2016

Noted (AI summary) Yorkshire Ambulance Service states they are not primarily responsible for contacting family members when conveying a patient to the hospital, but would do so when making referrals to other services. They believe existing processes are adequate. North Yorkshire Police will amend its Mental Health and Suicidal People Policy to reflect the College of Policing's Authorised Professional Practice by April 2017. It will also include instruction to staff to attempt to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing.

Noted (AI summary) Virgin Care has implemented a process to ensure colleagues have completed ACCT awareness training and are aware of PSI 1700 upon starting at HMP High Down, with annual refresher training. An auditing process has also been implemented for Fitness for Segregation forms, carried out by Lead Nurses. The Department of Health has brought concerns regarding AMHP training to the attention of the HCPC, which sets criteria and approves training programs. Responsibility for AMHP training is due to become the responsibility of a new regulator; Social Work England, in 2018. The Health Care Professions Council (HCPC) states that its existing criteria for AMHP training programs are appropriate and that individuals completing training have acquired the necessary skills in carrying out mental health assessments. They suggest that issues are best addressed by Local Social Services Authorities through ongoing training. Hampshire County Council and Portsmouth City Council have taken several actions, including reviewing AMHP practices, providing additional training, commissioning audits, and reviewing policies. The HCPC reviewed documentation and closed the case, taking no further action regarding the AMHP's fitness to practice.

Noted (AI summary) NHS England acknowledges the concerns and states that the Leicester City Clinical Commissioning Group (CCG) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. They have asked the CCG to respond and provide assurance regarding actions taken and have reviewed the CCG's response, finding the identified actions robust. University Hospitals of Leicester NHS Trust has reviewed medical records, discussed the case with the consultant and junior doctor involved, will strengthen the "Letters Policy" by January 2017, and will audit discharge letters with GP feedback, reporting to the Executive Quality Board in March 2017. Leicester City CCG has worked with University Hospitals of Leicester (UHL) to improve discharge information by reviewing systems, auditing discharge letters monthly, discussing the Regulation 28 Report at the Clinical Quality Review group, and planning to include a quality indicator in the 2017/2018 contract with UHL.

Noted (AI summary) Leicestershire Partnership NHS Trust is working with commissioners to procure a local, medium to long-term solution for female Psychiatric Intensive Care Unit (PICU) placements. They are also developing an integrated clinical pathway and model for care for people with Personality Disorders. East Leicestershire and Rutland CCG are in discussion with potential provider organisations and regional commissioning colleagues to provide a wider range of options for female PICU beds and are developing a model for a local network for the support of patients diagnosed with a personality disorder. The Department of Health acknowledges the concerns raised about the availability of psychiatric intensive care beds and the quality of care planning, noting that CCGs commission psychiatric intensive care beds locally. They highlight national initiatives to improve community mental health provision and strengthen patient involvement in care planning.

Noted (AI summary) NHS England states it has no jurisdiction over the regulation of nurses or independent practitioners, as the NMC is the regulatory body. However, it expects general practices to declare annually that they ensure all healthcare professionals have the right skills, experience and qualifications and that all staff have annual appraisals aligned to revalidation. The NMC acknowledges the concerns but asserts that its existing statutory framework and revalidation process are sufficient to protect the public in respect of advanced practice, so it will not take further action.

Noted (AI summary) Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record. Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures. NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services. The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.