To ensure driving status is confirmed on admission (Target 100%) and to confirm driving advice is given to all patients deemed unfit to drive (Target 100%) and to ensure adequate documentation is made in online clinical notes with regards to discussions about driving

The first cycle of data involved collecting retrospective data from two acute adult psychiatric units and one old age mental health ward. The first cycle of data consisted of inpatients admitted over a two month period in 2020 (36). Data were collected from OpenRio progress notes, OpenRio ward round notes and patient discharge summaries. Following the implementation of interventions the second cycle of data were collected over a 2 month period in 2021. 51 patients met the inclusion criteria for this.

Following our interventions, 47% (24) of patients had their driving status confirmed on/during admission compared to 42% (15) in the first cycle. 15 current drivers were identified in the second cycle.

Of the confirmed drivers, there was a 6% improvement of patients informed they were unfit to drive. A 22% increase in patients given DVLA driving advice was also noted. DVLA notifications increased by 18% following the interventions.

This quality improvement project has shown that educational awareness through teaching sessions and written guidance can improve adherence to national legal guidance. However, further work is required to ensure all psychiatric patients receive adequate information regarding their fitness to drive.

Prescribing is a neglected skill amongst trainees. Prescription errors can harm patients. A recent Economic analysis published in BMJ Quality & Safety. Estimated that 237 million medication errors occur in England annually. Costing the NHS £98,462,582. Prescribing errors contributed to 21% of the total errors. It is important that all prescribers are aware of principles of safe prescribing. Our aim is to is to establish whether our practice is meeting standards of prescription writing in old age psychiatry ward setup.

We used prescription standards set by BMA, BNF and SABP (Surrey and Borders Partnership Foundation NHS Trust) to assess all prescriptions. The following parameters were checked: GMC number, Sign, Name of Doctor, Name of drug, Indication, Dose, Route, Frequency, Original start date, current Date, medication timings.

We performed a closed loop audit. A retrospective data of 228 prescriptions were collected from August 2020 to January 2021 from patients admitted in Victoria Ward. The data were analysed and presented at departmental meeting. Re-training on prescription writing conducted. New data was prospectively collected comprising of 230 prescriptions from March 2021 to June 2021 to complete the audit cycle.

Excel sheet was used to collect the data and to get the results. All Prescription charts were collected from SystmOne (clinical software system). Data from both the Audit's were analysed and compared.

We found errors in all parameters, except for medication timings. Comparison of the data from the first audit and re-audit showed an increase in prescription errors.

There was an increased 20.33% error in writing GMC number, 16.87% error in writing name of the doctor, 12.94% error in indication and 5% error in original start date. There was improvement of 10.88% in one parameter, “Name of the drug”.

A significant error was found in writing the GMC number and the Doctor's name, despite regular training during induction. There are no clear guidelines on the writing of GMC registration being compulsory on Drug chart. With one exception if online and you are not the patient's regular prescriber, then your GMC registration number is required.

1. 1. We recommended the trust to issue stamps with GMC number and doctor's name.

2. 2. Re-audit in 6 months’ time after introduction of the stamps.

3. 3. Quarterly regular training of new Trainee doctors.

After the Audit was submitted locally, stamps were introduced and issued to junior doctors at Victoria Ward by the Trust.

To assess whether consultant discharge letters from the mental health liaison team are: 1. Written to patients as advised by NICE shared decision making guidance. 2. Easy to read using the Flesch Reading Ease Test as advised by the Academy of Medical Royal Colleges, which equates to a score of 60 to 70.

50 consultant discharge letters were collated from April to November 2021. Each letter was assessed whether they were written directly to a patient and scored according to their Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) via Microsoft Word.

FRE scores a text from 0 to 100 from the average length of sentences and the number of syllables in words to indicate its difficulty to read. The higher the score achieved, the easier it is to read the text. It is a recommended tool by The Academy of Medical Royal Colleges’ guidance on outpatient clinic letters, however, does not specify a target level of readability. A score of 60 to 70 equates to plain English easily understood by students aged 13 to 15 years and was concluded to be the equivocal score expressed in the guidance.4

The FKGL presents a score as a U.S. grade level to indicate the level of education generally required to understand a text. Words per sentence and syllables per word are factored in to calculate the grade.5

The median FRE was 50.9 (n = 50, IQR 8.9). Only one letter met the desired standard. The mean score was 50.6 (SD 6.4). This mean was significantly different from a hypothetical ideal mean of 65 (t(df) = 15.9(49), p < 0.0001) so could not, unfortunately, be explained by chance. The median FKGL was 10.1.

Overall, the letters were of greater difficulty than the desired score of both FRE and FKGL. Lay language and patient-directed writing will aid in improving scores.

