Aims: To check compliance with the NICE guidance for behaviour that challenges, and to identify potential actions/change ideas for areas requiring improvement.

Methods: Data collection took place between 15 January and 15 April 2024. Data was collected by clinical staff on proformas based on the NICE guidance, which were co-designed by the Improvement Team and clinical staff. Data was collected using patients’ electronic records held on the Carenotes system and shared drives.

3 pilot proformas were initially completed across 3 different services to assess the robustness of audit proforma and to identify any changes required prior to the main audit. Following the pilot, changes were made to audit proforma after discussion in the audit meeting. Both inpatient and community teams collected data during the above-mentioned timeframe, and data was then sent to the Improvement Team for analysis. Data was input into a Microsoft Excel spreadsheet and analysed by the Improvement Team.

Results: 30 patient records assessed.

97% of patients had an initial assessment, and 95% of community patients and 100% of inpatients had a named lead practitioner.

93% of patients had a care and support plan. All inpatients (100%) had timetabled daily activities with documented evidence of participation.

90% of community patients had access to specialist behavioural support. However, only 55% of applicable community patients were supported to choose where and how they live.

100% of restrictive interventions had a documented review.

77% of patients were prescribed antipsychotics, with 100% receiving psychological support alongside medication. Among these, 65% had a multidisciplinary review (MDT) of their antipsychotic use, with 45% reviewed within 3 months of initiation and 70% having subsequent reviews every 6 months.

Conclusion: Most patients had initial assessment and a named lead practitioner with specialist beahviour support in the community. Some areas of improvement include review of PBS plans and more MDT work around antipsychotics and physical health reviews.

Aims: This audit aims to record the ethnicity of referrals to Liaison Psychiatry from January 1 to December 31, 2024, to evaluate whether the ethnic representation of these referrals aligns with the demographic composition of the local population and to identify any disproportionality in certain ethnic groups, which may require targeted intervention or further investigation.

Methods: Electronic records of all Liaison Psychiatry referrals made between January 1 and December 31, 2024, were reviewed. 539 patients were referred for self-harm and 607 patients were ward referrals. Emergency and ward referrals were grouped under ‘ward referrals’. Data from electronic records were cross-referenced with paper records to ensure accuracy. Ethnicity data, where missing, were retrieved from SCI-Docs when possible. Referral ethnicity data were compared with 2024 census data from four constituencies. All analyses adhered to strict confidentiality protocols, ensuring anonymity and privacy for all patients.

Results: Between January 1 and December 31, 2024, most of the patients in the 'self-harm’ and 'ward referrals’ groups identified as White (90.9% and 89.5%, respectively), which is consistent with 2024 census data (91.4%). ‘Mixed or multiple ethnic groups’ were absent in the self-harm group and underrepresented in ward referrals (0.7% vs. 1.3%). ‘Asian, Asian Scottish or Asian British’ individuals (1.7% and 1.5%) and African individuals (0.4% and 0.8%) were also underrepresented compared with census data. The proportion of ‘Caribbean or Black’ individuals is consistent across all groups, aligning with their low representation in the overall population (0.2%). Patients in the ‘Other ethnic groups’ category were slightly overrepresented, highlighting areas for further investigation and intervention.

Conclusion: This audit has highlighted significant findings regarding the ethnic representation of patients referred to the Liaison Psychiatry Department at Aberdeen Royal Infirmary. ‘White’ individuals dominate referrals, while ‘Mixed or multiple ethnic groups’, ‘African’, and ‘Asian, Asian Scottish or Asian British’ individuals are notably underrepresented. Conversely, individuals from ‘Other ethnic groups’ are slightly overrepresented. To address these disproportionalities, recommendations include improving ethnicity data collection, comparing the urgency of referrals, fostering community outreach to underrepresented groups, and providing cultural competency training for staff. Further research into systemic and social factors is essential, alongside ongoing monitoring and evaluation of progress. These measures aim to promote equitable, culturally informed mental health services, ensuring inclusive care for all ethnic backgrounds.

Aims: To reduce or stop inappropriate prescriptions of antipsychotic medication in Older Adults with dementia or functional illness residing in care homes in NPT, by ensuring adequate and timely reviews of antipsychotic medications.

It also compares its findings with the last audit results in October 2022.

Methods: Retrospective Audit included patients in care homes under CHIRT from NPT, a total of 164 patient were on antipsychotic medication starting this audit compared with 146 total number of patients on last audit in 2022.

Audit period: 10/5/2023 to 10/05/2024.

Data were collected from the antipsychotic register, reviewing the initiation and monitoring charts to assess patients for side effects.

Patients were classified according to Age, Gender, Diagnosis, Prescribed Antipsychotic and status of the antipsychotic reviews.

Results: A larger number of patients on antipsychotics compared with previous audit with expected demographics and side effects given the offered medication.

A total of 83 patients were continued on antipsychotics, 56 patients discontinued antipsychotics, with 25 reported deaths within the audit year. This shows a significant increase in number of patients discontinuing antipsychotic medication by 34% of total numbers in comparison to the 2022 audit.

