Clinical audit and evaluation are processes used by the trust to improve the quality of our services.
Clinical audit does this by comparing current practice to explicit standards and identifying areas where we are falling short. It can also help to highlight standards we are performing well against.
Clinical audits may be undertaken as part of a national programme, or may be prioritised within the trust. Evaluation projects usually reflect on an existing service or intervention in terms of how effective it is, which may include collecting feedback from service users, carers and staff, as well as analysing data collected as part of routine practice.
The trust develops a Clinical Audit and Evaluation Programme annually, which is a dynamic document that is updated regularly throughout the year to reflect changing priorities.
The 2024/25 programme is currently in development and will be published on this page once it has been approved by the trust’s Quality Committee.
2023/24 clinical audits and evaluations
The following projects were completed during 2023/24. Please click on each link for further information. If you would like to see the full report of any of these projects, or have any queries, please contact Corrina Bentley, Clinical Audit Manager (corrina.bentley@combined.nhs.uk) in the first instance.
An Evaluation of a Pilot Intervention for Functional Neurological Disorder (FND) including Non-Epileptic Attack Disorder (NEAD) using Psychoeducation and Grounding Techniques
Good practice:
- Physical health assessments and baseline blood investigations performed as per protocol.
- Adequate recording of utilisation of PRN medications.
- Positive results in relation to planned referrals, review of physical and mental health status and ongoing physical health monitoring.
Key recommendations:
- Ensure that all patients have ECG done and reviewed before admission for detoxification.
- All patients to be offered hepatitis and HIV screening before discharge, with clear documentation in notes.
- Ensure regular and consistent recording of reason for missing doses of clonidine for all patients.
An Evaluation of the Implementation of Team Formulation in NSCHT City Community Mental Health Team
Good practice:
- Introduction of team formulation is generally well-received.
- Formulation meetings have encouraged an alternative way of thinking about service users’ care, with the potential to enhance clinical practice.
Key recommendations:
- To clarify the route for further support following a team formulation meeting.
- To increase the frequency of team formulation meetings.
- To provide suggestions for further reading following a meeting.
Audit of Assessment and Management of ADHD in Child and Adolescent Mental Health Services (CAMHS)
Good practice:
- Full developmental history, Conners questionnaire and QB testing undertaken in all cases.
- Evidence of school report / discussion with teachers in all cases.
- Treatment plan in place covering symptom severity and impact on everyday life in all cases.
- All medications initiated by a clinician with appropriate training and baseline blood tests undertaken, except where these were declined.
- Evidence of regular medication monitoring in all cases.
Key recommendations:
- Introduction of new template clinic letter.
- Design of new healthy lifestyle advice leaflet for distribution to patients with ADHD.
- Findings to be shared with other CAMHS teams.
Audit of Benzodiazepine Repeat Prescribing in an Adult CMHT
Good practice:
- Increase in percentage of care plans which evidenced the need or otherwise for repeat prescribing, from 27% at baseline to 94% at re-audit.
- Improvement in the proportion of service users who had the risks of long-term prescribing explained to them, from 56% at baseline to 82% at re-audit.
Key recommendations:
Findings to be shared with all medics and prescribers at the Lymebrook Centre with the following good practice reminders:
- All service user care plans should document whether repeat prescribing will be undertaken via the GP or NSCHT.
- Risks of medications should be discussed with service users and, where appropriate, alternatives offered.
- Changes.org.uk offers sleep hygiene classes which may be of interest to those with sleep difficulties.
Audit of Controlled Drugs: Quarter 1
Good practice:
- The trust pharmacy was compliant against all red flag standards.
- Ward 6 and Summers View were compliant with all applicable standards.
Key recommendations:
- Individual ward-level action plans to be taken forward by Ward Managers.
Audit of the Quality of Care Plans
Good practice:
- 100% of adult care plans evidenced service user involvement in development.
- 92% of adult care plans clearly identified service user/carer views.
- 92% of adult care plans had a review date recorded.
Key recommendations:
- Current work underway to review the care planning process in adult services.
- Implementation of Goal Based Outcome measure alongside new care planning process.
- Review of new care planning process for adaptation to CYP services.
Evaluating the Use of Psychological Consultancy within a Community Mental Health Team
Good practice:
- All staff agreed that consultation helped them better understand the service user’s difficulties.
- 90% of respondents felt more confident following consultation.
- 90% of respondents found consultation useful and changed their practice as a result.
Key recommendations:
- Staff members within the psychological team to be provided with consultation specific training and supervision.
- Additional consultation slots to be offered.
Evaluation of Care Coordination Activity and Experience of the Role in an Early Intervention (EI) Service
Good practice:
- Care coordinators can be person-centred with their clients and use psychoeducation and the biopsychosocial model.
Key recommendations:
- More cohesive ways of recording information.
- More resources around psychoeducation.
Exploring Cross-Functional Collaboration between Quality Assurance and Improvement (QAI) Functions at NSCHT
Good practice:
- Senior leaders described as open and approachable.
