Aims: This audit is most relevant to acute inpatients at a general psychiatric hospital (St Ann’s Hospital and Chase Farm Hospital) in which there is high turn over of acutely unwell psychiatric patients being admitted. This set of patients are at significant risk of venous thromboembolism due to immobility and the nature of their illnesses.

People with psychiatric disorders may be at risk of developing venous thromboembolism, particularly when acutely unwell and admitted to an acute psychiatric ward. This may be due to the presence of risk factors such as reduced mobility due to psychiatric illness or sedation, dehydration due to poor oral intake or comorbid physical illnesses. The use of antipsychotic medications also increases thrombotic risk. Parity of esteem for mental health is a priority for health care and should include equity of provision for the management of physical health problems in those people presenting primarily with mental illness.

Also, there are issues which may cause concerns with regard to VTE prophylaxis in this population such as capacity to consent to interventions, interactions of psychotropic medications with pharmacological thromboprophylaxis and risk issues around the use of pharmacological and mechanical strategies for people who self harm.

The aim of this audit is to find out if admitting doctors are complying with North London NHS Foundation Trust policy and Department of Health guidelines. This will be carried out looking at 40 admissions across 4 wards in St Ann’s Hospital and Chase Farm Hospital between 1/1/2023 to 30/6/2023.

Methods: Data collection using designed questionnaire.

Standards: Trust policy and Department of Health guideline to be used as standard.

Results: Out of the 40 admission cases viewed, none of them had VTE risk assessment done. Hence no data available to analyse.

Conclusion: It is unfortunate that doctors are no longer doing VTE risk assessment on an acute psychiatric ward. This is still being emphasized by Department of Health.

It is should be noted that about 25% of those who have pulmonary embolism die from it and DVT can lead to pulmonary embolism. It also should be noted that after the age of 40 years risk of VTE almost doubles every decade.

Recommendations:

Assess all acute psychiatric patients to identify risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the first consultation review, using a tool published by a national UK body, professional network or peer-reviewed journal. The most commonly used risk assessment tool for hospital is the Department of Health risk assessment tool.

Reassess all people admitted to an acute psychiatric ward for risk of VTE and bleeding at the point of consultant review or if their clinical condition changes.

Consider pharmacological VTE prophylaxis with fondaparinux sodium if Low Molecular Weight Heparin is contraindicated for people admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding.

Continue pharmacological VTE prophylaxis for people admitted to an acute psychiatric ward until the person is no longer at increased risk of VTE.

Action Plans:

This audit should be repeated in 12 months time.

This audit report should be discussed during induction programme in August this year.

This audit report should be shared with all consultants in the trust.

Nursing staff to check if admitting doctor has completed the VTE risk assessment as part of admission clerking.

Ward consultants including Dr Neru, ward managers and Dr C. Ozongwu (if available) to monitor the implementation of these recommendations.

Aims: To assess whether discussions about breast and cervical cancer screening occur during female patient admissions to acute inpatient wards.

To evaluate the impact of an intervention on the rate of completion of these discussions.

To explore the obstacles which limit these discussions

Methods: Female adult patients aged 25–70 years old, admitted to Acute Adult Psychiatric Inpatient Wards (Galleywood, Topaz), Mother and Baby Unit (Rainbow), or Psychiatric Intensive Care Unit (Christopher Unit) between 1/2/2022 and 30/4/2022 were included in baseline data collection (n=57).

Patients aged 25–54 were eligible for cervical cancer screening discussions and aged 50–70 years old for breast cancer screening discussions.

Physical health check proforma and ward review entries were reviewed.

Resident doctors completed a survey to identify barriers to completing these discussions.

An intervention involving enhancing teaching during induction for resident doctors and local academic teaching was implemented over 9 months.

A re-audit was conducted with admissions meeting the same criteria during the period 1/12/2023 to 29/02/2023 (n=34).

Results: In the baseline data, 4 out of 43 patients (9%) who were eligible for cervical cancer screening and consented to having a physical health check were included in discussions about cervical cancer screening. This increased to 5 out of 26 (19%) patients during the re-audit.

In the baseline data, 1 out of 15 patients (7%) who were eligible for breast cancer screening and consented to having a physical health check were included in discussions about breast cancer screening. Completion rate remained low with no discussions taking place with the 5 eligible and consenting patients during the re-audit.

Feedback from resident doctors included that there was not enough time to ask these questions during admission, that the patient was unable to answer these questions or that they felt the questions were not relevant.

Conclusion: There was a slight increase in cervical cancer screening discussions but a reduced number of breast cancer screening discussions that took place following the intervention. Rates of completion remained low for both.

Clinician feedback highlighted that improvements could be made to understanding the importance of these conversations and alterations to the timing of when they took place.

Further teaching has been implemented, reminder posters have been displayed in all doctors’ offices and options for the timing of completion of these discussions have been recommended.

Aims: The aim was to examine if the communication needs of asylum seekers/non-English speakers who were admitted to Acute Care Settings were addressed on admission and during the first ward round to ensure compliance with the accessibility standard act that is mandated by the whole NHS and to ensure compliance with Mersey Care NHS Foundation Trust (MCFT) Policy.

