This audit aimed to investigate how VTE risk assessments on one of our older adult inpatient units meet to the recommended standard by:

1. 1. Assessing the compliance of admissions to the trust VTE policy, which is based on the corresponding National Institute for Health and Care Excellence (NICE) guideline.

2. 2. Determining if VTE assessments were performed using appropriate clinical tools, as recommended in the policy, and correctly recorded in patient notes.

All admissions to the ward (n = 77) within the one year from 01.06.2021 to 31.05.2022 were retrospectively reviewed for VTE assessments based on the abovementioned standards. Data was extracted from progress notes and ward round entries for completion of the VTE assessment during admission, documentation of the assessment tool, documentation of the VTE prophylaxis prescription if indicated, and reassessment of risks during admission.

This audit showed that only 3% of patients had a VTE assessment documented within the first 24 hours of admission. Overall, over a 10th of all patients never had an assessment, and of those who did, no one had the assessment tool used documented or uploaded on their clinical records. Also, of those who had a VTE assessment done, 5% were assessed to be at risk, and of these, only half had VTE prophylaxis prescribed.

This audit showed the ward is essentially not meeting the standard for VTE risk assessment, with recommendations to incorporate VTE assessment as part of the clerking proforma and the medication charts, similar to the usual practice on physical health wards.

The study aimed to assess staff understanding of the discharge process in an Elmdale ward, Halifax and improve the promptness of discharge reports to other primary care professionals.

Initially, the discharge process was reviewed in March 2023 to establish a baseline, focusing on completion time and personnel involved in the process. An online survey was conducted using Survey Monkey with 20 responses from the staff, including nurses, pharmacists, and doctors, to gather insights into their comprehension of the discharge process.

Electronic data for EPMA (electronic prescribing and medication administration) discharge form from SystmOne was analyzed to determine the percentage of completed discharge summaries and identify any incomplete or absent summaries among patients discharged from Elmdale ward (an acute inpatient ward) between March 1st and March 31st, 2023.

The data showed that 76.9% of discharges were completed within 24 hours, with weekend discharge completion at 4 and only 25% after 5 pm. Half of the discharge summaries were closed by nurses, 46% by doctors, and one by the ward clerk.

The median time taken to complete the discharge process was 25.83 hours, slightly exceeding the 24-hour target. Survey results indicated that 60% of staff were aware of the 24-hour timeline, but there were gaps in communication between staff members. Additionally, only 40% of staff had received formal EPMA discharge summary training, with nursing staff being the majority.

Eighty percent of survey respondents expressed challenges with the discharge summary process, particularly regarding communication with the pharmacy team and closing the discharge summary. Weekend discharge data revealed gaps in responsibilities when the ward clerk was unavailable to send letters.

Overall, the findings suggest a need for improved communication and training to enhance the efficiency and effectiveness of the discharge process, ensuring timely and accurate transmission of discharge reports to primary care physicians and other professionals.

More than half of the staff understood the discharge process however communication between staff in regard to the discharge process impacted on the timeliness of the summaries completed.

This audit focuses on assessing the compliance of health professionals with the UK law by informing the drivers with dementia about their legal requirement to report their condition to the DVLA and their insurance companies. The aim of this audit is to ensure public safety by adhering to the General Medical Council (GMC) guidance; “Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA”, as well as the Driving with Dementia or Mild Cognitive Impairment Consensus Guidelines for Clinicians; endorsed by RCPsych and Alzheimer's Society. This will help ensure public safety and prevent potential accidents or incidents caused by impaired driving.

The audit reviewed retrospective data of 40 patients selected randomly (17 males, 23 females and mean age 78 years old), referred to the memory clinic at Watermill Resource Centre in Berrywood Hospital, Northampton. The inclusion criteria was patients referred between 1st January and 31st December 2022 that were diagnosed with dementia. We set a compliance target of 100%.

The results showed that out of the 40 patients diagnosed with dementia, 23 had a recorded risk assessment. 11 patients were driving at the time of assessment. 7 patients were referred to occupational therapy for a driving assessment. The compliance in informing patients about reporting to the DVLA and their insurance companies was low. 8 out of 11 (73%) patients were informed about reporting to the DVLA, and 5 out of 11 (45%) were informed about contacting their insurance company. Additionally, only 4 out of 11 (36%) patients were informed about the consequences of not reporting to the DVLA and their insurer. There was also a lack of systematic documentation regarding driving risk assessment. There was no record of medics contacting the DVLA.

Overall, the audit revealed a need for improvement in compliance and documentation. It is recommended that health professionals strictly adhere to their responsibilities in risk assessment and informing drivers with dementia about their legal requirements regarding informing DVLA and insurance companies. Clear documentation should be made using a standard template available.

