Care Programme Approach

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1 Care Programme Approach Who Should Read This Policy Target Audience All Clinical Staff Care Coordinator Version 1.1 May 2017

2 Ref. Contents Page 1.0 Introduction Purpose Objectives Process Values Eligibility Criteria Care-Coordination Assessments including Risk Assessment Assessment Process Care Programme Approach (CPA) Reviews Care Programme Approach Review Report Transfer of Care Admission into Hospital Discharge Planning from Hospital including 7 Day Follow Up Integrated CPA and Care Management Including Maintaining Contact with Out of Borough Placements Procedures connected to this Policy Links to Relevant Legislation Links to Relevant National Standards Links to other Key Policies References Roles and Responsibilities for this Policy Training Equality Impact Assessment Data Protection and Freedom of Information Monitoring this Policy is Working in Practice 21 Appendices 1.0 Single Assessment Process (SAP) 2.0 Common Assessment Tool (CAT) 3.0 TAG Risk Assessment Tool 4.0 Sainsbury s Risk Assessment Tool Version 1.1 May

3 Explanation of terms used in this policy Assessment - A thorough holistic assessment of Health and Social Care needs which will involve the services user and carer, where appropriate, as central participants in the process. It may also involve the process of gathering information from reviewing case records, assessments and reports from medics and other professionals, services and agencies as required Care Coordinator - Involves deliberately organising patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient. Care Plan - The care plan is a record of needs, actions and responsibilities written in a way that is understandable to all relevant parties. It should detail: Interventions and actions required to achieve the agreed goals Identify who is responsible for specific actions Timescales Crisis and Contingency Plan Date of next planned review Crisis Plan - This forms part of the care plan and should set out any actions that should be taken in a crisis. It should identify: Who the patient is most responsive to How to contact that person Any previous strategy that has been successful Any early warning signs and relapse indicators Relevant contact numbers including out of hours services Other support available to prevent hospitalisation Practical needs if the patient is admitted to hospital including care of dependants, childcare or pets Contingency Plan - The contingency plan aims to prevent or reduce the likelihood of a crisis developing by detailing the actions to be taken at short notice, either where the Care Coordinator is not available or if circumstances prevent the care plan from being provided in part or whole Risk Assessment - This is an assessment of negative events of harm to self or others, including selfneglect, violence or exploitation. The risk assessment should consider and record: The likelihood of the event occurring When and where the event may occur History and indicator of past events Changes which may increase the risk The impact and severity of the outcome Whether there are any Safeguarding concerns Risk Management - This is the development of flexible strategies to prevent a negative outcome or to minimise potential harm from being caused. The risk management plan should: Aim to prevent or minimise the risks, where possible Build on the patients strengths Emphasise a recovery approach Be developed in collaboration with the patient and carer, where appropriate and other relevant professionals, services and agencies involved in the user s care Enables all relevant parties involved to communicate concerns and agreement with plan Review - Reviews are planned within an agreed timescale although unplanned reviews can be called at any time, by any parties involved in the user s care, including the patient or carer. The review will identify the users progress against the current care plan, explore barriers that prevent the users achieving their recovery goal(s) and: Version 1.1 May

4 Is arranged and held at a time and place accessible to all parties Ensures the users views are shared in the meeting Revisits the risk, crisis, care and contingency plans Ensures the goals and interventions identified are either still appropriate or achieved Identifies any new and emerging needs Revise and develop the new care plan with the patient and carer, where appropriate Identify any unmet needs and ensure these are communicated as appropriate Ensure the review is documented including attendance; feedback from absent parties, key information shared and agreed actions Ensures the care cluster is reviewed within given time frames for existing patients Plan the next review date Version 1.1 May