The Accessible Information Standard (AIS) SCCI1605, mandated by NHS England in 2015, is a legal duty placed on all organizations providing NHS or adult social care. Communication and/or information needs must be identified at registration/upon first contact with the service or as soon as is practicable thereafter.

One of the fundamental principles of AIS is that patients, service users, carers and parents should be asked to self-define their information and/or communication support needs. It is these needs (not their disability) which should be recorded. This initial question may be asked over the telephone, face to face at a reception desk, as part of a registration or admission form or through an alternative process and thereafter proactively and opportunistically.

Methods: This was a retrospective audit.

The inclusion criteria were Asylum seeker/non-English-speakers who cannot speak, understand and comprehend English. The exclusion criteria were Asylum seeker/non-English-speakers who can speak, understand and comprehend English.

Data from 24 patients during a 12-month period was collected and collated.

Results: Communication needs of asylum seekers/non-English speakers who don’t or have limited English speaking and understanding capabilities were recognised and documented clearly in the first 24 hours of their admission in 83%.

79% asylum seekers/non-English speakers who do not or have limited English speaking and understanding capabilities had interpreting services involved when important decisions regarding their care is being made during the first ward round.

Of the 24 cases audited, 14 had services involved face to face, phone, virtually, or other. Of the 10 that did not, 5 had a reason documented.

Conclusion: There is still room for improvement to meet the communication needs for the audited cohort.

Audit Team would put recommendations to MCFT to consider:

Amending the admission proforma to include a section for identifying and documenting any specific communication needs of the patient.

Incorporating a communication needs alert system for all patients to ensure staff are vigilant to response.

A bigger sample size over a longer time frame including multiple acute care settings in the trust would be planned.

Aims: This is a re- audit to assess if the same national guidelines in terms of commencement of medications, response to treatment, follow-up, pre/post treatment physical health monitoring, and use of rating scales are being followed for service users with working, but as yet confirmed, diagnoses of ADHD and ascertain utilization of recommendations from previous audit completed in December 2022.

Methods: A list of current service users open to South Durham Tier 3 CAMHS with a working diagnosis of ADHD and current trial of stimulant medication was compiled from the team case load.

Required data was collected from the electronic records of identified service users.

Results: Previous and current audit had equal sample size of 7 service users with same epidemiological data (sex, age, co-morbidity). All service users had physical and mental health assessment prior to commencing medications in both audits likewise with review of ADHD symptoms recorded following initiation of medication.

In both audits, 5/7 service users had regular contact for follow up, although all of them were offered regular appointments. All eligible service users had physical health check within 3 months of starting a trial of stimulant medication and review of medication side effects.

Like previous audit, 6/7 service users had their height and weight checked and plotted onto a growth chart. As rating scale was utilised to make decisions regarding progress, current audit showed 6/7 completed by parents and school, while none returned by parent and 3/7 schools from previous audit.

Other observations noted include improvement in waiting time from 12 months for majority of service users to 13 to >30 months for all service users from previous audit, attributed to change in assessment team. However, waiting time for initiating medication increased in current audit due to staffing issues.

Conclusion: Overall a green compliance was assigned to this clinical audit report, however, some issues were identified in terms of gathering information regarding progress and record keeping. Significant improvement noted following recommendation from previous audit with retrieval of rating scales. Although there is a centralized document with a list of service users as previously recommended, a more detailed document which shows salient information required for follow up will be more helpful. These activities should be added to the agenda of the weekly team meetings to allow monitoring progress in situations of staff sickness.

Aims: The general aim of the audit is to identify the assessment procedure and subsequent referrals of patients making contact with the Primary Care Practitioner at the Brentwood Community Centre.

Methods: All the patients who were assessed by the Primary Care Practitioner attached to The Brentwood Resource Centre from January 2023 till January 2024 in order of attendance were selected consecutively.

Audit standards:

1. All new referrals should be first seen by the Mental Health Practitioner.

2. MHP assessment template – MHP – PCN Consultation V2

Sampling: A list of all the patients who were assessed by the Primary Care Practitioner attached to The Brentwood Resource Centre in order of attendance were selected consecutively for the time period. Sample size was 776.

Data collection: Data was collected retrospectively from the operating system (Mobius) using a data collection tool.

Setting: Community Mental Health Team, Brentwood.

Inclusion criteria:

1. Adult patients aged 18–70.

2. All adult patients as stated above that presented to the Primary Mental Health Care Practitioner at the Brentwood Resource Centre.

3. Patients who were within the catchment area of the Primary Care Network for The Brentwood Resource Centre.

Exclusion criteria:

1. Patients aged below 18 years.

2. Patients aged above 70 years.

3. Patients who did not fall within the catchment area of the Primary Care Network for the Brentwood Resource Centre.

Data handling and analysis: SPSS Version 27 was used for data entry and analysis.

Time duration: The data collection and analysis was be completed in 3 months of obtaining approval.

Results: The target aim was for a 100% compliance however the compliance was less than 100%.

Overall referrals that were initially assessed – 69.2% (82.5%).

Referrals from GP that were compliant with audit standards – 67.2% (80.2%).

Assessment using MHP Assessment template – 100%.

These were because some of the patients referred did not engage with the service 190 (24.5%) and 44 (5.7%) of data were not available to be analysed.

