The risk of omitting an admission Electrocardiogram (ECG) in psychiatric inpatients can be high - patients may be more likely to have comorbid disease or require antipsychotic medication. Lack of an ECG represents inadequate physical health assessment, and may impact on morbidity and mortality from physical illness – impairing the ability to safely treat psychiatric illness, for example with antipsychotic medications. This audit aimed to establish achievement of admission ECG within 24hours, and to improve this if possible.

Two doctors gathered data retrospectively using written and electronic admission records for 41 psychiatric admissions in a one week period in September 2019.

Following the first audit cycle demonstrating low levels of policy adherence, an admission proforma containing prompts and requiring a signature of the admitting doctor was introduced. Data collection was repeated on 16 admissions during September 2020 using an identical process.

The intervention led to an increase in ECGs performed within 24hours (65% to 83% in 18-65 year olds, 52% to 60% in over 65 year olds), whilst documentation of delayed ECGs being justified and reattempted also improved (28% to 100% in 18-65 year olds, and 50% to 100% in over 65 year olds).

The proforma was utilised in 75% of audited general adult admissions, and 66% of audited older adult admissions.

This admission unit was failing to meet expected standards of physical health assessment, which could result in harm. Reasons for this varied, but were attributed to inconsistent admission processes resulting in junior staff being unaware of the requirement, or miscommunication between staff. Handover of outstanding tasks occurred, but was not taken ownership of.

Data collection was unfortunately impaired by reduced patient numbers secondary to COVID-19 admission processes – particularly in the older adult ward. As such some of the results in those over 65 years are positive, but may be spurious. It would be useful to repeat the audit once admission levels return to normal.

The unified assessment document provided a framework for inclusion of all relevant elements and reminders for the admitting doctor. It required formal responsibility to be taken by the admitting doctor to ensure completion. Qualitative feedback demonstrated that it improved the quality and ease of admission documentation, and enabled thorough assessments which were useful when planning patient care and discharge letters.

This audit demonstrated that use of an assessment proforma results in improved adherence to physical healthcare policies, and contribute towards improved patient care.

Non-attendances (DNAs) and cancellations are a very costly waste of resource within the NHS and so it is important to have a focused plan of action to proactively manage them. The Trust recognises that people may choose not to attend appointments, or discontinue contact with the services we provide for them. There will be occasions where a person's non-attendance is an indicator that :

• • they may be at risk to themselves or others through deterioration in their mental health, or other issues preventing them from attending.

• • Therefore, any failure of planned contact should be regarded as a potentially serious matter and should lead to an assessment of potential risk. Hence we aimed this study to see if trust policy of DNA and disengagement is being followed.

Data were collected for 51 patients who missed their scheduled appointment between February and August 2021, using a predesigned questionnaire tool.

Out of the 51 patients, 37 of them Did not attend the initial assessment whereas 14 of them did not attend follow-up appointments.

18 patients had the diagnosis of depression, 9 of then had anxiety as the diagnosis and 8 had the diagnosis of personality disorder. Please see figure above for distribution of Mental Health diagnosis.

98.1% patients were notified adequately and for all the patients, letter was sent to the patient and the GP.

In 50.9% cases Risk Assessment was completed (although 37 patient did not attend, they were already known to our services). In 25% of cases, risk assessment was updated.

Review of the Contingency plan was done in case of 26 patients.

Out of the 51 patients, family was contacted for only 3 patients. Remaining 48 patients other known contacts were contacted in 4 cases.

Out of the remaining 44 patients, 3 patients were referred for home visits or AHMP.

Out of the remaining 41 patients, police/welfare check was done for 4 of them.

The remaining 31 patients were discharged from the services after they did not respond to our multiple correspondences including phone calls and letters.

Though trust policy is being followed to a good extent in regards to adequately notifying and contacting service user, offer another appointment and informing GP, we are failing to adhere to trust policy in regards to updating risk assessments, review crisis plans or doing welfare checks.

This project was undertaken in the Tyrone and Fermanagh Hospital, an inpatient Psychiatric Unit in Omagh, Northern Ireland. It was recognised that the previous method of medical handover via anonymised WhatsApp messages had several issues including patient data on personal phones, over-reliance on phone apps which have the potential to crash and short messages with limited details were included. The aim of our project was to improve patient safety by improving communication between medical staff members.

The previous method of medical handover was via text message on messaging platform WhatsApp. A message was sent the morning of handover, to the WhatsApp group.

We continued to use a digital platform, but used Microsoft word, and Western Trust email addresses to record and send the handover. At the start of this project, we allowed free space recording, resulting in variation in the handovers.

We agreed a minimum number of details to be included to ensure quality of handover, and audited the word documents, to assess the adherence to this.

This change, still does not require face to face handover. There have been pros and cons to the change, which will be discussed in this presentation.

We reviewed four months’ worth of handovers. They were reviewed for specific elements of essential handover criteria. The areas included Patient Name, H&C, detained or voluntary, admission or review, presenting complaint, patient's history, risks, physical issues, and handover to specific person.

