Care Programme Approach Policy and Procedure

Transcription

1 Care Programme Approach Policy and Procedure This document describes the process and framework for the clinical application of the Care Programme Approach Key Words: Policy, CPA, Care Programme Approach Version: 9 Adopted by: Quality Assurance Committee Date adopted: 15 th November 2016 Name of originator/author: Name of responsible committee: Date issued for publication: Dr G Kunigiri Policy Lead Clinical Effectiveness Group November 2016 Review date: December 2018 Expiry date: June 2019 LPT staff involved in delivering Target audience: secondary mental health services Type of Policy (tick appropriate Clinical box) Which Relevant CQC Outcome 1, 4.16 Standards?

2 CONTENTS VERSION CONTROL 3 EQUALITY STATEMENT 4-5 DUE REGARD 5 ABBREVIATIONS USED INTHIS POLICY 6 DEFINITIONS THAT APPLY TO THIS POLICY: SUMMARY INTRODUCTION PURPOSE OF THE POLICY VALUES AND PRINCIPLES DUTIES WITHIN THE ORGANISATION CARERS ASSESSMENT PROCESS CPA CARE PLANNING CPA REVIEW CPA CARE COORDINATOR SERVICE INTERFACE ENDING THE FORMAL CPA PROCESS AND DISCHARGE INFORMATION SHARING GAPS IN SERVICE MONITORING COMPLIANCE AND EFFECTIVENESS LINKS TO STANDARDS/PERFORMANCE INDICATORS REFERENCES AND ASSOCIATED DOCUMENTATION: APPENDIX 1 APPENDIX 2 APPENDIX 3 APPENDIX 4 APPENDIX 5 APPENDIX 6 Due Regard Assessment Training Requirements Table of Indicators for CPA Definition of serious mental illness (DoH SIDDD ) Professional Background for a CPA Care Coordinator Care Coordinator competencies 1 of 126

3 APPENDIX 7 APPENDIX 7a APPENDIX 7b APPENDIX 7c APPENDIX 7d APPENDIX 7e APPENDIX 7f APPENDIX 8 APPENDIX 9 APPENDIX 10a APPENDIX 10b APPENDIX 11a APPENDIX 11b APPENDIX 12 APPENDIX 13 APPENDIX 14 APPENDIX 15 APPENDIX 15a APPENDIX 16 APPENDIX 17 APPENDIX 18 APPENDIX 19 APPENDIX 20 APPENDIX 21 APPENDIX 22 APPENDIX 23 CPA within Divisional Units CPA and Learning Disability Services CPA and Family Yong Persons and Children Services Protocol for Following CPA Process Out-of-Area CPA and the Dynamic Psychotherapy Services CPA and Therapy Services for People with Personality Disorders CPA and Huntington s Disease Services CPA and Risk Assessment Training Advance Statement of Wishes/Advance Decisions/Lasting Powers of Attorney Core Mental Health Assessment Form Adult & MHSOP Core Mental Health Assessment form used in CAMHS Risk Assessment Form CAMHS Risk Assessment Form Therapeutic Risk Taking Tool Copying Correspondence to Patients Consent Form CPA/Non CPA Review Form CPA Care Plan Out-Patient Letter Template for Patients non on CPA Patient Personal Safety Plan Covering Letter for assessment forms/cpa review Out-Patient Template for patients on CPA CPA Service Gaps CPA Service Gaps Learning Disabilities version The NHS Constitution Stakeholders and Consultation Out-of-Area CPA Responsibility 2 of 126

4 APPENDIX 24 APPENDIX 25 Appendix 26 Appendix 27 Appendix 28 Inpatient CPA Process Flow Chart E.B.S.3 Mental Health Measure- Care Programme Approach (CPA) 7-day Follow Up Flow Chart Advance Statement Form CPA Invite Letter Template Key Individuals involved in developing the document: Dr G Kunigiri, Consultant Psychiatrist Mark Griffith, CPA Lead Version Control and Summary of Changes Version number Date Comments (description change and amendments) 1 December 2015 Discussed in CPA Standards Meeting to include Appendix in detail. 2 March 2016 Discussed in CPA Standards Meeting to review contents in detail. 3 June 2016 Incorporated comments following consultation and CPA standards Group meeting. 8 November 2017 Altered to reflect changes in CPA 7-Day follow up practice. 9 November 2017 Addition of CPA Invite letter and Advance Statement Form within Appendices All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. Did you print this document yourself? Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most upto-date version. 3 of 126

