Surrey and Borders Partnership NHS Foundation Trust

“the Trust has embarked upon an Inpatient Improvement Plan which has the overarching aim of developing our inpatient care through safety and quality improvements to ensure better outcomes for those using our services. This is reported through the Inpatient Improvement Board and encompasses clinical, workforce, infrastructure, digital and environmental change.”

“The Trust's Access and Advice Team (AAT) provides a point of access to Mindworks Surrey and ensures that there is consistency of referral management, clinical screening and triage services.”

“If a routine referral has been waiting for over four weeks to be triaged, then it is now subject to a harm review.”

“The CYPS Standard Operating Procedures are being reviewed to ensure that staff are guided to consider safeguarding and liaising with the Surrey County Council c-SPA where children refuse to engage with care and treatment, record”

“The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients.”

“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”

“Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.”

“The Trust has now completed its guidance regarding”

“A retrospective baseline audit is also underway, looking back over a three month period between 1.8.2019 - 31.10.2019 to consider whether the Working Age Adult division identified and managed alcohol dependence appropriately. Once the improvements have been embedded, a second audit will be completed to check for improvements in our practices.”

“I am also under a duty to send the Chief Coroner a copy of your response.”

“The Department therefore expects care providers to ensure that those members of staff involved in the return of a patient following revocation of section 17 leave are aware of their powers and responsibilities towards that patient and that these are applied in a consistent manner.”

“The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”

“[SABP] has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or suicide whilst in the community, will find the opportunity to act in such a way as results in their death, whether intentionally or not.”

“we consider that this guidance, when followed, ensures safe prescribing and protects patient safety”

“The action plan is going to be monitored and followed up at the monthly Adult Mental Health Directorate Quality Assurance Group meeting”

“We have worked with our colleagues at East Surrey Hospital to ensure that a shortcut to Surrey and Sussex Hospital (SASH) policies is loaded onto all of our Psychiatric Liaison staff's computers to ensure ease of access for our staff. The SASH policy relating to using translation services has been made available as mandatory reading for our staff working at SASH.”

“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”