It should be noted that the doctors involved were aware of the changes made, and standards being introduced, and therefore were aware that they would be auditing their own handovers. This might have created bias in the subsequent handovers.

We then analysed each month to see what percentage of handovers had been concordant with the standards. These data were then represented in graphs, as we will show.

We identified areas which were performed well when completing handover. The areas which were consistently 100% included the date of handover and patient name or initials. Outstanding jobs were performed in 97.5% of handovers.

Areas for improvement identified when collecting results were the status of admission (i.e. voluntary or detained), the main patient risks and use of the document password.

100% of the shifts used the new digitalised format for handover using Microsoft word and trust email system.

We reviewed the results of the data, which highlighted areas for improvement

We hope to implement a standard performa for handovers, reducing the chance of key information being missed, thereby improving patient safety. We aim to collect data following this 2nd intervention in the next rotation and continue to examine handover processes using PDSA cycles.

The aim of this audit was to evaluate prescribing practices in patients with EUPD at South West London and St George's Mental Health NHS Trust and compare these to NICE guidance on the management of EUPD. We are aware that for a multitude of reasons including high levels of distress and long waiting times for psychological therapy, clients with EUPD are often prescribed psychotropic medication. NICE guidance states that drug treatment including antipsychotics should not be used specifically for EUPD or for associated behavioural symptoms. Drug treatment for comorbid conditions and short-term use of sedative medication may be considered as part of a crisis treatment plan. If prescribing, NICE recommends that written material be provided to the client along with regular treatment reviews.

We obtained a list of patients in the trust with a recorded diagnosis of EUPD on their electronic patient record (EPR) system (N=869). 10% of these clients were randomly sampled (N=87).

The notes were assessed for any prescribed psychiatric medication including the documented rationale for prescribing. We also assessed if medication use was consistent with NICE recommended time limited crisis prescribing and whether there was evidence of regular reviews of prescribed medication and of written material being provided to the client.

Of the sampled clients, 81.6% (n=71) were prescribed medication. Of these, 39.4%( n=28) had medication use consistent with NICE recommended time limited prescribing, and 57.7%( n=41) had timely reviews of medication. 4.2% (n=3) of those prescribed medication had evidence on their EPR of written material being provided.

Our results highlight the extent of drug prescribing for EUPD within the trust. Over half of patients sampled had timely reviews of prescribed medication. However, most were not consistent with NICE recommended time limited prescribing. The results were presented to the trust's Clinical Reference Group. A Working Group has now been formed to help bring prescribing practices better in line with NICE guidance, specifically around the provision and recording of written information of drug treatment to patients and reducing inappropriate prescribing and polypharmacy.

Rampton Hospital is the High Secure Hospital of Nottinghamshire Healthcare NHS Foundation Trust's Forensic Service. It is one of three such hospitals in England, following Security Directions set out by the Department of Health. Patient management occurs through the implementation of strict policies and procedures. Policy requirements highlight the need for MDT post-incident discussion of restrictive interventions, and in particular, of Rapid Tranquilisation (RT). This primary audit aimed to ascertain current practice and if necessary, suggest interventions to ensure that patient-care remains safe, effective, and well-led.

To establish current practice with regards to the discussion of individual cases of RT in MDT settings, specifically in Ward Round, we commenced a retrospective data collection from electronic notes covering all directorates within the High Secure estate between May and June 2022.

From these notes, we tried to ascertain whether the following policy standards were being met:

• • A de-brief with the patient should take place as soon after the incident as is practicable and reasonable, ideally within 72 hours.

• • The MDT meeting post RT episode should explicitly discuss the episode, and consider medication and any triggers of periods of acutely disturbed behaviour.

• • There were 81 data sets to explore.

Not all data sets were viable. Out of those analysed, less than 10% were found to have met the aforementioned ideal policy standards of having had a reflective discussion within 72 hours with both the patient and as an MDT, exploring the episode itself and its antecedents.

There are several interesting factors to consider from the results obtained. We postulate that the frequency of episodes of RT makes meeting the policy standard problematic; pragmatically, there is a significant time barrier to exploring these incidents in detail and the various teams, operating in dynamic and high-risk environments, may find it difficult to coalesce in order to debrief appropriately.

Furthermore, the reflections may actually be happening, but the burden of documentation mean that these are not being recorded formally in a way that can be measured.

There are limitations to the searches of electronic notes and we did not have access to Incident Reports, often completed at the time of these episodes; further information may have been uncovered if they were available.

Despite this, there is room for interventions that inform staff of this need and to provoke improvements in current practice.

Seclusion is a restrictive intervention used in inpatient settings for the safe management of patients who present with severe behavioural disturbance which is likely to cause harm to others. Clinical notes were used to establish if the trust policy of medical reviews for patients in seclusion was being followed on the Psychiatric Intensive Care Unit (PICU).