5 For further information contact: CPA Lead Leicestershire Partnership NHS Trust Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation. Equality and Diversity This policy should be read in conjunction with the Trusts Equality Diversity and Human Rights policy which promotes dignity, fairness, and respect in relation to the treatment and care of patients and carers and subsequent support for staff. Delivering equality and diversity is also about ensuring the needs of protected characteristics and equality groups are upheld at all times and assessed appropriately on entry to the service. This includes the needs of peopled based on their age, disability, ethnicity, gender, gender reassignment status, relationship status, religion or belief and sexual orientation. In some circumstances it will also be necessary to take account of specific needs re: pregnancy and maternity. The Trust is opposed to all forms of discrimination and works to ensure a culture where patients can flourish and be fully involved in their care and where staff and carers receive appropriate support. W here situations of inappropriate behaviour occur, the Trust expects the full cooperation of staff in addressing and recording these issues through appropriate Trust processes. A minimum requirement consistent with the promotion of equality of opportunity for patients and carers is to make all reasonable efforts to ensure that an appropriate interpreter is able to facilitate communication between Trust staff and patients and carers if their preferred spoken language is not English including ensuring availability of British Sign Language (BSL) interpreters. This includes, in particular, all ward and care co-ordination meetings, Mental Health Act assessments, Mental Health Review Tribunals and Managers Reviews. Embedding a culture of dignity and respect All staff must be aware of issues relating to equality, diversity and respect for patients and carers including: 4 of 126

6 Understanding how to ask questions about culture, religion and ethnic background Arranging interpreters where necessary Due Regard This policy has been screened in relation to paying due regard to the Public Sector Equality Duty of the Equality Act 2010 to eliminate unlawful discrimination, harassment, victimisation; advance equality of opportunity and foster good relations. The policy has specific sections on equality of access and equality and diversity; as well as emphasis throughout on placing the individual patient at the centre of their care, and taking into account at all stages the particular needs of the individual and any difficulties or disadvantages being faced. Equality monitoring of all relevant protected characteristics to which the policy applies will be undertaken. This will help identify any specific adverse or positive trends in respect of any relevant equality group and contribute to providing lesson learnt outcomes to improve service delivery. This policy will be continually reviewed to ensure any inequality of opportunity for patients, patients, carers and staff is eliminated. Please see Appendix 1 for Due Regard Assessment. 5 of 126

7 Abbreviations used in this Policy CPA LPT CCA CMHT CRHT MAPPA HoNOS STR Workers FYPC MHSOP CAMHS CQC Care Programme Approach Leicestershire Partnership NHS Trust Care Co-ordination Association Community Mental Health Team Crisis Resolution Home Treatment Multi-Agency Public Protection Arrangements Health of the Nation Outcome Scales Support Time and Recovery Workers Families, Young People and Childrens Mental Health Services for Older Persons Child and Adolescent Mental Health Services Care Quality Commission 6 of 126

8 Definitions that apply to this Policy Care Programme Approach Assessment Care Plan Review Care Coordinator Community Mental Health Team (CMHT) The Care Programme Approach (CPA) is the approach used in secondary mental health care to assess, plan, review and co-ordinate the range of treatment, care and support needs for people in contact with secondary mental health services who have complex characteristics Department of Health 2008 All patients are entitled to a full initial assessment. Those with complex needs will require a more comprehensive holistic assessment. This assessment must include clinical risk assessment. The CPA Care Plan is a record of needs, actions and associated responsibilities arising out of the Assessment process. The actions within the Care Plan should be outcome focused with the aim to address the identified needs and to optimise the mental health of the Patient. All Patients are entitled to minimum review at least annually whilst those on CPA will often require more frequent CPA Reviews. In this Trust, the standard minimum requirement is annually or as agreed in the Care Plan. The CPA Care Coordinator has the responsibility for coordinating care, keeping in touch with the Patient and ensuring the CPA Care Plan is delivered and reviewed as required. This title refers to all mental health teams working in the community including specialties. Advance Statement of Wishes Advance Decision A Statement of Wishes (preferences) although not legally binding, must be taken into account by those making best interests decisions on a person s behalf at a time when the person may be acutely unwell and temporarily lacks capacity (having been made when they had capacity. An advanced decision is a statement of instructions about what medical treatment a person wants to refuse in case of losing the capacity to make those decisions in the future 7 of 126

9 Due Regard Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. 8 of 126

10 1.0 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 Patient must be central to the whole process, with support provided by the practitioner and services, in order for the Patient to achieve his/her identified outcomes. W ithin this Policy, services are asked to focus upon: Values and principles of CPA for all Patients 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. Embedding culture of equality diversity and human rights 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. 2.0 Introduction 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. 9 of 126

