other Strategies Commissioner’s strategies for reducing cerebrovascular disease risk factors, including the prevention of obesity, reducing smoking, and the prevention of alcohol misuse, should take into account the potential for the prevention of dementia.

Y

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A local strategy was in the process of being developed.

81

PRIMARY CARE - WALSALL HEALTH SERVICES FOR PEOPLE WITH LEARNING DISABILITIES Ref

Quality Standard

Met?

Comments

Support for Service Users and Carers LA-101

Reasonable Adjustments Each general medical practice, dental practice and opticians should be able to state the ‘reasonable adjustments’ that the practice makes for people with learning disabilities in order to ensure that they have access to full range of services and choices (including National Choice policy).

Y

A health check was in place and used.

LA-102

Advocacy Services Information on advocacy services available for patients should be clearly displayed.

Y

Information was available but may benefit from review to include all available services.

LA-103

Annual Health Check Each general practice should offer a comprehensive annual health check to all people with learning disabilities registered with their practice, including access to: a. all relevant national screening programmes b. screening for dementia c. keeping healthy and preventing diseases d. contraception and sexual health e. review of medication (if applicable) f. Details of main carer/s and carer support needs (if appropriate) ‘Reasonable adjustments’ should be offered to people with learning disabilities to enable them to take up this offer.

N

Service users reported that there was a variation in practice and’d’ did not appear to be addressed.

LA-104

Health Action Plan Following their annual health check, all people with learning disabilities should be offered a Health Action Plan covering: a. Name and personal information b. If appropriate, family carer / carer details c. Reasonable adjustments needed d. Medication e. Who to contact if you need help f. Nature of illness/es or health concern g. Communication issues h. Allergies i. Keeping healthy (smoking, alcohol, weight control, mental health promotion) j. Arrangements for dental, eye and hearing care (if required) k. Screening history and planned screening l. Mobility requirements A summary of the Health Action Plan should be in an accessible format (for example, ‘easy-read’). The Health Action Plan should be recorded in their notes.

Y

See good practice section.

Staffing

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82

Ref LA-299

Quality Standard Training and Development General practice staff should attend the programme of training and development of primary care staff in responsiveness to the needs of people with learning disabilities.

Met?

Comments

Y

The health facilitation team was implementing a programme of awareness for GPs and practice staff.

N

An information sharing agreement had not yet been agreed by the Partnership Board.

This QS was not reviewed at this visit.

Guidelines and Protocols LA-597

Sharing Information Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Service Organisation and Liaison with Other Services LA-601

Referral Information Each general practice should have a system for ensuring that referrals of people with a learning disability to other services identify the reasonable adjustments that may be needed.

N/A

LA-602

Primary Care Learning Disabilities Liaison Worker A lead professional/s should be available with responsibility for: a. Liaison between general practices, community-based learning disability services, specialist health services for people with learning disabilities and other relevant health services (eg dentistry; pharmacy, diabetes services, cancer services; chiropody; podiatry) b. Supporting the training and development of primary care staff in responsiveness to the needs of people with learning disabilities c. Monitoring the number of practices achieving relevant Quality Standards and working to increase this number. d. Ensuring annual health checks are offered to and Health Action Plans produced for people with learning disabilities who do not have a general practitioner (for example, travelling families or people who are homeless). There should be arrangements for cover for absences of the lead professional/s.

Y

Practice Register Each general practice should have a register which identifies people with a learning disability registered with the practice, including: a. Demographic details (age, gender, ethnicity and postcode) b. Appropriate Read code c. Whether they are parents or carers of a child d. Whether they are a carer of an adult e. Whether their main carer is aged 60 or over This information should be shared with Commissioners on an annual basis.

Y

Governance LA-701

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General practice registers had been compared with Local Authority data by the Strategic Health Facilitator and Practice Managers. Registers had been developed identifying patients with moderate to profound learning disabilities. Work on appropriate coding of mild learning disabilities had also taken place. Registers were ratified annually.

83

SPECIALIST LEARNING DISABILITIES SERVICES - WALSALL HEALTH SERVICES FOR PEOPLE WITH LEARNING DISABILITIES Ref

Quality Standard

Met?

Comments

The information for carers did not cover all aspects of the QS. The information for service users was very good.

Support for Service Users and Carers LN-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

N

LN-102

Information about the Service Information should be available for service users and their carers covering at least: a. Directions to appointments b. Brief description of the service c. Advocacy and support services available and how to access them (QS LN-101) d. How to contact the service (for example, to change an appointment) e. Staff of the service f. Belongings, visiting arrangements and daily routine (in-patient services only) g. How to provide feedback on the service, including how to make a complaint and how to report safeguarding concerns h. How to get involved in improving services (QS LN-199) This information should be in a range of accessible formats, including ‘easy-read’.

Y

LN-103

Information about Therapeutic Interventions Information should be available for service users and, if appropriate, their carers covering at least: a. Description and implications of different types of learning disability b. Therapeutic interventions and expected outcomes c. Discharge from the Specialist Learning Disabilities Service This information should be in a range of accessible formats, including ‘easy-read’.

Y

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Information was available in easy read and via a video.

84

Ref

Quality Standard

Met?

LN-104

‘Keeping Health’ Information ‘Keeping healthy’ information for service users and their carers should be available covering at least: a. Diet and exercise b. Avoiding smoking and excessive alcohol consumption c. Contraception and sexual health d. Screening services This information should be in a range of accessible formats, including ‘easy-read’.

Y

LN-105

Long-term In-patients: Annual Health Check and Health Action Plan Service users who are in-patients for over a year should be offered a comprehensive annual health check (QS LA103) and a Health Action Plan (QS LA 104), including a summary of their Health Action Plan in an accessible format (for example, ‘easy-read’).

Y

LN-106

Care Plan Each service user and, where appropriate, their carer should agree their Care Plan. Service users and, where appropriate, their carers should be offered a copy of their Care Plan covering at least: a. Named Worker (ie Who to contact for help) b. Planned therapeutic interventions c. Expected goals / outcomes of the therapeutic interventions d. Early warning signs of problems and what to do if these occur e. Advance care directives (if any) f. Relapse prevention plan (if applicable) g. Risk management plan h. Review date i. Expected discharge date Service users should be given a copy of their care plan in an accessible format (for example, ‘easy-read’).