Patients admitted to male PICU at Springfield Hospital, Southwest London, over a 4 month period (February 2022 to May 2022) were included in this audit. Patients who were secluded outside this time period or prior to admission to PICU were excluded from this audit.

The clinical notes computer system (Rio) was searched using the term “seclusion”. The timing of initiation and termination of seclusion were noted as well as the timing and grade of medical professionals present for documented reviews.

Over this period, 12 discrete episodes of seclusion were identified. The length of seclusion varied from 8 hours 45 minutes to over 5 days, with a mean length of almost 3 days (2 days, 20 hours, 25 minutes).

As the length of seclusion differed so did the required medical reviews in line with trust policy. This involves Senior House Officer (SHO) review at 30 minutes, Registrar review at 8 hours, Consultant review at 24 hours followed by 2 senior reviews (one Registrar and one Consultant) over each subsequent 24 hour period of continuous seclusion.

10 episodes of seclusion lasted over 24 hours in this audit. Of these 40% had the required medical reviews documented in the clinical notes appropriately for the full period of seclusion. 50% of cases had at least 1 missed or not documented Registrar review. There were 2 incidents of missed Consultant medical reviews for a 24 hour period of continuous seclusion.

From these results medical reviews were not being correctly carried out, or were not documented correctly, in the majority (60%) of cases of seclusion over 24 hours. This suggests missed opportunities for patient review to terminate seclusion at the earliest safe opportunity in line with national and trust guidance. These results have informed the update of trust guidelines on seclusion to bring it in line with national guidance with a view to improve patient care and will be re-audited.

1. 1. To review the current level of compliance with CPFT (Cambridge & Peterborough Foundation Trust) guidelines by inpatients prescribed anti-psychotics at George Mackenzie House (GMH) low-secure unit and likewise, with NHFT (Northamptonshire Foundation Trust) guidelines by inmates prescribed anti-psychotics at HMP Whitemoor's Fens Unit.

2. 2. To identify any differences or similarities in compliance rates between both sites.

3. 3. To identify any possible areas of difficulty in ensuring full compliance with said guidelines and suggest possible solutions.

A retrospective design was used, in which the electronic and hardcopy patient records of service users at both sites, covering a specified time-frame (2nd Dec 2021- 2nd Dec 2022) were screened. Data collected from eligible users included demographic information, names of anti-psychotics used and results of each individual's screening profile measured against the respective Trust's guidelines.

The demographic profiles of eligible service users at both sites were largely similar.

17 out of 18 services users from GMH and 23 out of 50 service users from the Fens Unit were found eligible for the audit.

The majority of eligible service users at both sites (88-100%) were compliant with measurement of relevant laboratory markers, as per Trust guidelines.

However, at both sites, there were notable omissions in monitoring of certain physical parameters, especially waist circumference (100% omission in both sites) and ECG monitoring ( 60% omission in prison,14% in GMH), which is important given the significant comorbidity of cardiovascular risk factors amongst service users at both sites.

We noted disproportionate compliance in the monitoring of different physical health parameters. While laboratory tests were on the whole, satisfactorily monitored, there were gaps in other clinical measurements like waist circumference and ECG recordings. We postulate several reasons for this discrepancy, including:

• • A possible lack of awareness about the importance of measuring parameters like waist circumference, which also indicates a lack of familiarity with Trust guidelines.

• • A lack of time/inconvenience in ensuring adequate recording of clinical parameters

• • Inadequate reminders to conduct relevant physical health checks.

We suggest possible solutions to ensure 100% compliance: for example, creating a teaching session for staff and service users on pertinent topics, like metabolic syndrome or creating electronic aids to remind staff when physical measurements are due.

This audit also engendered further questions on appropriateness of anti-psychotic prescription and importance of educating service users about physical complications of anti-psychotic use. These could be the focus of future audits.

The aim of this work was to apply the well established standards for patients suffering from diagnoses classed as Severe Mental Illness (SMI) to patients with a diagnosis of emotionally unstable personality disorder (EUPD) in our EUPD psychotherapy service. This patient population is also known to suffer lower life expectancy and greater physical comorbidities than the general population, and indeed than patients with other personality disorders, and this represents part of the holistic care we hope to offer in our service. In order to bring this in line, we were aiming for an annual medical review including: height, weight, blood pressure, blood tests including lipids, up to date information about alcohol and substance misuse.

One month before a patient's 6-week and 12-month review we liaised with their general practitioner (GP) for the above information. We then followed up as needed. In the first cycle of this work (January through July 2022) we found that we were able to establish contact with patients' GPs and there was qualitative evidence from patient testimonials about improved relationships with their GPs. However, the information that we were receiving was not complete - 0% had all the information that was requested.

Following discussion in the team, a proforma was developed to make it as clear as possible to the GP which information we were seeking. We more proactively engaged GPs and patients' other physical care teams, including neurology teams. Where patients had home monitoring equipment like a blood pressure cuff or scales, we also collected information from these. Compliance was reviewed again at the end of the next six-month cycle (August 2022-January 2023).