Antipsychotic review status was up to date for 68 patients, overdue for 12 patients and not stated for 4 patients. This shows a significant decrease in number of patients with overdue reviews for antipsychotic medication currently at 19% of total reviews in comparison to last audit’s results of 61% of reviews.

Conclusion: It is good practice to review initiation of antipsychotics regularly once in 6 weeks–3 months in accordance with NICE Guidelines.

It is good practice to monitor antipsychotics in care homes once in 6 months to follow NICE Guidelines and ensure regular reviews.

It is recommended to audit prescribing of antipsychotic medication once in 6 months to maintain good medical practice.

Aims: This audit explores adherence of the Leeds Community Healthcare (LCH) Learning Disability Clinic to the STAMP/STOMP guidelines. This is to ensure that children with moderate to severe learning disability or autism are not overmedicated with psychotropic medications and are aware of their right to an annual health check.

Methods: This audit took place in 2 cycles: JA in November 2023 and EM in July 2024. On both occasions, 30 clinic patients were randomly selected. Data was collected from SystmOne and Leeds Care Record, to ascertain:

The number of children who had their Annual Health checks in the previous year.

Whether the drug names and dosages had been identified in case notes.

Whether indications for psychotropic treatment were documented.

If the drug was within British National Formulary limits.

Whether there was a discussion of side-effects at initiation and follow-up.

In cycle 2, EM set criteria for “enquiry for side-effects at follow-up”. This was interpreted as a relevant medical appointment in the past 6 months or since a change in dose. In addition, the age of the child was accounted for in the second cycle, as only children >14 years were advised to have an annual physical health review.

Results: Children receiving an annual health check: 70% (cycle 1)/80% (cycle 2).

Drug names and dosages have been documented: 100% (cycles 1 and 2).

Indication for psychotropic medications has been documented: 85% (cycle 1)/93% (cycle 2).

Discussion of side-effects at initiation has been documented: 73% (cycle 1)/38% (cycle 2).

Enquiry for side-effects at follow-up: 77% (cycle 1)/54% (cycle 2).

Conclusion: Medications and dosage were consistently documented across both Audits. In cases where only melatonin or ADHD medication is prescribed, it was more common to find that discussion of adverse effects, and specific impacts on sleep duration and latency were not documented. On an ongoing basis, team members must ensure that patients over the age of 14 (and their families) are aware of their right to an annual physical health check.

One limitation of this study is that ‘discussion of side-effects’ does not clarify the extent and frequency to which these should be discussed. This may account for the large difference between audit cycles. In addition, the spread of information between systems may have increased the possibility of information being lost or overlooked.

Aims: The aim of conducting this audit is to know whether the physical health monitoring of our clients are done appropriately in accordance with the BCUHB guidelines for physical health monitoring for adults prescribed antipsychotic therapy and also to reduce the risk of adverse side effects of antipsychotics on the physical health of our patients.

Methods: The sample in this audit consists of 18 patients (n=18) in Ty Llywelyn. To collect the data, we utilised the patients’ paper files, Paragon (computerised) clinical entries, drug charts and observation charts. The participants also had their waist circumference measured using tape measurement. Data collection was undertaken in June and July 2024 using the audit proforma. Completed GASS questionnaires were filed in the patients’ notes and the prescriptions initiated because of the questionnaires were accompanied by a Paragon entry to explain the rationale.

Results: In this re audit, it was noticed that most of the patients had their waist circumference measured. Whereas in the previous audit, waist circumference was not done on the patients. Out of the 18 people who participated in the audit only 17 people had their waist circumference measured. Out of the 17 people, 13 patients were shown to have obesity according to their waist circumference and 3 patients fall within the overweight range of waist circumference. Only one patient’s waist circumference falls within the range of normal. In addition, in this audit, we identified that 12 out of the 18 patients who participated in this audit have normal HBA1C meaning that they are not diabetic, while 6 out of the 18 patients are diabetic. Of the 18 participants in this audit, a total of 2 patients had normal weight. A total of 11 participants are obese. A total of 1 patient is overweight. A total of 4 patients are severely obese.

Conclusion: The results highlight the importance of regular monitoring and the need for targeted interventions to manage obesity, reduce and eliminate diabetes and also to reduce the risk of adverse side effects of antipsychotics on the physical health of our patients. Overall, the physical health of the patients in Ty Llywelyn medium secure unit is taken seriously, hence the higher percentage of people who have their physical health checked in this study.

Aims: Prescribing valproate to women of childbearing age in psychiatric settings requires a nuanced approach due to its teratogenicity. The Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Institute for Health and Care Excellence (NICE) guidelines emphasize the importance of avoiding valproate in this population, considering alternative medications, discussing benefits, side effects, and teratogenicity, conducting pregnancy testing before initiation, and ensuring the use of highly effective contraception. This study aimed to evaluate current prescribing practices against MHRA and NICE guidelines within Hamad Medical Corporation (HMC) psychiatric inpatient units.

