Masoud Ghaderi

“There was inconsistence records of engagement with service users. The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded in a consistent manner with appropriate staff training in application of the policy.”

“There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date.”

“The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward round. The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions .”