Care Programme Approach (CPA) Policy

Transcription

1 Care Programme Approach (CPA) Policy Date approved: Date for review: Dec 2010 Dec 2012 Responsible department: CPA Lead Care Services MMM TENTS M009 1

2 FOREWORD...4 EXECUTIVE SUMMARY...5 VALUES & PRINCIPLES INTRODUCTION...7 KEY STANDARD STATEMENTS FOR CPA WITHIN LPT CARERS ASSESSMENT CARE PLANNING CPA REVIEWS CPA CARE CO-ORDINATOR SERVICE INTERFACE SERVICE INTERFACE DISCHARGE FROM THE CPA PROCESS INFORMATION SHARING AUDIT AND MONITORING GAPS IN SERVICE CPA TRAINING GOVERNANCE OF CPA WITHIN LPT...26 APPENDIX CURRENT LAWS & GOVERNMENT UNDERPINNING THE NHS EQUALITY AGENDA THE EQUALITY ACT USEFUL WEBSITE ADDRESSES APPENDIX TABLE 1 INDICATORS FOR THE SUPPORT OF FORMAL CPA PROCESS APPENDIX SERIOUS MENTAL ILLNESS CRITERIA ORIGINAL DOH NATIONAL DEFINITIONS ( SIDDD ) APPENDIX CARE CO-ORDINATOR APPENDIX CARE PROGRAMME APPROACH CARE CO-ORDINATION CORE FUNCTIONS AND COMPETENCIES APPENDIX ROLE AND RESPONSIBILITIES WITHIN CPA TRAINING APPENDIX CPA AND LEARNING DISABILITY SERVICE

3 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES CPA AND THE DYNAMIC PSYCHOTHERAPY SERVICE THERAPY SERVICES FOR PEOPLE WITH PERSONALITY DISORDER

4 Foreword The aspiration for a more personalised approach to service provision is now public policy and transforming adult social care services as described in the concordant Putting People First (2007). The Care Programme Approach is at the centre of this personalisation focus, supporting individuals with severe mental illness to ensure that their needs and choices remain central in what are often complex systems of care. The aim of the national review of CPA in 2008, was to ensure a renewed focus on people who use mental health and learning disability services having greater choice and control over their care and support. Personalisation supports recovery by focussing far more on what the person finds valuable and meaningful and sees a new relationship between citizens and the publicly funded services they use. It involves all public services working together around the individual, rather than individuals navigating their way through a maze of publicly-funded services. It sees resources being used in new ways so that individuals have support that fits their life rather than their life being shaped by the support available to them. Our local updated CPA policy emphasises the importance of personalisation and different professionals and agencies coming together to provide a range of services coordinated by the framework of CPA. It remains a key part to delivering on Leicestershire Partnership NHS Trust 2012 vision. We are delighted that this policy has been developed through collaboration between health and social care agencies in Leicester and Leicestershire but most importantly with organisations representing the views and needs of people and their families who use our services. Anthony Sheehan, Chief Executive Signed for and on behalf of Leicestershire Partnership NHS Trust Helen Coombes: Director. Signed for and behalf of Health & Social Care Services Leicester City Council.. Colin Foster, Director of Adult Social Services Signed for and on behalf of Rutland County Council. Sue Disley: Director. Signed for and behalf of Social Care Health, Leicestershire County Council.... 4

5 Executive Summary This Policy is intended to serve as a framework for staff to follow in order to deliver high quality care and support for people who use mental health services provided by the Leicestershire Partnership NHS Trust (LPT). Though the use of CPA is re focused on those with most complex needs, the standards and emphasis on providing people and their families with clear information about the range of services available and choice in how their support is provided are applicable to all people who use our services. The Service User must be central to the whole process, with support provided by the practitioner and services, in order for the Service User to achieve his/her identified outcomes. Within this Policy, services are asked to refocus upon: Values and principles for all Service Users to be central to care delivery A whole system approach to personalised care planning and delivery Assessment and Care Planning standards Support for the workforce Measuring and Improving Quality Safeguarding issues: Vulnerable groups and individuals are protected by ensuring best practice in the area of Safeguarding - utilising national and local policies and guidance. This Policy covers the main elements of CPA and the role of the Care Co-ordinator that has long been recognised as the linchpin of the whole process. It is vital that CPA Care Co-ordinators are given the guidance and support to enable them to successfully undertake their responsibilities. A copy of the handbook produced by the CPA Association is provided to every CPA Care Co-ordinator within LPT. The information within the handbook provides additional guidance to support the LPT Policy. The key standards statements from each of the sections of this policy are listed together in the introduction to the Policy. 5