Conclusion: Details of good practice:

1. All referrals made were screened and timely invites sent to patients for further assessments.

2. Outcomes of assessments were clearly documented.

3. Trust protocols for referrals i.e. discussions in MDT were followed.

Areas of improvement:

1. Clear documentations of outcomes for referrals made to the service and patients did not engage.

2. The use of the MHP Assessment template – MHP PCN Consultation V2 and uploading to the correct platform on operating software of the service.

Aims: Patients being admitted on mental health wards all have different forms of co-morbid physical health disorders needing complex care. They may require prompt transfer to medical wards for acute conditions and may need long-term monitoring for chronic ailments. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) did a survey in 2022 focusing on the quality of physical health care delivered in psychiatry inpatients.

Aims were: To ascertain the percentage of patients that get a complete basic physical health examination.

To understand what physical health examinations are being undertaken during admission.

To check the proportion of patients that have their physical health conditions (co-morbidities) documented in their initial clerking.

Creating awareness on the gaps and potential improvements for physical healthcare on mental health wards.

Methods: Retrospective study.

Adult inpatients with mental health conditions admitted on Cedar Ward.

Duration of one-month period (28/10/2023–28/11/2023).

To compare the data with the NCEPOD report of 2022 (guidance).

Target of ≥ 40 patients.

Results: It was difficult to collect the data from records due to lack of uniformity in the documentation of physical health findings.

Physical health plan was made in 100% of patients, but only 72% got bloods done and 79% had a physical examination.

Despite DSU/MSU being planned by nursing staff for most of the patients only 15% got urine dip done.

70% got ECG done, but it was difficult to get this record as this was documented on different tabs on PARIS (Electronic patient records).

Among the different systems examined, surprisingly only 43% of the patients had a nervous system examination. Note that some patients had “moving all four limbs” as the only sign examined but this was not considered.

Of all healthcare providers, SHOs were the initial point of contact for assessment of physical health needs.

17% of patients did not have physical health conditions updated on electronic patient records platform (PARIS).

Conclusion: Firstly, there is a scope to improve the quality of physical health assessment in patients that get admitted on the wards.

Secondly a standardised structure for documentation can be helpful both for ease of access to information and to ensure that all our patients get a proper assessment of physical health needs.

Creating a standard proforma for physical health assessments in line with the guidance will act both as a guide and aid in uniformity in recording the findings.

Aims: To evaluate compliance with best practices in prescribing psychotropic medications for individuals with learning disabilities and behaviours that challenge, in line with National Institute For Health and Care Excellence (NICE) guidelines and the Stopping Over-Medication of People with a Learning Disability, Autism, or Both initiative.

Methods: A retrospective audit was conducted on five patients prescribed psychotropic medications between January 2023 and December 2024 at the Chester-Le-Street Adult Learning Disability Community Team. Data were extracted from electronic patient records using a structured audit tool aligned with NICE NG11 standards.

Results: Strengths:

100% compliance in documenting the rationale for prescribing.

100% ensured psychotropic medication was used alongside psychological interventions.

100% identified comorbid conditions influencing behaviour.

Areas for Improvement:

Timely medication reviews: Only 20% had effectiveness and side effects reviewed within the recommended 3–4 weeks.

Treatment duration documentation: Absent in 100% of cases.

Patient/carer involvement: Considered in 40% of cases.

Multidisciplinary team (MDT) reviews: Completed within three months in only 40% of cases.

Conclusion: The audit demonstrates strong adherence to prescribing rationale and psychological intervention use but identifies significant gaps in medication monitoring, patient involvement, and MDT reviews. To enhance patient safety and adherence to national guidelines, the following recommendations are made:

1. Standardizing early medication reviews within 3–4 weeks.

2. Improving documentation of treatment duration.

3. Enhancing patient and carer engagement in medication decisions.

4. Ensuring timely MDT reviews to optimize prescribing practices.

Implementing these changes will support safer psychotropic prescribing, reduce unnecessary medication use, and promote a holistic approach to managing challenging behaviours in people with learning disabilities.

Aims: To assess compliance with the trust policy and NICE guidelines on VTE risk assessment for new admissions into the acute psychiatric wards in Millbrook and Sherwood Oaks mental hospitals, Nottinghamshire NHS Foundation Trust.

Methods: A retrospective audit looked at case notes of patients aged 20–80 years, admitted within a 2 weeks period across 8 wards in April 2023. This was re-audited in April 2024 after all recommendations were actioned. Infornation was collated and manually analysed. Data collected included but not exclusive to date of admission, date VTE risk assessment was done and the level of VTE risk identified. These were compared with the standard criteria which were the trust policy 02.21 – 'Patients who are admitted should have VTE risk assessment within 24 hours of admission’ and the NICE guidelines NG (82) 2019 – 'Assess all acute psychiatric patients to identify their risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the first consultant review'.

Results: The first cycle found that only 69.3% of the patients admitted were assessed on admission (with 50% assessed within 24 hours of admission) whereas 30.7% were not assessed throughout the duration of their admission. The second audit cycle showed remarkable improvements. 80.5% were assessed for VTE risk (63.9% within 24 hours of admission) whereas 19.5% were not assessed.