Y

LN-107

Explaining Information Support to explain the available information (QSs 102 to LN-104 and LN 106) to service users and, if appropriate, carers should be available.

Y

LN-108

Information on Transition to Adult Care Information should be available for young people and their family carers on transition to adult care. This information should cover all aspects of the transition (QS LN-506).

Y

LN-109

Children’s Services – Environment & Education Services caring for children should have: a. A child and young-person friendly environment b. Low-stimulation environments for young people who need them, including designated quite areas c. A range of developmentally-appropriate play equipment and reading material d. Education facilities (in-patient services only)

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Comments

Reasonable support was available.

N/A

85

Ref

Quality Standard

Met?

Comments

LN-198

Carer Assessment Each family carer should be offered an assessment of their own needs and information and advice on services available to provide support.

N

LN-199

Involving Users and Carers The service should have: a. Mechanisms for receiving feedback from service users and carers b. A rolling programme of audit of service users’ and carers’ experience c. Mechanisms for involving service users and, where appropriate, carers in decisions about the organisation of the service. d. Links with the local User and Carer Engagement Leads.

Y

LN-201

Lead Practitioner and Manager The service should have a nominated lead practitioner and lead manager.

Y

LN-202

Staffing Levels The service should have sufficient staff with appropriate competences to deliver: a. the assessments, therapeutic interventions and rehabilitation for the usual number of service users and their usual level of need / complexity of care required; b. the service’s role in the identification and management of service users’ physical health needs (QS LN-504) c. the service’s role in diagnosis, capacity assessment, prescribing and Mental Health Act assessment. Staffing levels should be based on a competence framework covering skill mix, staffing levels and competences expected (QS LN-203). The relationship between the competence framework and the usual number of service users, their needs / complexity and the therapeutic interventions offered should be clearly identified.

Y

LN-203

Competence Framework and Training Plan A competence framework should cover expected competences for roles within the service (QS LN-202), including in Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. A training and development programme should ensure that all staff have, and are maintaining, these competences.

Y

A training matrix was in place.

LN-204

Crisis Advice Available 24/7 Specialist advice and support should be available at all times for service users and carers in crisis and for other agencies caring for service users in crisis.

Y

There was a single point of access telephone number that service users, carers and professionals could access for advice.

Following discussions with service users and carers it was not clear that carers assessments were consistently offered. Carers who met the reviewing team felt this could be improved.

Staffing

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86

Ref

Quality Standard

Met?

Comments

LN-205

Nominated Links - Other Services The service should have a nominated link practitioner for each of the following areas: a. Primary care b. Challenging behaviour c. Autistic Spectrum Condition d. Attention Deficit Hyperactivity Disorder e. Profound and multiple disabilities f. Forensic services g. Epilepsy h. Memory services i. Speech and language therapy j. Mobility k. Assistive Technology l. Prevention and treatment of physical health problems, including obesity, coronary heart disease and diabetes m. Links with local acute services n. Transition between children’s and adult services o. End of life care The nominated link should take a lead role in relation to guidelines, staff development and liaison with relevant services.

N

The nominated links for c, d, e, j, k and o were not identified.

LN-206

Cultural Change The service should run a programme which positively develops staff attitudes to empowering and enabling service users so that they can take responsibility for their own health and care and live as independently as possible.

Y

Equality Impact assessments were used but were not very detailed.

LN-298

Clinical and Managerial Supervision All practitioners should receive regular clinical and managerial supervision appropriate to their role.

Y

A policy was available

LN-299

Administrative and Clerical Support Administrative and clerical support should be available.

Y

Support Services LN-301

General Support for Service Users and Carers See QS LN-101.

N

LN-302

Support Services Timely access to the following services should be available: a. Primary dental and optical services with particular expertise in the care of people with learning disabilities b. Physiotherapy, podiatry, hearing and nutritional services with particular expertise in the care of people with learning disabilities c. Assistive technology for people with complex needs including i advanced communication equipment Ii technology to access information in languages and formats appropriate to people with learning disabilities.

Y

As LN-101. The information for carers did not cover all the aspects of the QS. The information for service users was very good.

Facilities and Equipment

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87

Ref

Quality Standard

Met?

LN-401

Facilities for Seeing Service Users and Carers Community-based services only: Appropriate facilities should be available for the service’s work with users and carers.

Y

LN-402

Team Accommodation Accommodation for the service should be sufficient for the whole team, including space for team meetings.

Y

LN-403

Assistive Technology A range of assistive technology should be available to support service users in living independently.

Y

LN-404

In-patient Facilities In-patient services should comply with the Environment and Equipment section of the Standards for Adult Inpatient Learning Disability Units (Accreditation for Inpatient Mental Health Services – Learning Disabilities (AIMS-LD), Royal College of Psychiatrists (2009).

Y

Comments

Accommodation was not seen. Compliance was based on the service’s self assessment.

Guidelines and Protocols LN-501

Assessment and Care Planning Guidelines Guidelines on assessment and care planning should be in use. This should ensure involvement of service users and, if appropriate, carers in developing the care plan. The care plan should cover: a. Named Worker (i.e. Who to contact for help) b. Planned therapeutic interventions c. Expected goals / outcomes of the therapeutic interventions d. Early warning signs of problems e. Advance care directives (if any) f. Relapse prevention plan (if applicable) g. Risk management plan h. Review date i. Expected discharge date The care plan and any revisions following review should be communicated to the service user, their general practitioner and, if appropriate, their carer/s. It should also be recorded in their case notes.

N

LN-502

Clinical Guidelines Clinical guidelines should be in use for each care pathway offered by the service. For each care pathway the guidelines should cover therapeutic activities, medication and prescribing (if applicable), and expected frequency of review.

Y

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Evidence for b, c, d, e, f and i was not available.

88

Ref

Quality Standard

Met?

