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The Royal College of Psychiatrists Improving the lives of people with mental illness

Spotlight on quality - case study 4

Spotlight on quality

Quality Improvement: a case study

Last month the college’s Quality Improvement lead Amar Shah brought you the third in a series of QI case studies, which we hope will inspire ideas for quality improvement in your areas of work.

It focused on work done by the Adult Learning Disability Unit in Durham.

This month we’re looking at a project which took place at Merseycare NHS Foundation Trust, focusing on preventing suicide.


The aim of the project

In 2015 Mersey Care NHS Foundation Trust (MCT) announced its ambitious commitment to ‘Zero Suicide’ and the aspirational goal of no suicides of service users in our care.  Four areas were initially identified for quality improvement approaches;

  • Service user and Partner engagement
  • Safe and effective care and treatment
  • Competent workforce
  • Research and Evaluation


Content theory

Under the ‘safe and effective care’ heading it was agreed to test the potential impact of the introduction of individual safety plans.


The ‘Safety Plan’ is a psychologically informed, risk management and reduction tool co-designed by Consultant Psychologist, frontline staff and service users. It is evidence based and built to national guidance standards.


Recovery orientated, it’s a key component of NCI safer services requirements. It supports skill enhancement, problem solving, generates hope and includes opportunities to learn from and prevent future crisis.




The Model for Improvement was used consistently to learn and refine the plan and a number of  PDSA cycles were completed prior to implementation.


Another PDSA was carried out with the aim of assessing the feasibility, acceptability and safety of implementing the safety plan into business as usual practice across four sites. 


A thorough service evaluation was carried out exploring potential impact on locus of control (MHLOC) for service users, impact on emotional coping (DERS), impact on working alliance and any adverse effects to ensure safety. 


Focus groups pre and post implementation were conducted and a thematic analysis completed to capture themes and maximise learning.



  1. The Safety Plan (SP) was successfully implemented in three out of the four sites.
  2. Operational management support was imperative for implementation
  3. Service User (SU) engagement was influenced by the attitudes of staff
  4. Staff initially candid about participation due to fear of administrative burden but once engaged became keen advocates



  1. SP is appropriate for all service users but timing of when to engage is important
  2. SUs found the safety plan emotionally challenging but very welcomed
  3. Benefits included validation of feelings, improved self insight, hopefulness, self reliance and affirmation of support networks
  4. Staff were doing something valuable
  5. Engaged staff noted improved job satisfaction and working alliances




  1. SP considered to provide an intensive, collaborative and personalised intervention over existing clinical practices
  2. SP provided a defensible, formal structure to their clinical practice which they valued
  3. Staff felt adequately prepared following training and several suggestions for improvements
  4. No adverse effects were reported by service users.




Broader implementation, monitoring and evaluation systems illustrate the following.




The SP is an evidenced based tool that enhances service user skills, staff engagement, confidence and satisfaction. Data included 0% readmission rate across a 90 day timeframe for service users supported by a safety plan compared to 4% readmission rate for those without. Also a reduction in the number of complaints relating to poor staff engagement noted post implementation. Broader implementation was indicated.



Contact  details, Project Lead

Dr Claire Iveson

Consultant Clinical Psychologist (Clinical Lead Safety planning)

Tel: 0151 473 2907


View full article with graphs (PDF).


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