The level of risk was categorized into low, moderate and high risk using Well’s scoring system. 69% of patients who were assessed in the first cycle, had low risk but risk of 31% of the cohort of patients audited were unknown because they were not assessed. In the second cycle,80.5% had low risk whereas 19.5% of the patients fell under the unknown category due to not having been assessed.

Conclusion: The importance of VTE risk assessment in acute inpatient wards can never be overemphasized. Studies show that psychiatric inpatients are likely to be at an increased risk of VTE due to – use of psychotropic agents, reduced mobility, dehydration as a result of self-neglect or suicidal attempts, prolonged restraints, sedation, co-morbid physical health problems etc.

There are still lapses in our patient management that need to be considered in order to provide an outstanding patient care and safety.

Aims: To evaluate if documentation of Anticholinergic burden (ACB) score is in accordance with the NICE guidelines.

To calculate the Anticholinergic burden (ACB) score for patients referred to memory clinic if not documented.

Methods: I conducted retrospective analysis using a systematic sampling method and a proforma on patient’s electronic medical record to ascertain if the ACBs of patients were documented when being reviewed.

Information was obtained from both SystmOne tabbed journals, SystmOne medications list, and referral letters (to determine ACB score documentation and calculation).

Two scoring systems were used to calculate ACB: ACB calculator (https://www.acbcalc.com/) and POMH data collection tool.

Results: Of the 92 patients referred to memory service, 30 patients were analysed and only 3 had documented ACB burden score (10%). Using the ACB scale. 13 individuals had ACB score of ≥2 which was 43% of patients analysed. Using POMH, 9 individuals had ACB score of ≥2 which was 30% of patients analysed.

Most common medication involved in individuals with ACB ≥3 was amitriptyline (67% using the POMH calculator and 37% using the ACB calculator) and all were commenced in primary care. If documented, this score would be classified as high risk and necessitate a medical review in line with the guidelines.

Conclusion: To regularly document Anticholinergic burden score for elderly patients referred to service.

Patients with high burden score may require a medication review with documented evidence of either: Discussion about reducing the dose; or stopping or switching the anticholinergic medicine.

Currently, no scoring system is recommended, to use an agreed system.

Reducing drugs with high ACB can also lead to less polypharmacy.

In addition, concomitant use with anticholinesterase inhibitors may reduce the effectiveness.

Reaudit second cycle in 6 months.

Aims: According to NICE guidelines children and young people with depression should be treated on an outpatient basis. Antidepressants should not be offered routinely to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy.

When an antidepressant is prescribed to a child or young person with a depressive disorder, it should be fluoxetine as this is the only antidepressant for which evidence shows that benefits outweigh the risks. There should be monitoring and review of mental state in the course of treatment.

The aim of the audit was to evaluate the use of antidepressants for the treatment of depression in children and young people and the monitoring in place for the duration of treatment at West Lancashire CAMHS outpatient clinic in keeping with NICE guidelines.

Methods: Cohort: Outpatients (young persons) at CAMHS outpatient clinic (Westgate House) prescribed antidepressants for the treatment of depression.

Sample size: 15–20 patients (randomly selected).

Data collection: Retrospective data collection looking through patient’s record (RIO) for documented diagnosis of depression, medication initiation process, choice of medication, psychological therapy offered and evidence of monitoring – side effects, review of mental state etc.

Results: All the young persons had a documented diagnosis of depressive disorder on their records following psychiatrist review. Medication and side effect profile were discussed with the young person and family prior to initiation.

85% of the young persons were prescribed fluoxetine as the first-line medication whilst sertraline was given to the remaining.

The range of offered psychological interventions together with pharmacological treatment include: distraction techniques, use of bedside box, psychoeducation, coping strategies, art/play therapy, behavioural activation, problem solving group, DBT, CBT, IPT and family therapy.

Monitoring was done by the prescriber and case managers weekly (60%), two weekly (25%) and monthly (10%).

Conclusion: The range of psychological interventions offered to the young persons were compared with NICE guidelines. Though DBT is not recommended by the guidelines, it was used as a psychological therapy in a background of trauma and emotional dysregulation.

Sertraline was used as first line in one of the young persons with co-morbid PTSD.

Recommendations made to improve the monitoring using the side effect checklist – before prescribing as stated in NICE guidelines and also to liaise with the case managers in the monitoring process after treatment initiation.

Aims: The data on safety of antipsychotics in children and young people (CYP) remains insufficient, mainly because this age group usually is not included in trials. It is also partially because there are relatively low numbers of CYP on antipsychotics. Use of antipsychotics come with risks of short- and long-term side effects, the cumulative side effects are particularly important in CYPs. Baseline investigation and regular monitoring are crucial to identify any underlying or emergent health conditions to ensure CYP’s safety.

We aimed to evaluate our clinic’s compliance with the standards to ensure patients receive the necessary care.

Methods: The standards for this audit are based on “NICE – Guidance on Baseline Investigations and Monitoring for Children and Young People Prescribed Antipsychotic Medication” and “TEWV (2024) Psychotropic Monitoring Guide (Pharm-0082-V3.2) – Antipsychotics (Page 3 and 4)”.