Our aim was to assess what proportion of patients in Acute Alcohol Withdrawal (AAW) experience harm during their admission to hospital. Our hypothesis was that patients who came to harm were likely to have had sub-optimal withdrawal management. Therefore, we also aimed to identify any underlying issues in the way AAW is currently managed which may be contributing to harmful outcomes.

Inclusion criteria for the audit was inpatients at Yeovil District Hospital over a three-month period from May to July 2021, clinically coded under the heading ‘alcohol abuse’, with a minimum two-day admission. Data were gathered from the patients’ medical notes. An outcome was determined as harmful if firstly, it occurred during the withdrawal period, and secondly it was clinically feasible that it had occurred at least in part, as a result of poor AAW management. Notes from 15 patients were qualitatively reviewed, guided by NICE recommendations, to assess both adherence to, and suitability of YDH AWW policy.

Alcohol abuse was identified at the time of medical clerking in all 15 patients. Audit-C scores were completed in 7 patients. All 15 patients had CIWA scoring initiated within 1 hour of clerking, and chlordiazepoxide prescribed as a STAT dose and then a fixed PRN dose according to whether CIWA score was above 10 or not. 10 patients had their CIWA scores monitored for at least 24 hours. 3 out of 15 inpatients had harmful outcomes, including falls, intracerebral haemorrhage, fractured neck of femur, and cardiac arrest.

Overall, adherence to YDH guidelines was good. Despite this, a high proportion of patients admitted under our care were harmed as a result of inadequate management of alcohol withdrawal. Where issues were identified, these were arguably linked to problems with the YDH AAW policy itself. Unclear guidance over how long to monitor CIWA scores, limitation of chlordiazepoxide doses to 10 mg for even the highest CIWA scores, and omission of Audit-C score in the current hospital guidelines, are suggested as contributors to harm in the three patients identified. Going forward, it will be important to review and make appropriate changes to the YDH policy in these areas according to NICE recommendations, to protect our patients from further harm. These results may well have wider implications in terms of adjustment to AAW policy at other hospitals across the UK.

Currently, practice is that if patients of childbearing age provide a urine sample on admission they will also be consented to test for pregnancy. As many new patients may refuse to provide a urine sample often due to their mental state or concerns about drug testing this results in some patients not being tested for pregnancy during admission unless required for medication or at patient request. Given the high level of vulnerability and the medication implications for pregnant patients, ascertaining pregnancy status early on in admission is beneficial to patients found to be pregnant. Therefore, we aimed to audit how pregnancy status is assessed and documented on admission and aim to improve the practice where areas for development are identified.

Over the 6 month period July-December 2021 there were 105 inpatient admissions on an acute female psychiatry ward. Using a random number generator 15 patients from this cohort were selected and their notes audited as to whether a urine pregnancy test or bHCG serum pregnancy test was completed on admission. If not, we searched the admission notes for documentation of ‘pregnancy, last menstrual period (LMP), sexually active status, contraceptive use’.

Of the 15 patients audited, 7 had a documented urine pregnancy test on admission (47%). Of the 8 patients that had not had testing only 1 patient had documentation of contraceptive use prior to admission, the other 7 non-tested patients had no notes regarding their LMP/contraception. 2 patients who did not have a pregnancy test had in fact had a urinary drug screen on admission, this coincided with a time of approximately 1 month when there were no urine pregnancy test strips available on the ward. At this time serum bHCG or LMP were not routinely used. One of these patients was found one month later to be pregnant.

We propose based on our findings that a more robust enquiry as to the risk of pregnancy should be conducted on admission for female acute inpatients. We have made recommendations that this should be in the form of a checklist to be conducted as part of the nursing admissions assessment such that if a urine sample is refused then a form detailing LMP, contraceptive use and any recent unprotected sexual activity will be completed. This can then be reviewed by the medical team prior to commencing medications. The use of this checklist will be reaudited between January-June 2022.

There are concerns following the Winterbourne view investigation and from the Learning Disabilities Census that psychotropic medications are being inappropriately given to people with learning disability as a means of managing difficult behaviours. Stopping Overuse of Medication in People with Learning Disability (STOMP) is a key area which has been identified as needing improvement for the Transforming Care Programme which is being supported by the Royal College of Psychiatrists. Members are encouraged include STOMP in their local audits. It is for this reason that the topic has been chosen. The overall aim of this project is to capture the snapshot of prescribing of psychotropic medications for people under SST care. This information has been used for establishing baseline of current practice as they are happening and to develop SST base response to support STOMP agenda.