6 Values & Principles LPT is committed to the values and principles of the CPA process and a service delivery aimed at a recovery based approach that supports people in living independent and valued lives 1 Recovery is the diagnosis, treatment and support considered in terms of the extent to which they help the person to do the things they want to do and live the life they wish to lead. It is not just about services but also about what people experience and how they are empowered to manage their own lives. Recovery can be described as a process of changing one s orientation and behaviour from a negative focus on a troubling event, condition or circumstance to the positive restoration, rebuilding, reclaiming or taking control of one s life. 2 Recovery and Independent living are key outcomes for mental health service and central to the both the Care Programme Approach and Personalisation agenda. An outcomes approach challenges us to focus the consequences of support received and the right results rather than the right way of getting their. It recognises that services in themselves do not produce outcomes and that people do. As such people are recognised and supported as active assessors and co producers of their own outcomes. The CPA is central to supporting people to achieve their outcomes by: Promoting recovery Seeing the individual as a person first, Service User second Putting the person at the centre of the process Seeing the person and their carers as having strength, skills and expertise that can help Supporting meaningful involvement Working together in partnership Creating open relationships, trust, honesty and respect Being optimistic and building confidence Safeguarding the person and supporting positive risk management Promoting social inclusion and involvement Enabling choice and control requires a positive approach to risk-taking where people have the right to live their lives to the full as long as they do not stop others from doing the same. CPA assists this by promoting person-centred thinking to positive risk taking and assisting people to have choice and control over their lives. Recognising that making choices involves risk, professionals using the CPA are able to assist people to understand their responsibilities and consequences of choices including the risks. CPA provides a framework to get the right balance in managing risk and respecting people s rights. 1 2 NIMHE Guiding Statement on Recovery.(January 2005) 6

7 1. Introduction 1.1 LPT aims to ensure that all services provided conform to laws and guidance underpinning the NHS equality agenda. (see Appendix 1). As such, service delivery will be periodically audited to ensure conformity to related policy procedure. 1.2 LPT has clear legal requirements in relation to Race, Gender, Disability Age, Religion or belief and Sexual Orientation. To this end, all Trust Policies will be impact assessed. 1.3 LPT CPA Policy supports Care Services aims to ensure that services provided are in accordance with an assessment of need and are allocated on an equitable basis across all authorities, without discrimination of any kind. 1.4 Criteria for deciding upon the level of support required under CPA should not be used as indicators of eligibility for secondary services or for entitlement to receive any other services or benefits All Service Users will be involved in every aspect of their assessment, care planning, implementation and review process. They will be encouraged to include any carer/relative/representative/friend they choose in that process. 1.6 At the referral stage, sufficient information should be gathered on the basis of needs that the person is presenting and the risks that are indicated, to decide whether a full CPA Assessment is appropriate. (also refer to LPT Clinical Risk Policy MO35). 1.7 Service Users who, based on their initial assessment, have more straightforward needs requiring low level support will not require the more formal CPA process. The person most likely to be facilitating or taking the lead in care delivery for such individuals will be in the role of, and identified as the lead professional. (see also 3.1, 5.2 and 10.2) The rationale for determining non CPA must be recorded. 1.8 Service Users having more complex health and social needs, with higher identified risk factors, requiring input from more than one professional will be assigned for the higher, more formal CPA process. (Appendix 2 and 3). Key Standard Statements for CPA within LPT Assessment All Service Users accepted into secondary mental health services care in LPT must receive a full assessment (including risk assessment), a care plan including the name of the person facilitating their care and regular reviews of that care plan and progress. 3 Refocusing the Care Programme Approach 2008 page 13 7

8 All Service Users will be screened at assessment and review to identify a carer who provides regular and substantive care Needs assessment is a focus on an individual s needs rather than on the services available or on any diagnosis made. It must be a continuous process based on the identification of strengths as well as vulnerabilities. CPA Determination Formal CPA process will be delivered to all those Service Users, accepted for secondary health care within Leicestershire Partnership and who, following a full assessment (including risk), have needs identified which are complex and predominantly mental health related and where the characteristics for CPA are evident. (Appendix 2 and 3) Risk Assessment A Risk Assessment must be completed and documented alongside or within CPA Assessments (in accordance with the Clinical risk assessment policy). Any new information gained during the continuous CPA process and risk assessments must be recorded with a risk management plan recorded. Care Plan It is the right of all Service Users to be offered and to receive a copy of an agreed written Care Plan, whether receiving the support of formal CPA or not. A copy of the e-cpa Care Plan must be offered to all those registered for the formal CPA process. The CPA Care Plan should identify the CPA Care Co-ordinator and all people involved in the care of the Service User. The CPA Care Plan should include the actions for which the Service User will take responsibility. CPA Review A CPA review will determine how effective the care plan is in assisting the Service User to achieve the identified outcomes. A CPA Review provides the opportunity to formally discuss any disagreements about the care plan which may have arisen. Where there are disagreements, these must be recorded. If the Service User or any other person involved in the Care Team requests an earlier CPA Review, immediate attention should be given to establishing the reason for the request and if necessary, such a review should be arranged. Care Co-ordinator The CPA Care Co-ordinator is a competent, trained, experienced mental health worker. That person is responsible for co-ordinating, the assessment, planning, implementation, monitoring and review of the CPA care plan for the Service User whether in hospital or community, and ensuring that all records, including MaRACIS are maintained and updated accordingly Service Users not considered to require referral on to Community Mental Health Teams (CMHT) for longer term care, but who have been engaged with Crisis Resolution & Home Treatment Team (CRHT) for and likely beyond six weeks, will 8