Between the first cycle, from January 2022 through July 2022 and the second cycle from August 2022 through January 2023, we improved compliance toward the target of having all these data points documented for all patients from 0 to 57%. This included 100% compliance for blood pressure and pulse measures and 86% compliance for documented weight.

We also note improved relationship between patients and GPs and other healthcare professionals including a patient testimonial “Having not had the support of Waterview dedicated staff and the group I probably would not attend any of the hospital appointments.”

Introducing the proforma significantly improved compliance with physical health monitoring targets from 0 to 57%. Further work within the team and with GPs including education on the diagnosis may improve this further.

An on-call email system was put in place to facilitate communication between wards and the on-call doctor, allowing prioritisation of duties according to green, amber and red tasks. Information regarding the patient, nature of request and clinical background are expected in the request form. The doctor is expected to respond to the email within 45 minutes. We completed a re-audit to compare if expected standards were reached in practice and attempt to find any areas of practice that could be improved.

We collected information on request forms, presence of adequate information and response time by reviewing the Teesside on-call email inbox. One day was randomly chosen from each week for a 24 month period and all emails were reviewed from chosen days. This amounted to (N=680) emails. The compliance was measured against local trust criteria with expected standard of 100%. We assessed four parameters of completion of request forms, providing adequate information including clinical information, patient identification and location, and response within 45 minutes by the doctor.

The compliance in all four standards was subpar, with notable decrease in compliance from previous results. Compliance was less than 70% across all standards, where previously three standards were above this mark. There was a notable increase in requests with inappropriate tasks defined as non-urgent tasks as per trust guidelines.

Better communication can be ensured with use of SBAR (Situation, Background, Assessment, Recommendation) in the request forms. Mutual sharing of information between doctors, nursing staff and administration with regard to appropriate written communication could constitute the base for structural change and improvement within the workplace. New staff members and doctors should be inducted with regards to the process of on-call email communication. Regular re-auditing and sharing of results is essential to the monitoring of change in compliance.

The aim is to improve quality of care and patient safety based on adherence to updated standards guiding the admission to non specialist wards of individuals under the age of 18.The objective is to assess adherence to the updated standards at NHS Grampian.

Methods.

• • An audit was registered with the quality and improvement and assessment department (Project ID 5584)

• • A list of patients admitted to Royal Cornhill hospital. NHS Grampian between 01 January 2020 and 31 December 2021 was obtained from the health intelligence department, NHS Grampian

• • The 2021-2022 period yielded 19 patients. In patients with multiple admissions only the initial admission was considered.

• • CCUBE electronic notes system was used to access all patient records for the admission period.

• • The MH case records, nursing notes and MHA documentation in CCUBE was assessed to obtain information relevant to the 8 categories of the Scottish government guidance.

• • MHLDS procedures for dealing with admissions to and discharges form Royal Cornhill hospital version 3 (May 2021) was used to ascertain current admission standards at NHS Grampian.

Environment and facilities

• • The ward has safeguards in place to monitor media use and prevent exposure to inappropriate material

Staffing and training

• • Staff trained to work with YP are available on each shift

• • Staff have training in managing LD in YP

• • Staff induction- includes policy on whistle blowing, covers key aspects of caring for YP on ward

Assessment, admission, transfer and discharge

• • Written care plan including evidence a social care needs assessment has taken place.

• • YP involved in choosing and developing a program of activities with staff- Documented in 1 Case only

Care and treatment

• • Staff wear name badges or picture board of staff so YP know who they are (uncertain about this)

• • Care plan shows evidence of social care needs assessment having taken place

• • YP are involved in developing a program of activities with staff

Information and advocacy

• • Parent/ carer information pack

• • Parents and YP receive information about how complaints may be made

• • Formal admissions- Parents and YP are given verbal and written explanation about MHA- verbal explanation documented in 2 cases

• • YP are informed how to seek independent advice and supported to use advocacy services- Documented in 5 cases only

Consent and confidentiality

• • Staff inform YP both verbally and in writing of their right to refuse or agree treatment and the limits of this.

• • Staff should inform informal YP with capacity that their consent to treatment can be withdrawn at any time

• • YP and carers receive verbal and written information of their rights to confidentiality and the limits of this

Other safeguards

• • After restraint staff should spend time with the YP reflecting on why it was necessary and their views are included in the post incident analysis

Unlikely that a ward would meet all of the extensive guidance therefore each standard classified as

• • Type 1-3

• • Type 1- failure to meet would result in significant threat to patient safety

• • Type 2-standards ward expected to meet

• • Type 3-excellent

• • There is no clarity on how many of the categories in each standard should be met to designate type 1-2

This clinical audit aimed to assess if monitoring of side effect of antipsychotics is adhered to using the Trust and National institute of clinical excellence (NICE) guidelines.One of the determinants of prognosis in schizophrenia is compliance to medications. Hence, the importance to monitor patient's tolerability of side effects when they are on antipsychotic medications. Several patients during episodes of relapse have reported that experience of side effects were their main reasons for defaulting on their medications. This underpins the importance to monitor patients’ tolerability of side effects when prescribed antipsychotics. Recommended monitoring scales are Glasgow antipsychotic scale, Liverpool University neuroleptic side effect rating scale, and Side effects scale for antipsychotic medication.

