Introduction

The Integrated Access Partnership (IAP) is a collaborative, award winning, innovative endeavour which is transforming urgent and emergency care services (999 and 111) for people in mental health crisis.

 

In collaboration, BrisDoc Healthcare Services (BrisDoc), Avon and Wiltshire Mental Health Partnership Foundation Trust (AWP) and South Western Ambulance Service NHS Foundation Trust (SWASFT) – as well as Avon and Somerset Police, Avon Fire and Rescue, and voluntary sector organisations – have implemented an integrated urgent and emergency care front door service across both 999 and 111 for people in mental health crisis. The service provides three layers of intervention and trusted onward referrals to support any person presenting with mental health needs to 999 or 111; providing remote advice through a multidisciplinary mental health team, or a rapid face-to-face response through a network of ‘mobile pods’ across the area.

 

The IAP services are outlined in the table below. Each part of the service is covered by a separate standard operating procedure.

 

Service Line	Service Provision
Mental Health Specialist Desk (MH SD)   SWASFT Emergency Operations Centre (EOC) St James A, St James Court, Bradley Stoke BS32 4QJ 0300 369 0151	BNSSG	24/7
	BSW	08:00 – 00:00 (7/7)
	Cornwall	08:00 – 00:00 (7/7)
	Devon	08:00 – 00:00 (7/7)
	Dorset	08:00 – 00:00 (7/7)
	Gloucestershire	08:00 – 00:00 (7/7)
	Somerset	08:00 – 00:00 (7/7)
Mental Health Response Vehicle (MH RV) Bristol Ambulance Station, Croydon Street, Easton, Bristol BS5 0DA   (contact via MH SD)	BNSSG	24/7
	Gloucestershire	14:00 – 00:00 Mon – Thurs only
	Somerset	10:00 – 22:00 (7/7)
Mental Health Link Officer (MHLO) (situated at MH SD)	Avon & Somerset Police footprint	24/7
Mental Health Clinical Assessment Service (MH CAS) BrisDoc Healthcare Services, Unit 21 Osprey Court, Hawkfield Business Park, Bristol BS14 0BB   0117 233 1402	BNSSG	24/7
Emergency Services Mental Health Professional Line (MH PL) incorporated within MH CAS 0117 233 1402	BNSSG	24/7
Urgent Assessment Centre Gloucester House, Southmead Hospital, Dorian Way, Bristol BS10 5NB	BNSSG	17:30 – 00:00 (7/7)

 

Objective

This standard operating procedure sets out how clinical contacts with the IAP will be audited to review the quality and consistency of the interaction with the service, the care/advice provided, and the records of the interaction.

As well as assuring the quality and standards of the service, the results of audits and any identified learning will be used to contribute to staff supervision and development, and service improvements.

Scope

This SOP relates to the audit of the following elements of the IAP:

• Mental Health Specialist Desk (MH SD): all cases
• Mental Health Response Vehicle (MH RV): BNSSG cases only
• Mental Health Clinical Assessment Service (MH CAS): all cases
• Urgent Assessment Centre (UAC): all cases
• Emergency Service Mental Health Professional Line (MH PL): all

Clinical Records

The IAP’s Overarching SOP details the primary and secondary clinical records for each service line of the IAP; the summary table is included below. Clinical audits will primarily consist of records reviews, supported by listening to call recordings.

 

Service Line	Primary Record	Secondary Record
Mental Health Specialist Desk (MH SD)	CAD (C3)	RiO*
Mental Health Response Vehicle (MH RV)	CAD (C3) & ePCR	RiO*
Mental Health Link Officer (MHLO) (situated at MH SD)	RiO	N/A
Mental Health Clinical Assessment Service (MH CAS)	Adastra	RiO*
Emergency Services Mental Health Professional Line (MH PL)	Adastra	RiO*
Urgent Assessment Centre (UAC)	RiO	N/A

 

*IAP staff will only be expected to submit information into the contemporaneous record (progress notes) of the relevant RiO record. The IAP staff member will select available options to add to the risk history if this is appropriate and available within the contemporaneous record. By exception, where patients have not previously had a risk history written, there will not be the option to add to the risk history. In these cases, where an assessment has been completed, IAP clinicians need to complete a risk history form within RiO.

 

Emergency Services Triage (EST)

EST comprises MH SD and MH RV, operating through South Western Ambulance Service NHS Foundation Trust (SWAFST).

For the purposes of IAP audit, the scope extends to MH SD cases across the SWASFT footprint in South West England, and MH RV cases within BNSSG only (the response vehicles in Gloucestershire and Somerset lie outside the scope of this SOP).

Mental Health Specialist Desk

The primary clinical record for MH SD cases lies within SWASFT’s CAD (C3) with secondary records completed within AWP’s Rio. Cases are managed through outbound telephone calls, which are made using a SWASFT recorded line.

Audit process

Five per cent of MH SD cases will be audited each month. The IAP Data Analyst will generate a random sample of cases each month, which is representative of the geographical breakdown of MH SD cases.