The use of psychotropics and polypharmacy among patients with learning disability have been widely discussed. Mental illness increases morbidity and mortality and the addition of polypharmacy potentiates these risks.

It is important to determine the proportion of inpatients with psychotropic polypharmacy, highlight associated socio-demographic and clinical factors, and follow up plans for such patients at the point of discharge.

A retrospective collection of data was completed using electronic records of patients 18 years and above who were discharged from inpatient psychiatric wards located in East Suffolk between 1st July and 31st December 2021.

Data available in discharge medication letters, discharge summaries and inpatient clinical notes were also used in the study.

Amongst 256 inpatient episodes included within the audit, polypharmacy was found in 52% cases.

Of which 80% of patients were above 65 yrs and 56.3% of them were male.

Out of the included episodes, 74% were on combination and 26% were on augmentation therapy.

About 40% had a single diagnosis of schizophrenia/schizophrenia-like delusional disorders, while around 25% had a mood disorder.

9% of episodes had a singular diagnosis of personality disorder and 8.4% of episodes had >1 psychiatric diagnosis.

Despite the increased side effect burden and risks in the presence of physical health co-morbidities, polypharmacy remained prevalent in this group of inpatients.

More than a quarter of patients were on sedative augmentation without any clear plan or recommendation for deprescribing after discharge.

In order to improve clinical practice, more frequent medication reviews should be recommended when there is high prevalence of psychotropic polypharmacy.

High doses of antipsychotic therapy (HDAT) are often prescribed in secondary mental health services and has been the subject of many audits and service improvements. This interest is largely due to the increased morbidity and mortality related to HDAT, and strong advocacy for clear rationales to guide this decision. There is a need for continuous review and monitoring to prevent unnecessary prescribing.

Our audit was used to determine the prevalence of HDAT in East Suffolk inpatient settings and assess whether review planning and monitoring of HDAT was practiced.

Standards for antipsychotic dosage were established using British National Formulary and Maudsley Prescribing Guidelines for Psychiatry.

Retrospective data was collected using electronic records of patients 18 years and above who were discharged from inpatient psychiatric wards located in East Suffolk between 1st July and 31st December 2021.

Data available included discharge medication letters, discharge summaries and inpatient clinical notes.

A total of 256 patients were discharged from East Suffolk wards in the 6-month period between 1st July and 31st December 2021.

Majority of the patients (80%) were above 65 years of age with more than half of patients being male 114 (56.3%).

Ninety-seven (37.9%) patients had a diagnosis of schizophrenia or schizophrenia-like and delusional disorders, while approximately 25% of the audited population had a mood disorder.

9% had a singular diagnosis of personality disorder.

One hundred and sixty-six (64.6%) patients were on antipsychotic medications and two (1.2%) patients were discharged on HDAT.

High dose antipsychotic prescribing was not as prevalent as initially assumed. This audit noted only one of the two patients on HDAT did not have the appropriate monitoring form completed.

Good clinical practice recommends the need for the completion of a high dose antipsychotic therapy (HDAT) form for each patient, which would allow proper monitoring.

The aim of the audit was to assess compliance with prescribing standards for antipsychotics in patients with BPSD as outlined within NICE guidance and with trust policy, Physical Health Monitoring of Patients Prescribed Antipsychotics.

The Bannerjee report published in 2009 highlighted the problem of inappropriate use of antipsychotic medication in the treatment of patients with behavioral & psychological symptoms of dementia (BPSD).

When antipsychotic use is considered appropriate, good practice is imperative to minimize risk and ensure optimal outcomes for patients. This audit looked to assess whether the use of antipsychotics in patients within CTT with a diagnosis of dementia adhered to best practice standards as outlined by the Bannerjee report and NICE guideline. The audit looked to assess adherence to physical health monitoring requirements as per trust policy for patients prescribed antipsychotics. Currently, there is limited guidance around monitoring of antipsychotics for use in BPSD as they are not licensed in the longer term.

A retrospective audit was undertaken for patients under the care of CTT between September 2020 and September 2021. 49 patients were prescribed an antipsychotic for BPSD.

Within the sample, 84% of patients were prescribed an antipsychotic at 12 months, 94% at 6 months and 98% at 3 months.

Compliance with the Audit standards showed: 82% of the patients had capacity assessed and documented prior to initiation of an antipsychotic.

98% of patients and/or carers had adverse effects of antipsychotics reviewed.

The risks and benefits of antipsychotics are discussed with the patient and/or carer(s) prior to antipsychotic initiation (94%). In 92% of patients, non-pharmacological interventions are tried prior to initiation of an antipsychotic. Clinical indications (target symptoms) are clearly documented (100%).