Methods: An initial audit was conducted between 25/10/2022 and 25/10/2023, followed by a re-audit between 10/11/2023 and 10/11/2024. The audit involved a retrospective review of electronic health records of all female patients of childbearing age (16–49) admitted to the psychiatry hospital and prescribed valproate for a psychiatric indication. Data were collected using a proforma, and the audit was approved by the HMC Audit Committee.

Results: During the first audit period, 32 patients were prescribed valproate. Of these, only 1 patient (3%) had documented discussion about teratogenicity, 7 patients (21%) about benefits, and 3 patients (9%) about side effects. 21 patients (65.6%) underwent pregnancy testing before prescription. However, none of the patients received documented education about highly effective contraception.

In response to these findings, results were widely disseminated within the department, and educational sessions were conducted for doctors and pharmacists. Additionally, the need to develop national guidelines was emphasized to ensure safer prescribing practices. Noteworthy, during the re-audit phase, there was an expansion in bed capacity for female patients.

The re-audit showed a reduction in valproate prescribing to 21 patients. Documented discussions on teratogenicity increased to 10 patients (47.6%), while 5 patients (23.8%) had discussions about benefits and 14 patients (66.7%) about side effects. Pregnancy testing before prescribing improved to 19 patients (90%). Additionally, 8 patients (38.1%) received documented education on effective contraception.

Conclusion: The re-audit demonstrated significant improvement in pregnancy testing, and noticeable progress in other aspects, though further work is required. This study underscores the importance of educational sessions and interdisciplinary collaboration among doctors and pharmacists to enhance prescribing practices. Towards sustained improvement, systematic changes are needed, including shifting clinicians’ perceptions of valproate prescribing, developing local guidelines, and introducing strict governance measures. This audit has served as a catalyst for the development and implementation of national guidelines and has led to the initiation of a quality improvement project.

Aims: This is round 2 of audit focusing 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.

Methods: This is the second cycle of the audit, including patients diagnosed in 2024. First cycle was completed last year for patients diagnosed in 2022. Retrospective data was collected from SystmOne. 40 patients were selected randomly from 807 patients referred to the memory clinic of Watermill resource centre in Berrywood Hospital.

Inclusion Criteria: Patient referred to the service between 1 January–31 December 2024 who were diagnosed with Dementia.

Results: The results showed that Compliance with informing patients to report to the DVLA following their diagnosis has improved from 73% to 80%. The compliance with informing patients to report to their insurance companies fell from 45% to 0% in the second cycle. Out of the 40 patients diagnosed with dementia, 34 had a recorded risk assessment. 5 patients were driving at the time of assessment. 3 patients were referred to occupational therapy for a driving assessment. 4 out 5 driving patients were informed they must report to the DVLA (compliance 80%), and 1 out 5 driving patients were informed they must contact their insurance company (compliance 20%). No documented evidence was found about informing the patients about consequence of not reporting to the DVLA and insurance companies. There was no record of medics having to contact the DVLA.

Conclusion: 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.

Aims: To carry out a retrospective audit of medical records of people with newly diagnosed dementia in North Devon Community Older People’s Mental Health Team for any evidence of anticholinergic burden review before dementia treatment.

Methods: Data for 49 patients with dementia were identified based on evidence of clinical coding on SystmOne (the Trust’s new electronic records system) from November 2023 to August 2024. Most of the newly diagnosed patients with dementia were not captured due to missing clinical coding.

Electronic records, including GP referral letters, assessment notes, and MDT discussions, were reviewed to determine whether anticholinergic medicines were rationalised and whether ACB scores were recorded before initiating medication for dementia.

In addition, pre-referral medications were reviewed from the GP referral letters to establish pre-referral anticholinergic burden and ACB scores.

Values from the ACB calculator were used for anticholinergic burden estimation in this audit as it collates information from the German Anticholinergic Burden Scale and the Anticholinergic Cognitive Burden Scale, which have been demonstrated to have the highest validity and reliability. According to the NICE guideline [NG97], there is not sufficient evidence to recommend one validated tool over the others.

Results: Out of 49 patient records, 27 were included in this audit. Twenty-two were excluded due to not meeting the inclusion criteria.

None of the clinicians documented that anticholinergic medicines were rationalised, and only 2 (7.4%) documented that the patient’s current medications were reviewed.

There was no documentation of ACB score for any of the patients included in this audit; whereas, the vast majority (70.4%) of them were on regular medications with anticholinergic burden before presentation and such medications were prescribed for their anticholinergic effect in 1 out of 10 (11.1%) of cases.

More than half (52.6%) of the audit patients with pre-referral anticholinergic burden had ACB scores of 3 or higher (high risk).

The most commonly prescribed medications leading to raised ACB were metformin, lansoprazole and sertraline in descending order of frequency.

Those prescribed specifically for their anticholinergic effect were solifenacin and oxybutynin with ACB score of 3 each.

Conclusion: We are not documenting that we rationalised anticholinergic medicines before initiating anti-dementia treatment.