The population audited was patients open to the SST LANCS/GM. Patients had to be between 18 and 65 years old, have a diagnosis of a learning disability and be known to have challenging behaviour. Patients were excluded from the audit if they had no challenging behaviour, had been discharged from services. The sample size was 20 (10 from GM and 10 from LANCS). Data were collected using the proforma and then entered into Microsoft excel for analysis.

Four overall standards were audited, each with key lines of enquiry within the standard audited to help determine compliance. Overall compliance for standard one, the indication and rationale should be clearly stated, was 50%. For standard 2, consent to treatment procedure, the third standard, regular monitoring of the treatment response and side effects, and the final standard, review and evaluation of the need for continuation or discontinuation of the psychotropic drug, the compliance was less than 10%. It should be noted that the audit erred on the side of counting in any information that suggested that the theme had been thought about at all: an in depth capturing of any of the themes did not feature in the sample.

This audit highlights important issues for improvement within the SST both in relation to better supporting STOMP and good psychotropic medication management practice, and in relation to its documentation. It also serves as a springboard to a number of initiatives that would help to turn that situation around. In the light of concerns, an early re-audit of practice is recommended.

Antipsychotic prescribing in acute inpatient settings is an integral part of patient care. The aim of this audit was to review optimisation of antipsychotics on an acute adult inpatient ward in South West London and St George's NHS Mental Health Trust (SWLSTG). It was ascertained how antipsychotic prescribing on an acute ward meets NICE standards, including duration of antipsychotic use prior to medication change. Furthermore, communication of medication changes was reviewed in the context of the paramount importance of collaborative decision-making in aiding adherence. NICE recommends a 4–6 week trial of antipsychotic medication at optimal dosage. However, it was hypothesised this may vary with side-effects, adherence and risk management in the inpatient environment. To establish the relationship between these factors, data were extracted regarding antipsychotic counselling, baseline physical health investigations, antipsychotic choice, dosage and duration, side-effects and treatment response.

Retrospective data analysis was conducted for patients on an acute adult inpatient ward in SWLSTG. Data extracted from Rio clinical record system and EPMA prescribing software were analysed in Excel. The inclusion criteria were patients admitted or transferred to a 20-bed acute mixed adult ward from 04/08/21 to 04/11/21 with a diagnosis of schizoaffective disorder, schizophrenia, bipolar affective disorder or nonorganic psychosis. This included patients being initiated or continued on antipsychotic medication. From 71 patients, 33 met inclusion criteria. Data were extracted regarding duration of treatment prior to changes in treatment, counselling and pre-treatment investigations. Furthermore, simple statistical analyses were carried out.

The most commonly initiated antipsychotics on admission were olanzapine (33%), quetiapine (21%), risperidone (15%) and zuclopenthixol decanoate (15%). In those requiring change in antipsychotic regime, mean duration from the start of treatment as inpatient to first change was 11.6 days, time between first and second change 13.8 days, and between second and third change 16.0 days.

The data showed in the majority (84.6%) antipsychotics were changed or up-titrated due to inadequate response. Out of the remainder 9.6% were changed due to intolerable side effects and 5.8% due to adherence concerns. In 73% of cases counselling was attempted regarding initial medication changes.

Antipsychotic therapy was altered more quickly than advised by NICE guidance in the acute inpatient setting evaluated. This can be explained by increased risk, need for intensive management and individual clinical factors including side effects and adherence. Collaborative decision making could be enhanced by ensuring that counselling is attempted for every patient.

Once refugees and migrants have accessed mental health services, there are a number of potential barriers to establishing a positive therapeutic relationship with clinicians and engaging patients in treatment. WHO recommend that training programmes can help clinicians to understand and assess mental health difficulties according to different cultural explanatory models of psychological symptoms. This audit aims to explore current training of those who work with asylum seekers and migrant patients, within the Merseycare Early Intervention in Psychosis teams.

A survey of 11 questions was sent out to all assessors, team managers, care co-ordinators, psychologists and doctors within the Early Intervention in Psychosis teams. Questions were asked regarding demographics of participants, their views of the difficulties and barriers of working with asylum seekers, their current level of training to work with this particular cohort of patients and their willingness to attend such training.

33 results were collected and consisted of a broad range of team members. Only 4 out of the 33 participants had any form of training prior to or during their time working with this cohort of patients and 3 of the 4 who had, stated that it was not specific training. Difficulties highlighted included; language barriers, cultural differences, a lack of understanding of the asylum process and a lack of knowledge for local support. All participants said they would be willing to attend training specific to working with the asylum seeker patient population.

This audit demonstrates that we are far from reaching the World Health Organisation recommendations of cultural training for all who work with asylum seeker and migrant patients. It also demonstrates a felt need amongst staff for training to be provided. Recommendations from this audit is to consider mandatory training for all staff, including; cultural training, guidance on use of interpreters and awareness of external support agencies.