The 1st cycle of the audit was conducted from March 30th to April 30th, 2021, and the 2nd cycle was done between 4th October and 28th October 2022. In both cycles random sampling was used to select 50 patients on the caseloads of two community mental health teams. The data were collected with a tool designed using NICE guidelines and the Trust policy on monitoring of psychotropic medications.

For all selected patients in the 1st cycle, no rating scales were used to assess side effects at three months or after one year of commencement of antipsychotics. However, there were random documentation of side effects written as case notes in 96% of patients. Extrapyramidal side effects (EPSE) were the most documented of side effects in the 1st cycle. The re-audit saw an improvement of 24% in the use of an objective rating scale to monitor side effects. Similarly, as in the 1st cycle, EPSE were the most reported side effects in the 2nd cycle.

This audit showed a significant gap in the objective monitoring of side effects of patients on antipsychotics as none of the recommended rating scales were used on the selected patients in the 1st cycle. Although, there was an improvement in the use of rating scales of up to 24% in the re-audit as compared to 0% in the 1st cycle, the uptake was still far from the ideal. There is a need for the Trust and NICE guidelines to be adhered to in the monitoring of side effects of antipsychotics as this is likely to have a positive impact on compliance to medications by patients.

To investigate current practice of collateral history-taking on inpatient adult and older person wards in Leicestershire Partnership Trust. COVID-19 visiting restrictions raised concerns that the collateral history may be side-lined due to the physical absence of carers. Collateral history is important in developing a working diagnosis and assessing level of function, and is part of ongoing assessment and formulation.

An initial audit of 46 patient records from 3 inpatient wards (2 adult and 1 functional old age) was carried out in January 2021 when visiting restrictions were in place. In response, a questionnaire was distributed and 2 focus groups of junior doctors conducted later in 2021; the aim being to explore factors affecting collateral history taking. A re-audit was completed in October 2022 when visiting was reinstated. 48 patient records were audited. Old Age organic wards for dementia assessment were not included in data collection, as collateral history-taking is unavoidable for initial assessment of those presenting with significant cognitive impairment.

In 2021 and 2022, 33% and 38% of sampled patients had a collateral history taken in the first 14 days of admission. Where a collateral history was omitted, only 10% and 13% were attempted and 46% and 27% planned. Associated themes were identified from the questionnaire and focus groups including consent; accessibility of contact details; lack of confidence and variability in history-taking; accountability/ clarity on whose role it is to complete the task; lack of time/space and poor consensus on how to document a collateral history.

The results of the re-audit continue to show poor collateral history completion early in admission for both old age and adult inpatient wards despite reinstatement of visiting after the COVID-19 pandemic. Numerous issues affect the completion and documentation of good quality of collateral histories within inpatient settings of Leicestershire Partnership Trust. These have been categorised into staff, system, environmental and other factors.

This audit forms part of a wider quality improvement project. The proposed actions are as follows:

1. 1. To share findings locally via the Trust Audit and Quality Improvement department, Trust email and Consultant Medical Advisory Committee;

2. 2. To improve education through Trust induction, regular bitesize teaching and development of a crib sheet to be placed on each ward;

3. 3. To consider wider quality improvement projects in line with themes identified above;

4. 4. To undertake a further re-audit in November 2023.

Learning Disability population has increased neuroleptic sensitivity which predisposes to development of side-effects at even lower doses of antipsychotics. STOMP practices (Stopping OverMedication of People with a learning disability, autism or both psychotropic medications) advocate regular review of psychotropic medications, providing information about non-pharmacological therapy and involvement of patients and families about medications. Our audit aimed to understand how the side-effects in the Learning Disability patients who are on antipsychotics in a Medium Secure Hospital were being monitored in a 12-month period. The objectives were to assess whether the side-effects were being monitored regularly, whether a scale (Liverpool University Neuroleptic Side-Effect Rating Scale or LUNSERS) was being used or not, the grade of staff conducting the assessment and whether the outcomes being scored and reviewed adequately in Multi-Disciplinary Team meetings or Care Programme Approach meetings.