Comments

LN-503

Clinical Guidelines – Detail Clinical guidelines (QS LN-502) should be explicit about alterations to the therapeutic interventions expected for service users with: a. A risk of harm to themselves or others (including consideration of safeguarding children and vulnerable adults) b. Dual diagnosis c. Substance misuse problems d. Profound or complex needs e. Dementia Clinical guidelines should also be explicit about: i. Criteria for admission to in-patient care and for access to alternatives to admission ii. Care and management of pregnant and lactating women iii. Service users with young children.

N

Specific information for c and d was not seen.

LN-504

Physical Health Care Evidence-based clinical guidelines should be in use covering the management of, at least: a. Diabetes b. Coronary Heart Disease and raised risk factors c. Epilepsy d. Dementia e. Pain

Y

The guidelines for CHD would benefit from being more explicit.

LN-505

Referral Guidelines Guidelines should be in use covering the indications and arrangements for seeking advice from, referral to, and discharge from the following services: a. Memory services b. Mental health services c. Speech and language therapy services d. Mobility services e. Services specialising in the care of people with challenging behaviour f. Services specialising in the care of people with autism g. Services specialising in the care of people with profound and multiple disabilities h. In-patient services for people with learning disabilities i. Forensic services j. Services specialising in the use of assistive technology k. Palliative care services Guidelines should include a requirement to identify on the referral any reasonable adjustments that may be needed.

N

Indications were available but not clear guidance covering arrangement for seeking advice.

LN-506

Transition to Adult Care Guidelines should be in use covering transition from children’s to adult services which should include: a. Age guidelines for the timing of the transfer b. Involvement of the young person and their carer/s in the decision about transfer, with advocacy, if required. c. Involvement of other agencies, including the young person’s general practitioner in planning the transfer d. Joint children’s / adult service meeting/s in order to plan the transfer to adult care e. A transition plan for each young person f. An annual health check to inform planning for adult

Y

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89

Ref

Quality Standard

Met?

Comments

services g. Allocation of a named coordinator for the transfer of care h. A preparation period prior to transfer to adult care i. Arrangements for monitoring during the time immediately after transfer to adult care. These guidelines should have been agreed with the children’s / adult service to/from which service users are usually transferred. LN-507

Out of Area Placements & Bespoke Packages of Care Staff should be aware of Commissioner guidelines on consideration of out of area placements and bespoke packages of care for people with learning disabilities and complex needs.

N

Work was in progress to develop guidelines.

LN-593

Discharge Planning A discharge planning policy should be in use which ensures that a discharge plan is agreed with the service user and, if appropriate, their carer. The discharge plan should be communicated to the service user, their general practitioner and, if appropriate, their carer and should be recorded in their case notes.

N

Discharge planning did not appear to reflect the discharge policy.

LN-594

Mental Capacity Act and Deprivation of Liberty Safeguards A policy on adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards should be in use.

Y

LN-595

General Policies The following policies should be in use: a. Lone Working b. Medicines Management c. Health and Safety d. Risk assessment and management

Y

LN-596

Safeguarding Policy A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for investigation and, if necessary, referral of complaints and incidents relating to the care of children and vulnerable adults b. Expected staff training c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy).

Y

LN-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Y

There were Trust-wide policies however localisation might be helpful.

Service Organisation and Liaison with Other Services

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90

Ref

Quality Standard

Met?

Comments

LN-601

Operational Policy An operational policy should be in use covering the work of the Specialist Learning Disabilities Service. This should cover, at least: a. Policy on ‘reasonable adjustments’ b. Ensuring each stage of the individual’s ‘user journey’ takes place within expected timescales c. Responsibilities for giving information to service users and carers (QSs LN-102 to LN-104) d. Allocation of a named worker for each service user who is responsible for coordination of their care e. Responsibilities of the named worker, including during any in-patient admissions or out of area placements f. Involvement of service users and, if appropriate, carers in the care planning process g. Providing appointments for service users outside normal working hours, if required h. Liaison with primary care services, especially on service users who have not been offered an annual health check (QS LA-103) and a Health Action Plan (QS LA-104). Where there is more than one provider of specialist learning disabilities services for an area, the operational policy should also cover the arrangements for liaison and communication between these services.

N

There was no overall operational policy that staff could access although various aspects were covered in other policies. Work was in progress to develop an overarching operational policy with the new organisation - Black Country Partnership NHS Foundation Trust.

LN-602

Operation Policy – Liaison with Social Care If the Service is not integrated with the social care Learning Disabilities Specialist Service, the operational policy (QS LN-601) should be clear about the way in which the service links with the social care Learning Disabilities Specialist Service, including for: a. Assessment b. Multi-disciplinary review of care plans c. Staff training d. Service development

Y

LN-603

Liaison with Community Paediatric Services Services caring for children should have arrangements for liaison with community paediatric services.

N/A

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91

Ref

Quality Standard

Met?

LN-604

Operational Policy – In-patient Services In-patient services only: An operational policy should be in use which ensures: a. Staff from the in-patient service are involved in preadmissions discussion about whether the unit is suitable for the individual’s needs b. Pre-admission assessments are undertaken jointly by the in-patient and referring community team c. Individuals being referred and their carers have information about the in-patient service (QS LN-102) d. The opportunity for individuals being referred routinely (ie not as emergencies) to visit the unit prior to admission wherever possible e. All relevant information on the individual is transferred as soon as possible f. Any individuals who are in-patients for over a year have an Annual Health Check and Health Action Plan (QS LA-103 and LA-104) at least annually. g. Discharge planning, including a meeting with community-based services and future carers to which the individual’s care will be transferred prior to discharge. h. Information on the individual’s in-patient stay and care plan at discharge is communicated to relevant community-based services, including the referring community team. i. Follow up reviews are arranged as necessary.

N

The operation policy did not cover all the requirements of the QS.

LN-605

Review Meetings – Other Services The service should meet at least annually with services to which individuals are regularly referred (QS LN-505) in order to review liaison arrangements and resolve any problems identified.

Y

Evidence of review meetings was seen.

LN-606

Liaison with Referring Services In-patient and specialist services which accept referrals from community-based specialist learning disability services should: a. Ensure referring community-based services have information on criteria and arrangements for referral b. Meet at least annually with referring communitybased services in order to review liaison arrangements and resolve any problems identified.

Y

Admission criteria and outcomes needed to be further developed.