Prescribing of psychotropic medications in pregnancy is still considered a ‘grey area’ in clinical practice. National Institute for Health and Care Excellence (NICE) in the UK suggests that the decisions should be person-specific, considering the risks to both the mother and unborn child, and the patient is supported to make an informed decision. It is important to explore the use of psychotropic medications during pregnancy, or lack of it, and its subsequent impact on maternal mental health. It was intended to review the decisions expectant mothers are making regarding taking psychiatric medications during pregnancy, and the associated clinical outcomes. Their mental capacity for taking decisions was also checked.

A retrospective audit of case notes of patients (n = 16) known to community psychiatric team (CMHT) and specialist perinatal mental health (PNS) services in Wolverhampton, who notified their pregnancy between December 2020 and December 2021. Demographic and clinical data were collected from the electronic records.

The sample had a mean age of 28.8 ± 6.3 years (range: 19 to 39 years), and 68.8% of them were Caucasian. A wide range of psychiatric diagnoses were present, most (62.5%) had comorbid diagnoses; and 25% had substance use, most commonly cannabis. Mean duration of gestation at the review following notification of pregnancy was 14.5 ± 7.7 (range: 6 to 29) weeks. It was observed that 25% were not taking psychiatric medications prior to pregnancy, 43.8% stopped taking their medication prior to the psychiatric review, most stopping abruptly, and 31.2% had continued their medication. The medications included aripiprazole, olanzapine, quetiapine, venlafaxine, sertraline and promethazine. Following the review, only 18.8% continued their medications. Of the 13 (81.3%) patients who were not taking medications, 9 (69.2%) had adverse mental health outcomes, with 2 (15.4%) patients requiring inpatient care. However, later 8 (61.5%) started taking medications whilst under the care of PNS. All of them had mental capacity to decide regarding their psychiatric treatment at the review.

Most psychiatric patients avoided taking psychotropic medications initially during pregnancy, however, a considerable proportion restarted their medications following review with the perinatal psychiatry team. The majority of patients who did not take medications had negative mental health consequences. It is important to develop an evidence base about the use of psychiatric medications in pregnancy and the associated short and long-term outcomes that may help the quality of information shared with patients.

It is well known that individuals suffering from mental illness have more comorbidities and lower life expectancies compared to the general population. It is unsurprising therefore, that these individuals are more vulnerable to both contracting COVID-19, and developing severe illness if infected. When patients are admitted to a psychiatric inpatient unit this offers an invaluable opportunity to ensure that unvaccinated patients are identified, and if consenting, are supported to receive whichever dose of the vaccine they require. We undertook an audit to examine the proportion of patients admitted who had not received their first, second or third dose of the COVID-19 vaccination. Reviewed in the context of gender, age, ethnicity, legal status, mental health diagnoses and additional comorbidities, in order to determine any trends that might assist in improving uptake. We then repeated the audit aiming to offer the appropriate COVID-19 vaccination to every newly admitted unvaccinated patient. If refused, to then council reluctant patients, providing simple, understandable vaccine information, and to re-offer vaccination.

The audit took place on a mixed adult psychiatric inpatient ward in London.

The first cycle of the audit was completed retrospectively. Data were collected from the electronic notes of new admissions from November and December 2021 (total 41). This included information on COVID-19 vaccination status, and documentation of vaccines offered and administered during admission. Additional information was also compiled to calculate risk stratification scores.

Subsequently, we repeated the audit cycle for admissions in January and February 2022 (on-going). However, this time with the aim that all patients have their COVID-19 vaccination status documented promptly, and that their next vaccination is offered/administered during admission if required.

Results from the initial audit cycle showed 33/41 patients had not received a full set of COVID-19 vaccinations (or no vaccination record found). Only 6/33 unvaccinated patients were offered the next vaccination during admission, and 3/33 actually received one. 21/33 patients without a full set of vaccinations were BAME (Black, Asian and minority ethnic).

Initial results from the second cycle showed an improvement in the number of patients offered the vaccine. 5/10 unvaccinated patients were offered vaccines in January, however data collection is ongoing.

Although our data set is not yet complete, initial results show that a simple intervention such as early identification of unvaccinated patients on admission, can act as a prompt to clinicians to ensure vaccines are offered. Thereby, increasing vaccine compliance in this vulnerable patient group.