• • It was a retrospective, cross-sectional audit involving inpatients on the Learning Disability Wards of Rowan View (Medium Secure Hospital under Merseycare) in the time period 01/06/21 to 31/05/22

• • No patients were excluded

• • Data pertaining to assessment of side-effects to antipsychotics were collected from electronic database PACIS, the computer database used in Rowan View using Microsoft excel tool created by author

• • Descriptive statistics were used to analyse data

There were 27 patients included in the study from four different learning disability wards in Rowan View Hospital. In all but one (96.3%), side-effects to antipsychotics were assessed at least once in 12 months, but formal assessment using a rating scale was conducted in only 88.5%. In majority of patients, only one assessment was done in 12 months (43.8%) whilst the maximum was 3 assessments in a year in 34.8%. None of the assessments had the grade of staff noted whilst only 8.7% assessments were scored despite 91.3% being calculated and only 26.1% assessments even reviewed further. All patients reported side-effects to some extent.

The modality and frequency of reviewing side-effects to antipsychotics in this neuro-sensitive patient population was noted to be inadequate. The practice of using LUNSERS appears to be completed only superficially with questionable delivery and review of results. There is no formal guideline available nation-wide for basing this assessment of side-effects despite STOMP actions (other than suggestions) and a real deficit was identified. A creation of a formal guideline for monitoring side-effects in patients with Learning Disability is needed and is currently being addressed by Rowan View Patient Safety Team.

Post-traumatic stress disorder (PTSD) is a mental health diagnosis resulting in symptoms which make daily functioning challenging and higher cognitive ability often troublesome, resulting in a diminished quality of life that requires specific intervention to improve. The objective of this audit was to evaluate whether evidence based best practice is being met, regarding the treatment of PTSD in 62 individuals experiencing inner city homelessness. The overarching aim of this research was to shine a light on some of the prominent obstacles that are preventing access to healthcare, particularly in a population that historically struggle to raise their hand and ask for help.

The method used was a classic audit-cycle structure, using quantitative and qualitative measures to visualise outcomes. Data were gathered through retrospective analysis of patient documentation, communications between services and records dating back to each original diagnosis.

The results indicated that best practice in the form of trauma-focused therapies is not occurring as outlined by national guidance within this sample, but instead medication is acting a crutch, allowing individuals to cope with daily life. Over the 13-year period, 11% of individuals received some form of psychological therapy. Possible reasons for this suboptimal outcome were investigated, resulting in recognition of an array of barriers faced by the homeless population in accessing required therapeutic intervention. Results indicated the most common reasons for unsuccessful therapy were lack of contact or engagement by the individual, discharge on the grounds of substance misuse, then lack of record or follow-up within the service records.

In conclusion, barriers to the delivery of effective therapy are multifactorial and recommendations have been made here to promote integration of care across services, possibly providing an alternative pathway for these patients. Forward thinking models of psychologically informed environments may be useful to deliver treatment to people experiencing homelessness, in way that is accessible and approachable to them. Additionally, it has been recognised that improvement in communication across services regarding mental health interventions is required, to allow continual evaluation and improvement of care in the area. Finally, the question was raised whether current guidance is suitable and generalisable to the homeless population, particularly those under complex circumstances and co-morbid with substance or alcohol misuse. All recommendations have been made in the aim of improving provision of care for this population, to avoid deepening of already established health inequalities and to combat the inverse care law.

• • To evaluate current compliance in monitoring metabolic side effects for the patients with the diagnosis of autism, following the recommendations of NICE guidelines.

• • Establish evidence based practices to reduce morbidity and increase quality of life.

• • To identify areas of improvement.

Springs centre is a male locked secure rehabilitation ward, specialised in treating people with Autistic Spectrum Disorder (ASD), Learning Disabilities (LD) and co-morbid mental health conditions. It is a 17-bedded ward for male adults between 18 and 65 years old. Service users are transferred from hospitals or community placements located at the South East of England.

We collected data from service users admitted to the Springs Centre between 1st of January and 31st of July 2022. The selection Criteria included in patients with a diagnosis of ASD, taking antipsychotic medication, with records of clinical interventions and investigations. We conducted a search to electronic and paper files. Electronic records were available at MYPATH system as well as ward files with physical observations and health Action plans. Data were collected on spreadsheets and later analysed.

A total of 17 patients were identified, we excluded 2 service users that were not taking antipsychotic medication, and 1 of these did not have a diagnosis of ASD. We collected data from 15 participants. All patients have Blood pressure, Body Mass Index and measure of HbA1C (100%), 86.6% had records of lipid profile, but only 60% have a waist circumference.

We analysed individually the risks factors for metabolic syndrome on the 15 selected patients; 79 % of the patients had excess central adiposity (large WC). 20% among males were diabetic type 2 and smokers. About 40 percent (40%) of sampled individuals were obese.

The findings of our study supports the notion that screening for metabolic side-effects needs to be prioritised for individuals. Clinicians need to be aware of the risk of metabolic syndrome. Periodical screening is required across all health services treating people with ASD, especially those taking regular medication. General measures of control such as losing weight, exercising regularly. Eating a healthy, balanced diet to keep blood pressure, cholesterol and blood sugar levels under control. Also, stopping smoking.