9 require the support of the formal CPA process and an identified CPA Care Coordinator from within the CRHT. Inpatient Areas Upon admission, the recorded CPA Assessment information should follow the Service User and be updated accordingly. At the point of discharge from in-patient services, all Service Users will have either the written discharge plan detailing immediate follow up care together with a crisis and contingency plan and discharge medication or a copy of the updated e-cpa Care Plan. Discharge information may be contained within an e-discharge letter to the GP, and where this is used, the Service User must be given a copy and be informed that this e-discharge letter serves as their discharge plan. Discharge plans are not a substitute for the CPA Care Plan. However, where the e- CPA Care Plan cannot be updated at the point of discharge, the discharge plan must include details for post discharge period. This and any other information contained within the discharge plan must be sent to inform the CMHT and the e- CPA Care Plan amended accordingly. The Service User (and carer where appropriate) should be involved in, and aware of, any changes to the CPA Care Plan and a copy of the updated e-cpa Care Plan must be given to the Service User as soon as is practical to do so. The relevant GP should be informed of the discharge and a copy of either plan faxed to the surgery at the point of discharge. Information Sharing Information sharing should take into account LPT s responsibility in relation to Safeguarding Adults. Consideration should be given to referring people who may be victims of abuse within the multi-agency procedures. Refer to the Trust Safeguarding Policy. Shared information systems will provide data relevant to people and agencies in accordance with public protection and data protection systems. Robust CPA requires that protocols be agreed for the sharing of information with the police, probation service, local prison (if appropriate) and court liaison, independent/voluntary sector agencies involved in the care provision. 9

10 2. Carers 2.1 A key element of CPA is that it recognises the importance of Service Users wider social relationships to their well-being and recovery. A key aspect of the Care Co-coordinator s role is therefore to consider these with the Service User and where of value ensure that the right people are involved in the assessment and care planning process. 2.2 Service Users have a right to the involvement and support of other people where they wish it. 2.3 In addition to family, friends etc who care about the Service User and who the Service User may wish to be involved in the CPA process, there will be others who care for the Service User. The partner agencies all recognise the importance of supporting carers those who care for people. Staff must actively seek to identify and support carers at all times. 2.4 Recognition should be given to the role of carer as being a valued member of the Care Team network. 2.5 A carer is someone who supports a person with a mental health problem, learning disability or physical disability or illness. They do not get paid for this or do it as voluntary work. Carers are often family or friends but they do not have to be. The support they provide might be physical care or practical support but it can also include emotional support or supervision. It is quite common for people not to see themselves as carers because they see what they do as a normal part of being a partner or friend etc. 2.6 LPT and Local Authorities recognise that caring for a person with mental health problems may have a significant effect on the life of that carer and this can affect the carer s own health, well-being and life chances. All staff in the partner agencies has responsibilities to support or signpost carers as required. 2.7 Local Authorities have a legal duty to offer carers who provide or intend to provide regular and substantial care an assessment of their own needs where the Service User they care for is eligible for services. Following an assessment, support and services may be provided to help the carer in that role. This can be directly to the carer or through additional support to the Service User. Staff undertaking these assessments should be familiar with the law, the national guidance 4 and the local authority s policies. 2.8 The Local Authorities in Leicester, Leicestershire and Rutland all want to promote the rights of carers to assessments and interpret substantial and regular to take account of the varying ways people are involved in caring. It is recognised, especially where the Service User s mental health fluctuates, that the caring role may also vary. All of the Local Authorities consider the impact that the caring role is having on the carer s life as part of the decision to offer an assessment. 4 Carers and Disabled Children Act 2000 and Carers (Equal Opportunities) Act 2004 Combined Policy guidance 10

11 2.9 Staff who come into contact with carers should inform them of their right to an assessment.they have a right to their own assessment whether the Service User consents to this or not LPT acknowledges and is committed to ensuring that Carers rights are met. Carers have a legal right to be offered an assessment of their own Clinicians may at times be working with individuals and have no direct contact with carers but become aware of them through the Service User. Sometimes Service Users may not want their carer to be contacted. In these situations staff are advised to explore the Service User s concerns and encourage him/her to weigh the possible benefits of the carer receiving support against the issues giving concern.information about what the carer s assessment involves and reassurance that confidentiality will be maintained may help If a Service User still refuses to give their consent, and there is no overriding responsibility in terms of risks then the Service User s wishes should be respected.the rationale for refusing consent must be recorded in the service user s notes The Service User s consent must be sought before any information relating to their mental health is shared with their Carer, unless risk/safety factors or lack of capacity, justify breaking such confidence.the rationale for this breaking of confidence must be recorded The Carer should be informed that records will be kept including their personal details. Consent for this should be obtained from the carer and recorded in the relevant section of the assessment form or the review form In order to enable carers to make an informed decision, whether to share information or not, it must be made clear how any information they provide will be used.they should also be made aware of their right to access records about them Where carers are under 18 their needs require particular consideration. The aim should be to provide the right support to the Service User so that the caring role does not impact adversely on their life. This support can include help with their parenting role. Some young people do wish to continue in a caring role and this can be appropriate and specific support is available to them The Carer can share their own views and any other information they feel is necessary with the care team, regardless of whether the Service User has given permission or not Where the Carer offers information but requests that this is not to be passed to the Service User, this request must be respected subject to Information sharing and Consent guidance 11