Although good prescribing practice was demonstrated, there was an area of concern due to a lack of compliance with physical health monitoring requirements. Most patients were prescribed an antipsychotic for longer than the licensed treatment period.

Agreed Actions:

Discussion with all professionals to emphasise the necessity for effective communication and a documented care plan for antipsychotic monitoring and review.

Present and disseminate audit findings within locality groups and wider teams.

All patients who are prescribed antipsychotic medications require annual blood tests which must include Full Blood Count (FBC), Urea and Electrolytes (U&E), eGFR, Lipids (Cholesterol & Triglycerides), Liver Function Test (LFT), HbA1c/Plasma glucose. Some patients also require prolactin blood test depending on their prescribed antipsychotic medication.

NICE and Maudsley guidelines recommend an annual check of the blood tests mentioned above.

This audit ascertained compliance in terms of annual blood test monitoring for patients who take antipsychotic medications and provided recommendations to improve where necessary.

Half of the caseload from two General Adult psychiatry Community Mental Health Teams (CMHT) were recruited from a sample population of 228 patients. Odd number randomisation was applied to select our sample (e.g., 1, 3, 5…). Sample size was of 114 patients, 8 of whom were not prescribed antipsychotic medications and excluded. Hence, 106 patients were identified as representative for inclusion in this audit.

Retrospective data collection was from clinical entries, clinic letters and blood test results.

Data obtained from these patients was collated and analysed using MS Excel spreadsheet.

The audit revealed that compliance was suboptimal for all required blood tests (Compliance 80% or above is recommended). The kidney function test of Urea & Electrolytes was the closest to recommended standards and best performance overall (77%), eGFR, was subpar at 60%. 74% of patients had the glucose monitoring tests (Plasma glucose/HbA1c) done while Full Blood Count and Liver Function Test were both completed in 76 patients (~72%). The worst performing category was Prolactin monitoring, of which only 9 of patients who required this had it done, recording a mere 31%.

Majority (66%) of the blood tests were done at General Practice (GP) surgeries, 25% by Mental Health Services, while the rest were contributed to by Accident & Emergency and Acute Hospital visits.

Following completion of this audit, recommendations were made to advise existing antipsychotic blood monitoring services (GP surgeries and private clinic affiliated with the Trust) of the recommended blood parameters for monitoring, and the need to update current systems. Also, Liaison with service managers and service leads to set up a dedicated physical health clinic for this purpose. The latter has been particularly successful as the Trust is now in the process of recruitment for the new physical health clinic team. A re-audit is planned in the near future.

Acutely ill patients on PICU are likely to be on High dose antipsychotic treatment (HDAT), which poses a risk to their physical health. Current guidelines require that appropriate criteria be met before prescription, and close physical health monitoring after prescription of HDAT. This audit aims to assess practices regarding prescription of HDAT to patients on PICU, Mill View Hospital, Hove according to standard guidelines.

Ten of the 38 patients admitted to PICU at Mill View Hospital between January and June 2023 were on HDAT and thus were eligible for this audit. The revised prescribing observatory for mental health topic 1h 3e audit tool was used to collect data regarding the patients. Data was collected from the clinical records including electronic, paper notes and uploaded drug charts and forms.

The age range was between 21–56 with an average age of 35. Eight of the 10 patients were white British, 2 were of another ethnic group or ethnicity unknown. All the 10 patients had clinical reasons for HDAT prescription clearly documented at the start of the treatment which ranged from cross titration of antipsychotics to treatment resistance to standard treatments.

Of the 10 patients on HDAT, 6 of them had documented clinical review in the 3 months, 1 had documented clinical review in last 3 to 6 months, 3 had no clearly documented review of clinical response in the last year.

Only 7 out of 10 had their temperature, pulse, blood pressure, body mass index and electrocardiogram (ECG) clearly documented. Seven of the 10 patients had their full blood count, urea and electrolytes, liver function tests, blood glucose, plasma lipid tests done and clearly documented in last year. Eight of the 10 patients had their serum prolactin checked while none of the patients had their creatinine phosphokinase checked and clearly documented in the last year. Only 2 of the patients had clearly documented examination of extrapyramidal side effects (EPSE) in the last one year.

This audit demonstrates that although clinical reasons for HDAT prescription were documented for all patients, current standard guidelines for HDAT prescription regarding regular review and physical health monitoring were either not being met, or not clearly documented.

The National Institute for Health and Care Excellence (NICE) recommends routine testing and replacing vitamin D in adults considered high risk of deficiency. Evidence suggests high prevalence of vitamin D deficiency among those with alcohol dependence and those with chronic liver disease regardless of etiological factors. These findings are particularly important for Bridge House Detoxification Unit, where patients with complex substance use disorder (SUD), and multiple physical and mental health co-morbidities, undergo detoxification. The purpose of this audit project was to establish current levels of vitamin D testing on Bridge House Detoxification Unit in comparison to the standard set by NICE guideline PH56, and to improve it.