5 1.0 Introduction This document sets out Care Programme Approach (CPA) policy for Black Country Partnership NHS Foundation Trust. The Trust is committed to the principles that patients should have access to high quality mental health services and CPA process puts the patient at the centre of all care provision safeguarding the patient and their carers and families. Where there is a carer involved, they are a vital source of support for the patient and may be key in helping to manage any risks identified. The Care Program Approach (CPA) is an overarching system for coordinating the care of people with mental disorders. The CPA requires identification of a named care coordinator, the approach used is to assess, plan, co-ordinate, monitor and review a range of interventions including treatment, care and support needs for people in contact with mental health services, who have complex health and social care needs. CPA policy will be used as a working guide to the delivery of care and support to patients and requires their active involvement and engagement. This principle will continue to be at the heart of the approach, focussing on reducing distress and stigma and promoting social inclusion and recovery. CPA provides a framework of care for adults of working age but the principles should be applied to any individual receiving services regardless of age. 2.0 Purpose The purpose of this policy is to set out a clear CPA framework. This is intended to create an environment in which recovery is enabled. Involvement is fundamental to everyday practice and the approach to care is one which maximises the safety and well-being of all as a priority. It is the foundation for excellent service provision and high quality patient experience provided through a multi-disciplinary and inter-agency approach. CPA is an overarching system for coordinating the care of people with mental disorders. It requires close engagement with patients and their carers and includes arrangements for assessing, planning and reviewing care. Central to CPA is the CPA care plan which aims to ensure a transparent, accountable and coordinated approach to meeting wide ranging physical, psychological, emotional and social needs which are associated with a person s mental disorder. Included with the CPA care plan are: A Treatment Plan which details medical, nursing, psychological and other therapeutic support for the purpose of meeting individual needs promoting recovery and/or preventing deterioration. Details regarding any prescribed medication Details regarding any actions to address physical health problems or reduce the likelihood of health inequalities. Details of how the person will be supported to achieve their personal goals. Support provided in relation to social needs such as housing, occupation, finances etc. Support provided to carers. Actions to be taken in the event of a deterioration of a person s presentation, and Version 1.1 May

6 Guidance on actions to be taken in the event of a crisis. CPA policy has been developed for use by all Trust services where it applies. The expectation is that the guiding principles within CPA policy may be used wholly or in part as relevant to the requirements of each service. Where the eligibility criteria set out in 4.2 Eligibility Criteria is met due to the complexity of needs, then the patient will be subject to CPA and the agreed processes applied. Where the service does not work with this level of complexity, the patient will be considered as being Non CPA. However, the guiding principles of developing a person centred care plan, monitoring and planned reviews should be applied to this patient group as good practice. 3.0 Objectives The key objectives of the CPA policy are: To promote a person centred approach that enhances the patient s experience of service delivery, recognising that they are best placed to understand their own needs. This will be based on ensuring the patient s active involvement and informed choice to enable their decision making, empowerment and recovery To provide clarity of professional roles and responsibility under the CPA framework with the aim to achieve consistency To provide clear CPA processes to support clinicians assessments, care planning, reviews To ensure the patients CPA care pathway is clear from admission into services, to transfer and discharge from services To provide the Trust with usable CPA performance data to understand and interpret the quality and quantity of care provided to patients To ensure the HoNOS and Mental Health Care Cluster Tool enable users to be allocated a care cluster which is part of the assessment process, supports care planning and Payment by Results (PbR). It is therefore essential that clinicians have a clear understanding of the system, their role and responsibility within the process and the importance given to it by the Trust 4.0 Process 4.1 Values The Trust recognises that patients have the same rights and responsibilities as other people. It recognises and appreciates patients individuality and ensures they are treated with dignity and respect. Services will be organised and delivered in ways that promote people s health, recovery, well-being and social integration, thus reducing stigma and social isolation. Transparency in the therapeutic relationship and partnerships are recognised as key to achieving successful outcomes. The patient will be central to a holistic assessment and care planning which supports them to meet their needs, with the aim of optimising their mental and physical health and well-being. Version 1.1 May

7 The patients independence and self-determination is encouraged to help them maintain control over their own support and care based on informed and realistic choices. Recognition of the patients diversity in planning care is crucial to their recovery and towards reducing inequality The role of carers is vital to support the patients recovery and their needs should be recognised and supported in their own right. Patients will be enabled to access the most appropriate services to meet their needs The patient should have the opportunity to be integrated, as far as possible, within their local community. 4.2 Eligibility Criteria CPA will be undertaken for all patients who have been assessed as having complex mental health care needs and deemed as high risk of suffering deterioration in their mental condition and need multi agency support, active engagement, intense intervention and or support with dual diagnosis and accepted for intervention and/ or treatment by specialist services within the Trust. Those patients over 65 years of age at the point of referral will be assessed in line with the local Single Assessment Process (SAP) (Appendix 1). However, CPA principles and documentation can be used to support the service delivery of more complex cases within Older Adults (OA) services. Transfer of care should occur when the needs of the person is better met by professionals working in OA and not because they have reached 65 years old. The list below provides guidance to highlight key areas of complex needs and the requirement of CPA: Severe mental health needs with a degree of clinical complexities including Personality Disorder Mental health needs having a significant impact on activity of daily living and social activity that require multiple service provision from different agencies including: housing, physical health care, employment, criminal justice, voluntary agencies Current or potential risk(s), including: - Suicide, self-harm, harm to others (including history of offending) - Relapse history requiring urgent response - Self-neglect - Non concordance with treatment plan - Vulnerable adult: adult/ child protection e.g. financial or sexual exploitation, physical or emotional abuse, self-neglect, financial difficulties related to mental health, cognitive impairment, or disinhibition - Current or significant history of severe distress/ instability or disengagement with services - Presence of non-physical co-morbidity e.g. substance/ alcohol/ prescription drugs misuse/ Learning Disability - Currently or recently detained under Mental Health Act (MHA) this would include most people who are entitled to aftercare under section 117 of the act Version 1.1 May