LN-607

Primary Care Liaison The service should have arrangements for liaison with the link primary care professional (QS LA-602).

Y

Primary care liaison was excellent.

LA-608

Acute Hospital Liaison The service should have arrangements for liaison with the link professional for people with learning disabilities in the local general acute hospitals and should contribute to acute hospital training and development programmes

Y

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Comments

92

Ref

Quality Standard

Met?

Comments

LA-609

Links with Partnership Board (or equivalent) The service should link effectively with the Partnership Board (or equivalent) with responsibility for improving services for people with learning disabilities through attendance at meetings or through arrangements for influencing and getting feedback on its work.

Y

LN-699

Primary Care Training and Development The service should contribute to primary care training and development programmes (QS LA-299)

Y

LN-701

Data Collection There should be regular collection of data and monitoring of: a. Referrals, including source of referral b. Individuals not considered appropriate for the service, including reason why not considered appropriate and onward referral destination / ‘signposting’ c. Individuals not accepted by the service for some other reason d. Key indicators of individual’s ‘user pathway’ e. Discharges, including expected care after discharge f. Delayed discharges g. Minimum data set

N

Some data were collected on 'Pacesetter' and via the health action plans but data covering all aspects of the QS were not available.

LN-702

Audit The service should have a rolling programme of audit of compliance with the clinical guidelines for each therapeutic intervention offered by the service (QS LN502).

Y

An audit programme was in place with service user and carer involvement.

LN-703

Service Strategy The service should have a strategy for its development over the next three to five years.

N

The service strategy was under review.

LN-798

Review and Learning The service should have appropriate arrangements for review of, and implementing learning from, positive feedback, complaints, outcomes, critical incidents and ‘near misses’.

Y

Robust systems were in place.

LN-799

Document Control All policies, procedures and guidelines should comply with Trust (or equivalent) document control procedures.

N

All policies were due for review in 2010.

Governance

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93

COMMISSIONING - NHS WALSALL HEALTH SERVICES FOR PEOPLE WITH LEARNING DISABILITIES Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers LZ-101

Advocacy Services Advocacy services to support people with learning disabilities in their contacts with health services should be commissioned. Commissioners should ensure information about these services is available in primary care.

Y

LZ-201

Primary Care Learning Disabilities Liaison Worker A lead primary care professional/s for people with learning disabilities with responsibilities as described in QS LA-602 should be employed or commissioned. There should be arrangements for cover for absences of the lead primary care professional for people with learning disabilities.

Y

LZ-299

Primary Care Development Programme Commissioners should ensure a programme of training and development of primary care staff in responsiveness to the needs of people with learning disabilities is available.

Y

See also main report about information on the various services offered.

Staffing

Guidelines and Protocols LZ-501

Out of Area Placements & Bespoke Packages of Care The following guidelines should have been agreed and circulated to all local providers of specialist learning disabilities services: a. consideration of out of area placements b. developing bespoke packages of care of people with learning disabilities with complex needs

N

Work was in progress to develop guidelines.

LZ-597

Information Sharing Agreement The Partnership Board (or equivalent) (QS LZ-701) should have agreed guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life.

N

Information sharing guidelines had not yet been agreed by the Partnership Board.

Service Organisation and Liaison with Other Services

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94

Ref

Quality Standard

Met?

LZ-601

Commissioning: Primary Care Services with Specialist Expertise The following services should be commissioned to supplement generic primary care services in meeting the needs of people with learning disabilities: a. Primary dental and optical services with particular expertise in the care of people with learning disabilities b. Physiotherapy, podiatry, hearing and nutritional services with particular expertise in the care of people with learning disabilities c. Assistive technology for people with complex needs including i advanced communication equipment ii technology to access information in languages and formats appropriate to people with learning disabilities.

Y

LZ-602

Commissioning: Specialist Learning Disability Services Specialist assessment, treatment and rehabilitation service/s for people with moderate or severe learning disabilities should be commissioned. For each service there should be: a. Agreed criteria and arrangements for acceptance. These criteria should be explicit about the ages and severity of learning disability of people cared for by each service. b. Agreed pathways and therapeutic interventions offered (QS LN-502) c. Agreed criteria and arrangements for discharge, including an agreed definition of ‘ready for discharge’ and agreed discharge planning process (QS LN-593) d. Information in accessible formats about the admission and discharge process. e. If applicable, support for people with learning disabilities during transition to adult services (QS LN506).

N

LZ-603

Information for Primary Care The indications and arrangements for referring clients to each service (QS LZ-602) should be circulated regularly to GPs and other relevant services.

Y

LZ-604

Criminal Justice Liaison Arrangements for criminal justice liaison which take account of the needs of people with learning disabilities should have been agreed.

N

Partnership Board A Partnership Board (or equivalent) with responsibility for improving services for people with learning disabilities should meet regularly. The Board membership should include, at least, service user and carer, commissioner, Specialist Learning Disabilities Service and primary care representatives. The Board should have mechanisms for involving service users and their carers.

Y

Comments

It was not clear from the evidence presented that there was a current plan covering all the requirements of the Quality Standard.

The forensic pathway was under review and there was no evidence relating to prison liaison.

Governance LZ-701

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95

Ref

Quality Standard

Met?

Comments

LZ-702

Needs Assessment Practice data (QS LA-701) on people with learning disabilities and other data should be aggregated and used to predict future need for health services.

N

Evidence of a joint needs assessment was not seen.

LZ-703

Strategy A strategy for meeting the health care needs of people with learning disability and their carers should have been agreed. This should specifically consider the needs of: a. people with learning disabilities from black and minority ethnic groups and their carers b. people with complex or profound learning disabilities c. older people with learning disabilities d. people with learning disabilities and challenging behaviour e. people with learning disabilities who offend f. people with learning disabilities who are in prison g. people with learning disabilities who are carers of a child h. People with learning disabilities who are carers of an adult.

N

The local strategy was under review.

LZ-704

Strategy - Detail The strategy for people with learning disabilities should include: a. access to pre-employment training and education opportunities for people with learning disabilities b. strategies to enable people with learning disabilities to access employment. c. use of assistive technology to promote independence.

N

The local strategy was under review.