- Good levels of trust associated with interpersonal relationships.
Key recommendations:
- To hold an engagement event to review findings and develop actions to improve communication between functions and knowledge of each other’s portfolios.
- To develop a QAI strategy, clearly outlining the roles, responsibilities and activities of the individual functions and considering their wider relationships with other trust functions.
- To identify an Executive lead to ensure clear direction and information sharing in relation to the QAI agenda.
Exploring Online Group Retention Including Reasons Why People May or May Not Choose to Attend an Online Psychological Mental Health Intervention
Good practice:
- Elements of choice, connectedness and accessibility were identified as a foundation to successful engagement with whatever format an individual is offered.
Key recommendations:
- To continue to offer both online and face to face opportunities to people who wish to attend a group.
- To offer administrative support to those who have technology-based barriers to engaging with an online intervention.
- To consider ways of increasing connectedness in order to support sustainable engagement with online interventions.
Internal Recruitment Survey
Good practice:
- Overall, applicants are satisfied with the service they are receiving.
- There has been an increase in the proportion of recruiting managers reporting that they are either satisfied or very satisfied with the service.
Key recommendations:
- To create an FAQ sheet to simplify the information provided.
- To review how technology could be used to provide a quick chat function.
- To review options for incorporating technology such as videos to explain processes into offer letters.
National Clinical Audit of Psychosis: Early intervention spotlight 2023
Good practice:
- Trust service rated Top Performing for 2023.
- Uptake of carer-focused education and support had risen to 93% from 69% in 2021.
- Positive progress in collection of paired outcome measures, which had risen from 57% in 2021 to 78% in 2023.
Key recommendations:
- To continue to work to improve SNOMED coding for assessments and interventions.
- To link in with CAMHS colleagues to build on joint training.
- To further develop dashboard reporting in conjunction with Business Intelligence colleagues.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD): Transition from child to adult services
Good practice:
Results not reported at local level – national report only provided.
Key recommendations:
- To complete review of Transitions policy.
- To develop and roll out coproduced training sessions for clinical staff.
Occupational Therapy Assessments: A scoping and feedback review
Good practice:
- Respondents highly valued MOHOST, viewing it as a reliable outcome measure.
- Common use of assessment tools such as OSA, LACLS and the Interests Checklist.
Key recommendations:
- To increase training and awareness.
- To explore licensing options.
- To periodically review the utilisation of MOHOST and its impact on practice.
Prescribing Observatory for Mental Health (POMH) Topic 7g: Monitoring of patients prescribed lithium
Good practice:
- All patients recently prescribed lithium had received e-GFR and thyroid function tests prior to initiation.
- Serum level had been measured at 6 months in 95% of cases.
- In 95% of cases, U&Es and e-GFR tests had been conducted at 6 months.
Key recommendations:
- To check that baseline monitoring requirements for specified medications (including lithium) are included in the trainee doctor handbook.
- To develop a chart for lithium monitoring for display at Medicines Monitoring/Physical Health clinics.
- To explore specific side effect monitoring tools for lithium.
Prescribing Observatory for Mental Health (POMH) Topic 20b: The quality of valproate prescribing
Good practice:
- Plasma level monitoring of valproate treatment is only used when there is evidence of ineffectiveness, concerns about medication adherence or closely related side effects.
- Of patients recently prescribed valproate 3 out of 4 had a review of therapeutic response, side effects and medication adherence within 3 months of initiation.
Key recommendations:
- To remind prescribers in CMHTs what the standards are when initiating valproate treatment and how to document this appropriately.
- To remind prescribers of the requirements for women of childbearing age on valproate treatment.
Re-Audit of the Quality of Neuropsychological Assessment Practice using a Self-Assessment Tool
Good practice:
- 100% compliance on most standards at both time points.
- Improvements observed in seven standards at re-audit.
Key recommendations:
- To improve practice in relation to report length, waiting times for feedback sessions, use of performance validity tests and provision of service leaflets.
Service Evaluation of Opiate Detoxification at the Edward Myers Centre
Good practice:
- Physical health assessments and baseline blood investigations performed as per protocol.
- Adequate recording of utilisation of PRN medications.
- Positive results in relation to planned referrals, review of physical and mental health status and ongoing physical health monitoring.
Key recommendations:
- Ensure that all patients have ECG done and reviewed before admission for detoxification.
- All patients to be offered hepatitis and HIV screening before discharge, with clear documentation in notes.
- Ensure regular and consistent recording of reason for missing doses of clonidine for all patients.
Understanding the Knowledge Amongst Mental Health Nursing Staff of the Regulatory Requirements in Line With the Regulation 9 of the Health and Social Care Act (2022)
Good practice:
- Designated structures and processes were in place to enable the learning and development of staff.
- Mechanisms for staff engagement were present and functioning.
Key recommendations:
- To develop a more robust mentoring programme for staff.
- To introduce a shadowing system for staff new into post.