8 as well as all guardianship patients and everyone subject to a Community Treatment Order (CTO) because of the specific statutory obligation or referred to Crisis/ Home Treatment Team. - Significant reliance on carer(s) or has own significant caring role and responsibilities CPA will also be considered where complexities include experiencing disadvantage or difficulty as a result of: - Parenting responsibilities - Physical health problems/ disability - Unsettled accommodation/ housing issues - Employment issues when mentally ill - Significant impairment of function due to mental illness - Protected Characteristics e.g. ethnicity, immigration status; race/ cultural issues; language difficulties; religious practices; sexuality or gender issues The default position for users meeting the eligibility criteria will be through CPA unless a thorough assessment of need and risk shows otherwise and is supported by a decision by the Responsible Clinician. The decision and reasons not to include individuals from these groups should be clearly documented in all care records. 4.3 Care-Coordination CPA has two levels to distinguish the difference between the complexities of patients needs CPA and Non CPA. Patients on CPA will meet the eligibility criteria set out in 4.2 Eligibility Criteria. Users that do not meet the criteria will be considered as Non CPA. The quality of the service, interventions and support provided to the patient is not compromised by being on either level of CPA; but recognises that those on CPA are on a formal process, having met the eligibility criteria. The expectation of the CPA policy is that all users open to services can expect to receive care under the key CPA principles of being allocated a Care Coordinator, having a person centred care plan, being monitored and reviewed in a timely manner. The same CPA documentation can be used irrespective of the patients CPA status providing standardisation and reducing the need for separate paperwork. The revised documents will indicate whether the patient is on CPA or Non CPA. 4.4 Assessments including Risk Assessment The assessment and planning process should aim to identify and meet the patient s needs and choices. It should not focus purely on what professionals and services can offer. The assessment should address the person s aspirations and strengths, as well as their needs and difficulties. Information will be included in the record of review and care plan regarding any unmet needs. Where there is a carer involved, they are a vital source of support for the patient and may also be a key person in helping to manage the risks identified. Practitioners should be sensitive to the relationship between the patient and the carer, as there may be risks within this relationship and different points of view about the best actions to be taken. If the carer is at risk, they should be seen individually so that the risks can be explored and actions can be agreed. The carer should receive enough information in a comprehensible format to enable them to provide the necessary care. Any concerns raised by the carer should always be taken seriously, even if the Version 1.1 May

9 care team is less concerned. The carer should be offered an assessment and should be helped to develop a plan for meeting their specific needs. The assessment will be completed using the Common Assessment Tool (CAT) (Appendix 2), which will be used as a framework for the assessment process and also used to record the information gathered. Risk assessment is an integral part of screening referrals, assessment and the care planning processes. Patients will have risk assessment undertaken as part of their assessment and review of their care needs. The Trust uses the TAG Risk Assessment Tool (Appendix 3) for initial risk assessments, CPA reviews and transfers between services. The adapted Sainsbury s Mental Health Centre risk assessment tool, known as Sainsbury s Risk Assessment Tool (Appendix 4) is used where more complex risk is a feature. Clear recording of assessment information and subsequent risk management plans are essential. It relies on high quality history taking, sharing of relevant information between services and tracking past clinical and forensic information, if relevant, to inform areas of risk. A thorough risk assessment, with full patient and carer involvement, should be undertaken before a decision is made that the support of CPA is not required. Additional support of CPA should not be withdrawn without: Appropriate review Exchange of information including with carers Plans for review, support and follow up Clear statement about who and what to do in the event of relapse or change If there are any language barriers for either the patient or their carer translation and interpretation services can be used. Please see Interpretation and Translation Policy for further information. 4.5 Assessment Process Once the referral is received, an assessment will be arranged within specified time frames. The person undertaking the assessment will contact the patient by telephone or letter within the specified time frame to arrange a mutually convenient time and place to complete the assessment. Information will be provided to the patient of the purpose and aim of the assessment and this will be reinforced at the assessment. The Common Assessment Tool (CAT) and TAG Risk Assessment Tool will be used to guide the assessment process and record the information. The assessment process must: Be explained to the patient Be systematic, holistic and thorough Identify any current or potential risks to self or others Provide a unified Health and Social Care assessment Consider the needs of children living with or visiting the patient Record whether there is an Advanced Decision or Advanced Statement Version 1.1 May