Almost 3 out of 4 of the patients referred to our team for dementia diagnosis were on medications with an anticholinergic burden. More than half of those on anticholinergic medications had ACB scores in the high-risk range.

The most commonly prescribed medication resulting in anticholinergic burden was metformin.

Aims: For the first QIP our objective was by August 2024, a completion of admission checklists jobs on clerking by out of hours Doctors in Solent and Southernhealth Foundation Trusts Psychiatric Inpatient Units by 100%.

However, if tasks were not completed, we would be expecting documentation of the reason why on SystmOne tabbed Journal and Rio progress notes (electronic records).

Methods: For the first QIP, 30 patients were randomly selected from current admissions in three facilities: The Limes (10 patients), The Orchards (Maples and Hawthorn, 5 patients each) and Elmliegh Hospital (10 patients).

For the completed audit Cycle, 35 patients were randomly selected from current admissions in four facilities: The Limes (10 patients), The Orchards (Maples and Hawthorn, 5 patients each), Elmleigh Hospital (10 patients), and Ravenswood House Forensic Hospital (5 patients).

The audit involved reviewing clerking documentation on SystmOne and Rio, measuring performance indicators for the completion of admission tasks, including DNACPR, mental capacity assessments, mental state examinations, physical examination, current medications, allergies and sensitivities, and VTE assessments.

During our first QIP, a guide was introduced in the trainee handbook to demonstrate how to complete an admission on S1 in addition to a video demonstration, link shared with all doctors working within the trust.

Results: There was excellent compliance with admission tasks across most wards, with a 100% completion rate in the Limes, The Orchards and Ravenswood House. Key achievements included successful documentation of physical examinations, current medications, allergies, and sensitivities. The audit demonstrated substantial progress in standardising admission documentation processes.

Conclusion: The audit results showed excellent overall compliance in completing admission tasks across most wards, with particular success in completing physical examinations, current medications, allergies, and sensitivities documentation. This audit reflects significant progress in standardising admission documentation across psychiatric inpatient units. This audit’s findings will support continued improvements in admission processes, enhancing both compliance and patient safety. The results have been disseminated trust wide and incorporated as part of the junior doctor induction programme.

Aims: Serious concerns have been raised by a HM Coroner in England regarding poor medical recording and communication following Mental Health Act Assessments (MHAA). We aimed to undertake a ‘deep-dive’ audit of documentation and inter-professional communication to assess compliance with GMC Good Medical Practice (GMP) and Mental Health Act Code of Practice 2015 (MHACP) following a MHAA in the Doncaster locality of Rotherham Doncaster and South Humber NHS Foundation Trust (RDASH).

Methods: Audit standards were set using the GMC GMP guidance and the MHACP. GMC GMP states ‘You must make sure that formal records of your work (including patient records) are clear, accurate, contemporaneous and legible’ and makes clear each doctor is responsible for recording their own independent medical opinion for any significant clinical intervention.

All patients detained on section 136 in September 2024 in the Doncaster locality were selected. The electronic records system (SystmOne) was scrutinised for (1) length of time taken for the assessment to be documented on SystmOne by any of the assessing team, (2) the number of doctors documenting the assessment, (3) whether any doctor communicated with the GP.

An email was sent to each patient’s GP regarding any communication they received from a doctor relating to the MHAA in case communication was not included on the internal Trust system.

Data was also collected on the outcome of the assessment, number of doctors involved, their roles and whether they were employed by the Trust.

Results: Of the 23 MHAAs, 18 took place in the Doncaster S136 suite and 5 in A&E. Nineteen assessments did not result in detention, 3 resulted in an informal admission, and 1 in detention.

Documentation on SystmOne took over 1 day for 61% (14/23) of MHAAs, all completed by an Allied Mental Health Professional (AMHP). In 26% (6/23) documentation occurred within 4 hours, all by an assessing doctor. In 4% (1/23) it was completed within 12 hours by an AMHP.

A total of 9% (2/23) had no AMHP report or documentation. In 70% (16/23) neither doctor documented, while in 30% (7/23) one doctor documented.

In only 22% (5/23) of MHAAs a letter was sent to the GP by an assessing doctor.

Conclusion: The documentation and communication following a MHAA was not in keeping with GMC GMP guidance and the MHACP in the vast majority of cases assessed. This poses a significant patient safety concern.

Aims: To audit the current practices of vitamin D screening and replacement in patients admitted to Rosewood Mother & Baby unit in Kent.

Methods: Retrospective audit was conducted to evaluate current practices in screening and treating vitamin D deficiency among patients admitted to mother and baby unit. Relevant standards were set and data collected for patients admitted Jan 2023–Dec 2023. Results presented to stakeholders and improvement plan implemented by circulating trust vitamin D guidelines and discussion with unit dietician. Re-audit was carried out reviewing details of patients admitted from Jan 2024 to Dec 2024.