12 2.19 Throughout the CPA processes, staff must be mindful of the needs of the Service User s family/network and where any needs or issues are identified, further reference for guidance may be obtained in other Trust policies: Safeguarding Adults: MO28a Safeguarding children: MO28 Domestic Violence: MO40a Clinical Risk Policy: MO Care Co-ordinators must offer LPT Carer s Self Assessment documention to an identified Carer who may not meet the local authority criteria in regards to regular and substantial. Key Standard Statement: All Service Users will be screened at assessment and review to identify a carer who provides regular and substantive care. 12

13 3. Assessment 3.1 A full, initial assessment, common to all referrals to LPT, will determine the level of input required to provide the care and treatment appropriate for those identified needs. The CPA Determination Tool, the Generic Risk Assessment tool and HoNOS must be completed as part of this initial assessment. 3.2 Service Users who require support of the formal CPA process will receive a systematic holistic assessment of their health and social care needs and this may involve more than one assessor using the CPA Assessment tool or its approved equivalent. (Approved by LPT CPA Standards Group) 3.3 The Assessment must involve the Service User and the Carer, where appropriate, as central and active participants in the CPA process. 3.4 Assessments must ensure that the strengths and achievements of the service user are identified. 3.5 The Assessment process must contain an assessment of risk. (Refer to the LPT Clinical Risk Assessment Policy). During the assessment process attention must be given in respect to whether or not the Service User fulfils the criteria for registering under the Multi Agency Public Protection Arrangements (MAPPA) 3.6 Appropriate Outcome ratings (HoNOS) ratings will be completed at assessment, upon discharge from an inpatient setting, at six month intervals and at significant points throughout the CPA process. 3.7 During Assessment, detailed information must be collated regarding any issues or needs of family members/dependants safeguarding, children or vulnerable adults (See also ) Key standard statement: Needs assessment is a focus on an individual s needs rather than on the services available or on any diagnosis made. It must be a continuous process based on the identification of strengths as well as vulnerabilities. Key standard statement: Formal CPA process will be delivered to all those Service Users, accepted for secondary health care within Leicestershire Partnership and who, following a full assessment (including risk), have needs identified which are complex and predominantly mental health related and where the characteristics for CPA are evident. (Appendix 2 and 3) Key standard statement: A Risk Assessment must be completed and documented alongside or within CPA Assessments (in accordance with the Clinical risk assessment policy). Any new information gained during the continuous CPA process and risk assessments must be recorded with a risk management plan recorded. 13

14 4. Care Planning 4.1 A Care Plan is a record of needs, actions and responsibilities. It must be written in an accessible and jargon free way. Care plans exist for the benefit of the Service User and should be based around their (assessed and identified) needs, not around the ability of the service to provide. 5 (Information relating to the contents of a CPA Care Plan can be found in CPA Policy Guidance notes.) 4.2 CPA Care Plans must be outcome focussed. 4.3 Dependant upon assessed mental capacity, Service Users have the right to be fully involved wherever possible in the formulation of their CPA Care Plan and have the right to be given a copy of their CPA Care Plan. 4.4 CPA Care Plans must include a crisis and a contingency plan. 4.5 Where there are two Service Users within one household, each CPA Care Co-ordinator must be aware of the contents of each of the CPA Care Plans. In such cases, there must be regular dialogue (at least quarterly) between the Care Co-ordinators (or lead professional where one of the Service Users may not be on CPA). 4.6 The CPA Care Plan must be recorded on the e-cpa (MaRACIS) system. 4.7 A copy of the CPA Care Plan will be provided to all personnel in the care team and, with the consent of the Service User, other relevant parties. 4.8 The effectiveness of the agreed CPA Care Plan will form part of ongoing monitoring and discussions between the Service User and their Care Coordinator. 4.9 The Service User has a right to decline involvement in all or any aspect of the CPA Care Planning process. (See also 8.3). Key standard statement: It is the right of all Service Users to be offered and to receive a copy of an agreed written Care Plan, whether receiving the support of formal CPA or not. A copy of the e-cpa Care Plan must be offered to all those registered for the formal CPA process. Key standard statement: The CPA Care Plan should identify the CPA Care Coordinator and all people involved in the care of the Service User. The CPA Care Plan should include the actions for which the Service User will take responsibility. 5 UK Care Standards Act