Data was collected retrospectively from a total of 76 patients, through 3 rounds of data collection. In each round all the patients discharged within a 2 months period were included. The Audit tool looked at whether vitamin D was tested on admission. Vitamin D level ranges were defined according to the Royal Osteoporosis Society: <25nmol/L is deficient, 25–50nmol/L inadequate, >50nmol/L is sufficient. After the first round, an intervention in the form of pre-populated blood form including vit D testing was introduced. This was to be used on the first day of admission. The second round measured improvement while the third round measured maintenance. Microsoft Excel was used to analyse data.

During the first round of data collection, no patient had their vitamin D tested. Following our intervention, 86.67% of our patients had their vitamin D tested suggesting significant improvement to compliance in the second round. In the third round, we were able to maintain compliance at 90%. Of the 44 patients that had their vitamin D tested after our intervention, 30 (68.18%) patients were within the deficient and inadequate thresholds, requiring vitamin D replacement.

This audit project examined international literature and local data identifying that vitamin D is indeed low among our patient group, therefore should be regarded as a high-risk group for vitamin D deficiency. There is sufficient evidence among the international literature that people with SUD suffer through significant physical and mental health effects of low vitamin D. A simple intervention of a prepopulated blood form was able to increase our compliance and maintained this.

1. 1. Measure compliance with NCEPOD Recommendations in the quality of physical healthcare provided to adult patients admitted to a mental health inpatient setting across the East and Central areas of North Wales.

2. 2. Guide further service development and improvement in the quality of physical health care provided in mental health inpatient settings in North Wales.

1. 1. A retrospective case notes audit of 10 patients each who were inpatient for at least one week duration on the adult mental health wards was conducted in April 2023 across the East and Central areas of North Wales.

2. 2. The audit was conducted using the NCEPOD audit Toolkit for “Physical Health in Mental hospitals”.

1. 1. Inpatients percentage (%) compliance against NCEPOD recommendation 1, 5, 6, 7, 9 and 11 was 0% for both East and Central areas of North Wales respectively.

2. 2. Recommendation 2 had 65% compliance for Central vs 61% for East.

3. 3. Recommendation 3 had 62% compliance for Central vs 25% for East.

4. 4. Recommendation 4 had 88% compliance for Central vs 40% for East.

5. 5. Recommendation 8 had 3% compliance for Central vs 20% for East.

6. 6. Recommendation 10 had 100% compliance for Central vs 94 % for East.

7. 7. Recommendation 12 had 72% compliance for Central vs 71% for East.

1. 1. Improve compliance with the NCEPOD recommendations in the quality of physical healthcare provided to adult patients in mental health inpatient settings.

2. 2. Develop a Trust wide policy document for physical health care in mental health inpatient settings in North Wales as per NCEPOD recommendations.

3. 3. Develop a new physical health assessment booklet for Betsi Cadwaladr University Health Board Mental Health and Learning Disabilities Division to be used by all inpatient staff for the provision of physical healthcare of mental health inpatients in line with the NCEPOD recommendations.

To evaluate whether a comprehensive biopsychosocial assessment is performed for patients presenting with self-harm or suicidal ideation in clinical practice, following National Institute for Health and Clinical Excellence guidelines 225 (NG225). We assessed Dorset Healthcare Liaison Psychiatry practitioners' compliance with a standardized biopsychosocial assessment template.

A standardized biopsychosocial assessment template, aligned with NG225, is utilised in all Dorset Healthcare Liaison Psychiatry services for conducting initial assessments. Included data were the initial assessments of adult patients presenting from 01/08/2023 to 30/09/2023 for the following indications: 1) a suicide attempt, 2) a self-harm incident, or 3) suicidal ideation. Any initial assessment that did not use the standardised template was excluded. Retrospective analysis of Rio records assessed compliance with each heading on the biopsychosocial assessment template.

A total of 60 records were included from Dorset Healthcare Psychiatry Liaison Services. Only one heading, the “Presenting Situation”, was documented in all assessments (100%). Psychiatric headings on the template showed high compliance: “Mental State Examination” and “Risk Summary” were each documented in 98% of assessments, and “Psychiatric Formulation” in 92%. The “Carer/Parent's Understanding of the Assessment” was the least assessed (40%). Other significant headings that showed moderate compliance were, “Safeguarding Concerns” (71%), “Physical Health History” (75%) and “Social Situation” (81%).