Results: Audit 2023: Out of 60 patients admitted, 95% patients (57) were screened for vitamin D status. 65% of screened patients were either insufficient or deficient (12 insufficient and 27 deficient). Patients received vitamin D replacement as per KMPT guidelines. Aftercare instructions to GP communicated for 93% and 100% patients with vitamin D insufficiency and deficiency respectively. Regarding infant feeding mode 50% were breastfed, 35% on formula milk and 11.6% received mixed feeding. One patient was pregnant and data of one patient not recorded.

Re-audit 2024: Of 56 patients admitted in 2024, 2 patients were not screened. Among 54 patients, 21 and 9 were insufficient and deficient respectively. Out of these 30 patients, 24 were given appropriate supplementation in line with current KMPT clinical guidelines. Aftercare instructions to GP communicated for 17 patients. There was a drop in GP communication and this has been noted for improvement. Four infants were breastfed, 29 on formula milk and 16 received mixed feeding. Three patients were pregnant and for 2 patients the data not recorded.

It is important to highlight that lactating mothers can be deficient in vitamin D. Therefore, this was especially analysed in both audit reports. In both audits, 57 out of 116 patients either breastfed or mix fed the babies. Among these 57 patients, 8 were deficient while 28 were insufficient. This indicates significant (63%) number of patient in both were deficient/insufficient. As vitamin D is implicated in mood and immune system regulation it could play a vital role in the mental state of post-partum patients.

Conclusion: This audit/re-audit highlighted need for routine vitamin D screening in patients admitted to psychiatric units especially breastfeeding mothers. It is also important to note that vitamin D could play a vital role in mood and immune system regulation.

Aims: To evaluate and improve the adherence to NICE guidelines in recording physical health parameters during the initiation and maintenance of ADHD medications.

Methods: Retrospective data was collected from electronic medical records (RIO) of patients who were initiated and maintained on ADHD medication, referred to Islington CAMHS in 2023. Collected data was stored and analysed using Microsoft Excel. Inclusion criteria:

1. All the patients with ADHD referred to Islington CAMHS in 2023 for initiation of medication were sampled.

Exclusion criteria:

1. Patients not started on medication.

2. Patients who had previously been on medication.

3. Patients who had medication initiated by paediatrician.

4. Patients who had medication initiated by private psychiatrist.

Results: A total of 74 patients were identified, 55 males and 19 females.

Pre-medication Physical Health Assessment: The physical health parameters before initiating medication were recorded in 100% of cases, with 96% adhering to the standards outlined by NICE. This indicates a strong adherence to pre-medication assessment protocols.

Medikinet XL was the most prescribed medication for both initiation and maintenance.

Side Effects and Medication Management: Side effects were reported by 22% of patients, with reduced appetite being the most common. Medication was stopped in 4% of cases due to side effects, and 11% required a change in medication. This highlights the importance of ongoing monitoring and the need for flexibility in treatment plans to address side effects promptly.

Standard Monitoring Compliance: The monitoring of physical health parameters during medication maintenance also met the standards in 100% of cases, underscoring a consistent approach to ongoing patient care.

Comorbidities: The audit identified patients with psychiatric comorbidities, such as Autism Spectrum Condition (47%), Tourette’s (3%), Anxiety (3%), and Dyslexia (1%).

Conclusion: The audit highlighted the importance of maintaining high standards in ADHD medication management and suggested areas for further improvement, such as the documentation of rating scales to objectively monitor medication effectiveness. Based on the audit results, an ADHD clinic proforma was developed to incorporate all required data points, ensuring comprehensive documentation during clinic appointments.

Aims: To assess compliance with record keeping policies.Medical records play a vital role in supporting patient care. However, effective record keeping in clinical practice, particularly in mental health, poses significant challenges. The General Medical Council’s (GMC) good medical practice, states that doctors must ensure their records are clear, accurate, and legible. Regulation 28 of the Coroners and Justice Act 2009 empowers coroners to address concerns that could lead to future deaths. Davies Arnold Cooper (DAC) Beacroft’s 2022 report identified record keeping as a key issue in mental health.

Methods: Patients across three older adult inpatient wards were identified using convenience sampling method. Five hundred and thirty-three entries made by doctors for the audit and 424 entries made by doctors for the re-audit were identified using patient identifier. Data compilation was done using Excel spreadsheet and analysed using descriptive statistics. Outpatient entries and ECT entries made by doctors were excluded, ensuring a focused assessment of inpatient records. The results were presented using bar charts, pie charts and tables.

Results: The results were compared with the trust’s Record Management Policy and the previous audit conducted in January 2023. The re-audit found an improvement in the percentage of validated entries across all three wards compared with the previous audit. One of the wards showed the highest improvement, with a 35% increase in validated entries. However, the overall validation rate was still below the 80% requirement standard set. The timescales for validation across the three wards also showed some improvement, with the majority of validated entries meeting the 12-hour standard, although a small percentage remained unvalidated for longer periods. In addition, doctors were more likely to sign off their entries during normal work hours than out of hours

Conclusion: The findings suggest that while there has been improvement in the timeliness and completeness of clinical entries validation, more work is needed to ensure full compliance with the trust’s policies and the GMC’s good medical practice. Recommendations include regular reminders to doctors on promptly signing off clinical entries, incorporating record-keeping guidelines into local inductions, and a review of the trust’s guidelines on note validation for inpatient entries. This audit cycle led to a broader quality improvement project and trustwide policy change on validation of clinical entries. It highlights the importance of maintaining accurate and timely clinical entries.