15 5. CPA Reviews 5.1 Review is a structured and flexible process as well as a planned periodic event. 5.2 Frequency of Review: On CPA - every 6 months; or as agreed by all parties involved in the care plan taking into consideration Service User choice, complexity of identified needs and planned outcomes and any risk factors. The rationale for this agreement must be recorded. Not on CPA at least annually. 5.3 Service Users have the right to request a CPA Review at any time. Where this request is not granted, the reason must be recorded and an explanation given to the Service User, and their Carer if appropriate. 5.4 Every consideration must be given to a request from a Service User or the Carer, to hold the CPA Review in a specific venue. 5.5 The CPA Review is the responsibility of the CPA Care Co-ordinator, who must be satisfied that all those involved professionally in the Service User s care, have had the opportunity to contribute to the Review as well as all other relevant people, dependant upon the Service User s consent. 5.6 When a social care support package is in place, the Care Co-ordinator must involve a social care worker in the CPA Review. Adequate planning is required in order for the social care report/update to be prepared. 5.7 At each Review the date of the next Review must be set and recorded in case notes and on MaRACIS, and as appropriate, the Local Authorities information systems. 5.8 Decisions made and agreed in a CPA Review must not be changed by any individual without full consultation with all other named participants. 5.9 The CPA Care Plan must be updated to reflect any change resulting from a CPA Review. The Service User must be offered a copy of the updated plan A CPA Review must take place prior to transfer of care into another team, in or out of area, to formally handover care and all relevant information. All relevant parties in the care team network should be involved in the review. (see also 6.10 and 7.7) 5.11 Where there is more than one CPA Care Co-ordinator within one household, both should be involved in each of the Service Users CPA Reviews and be fully aware of all vulnerabilities and risks identified in each case. 15

16 5.12 Section 117 is reviewed as part of the CPA Review process. (Refer to LPT s Section 117 Policy guidance) CPA Reviews may be a planned meeting or a series of conversations or a more formal meeting.the CPA Review documentation should be used regardless of how the review is held A planned CPA Review meetings should be allotted dedicated time and not be part of another meeting A CPA Review may be a series of conversations between the Care Coordinator and the identified professionals involved in the care delivery for a Service User. These would follow a discussion between the Service User and the Care Co-ordinator, and, would always be in the best interests of the Service User Where an informal CPA review has taken place, the date of the Review will be the date when the Care Co-ordinator records the agreed review outcomes and has agreed the date of the next review. Key standard statement: A CPA review will determine how effective the care plan is assisting the Service User to achieve the identified outcomes. Key standard statement: A CPA Review provides the opportunity to formally discuss any disagreements about the care plan which may have arisen. Where there are disagreements, these must be recorded. Key standard statement: If the Service User or any other person involved in the Care Team requests an earlier CPA Review, immediate attention should be given to establishing the reason for the request and if necessary, a review should be arranged. 16

17 6. CPA Care Co-ordinator 6.1 The Care Co-ordinator has responsibility for co-ordinating care, keeping in touch with the Service User ensuring that the CPA Care plan is delivered and ensuring that the plan is reviewed as required The Care Co-ordinator should be a qualified individual with the requisite knowledge, skills and experience and will in most cases be registered to a profession (see Appendix 4). Care Co-ordination should form part of the job description with co-ordination support recognised as a significant part of the caseload 7. Care Co-ordinator competencies (Appendix 5) should be completed and recognised as part of job specifications. 6.3 There will be one person acting in the role of CPA Care Co-ordinator, irrespective of input from more than one service within LPT. (see Appendix 8 ) 6.4 No qualified member of a service, organisation or discipline is exempt from being allocated the role of CPA Care Co-ordinator. 6.5 The CPA Care Co-ordinator will have the appropriate skills and experience and be the person best placed to oversee CPA Care Planning and resource allocation. 6.6 The CPA Care Co-ordinator can be of any discipline depending on capability and capacity 8. Generally the following will not usually be identified into the role: Support Treatment and Recovery (STR) Workers G.P.s Unqualified/unregistered health or social care workers 6.7 Following the assessment outcome where the Service User is placed on CPA, a CPA Care Co-ordinator must be agreed and assigned immediately 6.8 Service Users assessed to have the greatest level of need should be assigned a CPA Care Co-ordinator with the most skill and experience. 6.9 A choice of CPA Care Co-ordinator gender should be offered to Service Users with particular attention to those who are known to have encountered sexual abuse or violence Change in Care Co-ordinator will be by agreement of the care team and will follow a CPA Review and full handover of care between the 2 Care Coordinators or the Care Co-ordinator and lead professional or vice versa. (see also 7.7 and 7.11)) 6 Effective Care Co-ordination: Modernising the Care Programme Approach Oct Refocusing the Care Programme Approach: DoH March 2008 page 16 8 Refocusing the Care Programme Approach: DoH March 2008 page 36 17