Clozapine is an atypical antipsychotic primarily used in the management of individuals with schizophrenia and schizoaffective disorders, prescribed to those with symptoms unresponsive to alternate antipsychotic medications. Clozapine is known to have cardiovascular side effects and is associated with an increased risk of significant cardiac events including myocarditis, cardiomyopathy, and sudden cardiac death. Regular electrocardiogram (ECG) monitoring is recommended to facilitate early detection of cardiac complications. This study aimed to identify the prevalence and evaluate the nature of ECG changes, assessing for tachycardia and corrected QT (QTc) interval prolongation, in patients prescribed Clozapine, and to determine whether the appropriate action was taken following identification of these changes.

We conducted retrospective data collection examining consecutive ECGs of 50 adult patients prescribed Clozapine within the East sector of the Cherrywood Outpatient Psychiatry Department at The Royal Oldham Hospital. Patients were identified using the clinic's Clozapine database. The PARIS electronic record system and patient written notes were utilised to obtain patient demographics, diagnoses, and ECGs. We assessed rate, rhythm and QTc intervals amongst the ECGs taken and compared the most recent ECG findings with those from previous ECGs.

Of the 50 patients prescribed Clozapine, 34 were identified as having 2 consecutive ECGs in their notes, enabling ECG comparison and assessment for changes. Amongst these 34 patients, 11 (32.35%) demonstrated new-onset ECG changes; 8 with new sinus tachycardia, 1 with new QTc prolongation and 2 with additional rhythm strip abnormalities. Based on these new findings, 50% were then referred for a repeat ECG. No plan had been made for the other 50%. ECGs of 8 (23.53%) individuals demonstrated changes which remained present across the consecutive ECGs. Plans for these patients included referral for cardiology opinion (25%), repeat ECG (25%) and dose reduction (50%). A further 8 patients demonstrated an improvement in findings on their most recent ECG. In 3 (37.50%) of these cases, Clozapine had been reduced during the period between ECG recordings. 7 (20.59%) individuals demonstrated no ECG changes.

Our findings suggest many individuals prescribed Clozapine develop ECG abnormalities, with the largest proportion developing sinus tachycardia. Regular monitoring remains beneficial within the outpatient department to determine the nature of ECG changes, and further methods may be required to ensure appropriate management plans are in place should these changes arise.

This study aimed to determine the impacts of the COVID-19 pandemic on the Wandsworth Home Treatment Team (HTT), South West London and St. George's Mental Health NHS Trust. We hypothesised that demographics and illness characteristics of patients would differ before and during the first wave of the COVID-19 pandemic and that concerns about possible infection with COVID-19 influenced the decision to be referred to the HTT. Additionally, we hypothesised that there would be fewer face-to-face contacts during the initial months of the pandemic.

Routinely collected data from the trust's electronic records (RiO) were compared from the 15th March – 15th May in both 2019 (control) and 2020 (early pandemic). Patients could have a maximum of 1 variable absent to be included in the study and should have been under the care of the WHTT for longer than 2 days. Overall, 301 patients were included in this study, 181 from 2019 and 122 from 2020. Variables compared were: marital status, age, sex, ethnicity, diagnosis, referral source, referral urgency, referral reason, referral weekday, count seen (number of contacts with a clinician), face-to-face contacts, and length of stay.

The demographic variables: age, sex, marital status, and ethnicity were not significant. Likewise, the length of stay of patients, referral reason, and referral weekday were also not significant. However, during the early pandemic, there was an increase of 11% in the diagnosis of psychotic disorders/psychotic episodes (p = 0.039). Further, the referral urgency of patients within the 2020 period was significantly raised (p=>0.01). The referral source of patients was significantly different with an increased number of patients having been referred to the HTT from the ward (p = 0.017). The mean interactions (count seen) between patients and clinicians significantly lessened from 2019 to 2020, 12.8 Vs 10.2 (p = 0.008). Moreover, the percentage of face-to-face contact had also decreased from 2019 to 2020, 56.1 Vs 46.6 (p = 0.007).

Overall, less patients received care from the home treatment team during the first wave of the pandemic. Age, marital status, sex, ethnicity, length of stay, referral reason, and weekday were not significant. On the contrary, the diagnosis of patients, count seen, face-to-face contacts, referral urgency, and referral source were statistically significant. These findings reflect a different referral pattern to the Wandsworth HTT during the initial months of the pandemic accompanied with fewer face-to-face and other interactions overall.

The RCPsych Standards for Early Intervention in Psychosis Services documents Gold Standard treatment, including: every service-user with psychosis is offered antipsychotic medication; if their illness does not respond to therapeutic dose of 2 different antipsychotics, they are offered clozapine. The Southwark Team for Early Psychosis (‘STEP’) in the South London and Maudsley Trust (SLaM) treats adults in their first 3 years of psychosis diagnoses. We aimed to compare prescribing practice in STEP to RCPsych Standards.