Our findings emphasize the need for more comprehensive biopsychosocial assessments in Dorset Healthcare Liaison Psychiatry services. While Liaison Psychiatry practitioners exhibit proficiency in evaluating psychiatric aspects, there is reduced compliance in assessing social aspects, notably in assessing family understanding. Future qualitative analyses will evaluate practical barriers and human factors affecting compliance with specific headings. Moreover, data collection can expand to encompass additional Mental Health services in a wider catchment area, including settings such as community and inpatient facilities.

Patients with disordered eating in psychiatry are considered highly complex in the acute hospital setting. In Spring 2023 a pilot for a specialised dietitian was introduced to identify and target such patients; aimed at reducing length of stay to the acute medical wards. Hospital admissions for eating disorder increased by 84% between 2015/16 and 2020/21; with increasing complexity of presentations and a demand for Specialist Eating Disorder (SEDU) beds, there are increasing numbers admitted to acute medical beds for initial treatment and management. In 2021 the Royal College of Psychiatrists published its updated guidance, Medical Emergencies in Eating Disorders (MEED). There is recognition that acute trusts must identify care pathways for the management of patients with eating disorders and severe food restriction for psychiatric reasons. This audit aims to show how these guidelines are being implemented locally and where there is a need for improvements in care pathways focusing particularly on length of stay, frequent attenders and avoiding hospital admissions.

A retrospective audit of 26 patients presenting between 01/03/2023 and 31/12/2023 was completed. Patients were identified from data collated by the specialist dietitian as having presented with an existing diagnosis of eating disorder or disordered eating in the context of psychiatry. Some patients were detained under the Mental Health Act. Some patients presented on multiple occasions to the acute hospital during this period; each inpatient episode was analysed independently. Data was collected retrospectively by analysing PICS documentation (electronic notes system) and entered into a data collection spreadsheet. A Google Form checklist was created to capture whether key points from MEED guidelines were met.

Demographic data, details of initial presentation and admission events were collated including the team initially referred to and how long after the initial admission this occurred. Outcomes of admission were also recorded. Data was quantitatively analysed to understands trends in referral process, MDT working (inclusion of emergency clinicians, acute medicine, psychiatrist, specialist dieticians and nursing colleagues). Average lengths of stay, number of attendances and planned admissions were also captured.

An overall reduction in length of stay for detained patients with dietetic and wider MDT input was noted from 50 days prior to January 2023, to 29 in the period from March 2023 onwards. Frequent attendance for electrolyte abnormalities was significantly improved though implementing MDT working with teams in the community and planned admissions from inpatient units or SEDUs for medical management reduced overall length of stay for those patients.

Electroconvulsive Therapy (ECT) is a treatment used for patients with severe depression, mania, catatonia, and schizophrenia. National Institute for Clinical Excellence (NICE) guidance for the use of ECT advises that for all patients, a risk/benefit assessment for the treatment should be made and documented with particular reference to anaesthetic risk and the adverse effect of cognitive impairment.

For patients who can consent to treatment, NICE recommends the use of patient information leaflets to help people to make an informed decision about their ECT treatment.

For patients who cannot consent to treatment, psychiatrists can authorise the use of ECT using the Mental Health Act. However, NICE recommends that any advance directive should be fully taken into account, and someone who speaks on behalf of the patient should be consulted.

This project aimed to audit whether the documentation of the consent process of patients undergoing ECT in NHS Grampian was in line with the above NICE Guidance.

The clinical notes and ECT folders of the six patients undergoing ECT treatment in NHS Grampian in January 2023 were reviewed in reference of the following domains:

1. 1) The clinical indication for ECT.

2. 2) If the patient (or their family/advocate) had the opportunity to receive the RCPsych Patient Information Leaflet for ECT.

3. 3) If a discussion about the risks/benefits of ECT had taken place with a patient, their family or advocate.

4. 4) If specific risks and side effects – namely anaesthetic risk and cognitive impairment – had been discussed with the patient, their family or advocate.

The project had been registered with the NHS Grampian Quality Improvement & Assurance Team prior to data collection beginning.

All of the notes reviewed (100%) had the clinical indication for ECT clearly documented.

Three (50%) of the patients had received the RCPsych Patient Information Leaflet for ECT.

A clear risk/benefit assessment discussion was documented in three (50%) of the patients' notes.

Specific discussion of side effects including cognitive impairment and anaesthetic risk was documented in three (50%) of the patients' notes.

There is a clear need for improvement in the documentation of the consent process for ECT in NHS Grampian. While the indication for receiving ECT is being clearly recorded, documentation of the risk/benefit assessment, discussion of specific side effects, and involvement of family or advocacy is less consistent. The introduction of the NHS Grampian standardised consent form is being considered as an option to improve this documentation. The documentation of the consent process for ECT can be re-audited once this form has been introduced.