18 6.11 Practitioners working as CPA Care Co-ordinators will act within their own professional code of conduct and within LPT operational requirements and will hold professional accountability for their actions Medical accountability does not rest with the Service User s Care Coordinator, unless the role is assigned to the Consultant Where the Responsible Clinician is working in the role of CPA Care Coordinator for a Service User assessed to require the support of CPA, the formal CPA process must be followed consistent with that of other disciplines Any dispute relating to the allocation of a CPA Care Co-ordinator, must be raised with the appropriate management as a matter of urgency Pro-active planning to cover annual leave periods: Care Co-ordinators must arrange for crisis and contingency plans to be amended to include details of the person to be contacted by the Service User if their mental health deteriorates. Key standard statement: The CPA Care Co-ordinator is a competent, trained, experienced mental health worker. That person is responsible for co-ordinating, the assessment, planning, implementation, monitoring and review of the CPA care plan for the Service User whether in hospital or community, and ensuring that all records, including MaRACIS are maintained and updated accordingly. Key standard statement: Service Users not considered to require referral on to CMHTs for longer term care, but who have been engaged with CRHT for and likely beyond six weeks, will require the support of the formal CPA process and an identified CPA Care Co-ordinator from within the CRHT. 18

19 7. Service Interface 7.1 Admission to in-patient services is a change in the location of the delivery of care and is not to be interpreted as the end of one episode of care and the beginning of another. CPA Assessments should follow the Service User from Community and vice versa. 7.2 The CPA Care Co-ordinator retains responsibility for maintaining contact with the Service User and Carer (where applicable),and throughout the admission stay in order to update the care network. 7.3 In-patient staff have an important role to play during the period of crisis which has necessitated a hospital stay. The Service User s CPA pathway should be a collaborative process with all parties working together. 7.4 Service Specific requirements in Learning Disabilities Services, Specialist Services, CAMHS or Mental Health Services for Older Persons may determine alternative interface arrangements. Where this is the case, the importance of working closely and effectively with in-patient staff remains paramount. (see Appendix 8) 7.5 In-patient services should inform and involve the appropriate CPA Care Coordinator for a Service User intending to take leave, planned or unplanned. Specific arrangements to involve the CRHT may be included in the leave plan. 7.6 The support of formal CPA will not discontinue because a Service User is discharged from inpatient services. Any such decision will be as an outcome from the pre-discharge CPA Review Process (See also 8.2) and this will be recorded in writing. 7.7 Service Users on CPA, discharged from in-patient services, must receive follow- up care within 7 days of the discharge date 9. Ideally, this should be face to face contact. The Care Coordinator is responsible to ensure this takes place, but does not have to be the person carrying out the contact. 7.8 Discharge plans for all in-patients who have a severe mental illness (Appendix 3) or history of self harm are to include specific follow-up arrangements for the first week after discharge with more intensive follow up provision for at least the first three months 10 and planning for this will be the responsibility of the Care Co-ordinator. 7.9 Each change in the following must be recorded on MaRACIS: o CPA Care Co-ordinator/Lead Professional o CPA determination o Transfer between wards o Transfer to another RMO/Responsible Clinician o Leave time and date of leaving ward and time and date of return 9 Safety First: National Confidential Inquiry into Suicide and Homicide by People with mental illness: DoH Care Programme Approach; Care Co-ordination, core functions and competencies DOH 2008 page 32 19

20 o Discharge 7.10 Care Coordination will continue temporarily within CRHT, during facilitation of early discharge and follow-up for a Service User requiring CPA and who is awaiting allocation of, and a transfer to, an identified CPA Care Coordinator from the locality CMHT Where a CRHT member is facilitating early discharge and post discharge follow-up for a Service User not likely to remain on CPA in the foreseeable future, the role of Care Co-ordinator will be with the CRHT until a CPA review agrees discharge from CPA or transfer to a Care Co-ordinator within the CMHT. (see also 6.10) 7.12 Managers and CPA Care Co-ordinators must be aware of any staff changes that may affect continuity of care delivery, The Service User must not be left without a contact in the event of transfer from inpatient to care in the community Where a Service User moves in or out of area there needs to be a CPA Review for communication between the current care team and the future care team regarding who would be most appropriate, best placed person to undertake the care co-ordinating role. Key standard statement: Upon admission, the recorded CPA Assessment information should follow the Service User and be updated accordingly. At the point of discharge from in-patient services, all Service Users will have either the written discharge plan detailing immediate follow up care together with a crisis and contingency plan and discharge medication or a copy of the updated e-cpa Care Plan. Discharge plans are not a substitute for the CPA Care Plan. However, where the e-cpa Care Plan cannot be updated at the point of discharge, the discharge plan must include details for post discharge period. This and any other information contained within the discharge plan must be sent to inform the CMHT and the e-cpa Care Plan amended accordingly. The Service User (and carer where appropriate) should be informed of any changes to the CPA Care Plan and a copy of the updated e-cpa Care Plan must be given to the Service User as soon as is practical to do so. The relevant GP should be informed of the discharge and a copy of either plan faxed to the surgery at the point of discharge. 20