STEP's caseload of 296 individuals was reviewed on 7th June 2021. Those excluded: inpatients/under Home Treatment Team; not yet assessed. Final number of outpatients assessed = 269. Data gathered: 1) Taking an AP? If taking an AP, the name and dose of AP. If not taking, trial discontinuation with medical advice or unsupervised refusal? 2) Remission status 3) Total number of AP trials. Uncertainties in categorisation were reviewed by the 2 other contributors.

In 269 outpatients on 7/6/21, 186(69%) were taking an antipsychotic (167:19 oral:depot), with a further 62(23%) recommended but declining. 21(8%) were not recommended, following change in diagnosis or resolution of psychotic symptoms.

7 service-users had down-titrated off AP with medical collaboration. All but 1 remained in remission. 35/47(74%) who discontinued AP independently had relapsed.

172 patients were reliably taking antipsychotic medication as prescribed. 56(32.5%) had ongoing psychotic symptoms (ranging from non-preoccupying residual delusions to distressing delusions/hallucinations). 4 symptomatic service-users were prescribed lower than BNF minimum effective doses.

Of those symptomatic and on hypothetically therapeutic doses (n = 52; median% of BNF Maximum Dose 50%; mean 54%), 26 were on their 1st AP, 26 on or beyond their 2nd AP. 8 service-users had ever trialled clozapine.

Even in an experienced EI team for a highly psychiatrically morbid population, there remain gaps between best practice and actual prescribing.

Close to 1/3 of patients taking their prescription weren't in remission, almost all of whom had room to increase doses or trial an alternative medication. Clozapine is under-utilised in the treatment resistant group. For those who stopped AP, supervised tapering is a reasonable treatment option.

The next steps will be run as a quality improvement project addressing MDT and service-user barriers to assertive medication management:

• – Trial methods to improve adherence (depot prescribing, psychoeducation, peer support)

• – Encourage efficient up-titration and frequent MDT review of AP efficacy (empowering service-users self-management, care-coordinator opportunistic mental state assessments to trigger dose increase, medical review frequency)

• – Identify and refer service-users suitable for clozapine

Lithium is a commonly prescribed mood stabiliser given to women of childbearing age. There are risks of teratogenicity in first trimester of pregnancy, most notably cardiac abnormalities. It is not clear whether this is highlighted to patients. Our aim was to evaluate whether women were being counselled according to NICE and BNF guidelines.

We analysed records for 25 female inpatients who were commenced on lithium in Goodmayes Hospital from August to September 2021 to see if lithium counselling was done and documented on Rio. This was corroborated with e-prescribing records on ePMA.

Data were collected from 26 patients; 1 was post-menopausal (excluded), final sample size n = 25. 16% were given a lithium leaflet, 92% had trialled alternative antipsychotics, 8% were asked if planning pregnancy, 4% had the risks of lithium in pregnancy explained and 12% were offered contraception.

Lithium counselling needs to improve. We should give patients information via lithium leaflets and explain the risks when they improve in mental state. We should arrange contraception referrals if desired and signpost perinatal psychiatry team if planning a pregnancy.

The trust policy dictates that all urgent GP referrals should be contacted within 48 hours by the duty team. The duty team carries out a telephone screening assessment and offers the patients who are deemed to be urgent, a face-to-face assessment. Those who are not assessed to be urgent are signposted to the right service.

All the urgent GP referrals of the month of July 2021 were followed up retrospectively and the outcome was recorded to assess the influx and outcome of urgent referrals from primary care. The urgent referrals from all other routes such as Psychiatric Liaison, and Social Services, Police etc were not included in the data.

A total of 124 urgent referrals were received in the month of July 2021. Only 13 out the 124 were deemed urgent following the telephone assessment and they were offered a face-to-face assessment. Fifty three patients were referred to primary care mental health team, 24 were referred to the secondary community mental health, 20 were referred to the older adults team and 10 were discharged back to the GP following. Out of the 13 who were assessed by the duty team, 6 patients were referred to primary care mental health team and 6 were referred to the secondary community mental health team. The urgent referrals came from 20 GP surgeries that cover a wide area of the rural and urban communities and the surgeries with most urgent referrals were highlighted

Trying to work on improving the quality of urgent referrals, the team tried to analyse the results, which proved to be complicated. The efforts to standardise the referral process has depended mainly on the degree of awareness of the GPs about the way the mental health service operates considering there is a percentage of locum GPs who might not be fully aware of how mental health service works.

The recommendation of the audit is to arrange visits to the GP surgeries to work on raising awareness among GPs about the referral system to the Mental Health team. It is also recommended that the GPs should be able to complete a brief risk assessment to justify why the referred patient needs to be reviewed urgently instead of on routine basis.