10 The assessment will be fedback at the MDT clinical meeting and a decision made to allocate or not, based on any identified need. If allocation is agreed, the CPA status will be identified based on the needs assessment. This will also reflect the appropriate professional/ discipline that should be allocated based on needs, level of skill and expertise required. The assessment will be inputted onto OASIS within the given time frame and a HoNOS Care Cluster allocated. The outcome of the assessment should be communicated to the individual and the referrer, if appropriate, in a way that is understandable and free from jargon. If the outcome is not to allocate, the user will be signposted to an appropriate service or discharged to the care of their GP. The assessment will be stored as a paper copy with information, the OASIS system and the care cluster details updated. The Mental Health and Learning Disability Minimum Data Set (MHLDMDS) expect HoNOS care cluster codes to be recorded within the CPA documentation and will be completed by all clinical staff. MHLDMDS facilitates the collection of person focused clinical data and the sharing of such data underpins the delivery of mental health care 4.6 Care Programme Approach (CPA) Reviews A review will be arranged and chaired, by the Care Coordinator in collaboration with the patient, to determine any progress made and agreed care plan outcomes achieved. For patients on CPA, this meeting will take place within 12 months minimum but more frequent reviews can be planned, depending on the patients changing needs and circumstances. The Care Coordinator will provide information on the CPA review process to the patient prior to the meeting to alleviate any anxieties, increase their understanding of the benefits of their full engagement and encourage the patient to participate and express their views. It is recognised that full attendance at CPA reviews by relevant representatives is best practice. Where key members are unable to attend the planned review, written or verbal information can be requested by the Care Coordinator in advance of the review and shared at the meeting. The Care Coordinator will ensure any identified actions are followed up by the relevant individual or agencies involved. The reviews will: Be arranged at a time and place accessible to the user Be a safe environment for all parties Include carer and significant others, as requested by and relevant to the user Include all relevant agencies and/ or multidisciplinary staff involved in the users care, taking into account all views and feedback shared Version 1.1 May

11 Ensure the patient is central to the review, communication is clear and jargonfree, uses an interpreter if required Ensures the patients views are heard, acknowledged and recorded Ensures there is collaboration with the patient throughout the process Ensure the patients are offered choice where possible Review the current care plan and develop a new care plan in relation to needs and goals identified Identify where needs have been met/ recovery goals achieved Identify new and emerging needs including potential risks Identify any unmet needs and consider alternative options that may support the patient; communicate this deficit through relevant structure, as required Acknowledge and record concerns or differing views raised by any party involved in the users care Acknowledge and record achievements and progress Acknowledge any good practices shared Ensure all parties are clear about their role and responsibilities within the agreed care plan Share relevant information on a need to know basis while being mindful of confidentiality. Relevant risk to self or others should be shared as good practice Consider whether the patient has or is in contact with children and if there are any potential or actual safeguarding concerns Ensure the patient is given information on new treatment, interventions or services available and/ or recommended, in a language or format they understand or prefer Consider the carers needs and ensure an independent assessment is accessed and offered by the Carers Team Consider if patient is to remain on CPA Consider if discharge from service is appropriate Ensure patient and carers receive eligible entitlement and services, regardless of CPA status Arrange a date for the next CPA review meeting Be recorded on CPA documentation, in clinical records and electronic systems within agreed time frames This collaborative model of working is designed to ensure that patients and their carers receive the best possible service. 4.7 Care Programme Approach Review Report The Trust Quarterly CPA Review report will be monitored by the relevant Service Managers and informs Team Leaders and staff of reviews due during a given period. Care Coordinators will be aware of changes with patients that require an unplanned review to take place earlier than scheduled. During the CPA Quarterly Review process, the progress of achievement is monitored closely to avoid any shortfalls with the performance target. Inaccuracies within the report are also highlighted and communicated to ensure the correct performance data is captured. The completed CPA reviews are submitted onto the electronic system by relevant services which provide data for the Performance Team. The quarterly figures are reported to the Group Management Board Meeting who monitor the target progress. Version 1.1 May