MH SD cases will be audited through a review of the notes in CAD and in Rio (for cases within AWP’s footprint (BNSSG and BSW)), ensuring that these notes are reflective of each other and do not contain discrepancies. Clinical notes will be audited against the framework in Appendix 1.

Five per cent of telephone call recordings will be listened to, to ensure that the recorded notes are reflective of the conversation that has taken place. The IAP Administrator, as well as team managers and EST Service Manager, will have access to pull call recordings, which will be saved in a secure shared drive, where IAP auditors are able to listen to recordings.

This triangulated audit approach will rigorously assure the accuracy of contemporaneous progress notes as an accurate record of clinical interventions undertaken by the MH SD.

Each case audit completed will be recorded using a Microsoft Form, which will measure where standards are met/not met. For each case that is ‘passed’, with or without comment, an automated feedback email will be sent to the relevant clinician. Any cases that do not meet the expected standard will be referred for a group review of the case, following which time constructive feedback will be shared with the consulting clinician in the most appropriate manner, in conjunction with the audit team and the clinician’s line manager.

Mental Health Response Vehicle

The primary clinical record for MH RV cases in BNSSG lies within AWP’s Rio system, with secondary records completed in SWASFT’s CAD (C3) and ePCR. Cases are managed through face-to-face attendance at the scene of mental health emergencies.

Audit process

Five per cent of MH RV cases will be audited each month. The IAP Data Analyst will generate a random sample of cases each month.

MH RV cases will be audited through a review of the notes in Rio. Clinical notes will be audited against the framework in Appendix 1.

 

Each case audit completed will be recorded using a Microsoft Form, which will measure where standards are met/not met. Any cases that do not meet the expected standard will be referred for a group review of the case, following which time constructive feedback will be shared with the consulting clinician in the most appropriate manner, in conjunction with the audit team and the clinician’s line manager.

Mental Health Clinical Assessment Service

MH CAS operates through BrisDoc Healthcare Services, as part of SevernSide Integrated Urgent Care.

MH CAS receives cases through Directory of Services referrals, where patients, or someone on behalf of a patient, contacts NHS 111 directly, either by phone or through NHS 111 online. MH CAS clinicians will also support the assessment of patients where mental health needs are identified, who have received a physical health pathways disposition. These patients will be identified, either by mental health clinicians ‘fishing’ from the physical health advice queue, or by physical health clinicians flagging these cases for review by mental health clinicians.

Clinical Guardian

Audit of MH CAS cases is completed through Clinical Guardian, a web-based programme that randomly selects cases for audit. The selection of cases within Clinical Guardian is based on clinician rather than the service as a whole; however, this still equates to approximately five per cent of cases.

Clinician status

Every MH CAS case is uploaded to Clinical Guardian on a weekly basis, by BrisDoc, as part of all of SevernSide’s cases. Clinical Guardian identifies the consulting clinician and randomly selects five per cent of their cases for audit. This applies to ‘green’ clinicians, which are the majority of clinicians, once they have become familiar with MH CAS and met the expected standards in the initial auditing of their caseload.

Clinicians who are new to MH CAS have a ‘purple’ status, whereby 100 per cent of their cases will be allocated for auditing. All ‘purple’ clinicians will have at least 10 of their cases audited and up to three telephone call recordings audited, before their status is changed to ‘green’. When an auditor feels a clinician is ready to have their status changed, they will email awp.IAPTeamManagers@nhs.net, in order for a team manager to confirm the status and update the clinician’s status to green. Thereafter, Clinical Guardian will continue to select five per cent of their cases for audit.

Audit process

Cases selected for audit within Clinical Guardian, for ‘green’ clinicians, are presented to auditors anonymously, who then review the Adastra case notes and Rio progress notes for each case.

Cases for ‘purple’ clinicians are not presented anonymously, in order that a sample of the clinician’s cases can be reviewed in one go, in order to effectively review whether they are able to have their status changed.

Each case must be audited through Clinical Guardian, before recording the audit using the Microsoft Form, which will measure where standards are met/not met. For each case that is ‘passed’, with or without comment, an automated feedback email will be sent to the relevant clinician. Any cases that do not meet the expected standard will be referred for a group review

 

of the case, following which time constructive feedback will be shared with the consulting clinician in the most appropriate manner, in conjunction with the audit team and the clinician’s line manager.

Group reviews are scheduled to take place fortnightly, between at least three auditors, where any referred cases will be reviewed, with any necessary feedback and learning for clinicians being shared collectively by the audit team, sensitively and constructively.

Urgent Assessment Centre

The UAC hosts face-to-face assessments with patients who have been referred either from MH SD, MH CAS, or from the emergency department at Southmead Hospital (with the UAC sited within the grounds of Southmead Hospital).

Only one clinical record is made for UAC interactions, within AWP’s Rio system.

Audit process

Five per cent (or a minimum of two) UAC cases will be audited each month. The IAP Data Analyst will generate a random sample of cases each month.