LZ-705

Other Strategies Commissioners’ health promotion strategies for reducing obesity and premature death should include reference to the differential needs of people with learning disabilities and actions to address these needs.

N

LZ-706

Quality Monitoring – Primary Care Commissioners should ensure that all general practices are: a. Making ‘reasonable adjustments’ for people with a learning disability registered with the practice (QS LA101) b. offering a comprehensive, annual health check to all people with learning disabilities registered with their practice(QS LA-103) c. offering a Health Action Plan to all people with learning disabilities following their annual health check (details in QS LA-104) d. collecting data on people with learning disabilities registered with their practice (QS LA-701).

Y

LZ-707

Prisoner Primary Care Commissioners responsible for prison health services should ensure that QS LZ-706 is met by these services.

N/A

LZ-708

Quality Monitoring – Learning Disability Services Arrangements for regular review of the quality of services provided by Specialist Learning Disability Services (QS LN-701) should be in place.

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This QS was not applicable as Walsall PCT did not have responsibility for prison health.

Y

96

Ref LZ-709

Quality Standard

Met?

Monitoring – Out of Area Placements Commissioners, working closely with the commissioners of social care, should monitor: a. The number of people with learning disabilities who are being cared for by services outside the local area (out of area placements) b. The expected date of review of each out of area placement c. Whether the individual could be cared for locally and, if so, when this change is expected to take place.

Y

Comments

VULNERABLE ADULTS - ACUTE TRUST-WIDE – DUDLEY GROUP NHS FOUNDATION TRUST Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers MC-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

A Patient Information Officer was in post, with a focus on reviewing patient information and liaising with service users and carers.

MC-102

Raising Concerns Information on how to report compliments, concerns and complaints should be easily available, including information on how to report adult safeguarding concerns.

Y

Information was available in easy read and different languages. The Trust policy flow chart for raising concerns was different from the flow chart in the Emergency Department. The Emergency Department was more explicit about the 'in and out of hours' procedure.

MC-199

Involvement of Vulnerable Adults [1] and their Carers: The Trust’s mechanisms for involving patients and carers should specifically include mechanisms for receiving feedback from and involving vulnerable adults and their carers.

N

The patient experience group did not have carer involvement. It was also not clear from the evidence available if patients attended the group.

Nominated Board-level Lead: The Trust should have a nominated Board-level lead for safeguarding and improving the care of vulnerable adults.

Y

There was a named lead.

Staffing MC-201

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Ref

Quality Standard

Met?

Comments

MC-202

Nominated Adult Safeguarding Lead: The Trust should have a nominated lead for safeguarding adults. This individual should have specific time allocated for this role.

Y

There was a medical and nurse lead. It was not clear that the medical lead had specific time allocated for this role.

MC-203

Lead for Improving the Care of Vulnerable Adults: The Trust should have a nominated lead for improving the care of vulnerable adults. This individual should have specific time allocated for this role.

Y

A nurse lead was in place.

MC-204

Cover for Adult Safeguarding Lead: The arrangements for handling urgent issues during absences of the Safeguarding Lead should be clearly defined.

Y

MC-205

Specialist Clinical Advice A registered healthcare professional or professionals should be available daily, on at least weekdays, to give specialist advice on the care of vulnerable adults to staff working in clinical areas. There should be cover for absences. The healthcare professional/s should have expertise in, at least, the care of patients with: a. Mental health problems b. Dementia c. Learning disabilities

N

Mental health advice was available for over 65s. For under 65s advice was via the Mental Health Trust. This was to be resolved in June 2011 by the mental health liaison team. There was no clinical advisor for people with learning disabilities though some support was available from the PALS officer.

MC-206

Staff Competences and Training Plan The Trust should have agreed a framework of the competences expected for staff in clinical areas and a training and development programme to ensure that staff have, and are maintaining, these competences, covering: a. Adult safeguarding b. Recognising and meeting the needs of vulnerable adults c. Dealing with challenging behaviour, violence and aggression d. Mental Capacity Act and Deprivation of Liberty Safeguards. The competence framework should be specific about timescales for updating.

Y

There was a training plan but, from the evidence in the last annual plan, only 45% of staff had attended MCA and DOLS training.

Support Services MC-301

HR and Legal Advice: The Safeguarding Lead (QS MC-202) should have access to: a. Legal advice and support b. Human resources advice and support

Y

Guidelines and Protocols

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98

Ref

Quality Standard

Met?

MC-501

Identification and Care of Vulnerable Adults: Trust guidelines on identifying vulnerable adults and ensuring appropriate management from an early stage should be in use in all clinical areas. The guidelines should cover at least: a. Access to and use of advance care plans b. ‘Reasonable adjustments’ which will be made in order to respond to the needs of vulnerable adults, including: i flexible arrangements for out-patient appointments ii flexible visiting times and opportunities for overnight stays for families and carers c. Help with feeding and personal care d. Triggering completion of individualised care plans (MM-502) e. Indications and arrangements for accessing: i Specialist clinical advice on the care of vulnerable adults during normal working hours (QS MC-205) ii Specialist clinical advice on the care of vulnerable adults outside normal working hours. f. Data collection on individuals identified as vulnerable (QS MC-501) g. Communication on discharge including, if applicable, communication to the patient’s provider of specialist services (for example, mental health, dementia or learning disability services)

Y

MC-504

Restraint and Sedation: Trust guidelines on dealing with challenging behaviour, violence and aggression should be in use. These should cover the use of restraint and sedation.

Y

The restraint policy was very comprehensive. The sedation policy was general and did not include vulnerable groups and behavioural modification.

MC-505

Missing Patients Guidelines on preventing and managing situations where patients leave the clinical area without making appropriate arrangements should be in use.

N

The missing patient’s policy (2005) on the 'hub' was due for review in 2008.

MC-593

Discharge Policy The Trust discharge policy should be in use which specifies arrangements for discharge of vulnerable adults, including communication on discharge (as QS MC-501)

Y

MC-594

Mental Capacity Act and the Deprivation of Liberty Safeguards: A Trust policy should be in use covering adherence to the Mental Capacity Act and the Deprivation of Liberty Safeguards.