12 Any key aspects of learning within the services will be shared by this group as required. 4.8 Transfer of Care A CPA review should be arranged prior to a planned discharge or transfer between teams and services, both internal and external to the Trust. Key review points are to be considered as highlighted in 4.6 Care Programme Approach (CPA) Reviews. Where transfers across teams or services are agreed, the Care Coordinator is responsible for initiating and coordinating the transfer arrangements. Responsible Clinicians responsibility in the transfer arrangements should be made clear to the Care Coordinator. A representative from the receiving team/ service should be invited to attend and participate in the CPA review. The review will identify the new team/ service and if known, the identified Care Coordinator the user will be working with. The patient and carer if appropriate should be provided with information on the new team/ service/ Care Coordinator prior to transfer and this should be reflected in the review notes and documented in the user s notes. A handover period should be agreed in collaboration with the patient which includes introduction of a new Care Coordinator and significant others as good practice. The handover period should be over a 3 month period though this can be increased or reduced to meet individual need; depending on the patients transfer destination/ referral point, risks present or other complexities of the case. A new care, crisis and contingency plan should be developed which reflects the new team/ services contacts and local resources available, where known, to support and meet the users needs. Relevant documents should be made available to the receiving team where known, including transfers into Trust Services from out of area placements such as: Referral form or referral letter for out of area Assessment and risk assessments CPA review CPA care plan Crisis and contingency plans Other significant reports and documents as specific to patients care The transfer period can increase the patients vulnerability and the care plan, crisis and contingency plans must therefore be robust to reduce any risk to their presentation and well-being. 4.9 Admission into Hospital During an episode of in-patient care, the responsibility for the users treatment programme will be the in-patient key-worker and Responsible Clinician. Version 1.1 May

13 The Responsible Clinician/ Admitting Doctor will inform the patient and carer if appropriate, of the purpose of the admission. All patients will be on CPA for the duration of their admission to hospital or while under the care of the Crisis Home Treatment Team. The patient will be discharged to the community team on CPA which will be reviewed after the 7 Day Follow Up process is completed or remain in place if the user continues to meet the eligibility criteria as described in 4.2 Eligibility Criteria. All users will have an initial care plan and risk management plan formulated within 72 of hours of their admission to hospital The Care Coordinator will remain involved and continue to be responsible for maintaining regular contact with the user. They will attend ward reviews to monitor progress and contribute to discharge planning arrangements. All hospital contacts will be recorded in the user s records and the electronic system. The following documentation will be made available to ward staff by the Care Coordinator: Up to date CAT assessment and/ or most recent CPA review Current risk assessment Current care plan Where the user is not previously known to services, the ward staff will complete a referral to the relevant community team in a timely manner, if this is required. The current needs and risks will be identified to support an assessment and potential allocation to a Care Coordinator. An early referral to the community teams will support the engagement process with the patient to facilitate their assessment of need and support their discharge plan whilst they are still under acute care or with the CHTT. The assessment should therefore be conducted jointly with representatives from the acute areas or from CHTT as best practice and documented within the case notes. The outcomes of the assessment should identify achievable goals which in turn will identify the most suitable practitioner to take on Care Coordinator responsibility. Due to their potential vulnerability from an admission to hospital or involvement with the CHTT, priority should be given to allocate this user group where possible. However, the MDT clinical judgement to allocate a Care Coordinator for any patient will also need to take into consideration any presenting risks to self or others and this will be the ultimate deciding factor to support the allocation process. A risk assessment of the safety of family/carers must be conducted Discharge Planning from Hospital including 7 Day Follow Up All discharges from hospital should be planned in advance with the multidisciplinary team and significant others, including the Care Coordinator. Significant others also include family/ carers who should be spoken to in private. Prior to discharge, the patient should have an opportunity to have home leave, as appropriate, to re-establish their ability to cope and resume responsibilities within Version 1.1 May

