An independent investigation into the care and ... - Hundred Families

to Mr Z not receiving the extra support he needed. This support might have prevented
deterioration in Mr Z’s mental health and might have prevented the attack on his father.
Comment
Performance processes in health and social services like any other employment must
be fair and follow good human resources practice. These processes must also be
sensitive to the need to maintain safety as the highest priority. Senior social worker
1’s line manager’s concerns about his performance did not result in decisive action
by more senior managers. It took the arrival of a new senior manager to take action
to safeguard safety.
Finding
F2 Senior managers failed to ensure that client safety was maintained while they
performance managed senior social worker 1. This failure was a contributory factor in Mr Z
not being allocated a care coordinator. A care coordinator might have prevented the
deterioration of Mr Z’s mental state and the consequent offence.
Recommendation
R2 The trust and local authority must ensure that their human resources policies
include processes setting out how immediate action can be taken to deal with clinical or
social work staff who are reported as posing a risk to patient/client safety. This may
include re-allocation to a non-patient/client contact area, restriction of their work or if
necessary suspension from work. The policy must also include how staff will be assessed
and deemed safe to practice before they return to patient/client contact work.
10.27 As part of finalising our report we met with trust managers to understand what
changes to staff performance management procedures have been made. The following is
an extract of the information supplied to us by the trust.
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