The Care Quality Commission’s review of mental health services: risk management recommendations

As readers will be only too aware, the CQC was commissioned to carry out a rapid review of Nottinghamshire healthcare NHS Foundation Trust by the Secretary of State for Health and Social Care, under section 48 of the Health and Social care act 2008, following the tragic events that took place after Valdo Calocane's discharge.

Having previously worked with Mersey Care and Calderstones on risk management in CQC's Driving improvement: Case studies from seven mental health NHS trusts (See pages 30-33). We wanted to draw out the wider risk management issues from this report that are applicable to providers in both the public and independent sectors, and indeed to commissioners.

In summary they cover:

• Risk assessment and record keeping
• Care planning and engagement
• Medicines management and optimisation
• Discharge planning

Risk management

The recommendations made by the CQC in the report are relevant to any provider and the following points should be reflected upon from a risk management perspective:

1. Learning

• Ensure any errors are not repeated and/or are minimised as much as possible

2. Risk assessments and care planning

• The concerns included:
• • Key details were minimised or omitted eg refusing medicine, ongoing and persistent symptoms of psychosis and escalation of violence
  • Staff didn't outline the seriousness or immediate threat of risks and known issues
  • There was no updated risk summary before discharge
• The Department of Health and Social Care has produced guidelines on managing risk in mental health services, which may be a helpful reminder for teams when considering risk assessments.
• CQC noted that information of any acts of “violence, self-harm or self-neglect” should be included in the risk assessment
• An analysis of the risks and the factors that may mitigate these risks can then inform care planning
• Care planning should consider any risk assessments that have taken place and include how these risks are to be mitigated
• Both the patient and families should be included/engaged in discussions around care planning

3. Discharge

• The concerns included:
  
  • A lack of clarity of thinking around discharge decisions
• If the crisis home treatment team are to be involved, this needs to be arranged before a patient is discharged. The day on which a patient is discharged may be relevant as discharge just before a weekend may not allow for crisis teams to be available.
• GPs need to be involved in assessment planning and up to date information regarding the patient needs to be provided to the GP as well as updated risk summaries.
• There needs to be clear evidence of discharge planning in patient care plans.

4. Medication management

• The concerns included:
  
  • His decisions not being balanced with other information
  • Diagnosis and treatment should have been reviewed
• A holistic approach is required in terms of medication management. 
• This should include consideration of dose, medication type and an individual’s compliance.
• Consideration should be given to alternative medication/approaches with the focus of mitigating risks in mind.

5. Family engagement

• If family raise concerns, this information needs to be consistently acted upon. Trusts can then be satisfied after acting upon a concern about whether it is a legitimate concern or not.

Findings

The review found that “opportunities to mitigate the risk were missed” and that there were a “series of errors, omissions and misjudgements” that took place in this case.

The CQC made recommendations to Nottingham Healthcare NHS Foundation Trust (NHFT), NHS England (NHSE) and the Royal College of Psychiatrists (the Royal College).

NHFT

The key recommendations include the need to:

• Review treatment plans for schizophrenic patients
• Supervise the decision to detain individuals under section 2 and 3 of the Mental Health Act
• Engage family members in care planning
• Ensure that robust discharge policies are in place

NHSE

The key recommendations include:

• Ensure that providers’ boards fully understand their role in the oversight of the needs of patients who have a serious mental illness and who find it difficult to engage with services. This includes developing local services in partnership with others to provide intensive support in order to prevent this cohort of patients from falling through the gaps.
• Ensure every provider and commissioner in England undertakes a review of the model of care in place for patients with complex psychosis who typically struggle to engage with services and who present with high risk.

The Royal College

The recommendations are that the Royal College, with NHSE:

• “Reviews and strengthens the guidance to clinicians relating to medicines management in a community setting, for example depot vs oral medication” and
• “Reviews how legislation is used in the community to deliver medication for those patients who have a serious mental illness and where it is known they are non-compliant with medication regimes.”

Training and support

If you'd be interested in developing workshops around risk management bespoke to your needs, please contact us and we can talk about what training/support would work best for you.

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