Aims: To help specialist mental health Trusts/healthcare organisations improve their prescribing practice. To assess the Trusts’ alcohol detoxification practices, benchmark against the national average performance and to compare results to the previous audit of 2016. This was the second re-audit in the cycle.

Methods: The audit included any person (Male and Female) admitted to an acute adult or psychiatric intensive care ward, or a specialist inpatient drug or alcohol unit, who underwent alcohol detoxification (assisted alcohol withdrawal) whilst an inpatient. Patients identified via RiO, EPMA, Pharmacy Databases and Ward/Team caseloads. The final sample consisted of 80 patients, 20 patients from each of the 4 boroughs (Warrington, Halton, Knowsley, Wigan).

Data was collected in May 2021 via clinical audit days over Microsoft Teams, checked for quality twice by the audit leads and inputted by the Medicines Management Team in June 2021.

Data was analysed by the national POMH team followed by the production of a national and trust level report. The findings of the audit were then presented at various forums.

Results: Five POMH-UK Standards were chosen for the audit that were divided in 12 criteria to assess results against. In addition, three “targets” for assessing alcohol intake at admission and follow up following detoxification process were also selected for the audit.

Four of twelve standard criteria (assessment of.iver function test and glucose tests, prescription for acute alcohol withdrawal and prescribing parenteral thiamine) and all the three targets (measurement of alcohol breath test at initial assessment, relapse prevention treatment and referral to specialist alcohol services for follow up) indicated less than 60% compliance with standards and a lower compliance than the national sample.

For all targets, practices across the trust were variable.

Conclusion: There is a need for developing guidance, detailing professional responsibilities and aligning procedures and documents across Mersey Care Foundation Trust to create a single standard method for alcohol detoxification. This includes developing a standard junior doctor admission checklist for both assessment and monitoring and raising the importance of assessment for alcohol detox at Junior doctor induction programme. It highlighted the need to consider alcohol breath test as part of the initial assessment at admission and including the required blood tests in routine admission blood investigations. The financial implications of this were also considered. The process emphasised the need for dissemination of results to all staff, focussing mainly on inpatient staff.

Aims: Community meetings in inpatient psychiatric settings provide a structured opportunity for patients and staff to discuss ward updates, raise concerns, and plan for the upcoming week. These meetings, often chaired by patients, are integral to promoting engagement and empowerment.

This study aimed to analyse and compare staff attendance patterns, patient participation, and issue resolution trends in Fairbairn Ward (Men’s Mental Health – Deaf Service) and Rose Ward (Male Brain Injury Rehabilitation Service) at St Andrew’s Hospital. The goal was to identify differences in engagement across professional roles and propose strategies to improve the effectiveness of community meetings.

Methods: Data was collected from weekly community meeting logs over a three-month period. Staff participants were categorized into clinical staff, administrative staff, healthcare assistants (HCAs), psychologists, social workers, and trainees. Attendance rates were analysed to identify which staff groups participated most frequently and how their involvement influenced issue resolution.

Fairbairn Ward caters to deaf or hearing-impaired men with complex psychiatric needs. Many staff and patients are trained in British Sign Language (BSL) to facilitate communication.

Rose Ward (male brain injury rehabilitation service) provides specialist forensic neuropsychiatric care for individuals with acquired brain injuries, dementia, stroke, or neurodegenerative conditions.

Results: Fairbairn Ward: 6.6 patients per meeting (38.8% of inpatients), patient-to-staff ratio: 0.509.

Highest staff participation: Healthcare Assistants (10 meetings), BSL Interpreters (7).

Lowest staff participation: Social Workers, Administrative Staff (1–2 meetings).

Rose Ward: 6.3 patients per meeting (39.5% of inpatients), patient-to-staff ratio: 0.959.

Highest staff participation: Clinical Administrators, HCAs.

Lowest staff participation: Assistant Psychologists.

Key Findings: Fairbairn Ward had lower administrative and senior clinical engagement, limiting issue resolution. Rose Ward had higher patient-to-staff ratios but lacked psychologist/psychiatrist involvement, impacting therapeutic discussions.

Conclusion: To improve meeting effectiveness, we recommend:

Increasing administrative and senior clinician participation to enhance issue resolution.

Enhancing follow-up mechanisms for patient concerns.

Encouraging multi-disciplinary engagement, especially in specialist wards with complex needs.

By optimizing staff attendance and patient engagement, community meetings can be strengthened as a tool for inpatient empowerment and collaborative care.