In the intensive care unit (ICU), delirium occurs in up to 80% of patients on mechanical ventilation. Delirium is associated with an increased risk of morbidity and mortality, long-term cognitive decline, and risk of reintubation. This initial audit aims to identify areas of improvement in the early detection, prevention, and management of delirium in the ICU of the general hospital following trust guidelines.

In this baseline audit, data was collected about all inpatients on admission over a 7-week period (81 patients in total). The parameters audited were in accordance with trust guidance on the management of delirium and compliance to this was recorded. Parameters included: the correct use and documentation of screening tools, type and cause of delirium, pharmacological and non-pharmacological management, and other demographics such as sensory impairment and length of stay. Confused patients handed over verbally during ward rounds were also assessed again at the time, with documentation and parameters reviewed.

Of the 81 inpatients in the ICU, 20 were observed with delirium during their stay. The documentation of delirium via the CAM-ICU screening tool was incorrect in 25% of patients with delirium (PWDs). Furthermore, behaviour (including sleep) was only monitored for 15% of PWDs and 0% had a complete “This is me” document (support tool for patient-centred care).

Sensory aids were not available for 50% of PWDs and 25% of this group had drug/alcohol dependence. A diagnosis of delirium was only formally documented in 40% of PWDs and of these, 15% had the type of delirium documented. Only 8 PWDs received a specific management plan, with 6 PWDs receiving haloperidol or lorazepam for agitation. Non-pharmacological managements were not documented.

The average length of stay in the hospital was 20% longer in PWDs compared with non-delirium patients, with 10 deaths in the ICU; 50% of these being PWDs.

There is a lack of accurate documentation and a lack of medical optimisation for PWDs, which may lead to missed delirium diagnosis, greater risk of mortality and longer hospital stays. The results highlight a need for further education about delirium in the ICU, to increase awareness for better detection, prevention and promotion of appropriate delirium management and formal documentation as per trust guidelines. Furthermore, a need to consider alternative pharmacological management for delirium, specifically in the ICU where lorazepam and haloperidol may not be suitable in consideration of anaesthetic drug interactions and respiratory support requirements.

As admissions have the potential to contribute to iatrogenic harm, Mersey Care NHS Foundation Trust (MCFT) introduced an admission checklist to help the decision-making process around admitting people with Borderline Personality Disorder (BPD).

1. 1. To conduct an audit to review if the admission checklist was being used after its introduction.

2. 2. To provide data on the context of admission including the use of MHA.

Data from admissions for people with BPD to nine acute care wards in (MCFT) over a three-month period were collected and assessed for 21 parameters.

A total of 60 admissions were identified for 51 patients (9 patients had more than one admission).

None of the recorded 60 admissions had a completed BPD checklist at the time of admission.

36 (60%) of the decisions to admit took place during the Normal Working Hours (NWH), 24 (40%) out of hours (OOH).

33 (55%) informal admissions, 27 (45%) on Section 2 of the MHA.

NWH admissions were associated with a higher number of informal admissions compared with OOH admissions (24 vs 9 respectively).

3 out of 27 OOH admissions requested by Crisis Resolution and Home Treatment (CRHT) resulted in informal admissions. The remaining OOH admissions were following a Mental Health Act Assessment (MHAA) by trainee psychiatrists.

At the point of admission, 9 (15%) patients were not open to secondary mental health team in MCFT prior to their referral for MHAA; 48 (80%) patients were under Community Mental Health Teams and/or the CRHT; 12 (20%) were open to the Personality Disorder (PD) hub, and 3 (5%) were open to other mental health teams including eating disorders team, Attention Deficit Hyperactivity Disorder (ADHD), Addiction Services and Criminal Justice & Liaison Team (CJLT).

There was no engagement with completing the BPD admission checklist. 40% of ST doctors reported on a separate survey that they cannot locate the Checklist on patient information system.

Admission decisions made during NWH have led to significantly more informal admissions compared with during OOH where the MHA was more likely to be used.

An action plan was designed to improve engagement with the admission checklist:

• • Introductory training was provided to CRHT, approved mental health professionals (AMHPs), MHA second opinion doctors and psychiatry ST doctors.

• • Inpatient teams were asked to complete the checklist.

• • Bed Management to request an updated completed PD admission Checklist prior to admission.

• • Re-auditing in 6 months.

Research has found that having a mental health condition is associated with smoking, and difficulties remaining abstinent. It is also evidenced that there is desire to reduce the amount smoked and cease smoking altogether by those with mental health conditions. Smoking can also affect some medications used to treat mental health conditions.

To assess nicotine replacement management in inpatients at Rathbone Rehabilitation Centre (RRC) against Mersey Care NHS foundation Trust (MCFT) Nicotine Management Guidelines (SA20).