Lithium is a well-recognised treatment in Affective Disorders. Careful monitoring is required due to its narrow therapeutic index. Adherence to monitoring standards has been generally poor with high levels of incidents reported to the National Patient Safety Agency leading to financial settlements and inclusion in patient safety alert potentially selected on inspection by the Care Quality Commission. This audit aimed at mapping the provision of lithium monitoring for patients stable on Lithium in Vale Royal to facilitate implementation of quality improvements in ongoing transformation of community services. There are twelve general practices in Primary Care (PC) for this area, one specialist mental health Trust Cheshire and Wirral Partnership NHS Trust (CWP) and one Hospital Trust MidCheshire Hospital Trust (MCHT).

1. Systems inventory

No lithium central register was identified.

All lithium requests were processed by North Midlands and Cheshire Pathology services (NMCPS).

In specialist care lithium was managed by one Consultant Psychiatrist.

In primary care nine practices provided information, all supported by a software overseen by administrative staff working collaboratively with doctors.

b. Data collection.

Anonymised Lithium results for adult patients stable between November 2021–2022 were collected from NMCPS.

Plasma levels and frequency were compared to generally accepted standards of 0.4-1 mmol/L every 6 months for stable patients.

Ninety patients were identified, eighty in PC and ten with CWP, median age 58, females (53%)/males (47%) gender ratio.

Frequency was mostly 3 monthly for 74% of patients in PC and 80% for CWP.

Levels below 0.4 mmol/L were found in 22.5% of levels measured in PC and 27% for CWP, and over 1 mmol/L in 5% in PC and 0% CWP.

This audit revealed that lithium monitoring for stable patients was primarily managed in PC.

Lithium level was measured more frequently than recommended which could be due to automated cues. Levels were often maintained at the lower end of the range. Those findings could be medically related.

Both computer and clinician led systems allowed for meeting, if not exceeding, targets.

Electronic systems are likely cost savings over a specialist clinic but could generate potentially unnecessary automatic checks, still require data reviews and medical oversight. This could be addressed by system amendments and an audit programme.

The absence of formally recognised central register could be remediated by shared agreement and managed by NMCPS.

Systemic approach to lithium monitoring can be collaboratively extrapolated to other localities, medications, or targets .

The aim of this audit was to look into the services’ fidelity of Naloxone provision and training across the Essex wide area compared with local guidelines as well as national guidelines (UK guidelines on clinical management of drug misuse and dependence, 2017)

The electronic records database for substance misuse services (THESEUS) was used for extracting the data. A total of 1991 patient records were analysed out of these 885 patient records were excluded, as these patients had never injected heroin. The remaining 1106 patient records were treated as the QUALIFYING POPULATION. A time frame period of 3 years (2019 to 2021) was further applied to the qualifying population, which resulted in 700 patient records being analysed for Naloxone data.

Naloxone provision was recorded under two different headings in the electronic database. The first heading, Naloxone episode – indicated the discussion held by the professional with the patient regarding the use of Naloxone. The second heading, Naloxone event – indicated the actual event of Naloxone being provided to the patient by a professional. There was a lack of clarity on both episode and events data capture regarding previously injected status.

Another important finding was that in the NON-QUALIFYING POPULATION i.e., patients who have never injected heroin in the past were provided with Naloxone for 367 patients, although this is a good practice it comes at the expense of missing out on providing Naloxone to patients who would definitely need it (OUALIFYING POPULATION)

1. 1. The robustness of the data collection done by the professionals was commendable, but this was let down by the ambiguity and obscurity of the data recorded on two different headings (episode and events)

2. 2. There was evidence of Naloxone being provided to the patients who have not injected heroin

3. 3. There was accurate documentation on the type of Naloxone being issued (Injectable vs Nasal)

4. 4. There was sparse documentation on the Naloxone training provision within the electronic system.

Background: It has long been known that having a Severe Mental Health Condition is a risk factor for cardiovascular disease. In order to facilitate early intervention, NHS has implemented annual physical health reviews. Within Sussex Partnership Foundation Trust (SPFT), compliance with this is outlined within local guidance and an assessment on admission and thereafter six-monthly is mandatory and called ALL-Physical Health Assessment. Historically, completion of this has been poor and therefore, this audit has been done to review the quality of completion and whether ALL is UpToDate and implement changes to improve the care. The Categorisation of completion into green, amber, and red as errors are linked to potential harm to patient's care. The review of actions taken from areas highlighted as abnormal results.

This study was done within the setting of Pine Ward, a 17-bed male, inpatient, low-secure forensic psychiatric ward.

Data were collected in November 2022 by reviewing ALL-Physical Health Assessments (six-monthly physical health check) on Carenotes(an electronic record system) and evaluating the quality of completion by categorising it as green(no errors), amber(minor errors, potential for risk to patient care), and red(major error/ missing documentation, which can lead to serious harm). ALL has fourteen categories. Smoking, Diabetes, Cholesterol/HDL ratio, Blood pressure, Pulse, Body Mass Index, Diet, Exercise, Alcohol, Substance misuse, National screening programme, Sexual functioning, Oral health and QRISK. This was compared with the results from February 2022 ALL assessments.

