Independent Oversight and Assurance Group on Tayside's Mental Health Services: workplans

Theme: Patient Safety

Timescales: April to end-May 2022

Recommendations: 11, 17, 19, 20, 22, 23, 27, 28, 29, 30, 31, 32, 37, 46

What we need to know and understand

Recommendations 11 and 31 - number of adverse events reviews is required (reference LLC scrutiny regarding numbers outstanding). The Oversight Group also need to know if there is clear separation of roles and responsibilities and if there is annual duty of candour report.  Assurance is needed that the concerns which gave rise to these recommendations have been fully addressed.

Recommendation 17 - need to revisit the purpose and outcome. The Oversight Group are concerned that the intended outcome, as set out, does not fully address the entirely of this recommendation and that suitable actions are in place to achieve this.

Recommendation 19 - need to understand what work is being taken forward to address this recommendation and how this is linking to national work on the development of standards.

Recommendation 28 - this recommendations states ‘Ensure appropriate psychological and other therapies are available for inpatients’. On the development of good psychological therapies, the Oversight Group need to understand what work is being advanced, what the impact of staff training has been and future plans. In an earlier business plan document (February 2020), Tayside Executive Partners set out the need to produce a position statement for inpatient psychology for the next 3 years - was this done and can the Oversight Group please have sight of it.

Recommendation 29 - arose out of concerns for deprivation of liberty. The Oversight Group need to understand the safeguards that are in place to ensure this does not happen and would welcome a specific meeting with colleagues in Tayside who have responsibility for that.

National Recommendation 32 - focus needs to be explicitly upon developing an agreed set of national guidelines, with less time spent on understanding variances of existing practice. Need to see progress and pace.

Recommendations 37 and 46 - written confirmation of the present position, in respect of conditions placed on practice by GMC and NES, is required.

What we need to see

** Recommendation 11 - the HIS guidance that was referred to (TEP submission dated 24 January 2022) provides a framework and a schematic - can the Oversight Group please see the Tayside process for adverse events given the adoption of HIS national framework.

** Recommendation 11 - Oversight Group letter 1 (23 December 2021) asked certain questions in relation to recommendation 11. A response is now required.

Recommendation 17 - Oversight Group letter 1 (23 December 2021), asked for evidence from the evaluation and review of all complex cases. A response to this is now required.

Recommendation 20 - TEP submission (24 January 2022) stated that ‘service specification can be provided. Details of live service and feedback from service users can be evidenced once service is live’. The Oversight Group now need to see this.

Recommendation 22 - TEP submission (2 February 2022) stated that ‘clearly defined referral pathways have been developed and implemented with University of Dundee and Abertay University’. Can the Oversight Group see what evidence partners are relying on in order to take assurance.

** Recommendation 23 - TEP submission (2 February 2022) stated ‘extensive trauma training of inpatient staff has taken place to underpin the improving observation principles. There is quantifiable evidence the impact of this work’. Please provide the Oversight Group with the evidence on the operation of the Observation Protocol, including the extent to which it is delivering on this recommendation and providing partners with necessary assurance.

Recommendation 27 - need to see the result of the baseline review of establishment. The Oversight Group are concerned that the intended outcome, as set out, does not fully address this recommendation and that suitable actions are in place to achieve this.

** Recommendation 30 - TEP submission (24 January 2022) stated ‘can provide evidence of progress to date and plans to continue response to this recommendation’. This needs to be provided please.

** Recommendation 31 - following TEP submission (2 February 2022), can the Oversight Group please have sight of the evidence referred to from staff feedback on training.

** Also need to see annual reports on adverse event reviews that have been submitted to the NHST Board (or the relevant sub-committee) on the outcome of these reviews and arrangements in place for cascade learning. If these reports to the Board (or relevant sub-committee) do not capture feedback from family and carers, can partners please provide the evidence that allows them to take assurance on these matters. For the avoidance of doubt, where the above reports are submitted to IJBs, can the Oversight Group please be provided with these as well.

** Can partners please provide the Oversight Group with annual reports to the NHST Board (or relevant sub-committee) and IJBs on duty of candour for the last two years. Also need to see NHST Local Procedures of Application of Duty of Candour.

Next steps

Meet with staff who have been identified as having responsibility for adverse event reviews as per local procedures and schematic requested (29/30 March).

Further discussion with Scottish Government Mental Health Division colleagues in respect of national recommendation 32 (end-March).

Meeting with Staffside Partnership (April and July).

Site visit to Carseview and Strathmartine to meet with staff to see/hear about improvement in practice (May/June).

Meeting with carers’ participation group (June).

Meeting with advocacy organisations engaged to support patients (June).