Data of all discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and the whole sample of 51 patients were audited.

47 (92%) were asked and recorded of their smoking status and 4 (8%) were not at the point of first contact on patient electronic records (Rio).

Of the 28 smokers who were identified on admission, 26 (93%) were offered support to stop smoking at that point. 3 other patients started smoking during admission.

Of the 31 patients who were identified as smokers (including 3 who began smoking during admission), 24 (77%) were offered support to stop smoking at regular intervals throughout their admission and 7(23%) were not.

Of the 28 smokers who did not wish to permanently stop smoking, there was documented evidence that 20 (71%) of these individuals were offered nicotine replacement treatment (NRT) in some form to manage temporary abstinence from smoking.

5 out of 31 smokers were referred to a Nicotine Dependence Treatment Advisor for counselling and support during their inpatient stay.

Below action plan was designed to improve compliance with MCFT Nicotine Management Guidelines (SA20):

Audit leads to communicate with every team member at RRC (Team meetings and emails) to remind them of the following:

1. ◦ To offer smokers support to stop smoking at regular intervals and document on Rio; via named nurse sessions or opportunistically.

2. ◦ To offer NRT where appropriate and document on Rio if accepted or declined during MDT reviews/named nurse session.

3. ◦ Ensure Physical Health Nursing Proforma is always completed on Rio, and if the service user is a smoker, to ensure referral status (referred/declined) to Nicotine management team is documented.

4. ◦ Increase awareness of referral pathway by putting up posters in relevant clinical areas.

To ascertain the service performance against the standards set by National Institute for Clinical Excellence (NICE) guidelines on physical health monitoring of children and adolescents prescribed antipsychotics.

Initial audit: April–June 2021.

Re-audit: January–February 2024.

Registered with the Lancashire and South Cumbria NHS Foundation Trust audit department. An audit tool was developed by the investigators. The investigators carried out a review of patient electronic records and clinical letters to gather information pertaining to initiation of antipsychotics and physical health monitoring.

Amongst other variables in this trust-wide audit, we considered age, ethnic background, reason of initiation of anti-psychotic, comorbid conditions among which most common is epilepsy, dose of antipsychotic used and distributions across various CCGs. Were they regularly reviewed by medic reviews and side effects monitored? We also looked at choice of antipsychotic used, which was largely aripiprazole and risperidone. Were antipsychotic bloods done or not and were we able to complete children's height and weight measurements whilst they were on antipsychotics? It was important that these are documented as being considered or ‘offered' even if could not be successfully completed due to e.g. challenging behaviour from the child. Detailed and comparative results can be shown in final submission along with charts.

The recommendations from initial audit were compared with the second audit, and whilst some of them were completed such as incorporating growth chart in the electronic records system, some ongoing challenges were identified. Positive and negative findings were both noted although the final conclusions lies in favour of good changes been made to service including the caseload becoming more ID specific in this age group.

To support evidence gathering for Esteem's RCPsych Early Intervention in Psychosis (EIP) network accreditation efforts, an audit was conducted to investigate compliance with EIPN's quality standards (QS) no. 33 and no. 36.

EIPN QS 33 = patients with first episode psychosis (FEP) are offered antipsychotic medication.

EIPN QS 36 = If the patient's illness does not respond to an adequate trial of two different antipsychotic medicines given sequentially, they are offered clozapine.

EIPN QS 36 is also specifically included in RCPsych's National Clinical Audit of Psychosis (NCAP) (listed as standard 4), but a more pragmatic definition is used, to factor in the issue of antipsychotic intolerance.

NCAP Standard 4 = People with FEP who have not responded adequately to or tolerated treatment with at least two antipsychotic drugs should be offered clozapine (NICE QS80).

This broader standard definition was used for this audit, to allow for results comparison with national data.

For EIPN QS 33, all patients on North East Esteem caseload (any primary diagnoses) for at least 6 months on 01/04/2023 were included.

For EIPN QS 36/NCAP Standard 4, the same inclusion criteria were used but refined to FEP cases only.

The electronic clinical records (EMIS) of such cases were reviewed manually by an ST5 and CT3 psychiatrist. Data on prescription history was collected then analysed in Microsoft Excel.

EIPN QS 33: 58 patients with any primary diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 58 (100%) patients were offered antipsychotic medication ⋅ 1 (2%) patient was prescribed an antipsychotic but never took it ⋅ 21 (36%) patients were only ever prescribed one antipsychotic ⋅ 17 (29%) patients were prescribed two antipsychotics sequentially trialled ⋅ 11 (19%) patients were prescribed three antipsychotics sequentially trialled ⋅ The remainder, 8 (14%) patients, had four or more antipsychotics sequentially prescribed (with the maximum number of trials being eight).

EIPN QS 36 / NCAP Standard 4: 55 patients with FEP diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 16 (29%) of these patients had at least three or more trials of antipsychotic medication, i.e. patients eligible for clozapine. However, only 5 (31%) of these 16 patients had either been prescribed clozapine (3 patients, 19%) or offered/trialled clozapine (2 patients, 13%). This 31% figure compares with 85% in Wales, 52% in England, and 50% in Ireland (NCAP 2021–22).

EIPN QS 33: The standard that patients with first episode psychosis are offered antipsychotic medication was fully met. About a third of patients required only one antipsychotic trial. Less than a third required two antipsychotic trials. One in five required three antipsychotic trials, and approximately one in seven patients required more than three antipsychotic trials.

EIPN QS 36/NCAP Standard 4: The number of eligible patients being offered or prescribed clozapine for first episode psychosis under care of NE Esteem falls well below NCAP averages for Wales, England and Ireland.

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) has 28 Promises as part of its Strategy.

Promise 16 is to: Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year.

This audit in November 2023 looked at the practice of using outcome measures for CAMHS patients in order to highlight areas of development for the service to work toward achieving the promise.

We wanted to understand if young people were having outcome measures completed and if so, when, what and how often. We achieved this by using a dip sample of five patients each across the three different localities (Rotherham, Doncaster and Scunthorpe).

A report was generated to include all patients discharged from CAMHS in the preceding three months to September 2023. Young people who had been with the service less than six months were excluded from the audit. Five patients were chosen randomly from each locality and their electronic patient record on System One was studied.

Information in the patient records was compared against the audit standards and recorded in Excel so the data could be analysed.

The results showed that 11 of 15 young people had an outcome measure completed at some point during their episode of care. All five young people in Scunthorpe had an outcome measure recorded in their clinical records however this tended to only happen at the very start, meaning there was no basis for comparison. Four out of five patients in Doncaster had outcome measures in the clinical record and these were undertaken throughout the episodes of care. In Rotherham, two of five young people had outcome measures recorded in the clinical records.

The most frequently used outcome measure was the RCADS but the SDQ was also used.

There is work to be done to ensure the use of outcome measures becomes routine, and also to standardise both the type and frequency of use. The Trust is aiming to increase their use by utilising SystmOne's capabilities to interface with service user mobile devices to send out outcome measures to patients. There is also a plan to inform staff within the service about the expected use of outcome measures. This audit will be repeated in 2024 to see if the Trust are moving closer to delivering their promise.

To audit telephone referrals to Beechcroft inpatient unit.

Beechcroft inpatient unit is a step 5 regional child and adolescent mental health inpatient unit in Belfast. It receives a large volume of referrals from across all five health and social care trusts in Northern Ireland. The process of referral to Beechcroft can vary between trusts and clinicians; the majority of admissions are emergency. The demand for beds has risen by 30% since 2019. Emergency admissions are commonly telephone referrals whilst others submit written referrals. The referrals process is managed by the ward sisters, as there is no bed manager post. Referrals are discussed with a consultant psychiatrist.

Referrals received often lack key clinical information, which makes decisions around appropriateness of admission or prioritising multiple referrals difficult. Furthermore, as the admitting doctor relies on this information, missing clinical information could result in patient safety issues.

24 telephone referrals were recorded between August to December 2023. 5 referrals were excluded for either no request for a bed (3) or telephone update following previous written referral (2). 19 telephone referrals were analysed across 7 different criteria as below, based on necessary information.

Criteria 1 Patient identifiable information

Criteria 2 Source of referral/referrer details

Criteria 3 Current location of patient

Criteria 4 Legal status

Criteria 5 Presenting symptoms

Criteria 6 Working diagnosis

Criteria 7 Risks warranting admission

Yes    No   %Yes

Criteria 1   19    0   100

Criteria 2    19    0   100

Criteria 3   13    6   68

Criteria 4    14   5   74

Criteria 5   18   1    95

Criteria 6    2   17   11

Criteria 7   15   4   79

Total     100   33   75.2

Patient identifiable information and source was documented in all referrals. Only 10% of referrals included a working diagnosis. Location of patient, legal status and risks warranting admission were documented between 68 and 78%.

Crucial information such as working diagnosis was missing in 90%. Risks or legal status missing in up to a quarter of referrals. This has an impact on timely access, bed flow and potentially patient safety.

A need for improvement in receiving and documenting telephone referrals has been identified. To aid improvement in patient safety and flow, a bed manager for in hours has now been appointed. A standardised proforma for recording data will be developed by inpatient staff in collaboration with community staff to include the above criteria. A re-audit will be carried out following these service improvements.