Concerns raised5
Lack of staff knowledge, skills or training to handle and de-escalate residents entering a road
Failure of communication processes to escalate a deteriorating patient
Lack of staff awareness of the nature and extent of resident support duties
Failure to communicate concerning behaviour and environmental damage to mental health staff
Lack of communication with the treating mental health team
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.
Concerns raised7
Failure to review relevant historical mental health records
Failure to distinguish denial of a suicide plan from refusal to answer
Disjointed coordination of care between crisis house and crisis team services
Unavailability of mental health records to crisis house staff
Risk assessment plans failing to be enforceable in an open crisis facility
Insufficient detail in written risk assessments provided to the crisis house
Failure to arrange crisis team follow-up meetings
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.
Concerns raised1
Failure of window stays to be disableable from inside in an emergency
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.