Y

MC-596

Safeguarding Policy: A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for referral and investigation of safeguarding incidents b. Expected staff training (QS MC-206) c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy)

Y

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Comments

The policy may benefit from links to Trust Human Resources and the Multi-Agency Policy.

99

Ref MC-597

Quality Standard

Met?

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Y

Comments

Service Organisation and Liaison with Other Services MC-601

Coordination Mechanism The Trust should have a clear mechanism for coordinating actions to improve the care of vulnerable adults.

Y

An Internal Safeguarding Board reported to the Patient Safety and then the Risk Committee (sub-committee of the Trust Board). Reviewers were impressed that the NonExecutive Director was a member of all of the groups.

MC-602

Participation in Local Safeguarding Adults Board The Trust should actively participate in the work of the Local Safeguarding Adults Board.

Y

The Trust had three staff members who were part of this group. See also 'further consideration' section of the report.

MC-701

Monitoring of Key Performance Indicators The Trust should monitor key performance indicators relating to safeguarding and improving the care of vulnerable adults.

N

MC-702

Audit The Trust should have a programme of audits relating to the care of vulnerable adults. This should include audit of the identification of vulnerable adults (QS MC-501) completion of individualised care plans (QS MM-502) and use of restraint and sedation (QS MC-504)

Y

It was not clear from discussions with staff what specific key performance indicators were collected. See also main report. CQC report on outcome 7 January 2011.

MC-703

Annual Report The Trust Board should receive an annual report on safeguarding and improving the care of vulnerable adults which should cover, at least, the analysis of complaints and incidents (QS MC-102) and progress with staff training (QS MC-206).

Y

MC-798

Review and Learning A system for identifying, analysing, reporting and learning from complaints and serious incidents relating to the care of vulnerable adults should be in use. The analysis should include whether the person was assessed as being particularly vulnerable (QS MC-501).

N

No reports were available although staff said that new arrangements were being piloted.

MC-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

N

Policies were all on the 'hub' though some were due for review.

Governance

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100

VULNERABLE ADULTS CLINICAL – DUDLEY GROUP NHS FOUNDATION TRUST Ref

Quality Standard

Met?

Comments

MM-101

General Support for Service Users and Carers As QS MC-101.

Y

There were plenty of notice boards detailing information.

MM-102

Raising Concerns As QS MC-102.

Y

MM-103

Communication Aids Communication aids to help patients with communication difficulties should be available.

Y

MM-104

Care Plans The individualised care plan for vulnerable patients (QS MM-502) should have been agreed with the patient and, if appropriate, their family or carer.

Y

Take the time' was in place to encourage individualising care plans. There were also standard care plans. There was evidence of individualised care planning.

MM-199

Involving Patients and Carers The service should have: a. Mechanisms for receiving feedback from patients and carers b. Mechanisms for involving patients and carers in decisions about the organisation of the service.

N

Patient and carer involvement was not always in place.

Staff competences As MC-206

N

45% of staff had completed safeguarding training

Staffing MM-201

Guidelines and Protocols MM-501

Identification and care of vulnerable adults As QS MC-501.

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Y

101

Ref

Quality Standard

Met?

MM-502

Individualised Care Plans: A system should be in use which ensures that people identified as being particularly vulnerable (QS MC-501) have a care plan which takes account of their individual needs and circumstances, including: a. Consideration of the need for advocacy and carer / family involvement in care planning b. An assessment of normal functioning, including the need for additional information or assessments c. A programme to return to and maintain normal functioning d. Allocation of a lead healthcare professional who will link with the carer / family e. An assessment of the need for enhanced care while in the ward / department and in other settings (for example, imaging), including need for alterations to the services usual clinical guidelines (QS MM-503) f. Environmental risk assessment g. ‘Reasonable adjustments’ required h. Consideration of the need for informing and involving specialist clinical advice (QS MC-205) i. Arrangements for involving the carer / family in providing care while in hospital j. Date for review of the care plan. k. An estimated date of discharge

Y

MM-503

Clinical Guidelines Clinical guidelines should be in use covering: a. Pain management b. Management of fluids and electrolytes c. Management of acute confusional state d. Falls prevention e. Pressure ulcer prevention f. Nutrition

Y

MM-504

Restraint and Sedation As QS MC-504

N

The sedation policy was general and did not include vulnerable groups and behavioural modification.

MM-505

Missing Patients As QS MC-505

Y

Staff were aware that the policy was available on the intranet.

MM-593

Discharge Policy As QS MC-593

Y

Staff were aware that the policy was available on the intranet.

MM-594

Mental Capacity Act and the Deprivation of Liberty Safeguards As QS MC-594

Y

Staff were aware that the policy was available on the intranet.

MM-596

Safeguarding Policy As QS MC-596

Y

Staff were aware that the policy was available on the intranet.

MM-597

Information Sharing Agreement As QS MC-597

Y

Staff were aware that the policy was available on the intranet.

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Comments Though the care planning approach was not consistent across all the areas visited.

102

Ref

Quality Standard

Met?

Comments

MM-598

Palliative Care Staff should be aware of local guidelines, agreed with the specialist palliative care services serving the local population, for the management of patients with palliative care needs.

Y

Staff were aware that the policy was available on the intranet.

MM-599

End of Life Care Staff should be aware of local guidelines for end of life care.

Y

Staff were aware that the policy was available on the intranet.

VULNERABLE ADULTS - ACUTE TRUST-WIDE – WALSALL HEALTHCARE NHS TRUST Ref

Quality Standard

Met?

Comments

Support for Service Users and their Carers MC-101

General Support for Service Users and Carers Service users and their carers should have easy access to the following services. Information about these services should be easily available: a. Interpreter services, including access to British Sign Language b. Independent advocacy services c. PALS d. Social workers e. Benefits advice f. Spiritual support g. Relevant support groups h. HealthWatch or equivalent organisation i. Where to go for further information

Y

Some information was not easily visible to patients and carers on the ward areas visited.

MC-102

Raising Concerns Information on how to report compliments, concerns and complaints should be easily available, including information on how to report adult safeguarding concerns.

Y

The Easy Read information about raising concerns was very clear.