Eligibility criteria included CYP on the Redcar CAMHS caseload between the dates 2/9/24–30/9/24, prescribed an antipsychotic with or without other psychotropics. All cases meeting eligibility criteria were included, with eligible samples identified through communicating with team members including team manager and prescribers. Seven CYP aged between 10–17 were identified eligible for the audit.

An audit tool was used in the data collection.

CITO (local electronic system) case notes and clinic letters are used as source of data. Search of key words such as “antipsychotic”, “aripiprazole”, “risperidone” also facilitated.

Results: The overall compliance rate was below 50% for this audit.

Areas of good practice: 80% compliance in the assessment of side effects at 3-month interval and 100% compliance in consideration of ECG, and completion of ECG if required, at 12-month interval.

Summary of issues identified: Poor compliance (below 80%) in recording weight, height, growth chart (or centile), waist circumference, blood pressure (BP) and heart rate (HR) checks, blood tests at the corresponding intervals, and pre-treatment ECG consideration or undertaking investigation.

Conclusion: In CAMHS, transitions between mental health services and patients being open to more than one team situations are common, often leading to confusion about responsibilities. Poor handover processes between teams can contribute to low compliance. Therefore, teams to improve their handover practices.

Due to small number of patients on antipsychotics in CAMHS, we do not have physical health check clinic within the team. Therefore, some of the physical health checks are requested from the GP colleagues (particularly blood tests and ECG). However, communication is not always immediate, making it difficult to track the results or document them. This can lead to missed or overlooked data. The communication and documentation to be more elaborate.

There is also no clear consensus on where to record monitoring data. For instance, while the Physical Health Tab on CITO is consistently used by some teams, this is not the case for my team. Additionally, some monitoring data is recorded in progress notes but not in the clinic letters. This issue to be discussed within the CAMHS team for clarification.

Aims: Stanley Ward is a 30-bed acute male ward in Wakefield. Quality of MDT meeting documentation was poor. We audited documentation quality in three cycles from March to November 2024, with interventions.

Methods: We set standards from the RCPsych CCQI Standards for Inpatient Mental Health Services and four domains of interest – capacity to consent to treatment, physical health, medications and leave. For each MDT meeting we noted whether each domain was documented fully, partially, or blank.

We audited for one-week periods in early and late March 2024, and for two-week periods in July and November 2024.

As first intervention, between early March and late March, we created an inpatient list for use by the ward doctors, including information for each domain, which could be easily copied in and updated. We continued to use the list after the audit.

As second intervention, between July and November 2024, we created a training video for new doctors, which described a psychiatric MDT and how to document. The video was interactive – a filmed simulated MDT, with audience invited to document as though present. This was shown at departmental teaching.

Results: Early March confirmed poor quality:

Capacity – 35% full, 30% partial, 35% blank.

Physical – 0% full, 46% partial, 54% blank.

Medications – 22% full, 16% partial, 62% blank.

Leave – 20% full, 11% partial, 69% blank.

Following first intervention, re-audit in late March showed improvement:

Capacity – 59% full, 2% partial, 39% blank.

Physical – 41% full, 32% partial, 25% blank.

Medications – 82% full, 0% partial, 18% blank.

Leave – 68% full, 2% partial, 29% blank.

Re-audit in July showed mixed Results:

Capacity – 20% full, 49% partial, 31% blank.

Physical – 48% full, 40% partial, 12% blank.

Medications – 91% full, 8% partial, 1% blank.

Leave – 71% full, 11% partial, 18% blank.

Following second intervention, results remained mixed, better than the start:

Capacity – 45% full, 35% partial, 42% blank.

Physical – 42% full, 16% partial, 42% blank.

Medications – 68% full, 19% partial, 13% blank.

Leave – 77% full, 0% partial, 23% blank.

Conclusion: Ensuring consistent improvement in quality for MDT documentation is a challenge, complicated by limited meeting time, and rotations of trainees new to psychiatry.

We have tried different interventions, including strategies to improve access to information, and producing training material.

Our next intervention is to create a training pack for new doctors in the department, which includes the interactive video. We will then re-audit.

Aims: The purpose of this audit was to re-audit (second cycle) the availability of physical health equipment on the psychiatric wards at the Mount psychiatric hospital. This was a second cycle of a previous audit performed in November 2023 to assess whether the previous recommendations had been successful in improving compliance with the 2022 CQC physical health recommended equipment list and equipment required to meet NICE guidelines for antipsychotic medication monitoring.

Methods: A stock check was performed of the physical health equipment available on the 4 old age psychiatric wards. This was against the items recommended in the 2020 CQC physical health guidance and key equipment required for basic investigations for monitoring of psychiatric medications, e.g. ECG and blood samples. The same criteria were used in the first cycle of this audit (completed by a different author), due to similarities in audit reference material, so this is a re-audit of the same checklist items.

Data was collected from all 4 old-age wards at the Mount on two separate occasions. Data from wards 1–3 were collected on 10/01/2025 and data from ward 4 were collected on 20/01/2025. This difference in date of data collection was due to staffing constraints.

Results: Overall, there was a lack of equipment across all four wards, with the percentage of recommended equipment that was not available ranging from 17.5–35%. There were 4 items that were missing across all 4 wards: Alcometer, Snellen chart, BMI chart, Tuning fork.