Aims: To assess variations in dementia treatment, diagnosis, and pathway practices across the memory services in Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust and how these compare to Trust and national policy. There were reports that the dementia diagnostic process across the trust was inconsistent. Thus, it was important to find out if the diagnostic pathway differed. NICE guidelines NG97 (2018) recommended neuroimaging, cognitive testing, and history to make diagnosis and the use of validated criteria to diagnose dementia subtypes. NG97 (2018) and TEWV Dementia Pathway suggested use of cholinesterase inhibitors to those with Alzheimer’s disease, mixed dementia, dementia with Lewy bodies and Parkinson’s disease dementia. These guidelines mentioned that memantine should be offered to those with severe Alzheimer’s, or those with moderate Alzheimer’s disease with a contraindication to cholinesterase inhibitors.

Methods: A simple random sampling of 150 patients seen at diagnostic appointments across the Trust 15 memory service between July 2023 and June 2024. 10 patients were selected from each memory service across the trust. The final numbers that fulfilled the inclusion criteria and analysed were 142. The audit of the collated data was done between July and September 2024. The analysis of the data, including inferences, deductions and diagrams was done using Excel.

Results: Across the trust, patients were given a dementia subtype where possible in 100% of cases. The overall practice in offering medications when indicated was 96% and 10 out of the 15 memory service achieved 100% in this area. There were clear documentations in most areas regarding the rationale for not prescribing medications or switching to another alternative. In the study, mixed dementia was the most common diagnosis by subtype, representing 35% of the data analysed, followed by Alzheimer’s dementia with 32% of the data analysed. Only 2 memory services offered Cognitive stimulation therapy (CST) to all the patients who were suitable. 10 teams scored below 40% in offering CST, and 3 teams scored between 50 and 67% for CST.

Conclusion: There was consistency across the Trust in the domain of considering clinical history to make a diagnosis. This good practice extends to the use of neuroimaging, cognitive screening and in some cases neuropsychology to make a diagnosis. A limitation of this study is that the small sample size per service could have limited the representativeness of the audit.

Aims: This audit aims to evaluate the quality of review letters from Psychiatry clinics against standardized practices in clinical communication with General Practices (GPs). The evaluation is based on the guidelines issued by the Royal College of Psychiatrists regarding GP letters in January 2021.

The 10 main domains letters will be judged by are:

1 – Contact details for the psychiatrist.

2 – Venue and date of meeting.

3 – Attending people + care coordinator/Lead professional.

4 – Diagnosis of the patient.

5 – Medications and allergies.

6 – A record of difference of opinion between the patient and the psychiatrist “the consultation”.

7 – Mental state examination and risk.

8 – Agreed on Plan that includes (changes in medication + treatment + follow up plan).

9 – User friendly evidence-based information and relevant links.

10 – Copying the patient into the letter/or asked if patient would like a copy.

Methods: The audit was conducted from December 2023 to January 2024. A Medical Secretary compiled 30 clinic letters sent to GP practices over three months, and auditors assessed compliance with Royal College guidelines using specified audit tool parameters. All audit data was collected from service users’ letters on the hospital system between September and December 2023.

Results: Good Practice:

100% (green compliance): Psychiatrist contact details, review date, consultation, participants, and agreed plan documented.

97% (green compliance): Venue and diagnosis documented.

93% (green compliance): Medications documented.

Issues Identified:

60% (amber compliance): Care coordinator details included.

70% (amber compliance): MSE included.

50% (red compliance): Risk assessment included.

13% (red compliance): Allergies documented.

23% (red compliance): User-friendly info/links included.

3% (red compliance): Service users copied in.

Conclusion: Based on the audit findings and identified issues, the following actions will be implemented:

Update GP Letter Template: Add sections for Allergies, Risk, User-Friendly Information, and Copying Patients into Letters, adhering to the Royal College of Psychiatrists’ January 2021 guidelines.

Standardize Letters: Ensure all prescribers use the updated template to maintain consistency.

Dissemination Plan: Present the updated template during team huddles.

Provide it to new trainees during handovers.

Laminate and place templates in all prescribers’ offices for reference.

Distribute the template via email to the team.

Aims: Determine the proportion of patients who have exercise documented as part of their initial treatment plan. Identify any trends in exercise recommendations across different mental health conditions. Highlight areas for improvement and develop strategies to increase the incorporation of exercise recommendations in clinical practice.

Methods: A retrospective review of patient records from September to October was conducted, focusing on documentation of exercise recommendations in their initial assessment. Data extracted included patient demographics, diagnoses, documentation of exercise advice, type of exercise (if specified), and clinician type. Variations by diagnosis and clinician practice were analysed.

Results: A total of 63 patient records were reviewed and of these only 4 (6.3%) had a documented recommendation of exercise in their care plan. Of these, 2 patients were recommended to go for walks, one to continue with horse riding, there was no specific recommendation noted for the fourth patient.

26 (41%) of the patients had a diagnosis of depression, 16 (25%) of anxiety, 11 (17%) had ADHD and for 12 (19%) patients, there was no diagnosis recorded. 27 (43%) of patients had pre-existing physical co-morbidities. 25 (40%) were seen by a Doctor, 24 (38%) by a Mental Health Wellbeing Practitioner and 14 (22%) by a Lead practitioner (Mental Health nurse or social worker).

