Kent and Medway NHS and Social Care Partnership Trust

“Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.”

“Once admitted to the ward, staff should seek to understand if patients admitted following overdose have any remaining medication at home, and if so, what quantity.”

“The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.”

“A reminder to staff in both organisations has been circulated through Trust wide communications in regard to the use of abbreviations in patient records.”

“Consider monthly interface meeting with agenda to include potential risk spots, developing shared learning and practice changes and building a culture of collaboration.”

“the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”

“The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care”

“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”

“The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainors to key individuals”

“We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is being requested. This is being monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts.”

“The CRISIS team are only paged by the acute hospital outside the hours of operation of the Liaison Psychiatry Service. With the expansion of the Liaison Psychiatry Service the need to use the resources of the CRISIS team are decreasing.”

“KMPT has developed a SMART tool (safeguarding, management and risk tool) for use between Accident & Emergency Departments and the Psychiatric Services which has been implemented in the east of the county and has been nominated this year for a National Patient Safety Award. This is based on guidelines produced by the National Institute for Health & Care Excellence and therefore compliant with national standards. It assists the Emergency Department staff to think through the immediate management”

“The steps referred to above will also address this aspect of your report. In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff. It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies.”

“We are introducing a recovery card on discharge from hospital for the patient to have and which includes information as to what to do and who to contact in the event of crisis. The card has been designed and is at the printers and will be implemented as soon as received.”

“KMPT is continuing to use the existing practice of a Written Discharge Notification being faxed to the GP within 24 hours of discharge including details of medication on the day of discharge. We are implementing an audit to ensure that this procedure is being followed which will include GPs.”