In addition to items that were lacking, as seen in item 2, there were several items that were either not working or expired. This includes several blood bottles and urinalysis sticks that are essential for basic monitoring. In terms of items that were not working, the only available otoscope and ophthalmoscope in the hospital was not functioning.

The variability in ECG machine function on all 4 wards means that QT interval monitoring cannot be performed reliably.

Conclusion: Overall, the results of the audit have shown that none of the wards at the Mount have all the necessary equipment required for adequate physical health care for psychiatric inpatients. This means that we are unable to provide adequate physical health care to psychiatric inpatients. Additionally, when compared with the results of the previous cycle of this audit there have not been significant improvements. Therefore, more clear-cut improvements are going to be required.

Aims: It is estimated that the rate of non-attendance at outpatient appointments in the NHS is 7.6%. As such, reducing the number of patients who “Did Not Attend” (DNA) is of paramount importance for improving capacity within the current NHS funding envelope.

The East Lancashire Memory Assessment Service (MAS) leads on cognitive assessment for patients from a geographically large catchment area which includes Hyndburn, Rossendale, Blackburn with Darwen, Burnley, Pendle and the Ribble Valley. Patients undergo a multi-disciplinary assessment, which typically includes a triage, initial assessment and diagnostic appointment. Medication monitoring is offered as required.

This audit aimed to establish how many patients DNA their MAS appointments and to understand the reasons for this.

Methods: We audited the records of the last 70 patients who had been discharged from the MAS as of 11 November 2024.

The Electronic Patient Record (EPR) was searched to identify key demographic characteristics and to establish whether any appointments were recorded as having an outcome of DNA. For any appointments that were not attended, we established what type of appointment had not been attended and whether any reminders had been sent.

Excel was used for data collection and analysis. Audit approval was granted by LSCFT.

Results: A total of 4 instances of patients not attending appointments were recorded in the EPR. These DNA were attributed to three patients. One who DNA an initial assessment, one who DNA a diagnostic appointment and one who DNA both an initial and a diagnostic appointment. In total, 99 appointments were offered to the patients in the audit sample, giving a DNA rate of 4%.

When there was a recorded reason for non-attendance, transport issues and an acute hospital admission were cited. Two patients sadly died whist awaiting already rescheduled initial assessments (these were not classed as DNA). Of the patients audited, there were no DNA for medication monitoring appointments.

Telephone reminders were offered to the majority of patients, 48 hours prior to their appointment, which may have reduced the total number of DNA. These reminders frequently led to appointments being re-arranged to more convenient times, helping to reduce the DNA rate.

Conclusion: Comprehensive telephone reminders ensure that the rate of DNA in the East Lancashire MAS is kept to a minimum and allows appointments to be rescheduled if necessary. This audit has demonstrated that non-attendance at MAS appointments happens due to varied factors that are often outside of NHS control.

Aims: The audit aims to check compliance with regards to assessment and management of substance misuse among patients admitted with psychosis in male wards, St George’s Park hospital. The following National Institute of Clinical Excellence (NICE) guideline was considered for the audit: Coexisting Severe Mental Illness (Psychosis) and Substance Misuse: Assessment and Management in Healthcare Settings – CG 120 (published on March 23, 2011).

Methods: All patients with diagnosis of psychosis and any comorbid substance use history admitted as inpatients in the wards from a period of July 1 to July 31 2024 were considered for the audit. Only patients who were on the wards for a minimum duration of 7 days were included.

A total of 37 patients were found as suitable. Patient progress notes and discharge letters were reviewed to check compliance with standards.

Results: Our results showed areas of both good compliance and poor compliance with regards to the standard. We found that 88.8% of patients were assessed for comorbid substance use during the first week of admission by the treatment team. In 62.06% of patients, there was evidence of involvement for specialist drug and alcohol services on admission and in the management of withdrawal symptoms. For 87.5% of patients, it was evident that policies were followed with regards to search procedures, visiting arrangements, planning and reviewing leaves, regular drug and alcohol testing and other security measures. However, only 42.8% compliance was noted regarding involvement with specialist substance use services on discharge.

Conclusion: The audit has demonstrated that wards showed good compliance to NICE guidelines around assessment of substance use and in following policies regarding measures to check for substance use in ward settings. However lower compliance was evident with regards to involvement of specialist substance misuse services during both admission and discharge. Following the outcome of audit and presentation in local team meetings, it was decided to initiate a service evaluation to look at barriers regarding involvement of specialist drug and alcohol services along with an educational programme for professionals especially nursing staff regarding the need of screening and referral for people with comorbid substance use in psychosis. A re-audit is planned after a period of 6 months.

Aims: To improve the overall quality of healthcare for mental health inpatients with a diagnosis of PD, PDD or DLB (with neuropsychiatric manifestations such as depression, agitation, psychosis or cognitive deficits), by improving: (a) physical healthcare screening and (b) the collaborative approach between inpatient mental health teams and PD specialists.

Methods: Our audit included 24 patients admitted to five MHSOP wards in Leicestershire, between 13/12/2020 and 27/10/2022. A list was obtained from the e-prescribing team, of patients on specific psychotropic or parkinsonian medications that were identified in advance by the audit team. An online audit tool was created which consisted of 17 questions relating to patient care. Three resident doctors conducted the retrospective data collection after being briefed by the audit lead, to ensure consistency in the data collection process.

Results: Antipsychotics were considered in 11/11 (100%) patients who had psychotic symptoms. 20/24 (83%) patients experiencing neuropsychiatric issues had bloods taken to rule out acute physical health causes. In 21/24 (88%) cases, an electrocardiogram was conducted prior to commencing an antipsychotic or cholinesterase inhibitor. Cholinesterase inhibitors were considered in 13/17 (76%) of patients with dementia.

Optimising dopaminergic therapy for those with PD was poor, with 8/18 (44%) patients having an intervention involving dopaminergic medications. For 5/24 (21%) patients, advice was sought from PD specialists (2 with geriatricians, 2 with neurologists and 1 with a PD specialist nurse). Of these, 3 (13%) were assessed in person by the PD specialist. In 8/24 (33%) cases, follow-up with a PD specialist was considered by the ward. There was poor compliance in screening for autonomic dysfunction in the context of PD (e.g. constipation, urinary dysfunction and orthostatic hypotension).

Conclusion: As stated in the DIAMOND-Lewy toolkit, “many patients with PDD or DLB do not receive the best possible management”. Furthermore, the pathway for obtaining PD specialist input is unclear, although the collaboration between inpatient mental health teams and PD specialists is potentially vital for holistic care.

This audit demonstrates areas for improvement in terms of physical health screening (particularly the domains of autonomic dysfunction) and in the collaboration with PD specialists, with view to providing comprehensive healthcare for mental health inpatients with PD, PDD or DLB. Interventions prior to re-auditing will include raising awareness amongst inpatient teams of the need to review parkinsonian medications and of screening for autonomic dysfunction, as well as discussions with PD specialists regarding how collaboration can be improved and streamlined.

Aims: Assess the number of patients discharged from General Adult Psychiatry wards with hypnotics prescribed for insomnia.

Evaluate the consistency of documenting discontinuation plans for hypnotics in discharge summaries.

Methods: We conducted a retrospective review of 24-hour discharge summaries for patients discharged from six adult inpatient general psychiatry wards between 15/01/2024 and 15/04/2024. The review focused on patients prescribed regular hypnotics for insomnia, specifically analysing the “Instructions to GP” section to determine whether a specific discontinuation plan was recommended or advised. This was done by reviewing our online database used within the trust.

Results: In the current audit, 56.25% of the sample had discharge summaries that included a medication review for hypnotics suggested to the GP, while only 18.75% included a specific discontinuation plan for hypnotic medication. A previous audit conducted in 2023 on two adult inpatient general psychiatry wards demonstrated 0% compliance, with no discharge summaries containing a medication review for hypnotics or a specific discontinuation plan. Following the implementation of changes, a re-audit in 2024 on the same wards showed significant improvement, with 66.6% of discharge summaries including a medication review for hypnotics and 33.3% containing a specific discontinuation plan for hypnotic medication.

Conclusion: The previous recommendations have led to noticeable improvements; however, strict adherence to these recommendations is necessary to achieve the target of 100% compliance. It is crucial for the inpatient General Adult Psychiatry team to consistently communicate a specific discontinuation plan for hypnotics to the GP. This practice is essential to reduce the risk of dependence and minimize potential side effects associated with hypnotic medications.

Aims: Clinical governance ensures accountability for continuously improving healthcare quality. This audit evaluates governance compliance across hospital sites in the London & South region, highlighting best practices and opportunities for improvement to enhance patient safety, care standards, and clinical effectiveness.

Aims were to: Identify good clinical governance practices across hospitals to enable peer learning, knowledge sharing and implementation of best practices.

Support continuous improvement by implementing lessons learned from top-performing sites.

Methods: Data was collected from Local Clinical Governance meeting minutes (September–December 2024) across multiple hospital sites. Key assessment areas included:

Meeting frequency and leadership involvement.

Attendance and representation from MDT and Operations.

Adherence to governance agenda.

Safety.

Training.

Clinical effectiveness.

Experience.

Leadership.

Audit and research.

Lessons learned.

Standards applied: National Standards on Clinical Audit – NHS England Clinical Governance Framework (2022); Local Clinical governance standards including the STEELL agenda (Safety, Training, Effectiveness, Experience, Leadership, Lessons Learned).

Results: Key findings:

Safety and Incident Reporting: Enhanced training programmes contributed to a decline in incidents, across different service lines including Acute, PICU, Rehabilitation, Learning disability and personality disorder units.

Patient and Carer Experience: Positive patient experience achieved with least restrictive practices and removing blanket restrictions with structured feedback from patient councils, advocacy services and Experts by Experience (EbyE).

Clinical Effectiveness and Governance: Higher compliance in care plans and activity programmes were noted in wards with good training and supervision and adherence to clinical models of care

Staffing and Workforce Development: Recruitment strategies helped fill critical vacancies in nursing, psychology, and occupational therapy, ensuring consistent service provision.

Patient Engagement and Activities: Structured activity programmes led to better engagement, particularly where collaborative interdisciplinary teams facilitated therapeutic and skill-based activities.

Areas for Improvement:

Standardisation of digital tracking for patient engagement to ensure accurate compliance data.

Increased MDT participation in governance meetings for enhanced multidisciplinary oversight.

Conclusion: Recommendations:

Standardise incident reporting and documentation protocols.

Enhance security for AWOL risk and contraband prevention.

Ensure hospitals share their best practices with the wider group.

Conclusion: This audit highlights significant progress in governance, patient engagement, and structured safety interventions across multiple hospital sites. By implementing targeted improvements in data tracking, workforce development, and interdisciplinary collaboration, hospitals can achieve greater compliance, patient-centred care, and long-term service effectiveness. A follow-up audit will assess the impact of these interventions on clinical outcomes and governance excellence.

Aims: Behavioural and psychological symptoms (BPSD) such as agitation and psychosis, are a common challenge faced in the management of dementia. Despite NICE guidelines prioritising non-pharmacological interventions, according to an audit conducted in 2022, antipsychotics were frequently used first-line by the React team at University Hospital Llandough, raising safety concerns. Following this audit, a care pathway for managing challenging behaviour in dementia was implemented. This study aims to evaluate adherence to BPSD management guidelines and assess improvements compared with the 2022 audit.

Methods: This is a retrospective audit that includes all patients referred to the React team between June 2023 and May 2024 with a dementia diagnosis and prescribed antipsychotics for BPSD. Data was extracted from case notes using the PARIS database, guided by Oxford Health’s BPSD management recommendations, derived from NICE Guideline 97. Information gathered includes dementia type, consideration of other causes for presenting symptoms, use of non-pharmacological methods, antipsychotic prescribing practices, and adherence to monitoring guidance. Results were compared with the 2022 audit using chi-square tests to assess statistically significant differences.

Results: 40 patients (mean age: 81, range 68–95) were included and compared with 73 (mean age: 79, range 63–95) from the 2022 audit. Alzheimer’s disease accounted for 30% of cases, while 33% had unspecified dementia. Consideration of other causative factors was documented in 23% of cases, with treatment provided in 20%. Non-pharmacological approaches were utilized in 35% of cases, a substantial increase from 1% in 2022 (χ2 (1,113) = 25.386, p<0.001). Antipsychotics were used first-line in 65% of cases compared with 99% in 2022. Risperidone was prescribed in 75% of cases, and 85% were started on the lowest dose (χ2 (1,102) = 10.891, p<0.001). Monitoring adherence improved from 12% to 45% (χ2(1,113) = 15.168, p<0.001).

Conclusion: Since the implementation of the care pathway there has been increase in non-pharmacological interventions, appropriate dosing, and monitoring of antipsychotic use. However, there was no significant improvement in considering and treating other potential causes for symptoms, and documentation gaps persist. To enhance guideline adherence, React’s processes for assessing underlying causes and documenting patient management require review. A checklist in patient notes could further standardise care and ensure comprehensive documentation. Collaboration with primary care and memory services is essential to prioritise early-stage non-pharmacological interventions, potentially reducing crises and antipsychotic reliance. Further studies are needed to evaluate long-term outcomes of these initiatives.

Aims: Safety planning has been identified as best practice for suicide prevention and is used to support patient who are at a high risk of suicide. A key aspect of safety planning is collaborative involvement with the patient and their family/carers.

Aims were to audit current compliance with safety planning standards for patients admitted to an acute hospital under the Exeter Psychiatry Liaison Team.

Methods: A snapshot audit was carried out for patients that had been admitted to Exeter Liaison Psychiatry caseload as inpatients over a two-month period. 25% of patients were reviewed, the patients being selected through a random number generator to ensure minimal bias. Initial assessment and discharge summary documents were reviewed, and data collected onto an Excel spreadsheet to record compliance with three standards.

Standard 1: Safety plan recorded – target compliance 95%.

Standard 2: Documentation that safety plan was collaboratively generated – target compliance 95%.

Standard 3: Documentation that patients were provided with a written copy of the safety plan.

Results: Data was collected from 25% of inpatients (n=29). Following initial assessment, safety plans were created with 69% of patients, 15% of these were documented to be co-created, and 0% were evidence to be provided in writing. At point of discharge, safety plans were created for 52% of patients, with 40% evidence to be co-created, and 33% were evidenced to be provided in writing. Duration of time under Liaison Psychiatry varied from 0–54 days, 35% of patients were discharged to a psychiatric admission and 38% discharged to their usual place of residence.

Discussion: There are clear gaps to collaborating with patients to create safety plans, with minimal evidence they are being provided in writing. This could be impacted by the nature of the workload of the Liaison Psychiatry department, and the unpredictability of awaiting availability of mental health beds. Patients awaiting psychiatric beds may have been too unwell to engage with safety planning. There should be consideration for how to keep this document live and accessible by patients, their regular clinicians and those who may encounter the patient at a time of crisis (GP, mental health teams, liaison teams, emergency department staff and emergency workers).

Conclusion: Prolonged inpatient admission due to either mental health or physical health reasons provides a good opportunity to engage patients with safety planning, an opportunity which is not being utilised within this Liaison Psychiatry department. Within this department there needs to be further uptake of engagement in safety planning.