21 8. Discharge from the CPA process If CPA is to end, it should be a decision, not a withering away which requires a CPA review in order that all potential players can express a view on the matter Refer to LPT Discharge Policy and also the LPT Section 117 Policy 8.2 Discharge from the formal CPA process within LPT, will be a decision taken within a CPA Review. The Service User s treatment and recovery will have progressed sufficiently and risk level reduced significantly in order to require future care to be managed by a lead professional. The Service User and the team will have agreed that self management of care, self direction and organisation is appropriate. 8.3 Discharge from CPA may occur if the Service User requests this and refuses to have any further care under the formal process, provided that all reasonable attempts have been made to explore alternative strategies for maintaining engagement.(agreement may be reached to continue to receive care from a lead professional.) A risk management plan must be formulated and agreed following a CPA review. 8.4 The intention to and reasons for discharge must be discussed with the Service User and Carer (if appropriate) and recorded in writing. 8.5 Service Users and Carer(s) as appropriate, must be given information of how to contact services at a future date if circumstances change. 8.6 Within LPT, discharge from formal CPA will occur if: a Service User re-locates or transfers to another Trust. Prior to this, a CPA Review must be held in order for LPT to handover their CPA responsibilities Or If the Service User has died. 11 Independent Inquiry into the Care and Treatment of MN. Avon, Gloucestershire and Wiltshire Strategic Health Authority, June Is also used in Leicestershire Partnership CPA Level 3 Training programme. 21

22 9. Information Sharing 9.1 Further detailed guidance can be referenced in national and local documents Information sharing should be undertaken with the agreement of the Service User. 9.3 Where consent has been withdrawn, a Service User s decision can be overridden when there is a concern or a risk of serious harm to either the Service User or any other person. Where this is the case, an explanation must be offered to the Service User. 9.4 Information may be shared in respect of police investigations (if appropriate and dependant upon awareness of the responsible clinician or line management). 9.5 Where a Service User is a Carer for either a child or another vulnerable adult, the safety of those persons is vital. To this end, staff on a ward or any member of the care team network may share information with the person nominated to act as a temporary carer or advocate. This should be on a need to know basis and the information will likely be shared during discharge planning stages and refer to leave arrangements and any associated risks and progress reports. Key standard statement: Information sharing should take into account LPT s responsibility in relation to Safeguarding Adults. Consideration should be given to referring people who may be victims of abuse within the multi-agency procedures. Key standard statement: Shared information systems will provide data relevant to people and agencies in accordance with public protection and data protection systems. Robust CPA requires that protocols be agreed for the sharing of information with the police, probation service, local prison (if appropriate) and court liaison, independent/voluntary sector agencies involved in the care provision. 12 Code of Conduct Date Protection and Confidentiality of Patient and Personal Information. Leicestershire Partnership NHS Trust (2004) Confidentiality: NHS Code of Practice, Department of Health (2003) Information sharing protocol, Leicestershire County Council (2006) Local Safeguarding Board Procedures Information sharing, Local Safeguarding Children Board, Leicester, Leicestershire & Rutland. The NMC Code of Professional conduct: standards for conduct, performance and ethics, Nursing and Midwifery Council (2004) 22

23 10. Audit and Monitoring 10.1 LPT must have an appropriate central record of all Service Users receiving treatment, care and the support being provided.this record will provide reports to managers and staff concerning caseload and other relevant information Compliance with this policy will be monitored through a dedicated assessment and care planning audit which will take place on no less than a quarterly basis and will be included within LPT audit calendar. This audit will be undertaken in conjunction with LPT Clinical Audit Department. Additional audits may be commissioned by Business Unit Service Line Assurance Monitoring groups, Service User groups or the CPA Leads. This should include audits to provide evidence of standards of care being given to Service Users not on CPA CPA related audits will be reported to the Clinical Effectiveness Standards Group.This Group will seek assurance from Service Directors and General Managers (via the CPA Practice Groups & CPA Standards Group) that any necessary remedial action is taken following the audit and that clinical staff are complying with the CPA Policy. Any issue raised as non-compliance will result in the formulation of an Action Plan which will be monitored by the CPA Standards Group. Action plans will include recommendations for addressing issues raised, review dates and responsibility as well as identifying any plans for re-audit The CPA Standards Group (or CPA Practice Groups, where appropriate) will support the design of appropriate audit tools. Audits will be performance managed by the CPA Standards Group (via the CPA Practice Groups) LPT will encourage qualitative audits to be led by Service User groups as well as by clinicians Services must support clinicians to undertake data collection and receive findings, whether Trust-wide or Service specific 10.7 In addition to the audits referred to above, managers are expected to monitor electronic MaRACIS data relating to CPA within their teams, by the use of SORD (Secure Online Reporting Data) reports. This information should be shared within supervision with care coordinators and also be used as part of caseload management. 23

24 11. Gaps in Service 11.1 Where a deficiency in service delivery is identified which potentially could affect an outcome as identified within a Service User s care plan, a Gaps in service form should be completed and the process contained within it followed: 11.2 This must be brought to the attention of the appropriate line manager, who will take the necessary action practically and reasonably possible to bridge the deficit The Chief Operating Officer is to be alerted to any such deficits by use of the Gaps in Service form. 24