Of the 17 patients, 15(88%) had an ALL done in the last 6 months. When splitting completion of the ALL, 89.9% of completions were green, 4.6% amber and 5.5% red.

In February, overall 76.4% of patients had ALL done and 67.2% of completions were green, 15.5% amber and 17.2% were red.

Improvement was seen in QRISK, Alcohol, diet, and exercise status, as they were 100% documented in November whilst it was 70%, 58%, 82%, and 70% respectively in February. The diabetic and smoking status is now 82% and 88% whilst it was 58% and 76% in February.

This audit has highlighted that certain areas of the ALL that are not completed up to the standard expected. The importance of the assessment needs to be raised to trainees to allow for the best patient care. There is potential for harm to patients if the assessment is completed inaccurately or incorrectly.

To determine whether the community treatment team (CTT) were meeting the following three trust standards for patients receiving antipsychotic depot medication: 1. 100% of patients should have side effects monitored using a validated scoring system in the form of the Glasgow Antipsychotic Side-effect Scale (GASS) once yearly. 2. 100% of patients should have had a GASS completed ever. 3. 100% of patients with a completed GASS should have this document available in full. Additionally adherence to these measures was compared to the previous year's audit to assess for change following interventions and change in documentation.

A list of 146 patients receiving antipsychotic depot medication within the CTT was produced and subsequently set up in a Microsoft excel spreadsheet. Exclusion criteria were then applied as follows: any patient no longer under the CTT, any patient no longer on depot antipsychotics and any patient admitted in hospital at the time of audit (to allow for comparison to previous year where this was applied.) Following this 127 patients remained for whom I accessed their online notes and searched for evidence of completed GASS, when this was completed and if the full completed form was available. Once these data were gathered percentage of completion was calculated for each of the three standards outlined above both overall and subsequently broken down by depot administration group. These results were then compared to the results of the previous year's audit.

None of the three standards outlined above were met, however notable improvement was noted when compared to the previous year and are listed below:

1. 1. In this audit 66% of patients had received a GASS in the previous year compared to 53% previously.

2. 2. In this audit 97% of patients had a completed GASS ever compared to 95% previously.

3. 3. In this audit 99% of patients with a completed GASS had the full document available compared to 98% previously.

4. 4. Additionally significant variation between depot administration groups was identified ranging from 17% completion to 100% completion.

It is clear the standards of 100% completion of GASS yearly are not being met however there was notable improvement following previous intervention suggesting this was beneficial and further interventions have been put in place including, but not limited to, supply of a spreadsheet with up to date list of when patients are due a repeat GASS for future tracking to further improve adherence to standards.

To investigate if current practices by nursing and medical staff in the dementia ward (New Craigs Psychiatric Hospital), acute medical unit and geriatric ward (Raigmore General Hospital) followed the local protocol for managing distress of non-pharmalogical approach and rapid tranquilisation (RT) in older adults (aged >65years). We believe the split between the general and psychiatric hospitals and the different time pressures experienced in these 3 wards will influence the management and RT of their older adult patients.

Data were collected from 17/09/2022 to 8/10/2022 from case notes and drug charts of older adult patients that received rapid tranquilisation from 3 wards:

1. 1. Ruthven Ward, New Craigs Psychiatric Hospital

2. 2. Acute Medical Unit (AMU), Raigmore Hospital

3. 3. Ward 2C (Geriatrics), Raigmore Hospital

Focus groups and informal discussions were made with the ward nurses and junior doctors to understand their point of view on managing distressing behaviours in patients with dementia using de-escalation techniques.

A table was collated using Microsoft Excel. The parameters used were:

1. 1. Patient Diagnosis and Legal status

2. 2. Administration

3. • Date and time started

4. • If de-escalation techniques were used

5. • If discussed with a senior doctor

6. • 1st and/or 2nd line of drugs administered (route, drug and dosage)

7. • If Haloperidol given and if ECG was done

Data collection showed the following:

1. 1. Ruthven Ward- all 32 patients did not receive RT.

2. 2. AMU- only 1 out of 280 patients received 4 subsequent RT in 5 hours including 3x haloperidol (total 3mg) and 2mg of Midazolam despite an ECG showing prolonged QT interval. The latter prescribed after consultation with a senior doctor.

3. 3. Geriatric Ward – all 10 patients did not receive RT.

Focus groups and informal discussions with staff nurses from all three wards concluded that in spite of the stressful environment posed by issues of understaffing and high patient load, de-escalation techniques (recognition of early signs of agitation, distraction and calming techniques, recognising the importance of personal space) were prioritised before moving on to RT as per local protocol. Restraining was often used if patient was at risk to self or others by staff trained in violence and aggression management.

Informal discussions with junior doctors rotating in and out of AMU showed limited awareness of the RT protocol. In general, it was evident that RT was a last resort when psychological and behavioural approaches failed but that further education was required to administer RT safely.