Conclusion: The audit highlights a gap in the integration of exercise recommendations into care plans, despite strong evidence supporting its benefits for mental health, in particular for depression and ADHD. A re-audit will be done in 3 months’ time to assess progress after presenting our findings to the team, creating aide-mémoire and relevant resources for staff and patients/carers.

Aims: Non-attendance (DNA) at appointments wastes NHS resources and can indicate potential risk, making it essential for Trusts to have robust policies to safeguard young people and reduce recurrence. As part of the National Health Service (NHS) process, organisations are required to have a ‘Was Not Brought’ (WNB) policy to address situations where children are not seen. This audit aimed to assess Clinician’s adherence with the Trust’s DNA/WNB policy and reduce WNB rates.

Methods: The audit was conducted in two cycles, analysing retrospective data from 50 patient case notes (on RIO) using a pre-determined data tool based on the Trust’s policy at each cycle.

Cycle 1 (August to October 2023) focused on DNA/WNB appointments and included an analysis of 8 patient survey responses, based on the policy 'Protocol for Managing DNA and Cancellations’ in Dudley and Walsall CAMHS.

Following our recommendations, a new policy was drafted, adopted and shared across the Trust.

Cycle 2 (September to November 2024) audited DNA/WNB appointments and incorporated a staff survey (20 responses) based on the new policy 'CAMHS WNB Standard Operating Procedure'.

Results: Audit revealed moderate compliance (over 50%) in documenting DNA/WNB appointments, contacting families, and rescheduling appointments across both cycles.

However, compliance was poor (≤40%) in key areas, such as documenting risk assessments, reviewing case notes, attempting to engage with the child, completing lateral checks, sharing rescheduled appointments with GPs/referrers/other agencies, and obtaining SMS consent for appointment reminders.

WNB rates were 8.3% in Cycle 1 and 9% in Cycle 2.

The patient survey revealed that common reasons for WNB included forgetfulness, lack of awareness of the appointment, and illness. Respondents suggested SMS reminders 48 hours before appointments.

The staff survey showed that 45% were unaware of the updated WNB policy, and 30% did not know about the new messaging reminder system and so were not using it.

Conclusion: Overall, the Trust policy is generally followed for documenting DNA/WNB appointments and rescheduling; compliance remains poor in areas like risk assessments, engaging with the child, and sharing rescheduled appointments with other agencies.

There is a need for improved documentation and adherence to the WNB policy. The Trust should implement a reminder system to update clinicians on policy changes and prioritize messaging to families to improve appointment attendance.

Aims: Scotland has the highest drug-related death rate in Europe, with 27.7 deaths per 100,000 people. The average age of drug-related deaths in Scotland has increased from 32 in 2000 to 44 in 2021, with a significant proportion involving multiple substances. According to NICE and Scottish Intercollegiate Guidelines Network (SIGN) guidelines, best practice management for inpatients with co-occurring substance misuse and mental health should involve: Screening and Identification of Substance Misuse, Integrated Dual Diagnosis Care, Pharmacological and Psychosocial Interventions, Harm Reduction Approaches in Acute Psychiatric Wards and Safe Discharge and Aftercare Planning. We have designed a closed-audit loop which has evolved into a quality improvement project to enhance the identification, management, and follow-up care of substance misuse among inpatients in general psychiatry ward at St John’s Hospital, Livingston, Scotland. This project seeks to achieve an 80% compliance rate in substance use assessments, implement standardized protocols for managing active substance misuse, and develop a policy for handling patients under the influence, in possession, or distributing substances by December 2025. Data presented in this abstract is for the closed-loop audit part of a larger quality improvement project.

Methods: Data for the initial audit was collected from Trak, the electronic patient record (EPR) system, for patients admitted to and discharged from a mixed acute general adult ward at St John’s Hospital, during the period from 13 February to 13 May 2024. Data was collected on documentation of previous substance misuse and substance misuse urine screening. As an intervention, our team introduced staff reminders for biological testing and incentivised staff, patients and carers to provide feedback on substance misuse history, substance misuse on the ward and testing. From 30 October till 30 January, a further cycle was conducted to assess for changes post-intervention.

Results: The closed-loop audit included 84 patients pre-intervention and 49 patients post-intervention. 35.3% had co-morbid schizophrenia/psychosis and a further 24.7% had combined depressive disorder and suicidality. Alcohol misuse was the highest reported substance misuse (33.33%), followed by cannabis (27.03%) and cocaine (11.71%). Post-intervention there was a 35.18% increase in biological testing compliance (post-intervention 57%) and 51.36% increase in substance misuse history documentation compliance (post-intervention 75%).

Conclusion: Substance misuse worsens prognosis for many patients with other mental health co-morbidities. We have identified that compliance is still low for documentation and testing. By identifying gaps in achieving compliance, this project seeks to guide better local policy in order to implement evidence-based practices improving patient outcomes.