The aims of the audit was to find out current practices regarding implementation of covert administration policy guidance. The Covert Medication Administration policy was introduced during the past two years, but due to ongoing pandemic, awareness of it was low. Guidelines for when making a decision to administer medication covertly were clear in the policy. Covert medication administration is a very restrictive practice, albeit clearly in a patient's best interests. Instances were found when medication for physical health was administered covertly and there isn't authority to do so under the Mental Health Act as noted in Care Quality Commissioning inspections.

The sample selection was obtained by Incident Reporting forms for covert medication prescription from which 10 patients were identified from a four month retrospective sample of geriatric psychiatric inpatient admissions at the Juniper Centre at Moseley Hall Hospital, Birmingham from April to August 2021.

Covert medications administered were used to treat physical and mental health conditions. The physical health medication given was not for side-effects of mental health medication. Of the 22 medications and 10 patients there were no instances where the covert medication checklist had been completed. 9 of 22 medications (41%) (across 7 patients (70%)) had neither a best interest meeting nor a separate discussion held with the patient's family, friend, carer or advocate documented on the electronic record. Of the 22 medications, 7 medications (32%) belonging to 3 different patients had documentation of pharmacist involvement in the decision of covert medication administration whereas 15 medications belonging to 8 different patients did not.

Our findings conclude inadequate following of the standards protocol of the covert medication administration policy. Despite 77% of medications being prescribed with a completed multi-disciplinary covert care plan and 95% of medications having had completed Incident Reporting forms, the rest of the standards were notably missed.

High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF, or a total daily dose of two or more antipsychotics which exceeds the BNF maximum calculated by percentage. HDAT is defined as ‘off-label’ prescribing and the prescribing clinician should clearly document rationale for its prescription and clear discussion with the patient regarding the risks and benefits. If the patient is deemed to lack capacity, this should be clearly documented, and appropriate legal processes followed as defined by the Mental Health Act 1983. The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of electrocardiogram (ECG), body mass index (BMI) and blood biochemistry. Aims: To re-audit the number of inpatients prescribed HDAT across three acute general adult inpatient wards, and to establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.

Initial audit was completed in January 2020. Education sessions were provided to rotational junior doctors in the six months following initial audit. For re-audit, medication cards for each patient on the electronic bed-state at 9pm on 27/11/2021 were checked for HDAT prescription. Data were collected from electronic notes of patients identified as being on HDAT.

Initial audit in 2020 demonstrated that 3 of 49 inpatients (6%) were prescribed HDAT, with no evidence of documentation of rationale, and variable monitoring of physical health indicators. Re-audit in 2021 demonstrated that 11 of 47 inpatients (23%) were identified as being on HDAT. Of those, seven instances of HDAT were commenced during review by the multidisciplinary team or the consultant, with only two of these cases noting that the medication prescribed would result in initiating HDAT. Of the remaining cases, the prescriber was unclear. Eight had an ECG within a month prior to commencing HDAT. Only three patients had a repeat ECG within 7 days of initiation. Three patients were noted to gain at least 5 kg in weight following implementation of HDAT.

Education of junior doctors following initial audit had limited impact, likely due to high turnover of doctors. Implementations currently in development include: 1) Departmental teaching session for doctors of all grades, 2) Introduction of stickers on medication charts for patients prescribed HDAT to highlight monitoring recommendations, 3) Development of ward round template to include review of HDAT.

NICE recommends that drug treatments shouldn't be used specifically for the treatment of individual symptoms or behaviours associated with Borderline Personality Disorder but may be considered for the overall treatment of comorbid conditions. National audits have been completed by Prescribing Observatory for Mental Health UK (POMH-UK) in 2012 and 2014, with a local Trust audit in 2017. Subsequently, ‘Guidance for Prescribing in Personality Disorder’ was published and circulated across the Trust in Dec 2020.This audit aims to establish whether there has been a change in the prescribing trends in the Trust since the last audit in 2017.

Electronic records of patients identified and presented at Personality Disorder forums throughout the Trust between June-December 2021 were reviewed.

Two audit standards and four treatment targets derived from the POMH-UK audit were used.

24 electronic patient records were reviewed.

79% patients had a documented crisis plan, fewer than the 87% in 2017.

The proportion on antipsychotics with documented clinical reasons for prescribing was 69%, compared to 43% in 2017.

For those on antipsychotics in the absence of a comorbid psychotic illness, 91% were on them for >4 weeks, compared to 86% in 2017.

Z-hypnotics were prescribed for >4weeks in 37.5%, significantly more than the 13% in 2017. Benzodiazepines were prescribed for >4 weeks in 38% of patients, with 28% recorded in 2017.

100% of patients eligible for medication reviews had had them, an improvement from 90%in 2017.