14 their home environment. The Care Coordinator should make efforts to visit the user at home, where possible, to monitor this process. Patients should be given information on the 7 Day Follow Up procedure prior to being discharged from hospital and their expectation to engage in this activity clearly explained. When the patient is discharged from hospital, a face-to-face follow up contact must be made within seven days of their discharge by the Care Coordinator, or a worker nominated by the Team Leader in their absence, to carry out this procedure. Face to face contact must be attempted but where this is made and fails, the patient may be contacted by telephone. Telephone contact may also be used where the user has been discharged out of area. Where patients are not open or known to a community team, the 7 Day Follow Up will be completed by the ward staff. This can be by invitation to attend the ward to complete a face to face contact or via telephone Where the patient is discharged to the care of the Home Treatment Team, they will be responsible for completing the seven day follow up. As post discharge is potentially a vulnerable time for patients, the 7 Day Follow Up contact should establish that: The patient does not hold any thoughts of harm to self or others. Where these may be evident, appropriate action to be taken and recorded to ensure the risks are minimised They understand and are concordant with their medication regime, as appropriate They have a copy of their care plan (including a crisis and contingency plan if currently known to a Care Coordinator) If living alone, they have contact with a carer or significant other, as appropriate There is heating / lighting/ water in their home (and systems have not been disconnected prior to or since admission) There are adequate food/ groceries in their home or they have funds and the ability to purchase essential items if required Where there may be concerns regarding any of the above, the Care Coordinator is responsible for regular monitoring, clear communication and coordination of appropriate resources to resolve the concerns. The default position for users that are not felt to be appropriate for referral to a community team on discharge will be the decision and responsibility of the Responsible Clinician. The decision and reasons not to refer on to a community team should be clearly documented in all hospital and electronic records. Hospital CPA status will be discontinued on discharge and the electronic system updated by hospital staff. Version 1.1 May

15 4.11 Integrated CPA and Care Management including Maintaining Contact with out of Borough Placements Care management is a system of monitoring patients in purchased care placements or those receiving a non-residential package of care. These may be within the locality or out of area. Where Care Management is practiced within team and services, it will remain the responsibility of the existing Care Coordinator/ Care Manager to continue this monitoring role within the CPA review process. Where residential or nursing home care is purchased outside of the borough for Sandwell residents, care responsibilities may be transferred to local services but the duty of care remains with Sandwell services that made the placement where Sandwell continue to fund the users placement. The Care Coordinator/ Care Manager must make every effort to attend the CPA review to: Monitor the needs of the patient as identified in the CPA Policy Ensure that the placement continues to be appropriate in meeting the users needs Be aware of time limited funded placements and work within discharge planning frameworks Consider if needs are met and/ or goals achieved; whether patient need a step down/ less intense service Negotiate reduced funding to reflect user progress Awareness that if placement is not working or meeting users needs, to seek alternative placements or packages, following discussions with Line/ Team Manager Where there are changes to the original placement or package of care, that this is brought to the attention of the Team Leader and relevant care management documentation is completed Ensure all care management reviews, monitoring and changes are recorded in line with CPA review process 5.0 Procedures connected to this Policy There are no procedures connected to this policy. 6.0 Links to Relevant Legislation Care Act 2014 Care Act 2014 sets out a clear legal framework for how local authorities and other statutory agencies should protect adults with care and support needs at risk of abuse or neglect. New duties include the Local Authority s duty to make enquiries or cause them to be made, to establish a Safeguarding Adults Board; statutory members are the local authority, Clinical Commissioning Groups and the police. Safeguarding Adults Board must arrange Safeguarding Adult Reviews (SARs) as per defined criteria, publish an annual report and strategic plan. All these initiatives are designed to ensure greater multi-agency collaboration as a means of transforming adult social care. Version 1.1 May