MC-199

Involvement of Vulnerable Adults[1] and their Carers: The Trust’s mechanisms for involving patients and carers should specifically include mechanisms for receiving feedback from and involving vulnerable adults and their carers.

Y

There was evidence of good patient involvement on the Dignity and Care, Disability Advisory and Patient Experience Groups.

MC-201

Nominated Board-level Lead: The Trust should have a nominated Board-level lead for safeguarding and improving the care of vulnerable adults.

Y

MC-202

Nominated Adult Safeguarding Lead: The Trust should have a nominated lead for safeguarding adults. This individual should have specific time allocated for this role.

Y

Staffing

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103

Ref

Quality Standard

Met?

Comments

MC-203

Lead for Improving the Care of Vulnerable Adults: The Trust should have a nominated lead for improving the care of vulnerable adults. This individual should have specific time allocated for this role.

Y

The Lead had a large operational and training commitment within her role see main report.

MC-204

Cover for Adult Safeguarding Lead: The arrangements for handling urgent issues during absences of the Safeguarding Lead should be clearly defined.

Y

Handover arrangements were in place for planned leave and training. For unexpected absences it was not clear how this would be managed consistently across the organisation. Staff commented on different cascade processes.

MC-205

Specialist Clinical Advice A registered healthcare professional or professionals should be available daily, on at least weekdays, to give specialist advice on the care of vulnerable adults to staff working in clinical areas. There should be cover for absences. The healthcare professional/s should have expertise in, at least, the care of patients with: a. Mental health problems b. Dementia c. Learning disabilities

Y

All were available Monday to Friday. The out of hours arrangement was to contact oncall social services or crisis team.

MC-206

Staff Competences and Training Plan The Trust should have agreed a framework of the competences expected for staff in clinical areas and a training and development programme to ensure that staff have, and are maintaining, these competences, covering: a. Adult safeguarding b. Recognising and meeting the needs of vulnerable adults c. Dealing with challenging behaviour, violence and aggression d. Mental Capacity Act and Deprivation of Liberty Safeguards. The competence framework should be specific about timescales for updating.

Y

Training analysis was available.

Support Services MC-301

HR and Legal Advice: The Safeguarding Lead (QS MC-202) should have access to: a. Legal advice and support b. Human resources advice and support

Y

Guidelines and Protocols

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104

Ref

Quality Standard

Met?

Comments

MC-501

Identification and Care of Vulnerable Adults: Trust guidelines on identifying vulnerable adults and ensuring appropriate management from an early stage should be in use in all clinical areas. The guidelines should cover at least: a. Access to and use of advance care plans b. ‘Reasonable adjustments’ which will be made in order to respond to the needs of vulnerable adults, including: i flexible arrangements for out-patient appointments ii flexible visiting times and opportunities for overnight stays for families and carers c. Help with feeding and personal care d. Triggering completion of individualised care plans (MM-502) e. Indications and arrangements for accessing: i Specialist clinical advice on the care of vulnerable adults during normal working hours (QS MC-205) ii Specialist clinical advice on the care of vulnerable adults outside normal working hours. f. Data collection on individuals identified as vulnerable (QS MC-501) g. Communication on discharge including, if applicable, communication to the patient’s provider of specialist services (for example, mental health, dementia or learning disability services)

Y

Individual guidelines were in place covering the flow chart for outpatients, a trigger plan for identifying vulnerable adults, meal time mate and the red tray system. Evidence was available for all the requirements of the QS though it was not included in wider polices. It may be helpful to review the information and consolidate to make it easier for staff to use.

MC-504

Restraint and Sedation: Trust guidelines on dealing with challenging behaviour, violence and aggression should be in use. These should cover the use of restraint and sedation.

N

There was a violence and aggression policy but this did not cover restraint. Further discussions with staff revealed that restraint was not used as extra staff were allocated on a needs basis. The Trust was planning to implement the 'safe enough to care' training which is about de-escalation and triggers and MAPA, which suggests that the policy would benefit from including this model. The sedation policy referred to general sedation and did not include sedation in response to violence and aggression.

MC-505

Missing Patients Guidelines on preventing and managing situations where patients leave the clinical area without making appropriate arrangements should be in use.

Y

MC-593

Discharge Policy The Trust discharge policy should be in use which specifies arrangements for discharge of vulnerable adults, including communication on discharge (as QS MC-501)

N

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The discharge policy did not specify the arrangements for the discharge of vulnerable adults.

105

Ref

Quality Standard

Met?

Comments

MC-594

Mental Capacity Act and the Deprivation of Liberty Safeguards: A Trust policy should be in use covering adherence to the Mental Capacity Act and the Deprivation of Liberty Safeguards.

Y

The policy on Deprivation of Liberty was due for review in April 2011.

MC-596

Safeguarding Policy: A Safeguarding Policy should be in use. This should cover at least: a. Arrangements for referral and investigation of safeguarding incidents b. Expected staff training (QS MC-206) c. Who staff should contact if they have concerns about safeguarding issues d. Action to take when safeguarding-related allegations are made against a member of staff (or link to relevant HR policy)

Y

It may be helpful to cross reference with other relevant Trust polices e.g. Disciplinary, HR, Complaints and Incidents, Flow Chart.

MC-597

Information Sharing Local guidelines on sharing information about vulnerable groups of the population who are likely to attend other health and social care services regularly or who are approaching the end of life should be in use.

Y

Service Organisation and Liaison with Other Services MC-601

Coordination Mechanism The Trust should have a clear mechanism for coordinating actions to improve the care of vulnerable adults.

Y

MC-602

Participation in Local Safeguarding Adults Board The Trust should actively participate in the work of the Local Safeguarding Adults Board.

Y

MC-701

Monitoring of Key Performance Indicators The Trust should monitor key performance indicators relating to safeguarding and improving the care of vulnerable adults.

Y

MC-702

Audit The Trust should have a programme of audits relating to the care of vulnerable adults. This should include audit of the identification of vulnerable adults (QS MC-501) completion of individualised care plans (QS MM-502) and use of restraint and sedation (QS MC-504)

N

A schedule of audits was available but there was no evidence that change and learning had taken place.