Compared to the previous audit, fewer patients had crisis plan documentation, but more patients had a clinical indication for antipsychotics recorded.

Rates of prescribing Z-hypnotics, benzodiazepines and antipsychotics for >4 weeks seems to have risen, demonstrating a lower compliance with the treatment targets.

The proportion of patients having medication reviews has improved, however, the quality of these reviews remains similar to the 2017 audit.

The findings will be presented within the Trust with the re-emphasis on guidelines.

Prescribing in people with personality disorders can be revisited in 2 years.

To evaluate current transition service provision from CAMHS to AMHS focusing on information sharing, transition planning and continuity of care. Many young people find service transition from CAMHS to AMHS stressful, sometimes because of there being multiple simultaneous transitions from child centred services to adult oriented models of care. If not handled well, this can lead to drop out from services, repeated assessments, suboptimal treatment and support, and raised likelihood of emergency psychiatric admissions. Longitudinal planning and sensitive management of transition is vital, because of transition being a risk period for young people.

A retrospective case note survey of service users who had transitioned from 1st February 2020 to 31st January to 2022 was undertaken. Fifteen individuals transitioned: 9 females and 6 males. All were White British except for one who was Sudanese and an asylum seeker. Six out of 15 young people had a diagnosis of Autism Spectrum Disorder (ASD) in addition to other diagnoses making transition more difficult, as more agencies were involved requiring multiple meetings prior to transition to adult services. One case of emerging personality disorder, despite our best efforts for smooth transitioning, had already disengaged from CAMHS.

Most individuals transitioned successfully to adult mental health services. Two were transferred to learning disability, and one to early intervention in psychosis services, the diagnoses having been confirmed by the treating psychiatrist near the patient's 18th birthday. One was transferred to a rehabilitation service. Only one referral was declined.

The transition pathway is patient centred, and provides clear transition plans to young person, family and carers. In the past 4 months AMHS, because of lack of resources, have not been able to identify a named worker till a few weeks before the patient's 18th birthday, which conflicts with NICE guidelines.

An effective transition service was found to include

• • A designated psychiatrist to facilitate smooth transition of complex cases to AMHS, providing continuity of care, good intra and inter agency working and maximising patient welfare.

• • CAMHS preparation of young persons for transition commencing six months before their 18th birthday.

• • Prior researching of best transition destinations.

• • An overlap period of CAMHS/AMHS joint working.

• • Identified CAMHS and AMHS transition coordinators.

• • Patient and family engagement with process.

• • Mindfulness and awareness of AMHS eligibility criteria.

To assess the monitoring of patients who present with first episode psychosis (FEP), who are commenced on antipsychotics, under the early intervention team (EIT), in accordance with NICE guidelines. Patients diagnosed with FEP are usually treated with atypical antipsychotic's hence have a higher chance of developing metabolic syndrome, thus screening for physical health is imperative.

This was a retrospective audit of patients with FEP, started on antipsychotics, under the EIT, between the 1st January 2020 to 31st December 2020. The date range allowed for a complete data set, as well as to assess the impact, if any, of COVID-19. A sample of 26 patients were identified by the EIT of which, once inclusion criteria was applied, 21 were audited.

Compliance was calculated on investigations being completed at every stage, as defined in the standards. For example: blood pressure had to be measured at 12 weeks and 1 year to be compliant with the standard. Data collection and analyses was completed using the IT system ‘Rio’ and Microsoft Excel.

There was an overall compliance rate of 51%. The results showed no patients had their weight/BMI monitored as per guidelines. Waist circumference was not measured in any patients. 43% met the monitoring standards for pulse and blood pressure. On further analysis, by 1 year 90% of patients had their pulse and blood pressure checked. Blood lipids were correctly monitored in 48% of cases, nevertheless when the results were broken down, 86% of patients had been monitored within a year. Prolactin monitoring occurred correctly in 52% of patients. Blood tests including full blood count, urea and electrolytes and liver function tests adhered to guidance greater than other parameters at, 86%, 86% and 90%, respectively. 48% of patients had plasma glucose/HbA1c monitored. An ECG at 1 year was obtained in 67% of the patients.

The compliance rate may have been lower than expected due to COVID-19 preventing in-person appointments, staff redeployment and disengagement from patients.

Monitoring after antipsychotic medication has been commenced requires improvement. Within one year, monitoring was generally met well. However, the monitoring did not always meet the specific time frames provided by NICE, thus current systems need reviewing. Recommendations included disseminating results throughout the EIT, adding waist circumference as an option on the physical health assessment form and create ‘blood sample sets’. Re-audit will allow us to assess the results of interventions and the impact COVID-19 had on monitoring.