16 Mental Health Act 1983 The Mental Health Act 1983 (which was substantially amended in 2007) is the law in England and Wales that allows people with a mental disorder to be admitted to hospital, detained and treated without their consent either for their own health and safety, or for the protection of other people. Mental Capacity Act 2005 Mental Capacity Act 2005, covering England and Wales, provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. The Act sets out who can take decisions, in which situations, and how they should go about this. In addition - in some cases, people lack the capacity to consent to particular treatment or care that is recognised by others as being in their best interests, or which will protect them from harm. Where this care might involve depriving adults at risk of their liberty in either a hospital or a care home, extra safeguards have been introduced in law Deprivation of Liberty Safeguards, to protect their rights and ensure that the care or treatment they receive is in their best interests. Domestic Violence, Crime and Victims Act 2004 The Domestic Violence, Crime and Victims Act 2004 made significant changes to the way in which instances of domestic violence are dealt with by the courts, together with measures to improve the treatment of victims and witnesses of domestic crime. The Act made many changes to the existing legal framework, including: Breaches of a non-molestation order became a criminal offence and same-sex couples are included within definition of 'cohabitants' A new offence of causing or allowing to cause the death of a child was introduced Multi-agency domestic homicide reviews have been established following the death of a person resulting from violence or neglect by a relative or within an intimate personal relationship Common assault has become an arrestable offence The Protection from Harassment Act 1997 has been amended to enable courts to extend the availability of restraining orders on conviction or acquittal in order to protect the victims Changes to powers following a finding of insanity or unfitness to plead Measures to allow non-jury trials in the Crown Court where the instances of offending conduct are too numerous to be dealt with at a single trial Changes to intermittent custody The Home Secretary is required to issue a code of practice for victims and witnesses of crime to be followed by those who have functions relating to victims or the criminal justice system as a whole A Commissioner for Victims and Witnesses has been created Crime and Disorder Act 1998 The Crime and Disorder Act was enacted in 1998 and places a statutory duty on all local authorities together with their partnership agencies to develop and deliver a Community Safety Strategy. There are six main topics for action: Preventing young people from committing crime Combating anti-social behaviour and encouraging increased community involvement in tackling local crime and disorder Version 1.1 May

17 Tackling racially motivated crime Speeding up the criminal justice system Protecting people from sex offenders, violent offenders and drug misusers Providing consistency and clarity in sentencing 6.1 Links to Relevant National Standards Ten Essential Shared Capabilities A framework for the whole Mental Health Workforce (2007) The aim of the Essential Shared Capabilities (CPA) is to set out the shared capabilities that all staff working in mental health services should achieve as best practice as part of their pre-qualifying training. Thus the ESC should form part of the basic building blocks for all staff who work in mental health whether they are professionally qualified or not and whether they work in the NHS, the social care field or the private and voluntary sectors. The ESC are also likely to have value for all staff who work in services which have contact with people with mental health problems. CQC Regulation 9: Person-Centred Care The intention of this regulation is to make sure that people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves. Providers must make sure that they take into account people's capacity and ability to consent, and that either they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment. Providers must make sure that decisions are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate. West Midlands Domestic Violence and Abuse Standards (2015) These standards reflect the commitment of statutory organisations and specialist domestic abuse services across the West Midlands region (Birmingham, Coventry, Dudley, Sandwell, Solihull, Walsall and Wolverhampton) to address domestic violence and abuse. They provide a framework for these organisations to develop their professional practice, improve services, shape commissioning of future services and deliver the right response across all settings and sectors. These standards are intended to identify and promote evidence-based, safe and effective practice in working with adult and child victims of domestic violence and abuse, and to ensure perpetrators are held to account increasingly effectively. Version 1.1 May

18 6.2 Links to other Key Policies Safeguarding Adults at Risk Black Country Partnership Foundation Trust has a duty to safeguard adults from abuse. The Purpose of this policy is to provide guidance for staff to assist them in identifying adults at risk and recognising abuse. The Policy applies to all staff employed by the Trust including students and volunteers and will provide information regarding their duties and responsibilities in relation to responding to any concerns. Domestic Abuse Stalking and Honour Based Violence Policy (Adult Services) The purpose of this Policy is to: Provide guidance and support to all staff Raise awareness on the incidence of domestic abuse Increase knowledge and understanding about the nature of domestic abuse and its impact on those who experience domestic abuse and their dependants Comply with legal framework and current national guidance Support effective communication and multi-agency working Interpretation and Translation Policy The purpose of this policy is to provide information for staff to enable them to support those who use our services to access interpreting and translation services and, through this, to reduce language, cultural and physical barriers to good communication. This policy sets out guidance to support communication with patients and carers who are non-english speakers, people for whom English is an additional language, people with hearing or visual impairment or who have learning disabilities. It sets out standards across the organisation to promote good practice and minimise risks that stem from communication barriers and it covers the use of face-to-face, telephone interpreting and written translation services in accordance with identified need. 6.3 References Department of Health (1991) Care Programme Approach. London: HMSO National Service Framework: Mental Health (1999) Effective Care Coordination in Mental Health Services: Modernising the Care Programme Approach. London: HMSO Department of Health (2008) Refocussing the Care Programme Approach: Policy and Positive Practice Guidance. London: HMSO National Service Framework (1999) Mental Health National Services Framework Department of Health (2014) Hard Truths: The Journey to putting Patients First. Crown Copyright Version 1.1 May