MC-703

Annual Report The Trust Board should receive an annual report on safeguarding and improving the care of vulnerable adults which should cover, at least, the analysis of complaints and incidents (QS MC-102) and progress with staff training (QS MC-206).

Y

The system in place was comprehensive containing details of complaints and staff training.

Governance

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106

Ref

Quality Standard

Met?

Comments

MC-798

Review and Learning A system for identifying, analysing, reporting and learning from complaints and serious incidents relating to the care of vulnerable adults should be in use. The analysis should include whether the person was assessed as being particularly vulnerable (QS MC-501).

Y

The format of reporting to the Trust and the Safeguarding Committee was excellent. There was also evidence of review and learning across various levels of the organisation via the divisional quality meetings and the 'Ward to Board' performance reports.

MC-799

Document Control All policies, procedures and guidelines should comply with Trust document control procedures.

N

Some documents did not follow the Trust policy for document control.

VULNERABLE ADULTS CLINICAL – WALSALL HEALTHCARE NHS TRUST Ref

Quality Standard

Met?

Comments Some information was not readily available on all the ward areas visits.

MM-101

General Support for Service Users and Carers As QS MC-101.

N

MM-102

Raising Concerns As QS MC-102.

Y

MM-103

Communication Aids Communication aids to help patients with communication difficulties should be available.

N

On some areas visited the staff said that aids were not available 'out of hours'. During normal working hours they were easily accessible.

MM-104

Care Plans The individualised care plan for vulnerable patients (QS MM-502) should have been agreed with the patient and, if appropriate, their family or carer.

N

Some patients did not have care plans.

MM-199

Involving Patients and Carers The service should have: a. Mechanisms for receiving feedback from patients and carers b. Mechanisms for involving patients and carers in decisions about the organisation of the service.

Y

Staff competences As MC-206

Y

Staffing MM-201

Guidelines and Protocols MM-501

Identification and care of vulnerable adults As QS MC-501.

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y

107

Ref

Quality Standard

Met?

MM-502

Individualised Care Plans: A system should be in use which ensures that people identified as being particularly vulnerable (QS MC-501) have a care plan which takes account of their individual needs and circumstances, including: a. Consideration of the need for advocacy and carer / family involvement in care planning b. An assessment of normal functioning, including the need for additional information or assessments c. A programme to return to and maintain normal functioning d. Allocation of a lead healthcare professional who will link with the carer / family e. An assessment of the need for enhanced care while in the ward / department and in other settings (for example, imaging), including need for alterations to the services usual clinical guidelines (QS MM-503) f. Environmental risk assessment g. ‘Reasonable adjustments’ required h. Consideration of the need for informing and involving specialist clinical advice (QS MC-205) i. Arrangements for involving the carer / family in providing care while in hospital j. Date for review of the care plan. k. An estimated date of discharge

N

There was a system for assessment of need but, in some areas visited, these assessments had not been translated into actions to ensure these needs were met.

MM-503

Clinical Guidelines Clinical guidelines should be in use covering: a. Pain management b. Management of fluids and electrolytes c. Management of acute confusional state d. Falls prevention e. Pressure ulcer prevention f. Nutrition

Y

The policies for pressure ulcer prevention and enteral feeding said that they had been updated but conflicting dates were included.

MM-504

Restraint and Sedation As QS MC-504

N

The sedation policy was general and did not include vulnerable groups and behavioural modification.

MM-505

Missing Patients As QS MC-505

Y

Staff were aware that the policy was available on the intranet.

MM-593

Discharge Policy As QS MC-593

N

The discharge policy did not specify the arrangements for the discharge of vulnerable adults, though staff were aware that a discharge policy was available on the intranet.

MM-594

Mental Capacity Act and the Deprivation of Liberty Safeguards As QS MC-594

Y

Staff were aware that the policy was available on the intranet.

MM-596

Safeguarding Policy As QS MC-596

Y

Staff were aware that the policy was available on the intranet.

MM-597

Information Sharing Agreement As QS MC-597

Y

Staff were aware that the policy was available on the intranet.

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Comments

108

Ref

Quality Standard

Met?

Comments

MM-598

Palliative Care Staff should be aware of local guidelines, agreed with the specialist palliative care services serving the local population, for the management of patients with palliative care needs.

Y

Staff were aware that the policy was available on the intranet.

MM-599

End of Life Care Staff should be aware of local guidelines for end of life care.

Y

Staff were aware that the policy was available on the intranet.

VULNERABLE ADULTS IN ACUTE HOSPITALS COMMISSIONING – NHS DUDLEY Ref

Quality Standard

Met?

MZ-501

Advance Care Plans The local health economy should have agreed arrangements for advanced care planning for vulnerable groups of the population who are likely to use acute services regularly or who are approaching the end of life and ensuring that all services have access to the advance care plans.

Y

MZ-597

Information Sharing Agreement Commissioners should have agreed guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life.

Y

Quality Monitoring Commissioner Clinical Quality Review meetings with providers of acute hospital services should consider the Trust’s annual report on safeguarding and improving care for vulnerable adults (QS MC-703)

Y

Comments

Guidelines and Protocols

Governance MZ-701

Clinical Quality Review meetings were in place

VULNERABLE ADULTS IN ACUTE HOSPITALS COMMISSIONING – NHS WALSALL Ref

Quality Standard

Met?

Advance Care Plans The local health economy should have agreed arrangements for advanced care planning for vulnerable groups of the population who are likely to use acute services regularly or who are approaching the end of life and ensuring that all services have access to the advance care plans.

Y

Comments

Guidelines and Protocols MZ-501

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109

Ref MZ-597

Quality Standard

Met?

Comments

Information Sharing Agreement Commissioners should have agreed guidelines on sharing information about vulnerable groups of the population who are likely to attend health and social care services regularly or who are approaching the end of life.

N

The PCT did not have an information sharing agreement for use across the health economy, though Walsall Healthcare NHS Trust did have an information sharing agreement. .

Quality Monitoring Commissioner Clinical Quality Review meetings with providers of acute hospital services should consider the Trust’s annual report on safeguarding and improving care for vulnerable adults (QS MC-703)

Y

Included in the reported schedule for quarterly reports to be received by the Clinical Quality Review Meetings.

Governance MZ-701

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110