25 12. CPA Training 12.1 CPA Training within LPT will be provided at 2 levels. Level 1: CPA Awareness Training will form part of mandatory clinical training and cover a very basic overview of CPA. Level 2:Aims to provide detailed information regarding the process and application of CPA within each of the Services and will include reference to the Care Co-ordinator competencies (Appendix 6). Level 2 is ongoing training and must be given to: Newly qualified staff. New member joining a team from another service within LPT New member joining a team from another area outside LPT. Refreshed every 3 years 12.2 The Chairperson of each Business Unit s CPA Practice Group has delegated responsibility to identify and thereafter support CPA Champions to enable them to deliver the CPA Training presentation to the members of that team CPA Champions will be further supported by LPT CPA Lead who is responsible for updating the CPA training and Policy information as/when national or local amendments to the CPA process occur Training Records must be completed and forwarded to Alfred Hill (the Academy) for inclusion in central database. 25

26 13. Governance of CPA within LPT 13.1 Duties and Responsibilities Chief Executive General Managers Service Managers Team Managers Clinical Staff Overall responsibility for adherence to legislation and policy, ensuring that all services have procedures for the assessment, planning and reviewing of Service User care in line with latest Department of Health guidance. Have delegated responsibility to ensure that processes and procedures are understood and embedded in practice by those involved in the assessing, planning and reviewing of care delivery to Service Users. Responsibility to facilitate CPA Training to provide staff with the requisite knowledge of the subject. By ensuring best practice in CPA delivery, risks to Service Users, staff and public are minimised. Responsible for adhering to the CPA Policy when assessing, planning and reviewing care for those individuals accepted into secondary mental health services. To attend mandatory CPA Training in line with Trust Policy 13.2 LPT CPA Standard Group will be the supervisory group to set and agree the standards of CPA practice throughout LPT. This group will be co-chaired by an operational and a clinical director Each Business Unit in LPT will have a CPA Practice Group and the chair will represent their area on the Standard Group CPA reporting to the Senior Clinical Group will be via the Clinical Effectiveness Standards Group. CPA Policy Final Draft (14) December

27 APPENDIX 1 Current laws & government underpinning the NHS equality agenda. Sex Discrimination Acts 1975 & 1986 These Acts (which applies to women and men of any age, including children) prohibit sex discrimination against individuals in the areas of employment; education; in the provision of goods, facilities & services; and in the disposal or management of premises. Race Relations Act 1976 This Act makes it unlawful to treat a person less favourably than another on racial grounds. These cover grounds of race, colour, nationality (including citizenship) and national or ethnic origin. Race Relations (Amendment) Act 2000 This Act outlawed discrimination (direct and indirect) and victimisation in all public authority functions not previously covered by the Race Relations Act 1976, with only limited exceptions. It also placed a general duty on specified public authorities to promote race equality and good race relations. Disability Discrimination Act 1995 This Act prohibits discrimination against disabled people in the areas of employment; the provision of goods, facilities, services and premises; and education. Disability Discrimination Act 2005 This Act makes substantial amendments to the Disability Discrimination Act It places a general duty on public authorities to promote disability equality and to have due regard to eliminate unlawful discrimination. Human Rights Act 1998 This Act came fully into force on 2 October It gives further effect in the UK to rights contained in the European Convention of Human Rights. The Act: makes it unlawful for a public authority to breach Convention rights, unless an Act of Parliament meant it could not have acted differently means that cases can be dealt with in a UK court or tribunal says that all UK legislation must be given a meaning that fits with the Convention rights, if that is possible. Civil Partnership Act 2004 This Act creates a new legal relationship of civil partnership, which can be formed by two people of the same gender, by their signing a registration document. It also provides same-sex couples that form a civil partnership with parity of treatment in a wide range of legal matters with those opposite-sex couples who enter into a civil marriage. CPA Policy Final Draft (14) December

28 Gender Recognition Act 2004 The purpose of this Act is to provide transsexual people with legal recognition in their acquired gender. In practical terms, legal recognition will have the effect that, for example, a male-to-female transsexual person will be legally recognised as a woman in English law. The Equality Act 2006 This Act Establishes single Commission for Equality and Human Rights (CEHR) Outlaws discrimination on the basis of religion and belief Makes regulations possible for outlawing discrimination on basis of sexual orientation (now done under the Equality Act (Sexual Orientation) Regulations 2007) Introduces positive duty for gender (including transgender in relation to employment and vocational training) Other relevant legislation includes; The Employment Equality (Age) Regulations 2006 The Employment Equality (Sexual Orientation) Regulations 2003 The Employment Equality (Religion or Belief) Regulations 2003 Mental Capacity Act 2005 The principles of the MCA 2005 apply to everyone open to our Service: 1. A person must be assumed to have capacity unless it is established they lack capacity 2. A person is not to be treated as unable to make a decision unless all practicable steps to help him do so have been taken without success 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision 4. An act done, or decision made, under this act for or on behalf of a person who lacks capacity must be done, or made in his best interests 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be effectively achieved in a way that is less restrictive of the persons rights and freedom of action Useful Website Addresses Mental Capacity Act Update For updates on the Mental Capacity Act, Code of Practice, related documents, information booklets and leaflets etc go to: CPA Policy Final Draft (14) December