19 7.0 Roles and Responsibilities for this Policy Title Role Key Responsibilities Care Coordinators Adherence - Can be any professional member of the multi-disciplinary team - Ensure completion of a comprehensive Health and Social Care needs assessment - Develop a care plan with active user involvement and carers input, if appropriate - Coordinate care delivery with relevant multi-disciplinary professionals, services and agencies as required - Review the care plan as required within agreed monitoring timescales - Liaise and prioritise with relevant others where there are changes that require an earlier review of the users needs and not waiting for the planned review to take place - Ensure accurate recording of contacts in paper and electronic records - Ensure patients are afforded a choice of Care Coordinator which takes account of any gender, cultural or other needs - Support the patient to access services they need but it is not the intention that they are responsible for delivering the majority of care, especially if this is not appropriate to their expertise or skill Team Managers/ Team Leaders General Managers/ Service Managers Operational - Ensure cases are appropriately allocated to Care Coordinators - Ensure CPA assessments, reviews and monitoring of care are delivered through supervision and team systems, within their sphere of responsibility - Ensure that the CPA reviews and Crisis Care Plans are completed to achieve the Trust performance targets - Ensure that staff are carrying out their roles and responsibilities under the CPA policy as required Implementation - Ensure that CPA review monitoring data is collected from clinical areas - Act effectively on the information gathered Combined Clinical Quality Review (CCQR) Meeting Mental Health Quality and Safety Group Executive Director of Nursing, AHPs and Governance Chief Executive Monitoring - Monitor the development of the CPA policy Responsible - Oversee the implementation of a systematic and consistent approach - Approve this policy prior to ratification - Address any issues relating to CPA at a Group level in detail Executive Lead - Lead responsibility for the implementation of this policy - Allocation of resources to support the implementation of this policy - Ensure any serious concerns regarding the implementation of this policy are brought to the attention of the Board of Directors Accountable - Overall accountability and responsibility for ensuring that effective assessment, care delivery, reviews and monitoring systems are in place within the Trust Version 1.1 May

20 8.0 Training Care Programme Approach Policy What aspect(s) of this policy will require staff training? Use of CPA assessment tools and OASIS inputting CPA reviews and monitoring of care Which staff groups require this training? Care Coordinators Care Coordinators Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? No, staff will receive specific training in relation to this policy where it is identified in their individual training needs analysis as part of their development for their particular role and responsibilities No, staff will receive specific training in relation to this policy where it is identified in their individual training needs analysis as part of their development for their particular role and responsibilities If no, how will the training be delivered? Who will deliver the training? How often will staff require training Who will ensure and monitor that staff have this training? Internally Business Intelligence As required Team Managers/ Team Leaders Training will be delivered internally Team Managers/ Team Leaders As required Team Managers/ Team Leaders 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different fo rmat e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext or Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that ap ply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s a ctivities in respect of patients in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. Version 1.1 May

21 11.0 Monitoring this Policy is Working in Practice Care Programme Approach Policy What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Ensuring that staff are carrying out their roles and responsibilities under the CPA policy 7.0 Roles and Responsibilities for this Policy Supervision process and other team systems, as agreed locally Team Leaders and Supervisors As required Mental Health Quality and Safety Group Mental Health Quality and Safety Group Minutes of meetings CPA Review report 4.7 Care Programme Approach Review Report CPA Review Report Relevant Service Managers Quarterly Group Management Board Meeting Group Management Board Meeting Minutes of Meetings/ Signed off action plans Progress of achievement 4.7 Care Programme Approach Review Report CPA Review Report Relevant Service Managers Quarterly Group Management Board Meeting Group Management Board Meeting Minutes of Meetings/ Signed off action plans Version 1.1 May

22 Appendix 1 - Single Assessment Process (SAP) Appendix 2 - Common Assessment Tool (CAT) Appendix 3 - TAG Risk Assessment Tool Appendix 4 - Sainsbury s Risk Assessment Tool Please follow links to appendices. These documents can also be found separately on the Trust Intranet. Version 1.1 May

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