Independent investigation: Dawn Green, Newquay (2016)

The Trust must ensure that it fully executes its Duty of Candour responsibilities and that where there are parallel investigations by other agencies, advice is only sought from senior staff about the most appropriate methods of communicating with affected parties. Read more The Trust must ensure that it fully executes its Duty of Candour responsibilities and that where there are parallel investigations by other agencies, advice is only sought from senior staff about the most appropriate methods of communicating with affected parties. Show less

If it has not already been actioned, the Trust must ensure that appropriate audits are undertaken regarding the effectiveness of the new protocol for the Complex Care and Dementia Team, taking any remedial action required if the effectiveness is found … Read more If it has not already been actioned, the Trust must ensure that appropriate audits are undertaken regarding the effectiveness of the new protocol for the Complex Care and Dementia Team, taking any remedial action required if the effectiveness is found to be lacking. Show less

The Trust must provide assurance that the expectations of the clinical record keeping policy are met.

Kernow Clinical Commissioning Group must ensure that the policy covering the management of serious incidents includes a requirement for oversight of provider investigation action plans, and appropriate and documented dialogue between the commissioner and relevant provider/s. Read more Kernow Clinical Commissioning Group must ensure that the policy covering the management of serious incidents includes a requirement for oversight of provider investigation action plans, and appropriate and documented dialogue between the commissioner and relevant provider/s. Show less

Outlook South West must consider what actions it can take to mitigate the risk of patients choosing not to share relevant clinical information with their therapist, now that therapists no longer have access to the GP clinical record system.

The Trust must ensure that SBARD (Situation, Background, Assessment of individual, Recommendation, Decision) is introduced to community mental health teams, ensuring that relevant learning from implementation in inpatient services is transferred.

The Trust must ensure that staff are able to identify and recognise the different types of supervision set out in the Supervision Policy ratified in March 2016, in order that staff can use supervision sessions appropriately.

The Trust must ensure that staff explore patients’ literacy abilities and then communicate information in a way that is accessible and personalised.

The Trust and NHS Kernow Clinial Commissioning Group must assure themselves that the therapy strategy sufficiently addresses the provision and use of qualified therapy staff across the Trust, ensuring that gaps in access to appropriate therapy are properly addressed. Read more The Trust and NHS Kernow Clinial Commissioning Group must assure themselves that the therapy strategy sufficiently addresses the provision and use of qualified therapy staff across the Trust, ensuring that gaps in access to appropriate therapy are properly addressed. Show less