UAC cases will be audited by reviewing the clinical record made in Rio, in accordance with Appendix 1. The audit will be recorded using the Microsoft Form.

Emergency Services Mental Health Professional Line

The MH PL connects emergency service colleagues at the scene of an incident, with an IAP clinician. These cases may result in advice being given to a professional, or liaison with another IAP service, such as requesting the attendance of the MH RV, or attending an appointment at the UAC.

Whenever a MH PL call is managed by an IAP colleague, a record must be made using the IAP’s data capture form, and progress notes are added to any relevant Rio records.

Audit process

The MH PL is operated as part of the MH CAS. MH PL cases will be incorporated within MH CAS audit through Clinical Guardian.

Failed Contacts

Across IAP services, there will be occasions when it is not possible to make contact with a patient. In such cases, it is important to document all attempts to make contact, any actions taken during contact attempts (such as leaving answerphone messages), and any subsequent actions undertaken.

Owing to the random selection of cases for audit, cases with failed contact will be included within this sample, and auditors will assess the records of these cases to ensure that any appropriate actions have been taken and documented.

 

Audit Summary

 

Service Line	Audit Method	Monthly Audit Sample	Audit Record
Mental Health Specialist Desk (MH SD)	·         Review of CAD ·         Review of RiO notes ·         Review of call recordings	·         5% of cases, geographically representative ·         Call recordings reviewed for 5% of audited cases	·         IAP Audit MS Form
Mental Health Response Vehicle (MH RV)	·         Review of RiO notes ·         Review of call recordings	·         5% of cases (BNSSG only)	·         IAP Audit MS Form
Mental Health Link Officer (MHLO) (situated at MH SD)	·         Audit by Police	·         N/A	·         N/A
Mental Health Clinical Assessment Service (MH CAS)	·         Review of Adastra case notes ·         Review of RiO notes ·         Review of call recordings	·         Minimum of 10 cases for each new clinician ·         Up to three call recordings for each new clinician ·         5% of each clinician’s cases following initial period	·         Clinical Guardian ·         IAP Audit MS Form
Emergency Services Mental Health Professional Line (MH PL)	·         Review of Adastra case notes ·         Review of RiO notes ·         Review of call recordings	·         Minimum of 10 cases for each new clinician ·         Up to three call recordings for each new clinician ·         5% of each clinician’s cases following initial period	·         Clinical Guardian ·         IAP Audit MS Form
Urgent Assessment Centre (UAC)	·         Review of RiO notes	·         5% of cases (BNSSG only)	·         IAP Audit MS Form

 

Monitoring & Change Register

The IAP SOP will be reviewed at least annually and more regularly to account for service changes and expansion.

 

Date	Version	Author	Change
29/02/2024	0.1	Ollie Crandon	Initial Draft Completed
06/03/2024	0.2	Ollie Crandon	Recording of audit confirmed Audit sample sizes confirmed Audit summary table added
15/03/2024	0.3	Ollie Crandon	Audit criteria added Audit form link added
03/04/2024	0.4	Ollie Crandon	Formatting amendments Added failed contacts
12/04/2024	0.5	Ollie Crandon	Amended MH CAS audit process to include completion of MS Form
18/04/2024	1.0	Ollie Crandon	V1.0 published
23/06/2024	1.1	Ollie Crandon	‘Clinical Records’ amended ‘Mental Health Response Vehicle’ amended ‘Emergency Services Mental Health Professional Line’ amended ‘Audit Summary’ amended MH CAS audit record amended in audit summary table. MH CAS audit process amended for clarity
29/10/2024	1.2	Ollie Crandon	Updated following full review of all service lines

 

Appendix 1: Audit Criteria

Call Audit Requirements

• Makes effort to speak directly to patient/confirms ABCs
• Confirms patient demographics
• Introduces self and purpose of call
• Professional, caring and compassionate approach
• Accurately determines the presenting complaint
• Seeks collateral input from carers, friends and relatives wherever practicable
• Determines relevant past medical history, including medications and allergies where appropriate
• Reaches a safe and appropriate outcome and communicates this effectively
• Safeguarding (where relevant)
• Relevant, accurate clinical advice provided
• Targeted and general worsening advice provided
• Uses appropriate questioning techniques and avoids jargon
• Manages risk accurately to arrive at a timely outcome

Clinical Records Audit Requirements

• The level of clinical recording is proportionate in relation to review, triage and assessment
• Records are formatted in the same manner as an IAP Rio progress note and entered correctly on CAD
• The CAD and Rio records are reflective and consistent with one another
• Risks are clearly formulated using structured professional judgement with reference to the UK Mental Health Triage Scale
• The key components of mental state examination are recorded in all ‘triage’ and ‘assessment’ calls
• Any reference to capacity is decision-specific
• Non-registered staff reference a registered clinical supervisor in relation to all clinical decision making
• Records show a final impression and formulation that captures risk and clinical impression
• Plans are clear and proportionate to the presenting situation

Overall

• Was the management of this case satisfactory?