11 Personalisation supports recovery by focusing 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. This local updated CPA policy emphasises the importance of personalisation and of different professionals and agencies coming together to provide a range of services coordinated by the framework of CPA. Whilst adhering to National guidance, this policy has been developed, through collaboration between health and social care agencies in Leicester and Leicestershire and Rutland and with organisations representing the views and needs of people and their families who use our services. 3.0 Purpose of the Policy The purpose of this policy is to: Provide direction and guidance for implementation of the Care Programme Approach. Provide high quality and robust care to the patients who are on CPA by effective care co-ordination with all services within and outside Leicestershire Partnership NHS Trust. Those not on CPA will be managed utilizing the CPA framework taking into account individual needs and risk of the individual. Provide choice to patients and carers the different options available in their case and to fully involve them in developing a personalized care plan. Improve the physical health and well-being of mental health and learning disability patients and reduce health inequalities through a consistent approach in care delivery. Provide a holistic approach to providing care to patients to ensure that the case delivered covers both mental and physical well -being. Offering adaptations for people with disabilities e.g. Hearing Loop, Downstairs meeting rooms, accessible information, etc. Provide the opportunity to discuss relationships and issues relating to sexual orientation. Ensure that people do not suffer disadvantage due to age and are dealt with appropriately within services Ensure that the needs of both men and women are represented equally including the needs of transgender patients Highlight that staff have a responsibility to challenge discrimination they may witness and report back in accordance with risk management and complaints and incidents processes 10 of 126

12 Staff must also be aware of issues relating Human Rights including how they apply to staff and patients. 4.1 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. 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. 1 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 there. 1 NIMHE Guiding Statement on Recovery. (January 2005) 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, Patient 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 W orking 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 Challenge inequality 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. 11 of 126

13 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. Further information relating to risk assessment can be found in the Department of Health, Best Practice in Managing Risk; Principles and Evidence for Best Practice in the Assessment and Management of Risk to Self and Others in Mental Health Services LPT aims to ensure that all services provided conform to laws and guidance under-pinning the NHS equality agenda. (Appendix 2). As such, service delivery will be periodically audited to ensure conformity to related policy procedure 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 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 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 2 2 Refocusing the Care Programme Approach 2008 page All patients 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 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 The rationale for determining non CPA must be recorded. 4.2 Key Standard Statements for CPA within LPT Assessment All patients accepted into secondary mental health (or learning disability) 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. This is a requirement, whether assigned to formal CPA or not. Needs assessment is a focus on an individual s needs rather than on the services available or on any diagnosis made. 12 of 126

14 Collection of data relating to Social and Economic factors will be part of the Assessment process. All Clinicians should use the Core Mental Health Assessment Form (CMHAF). If using a detailed clinical letter to document the assessment it should be uploaded onto RiO and should be noted on the CMHAF CPA Determination Formal CPA process will be delivered to all those Patients, accepted for secondary health care within Leicestershire Partnership and who, following the 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). Those patients who meet requirements for CPA should not usually be open to outpatients only Risk Assessment A Risk Assessment is mandatory and is part of the Assessment process. The use of Clinical Risk tools is encouraged by the Department of Health to support informative risk assessment. The electronic risk assessment tool is accepted by the Trust as the main risk assessment tool. The Trust encourages all clinicians to use the tool to aid the assessment. The Trust acknowledges that the use of this tool may not be undertaken when the clinician is undertaking risk assessment using more sophisticated tools specific to the risk or has expert clinical skills in undertaking risk assessment. The risk assessment tool is mandatory for all patients on CPA. For those not on CPA the use of the tool is encouraged, however, detailed expert risk assessment will suffice. The risk assessment tool is completed/updated for the following situations: Patients under the care of the Crisis and Home Treatment Team Patients under the care of several professionals requiring co-ordinated care and clear communication If the clinical presentation changes to become more complex requiring change of CPA status and referral to another clinician to take over care coordinator responsibility, a risk tool must be completed by the referrer. All staff have a general responsibility in terms of acting on information they receive regarding risk and to liaise with the Care Co-ordinator of the patient. All identified risks and how they are to be managed must be recorded in a risk management plan. Risk management plans must be reviewed regularly, whether on CPA or not. Any change in risk factors must trigger a full review including clustering reassessment and care pathway check Care Plan 13 of 126

15 It is the right of all Patients and significant carer (or those who are below 18 years of age) to be offered and to receive a copy of an agreed written Care Plan. The Care Plan must be in an accessible format. A copy of the 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 Patient. The CPA Care Plan should include the actions for which the Patient will take responsibility. Every attempt must be made to evidence Patient involvement in formulating the care plan. Care plans should be signed by the Patient CPA Review A CPA review will determine how effective the CPA 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. W here there are disagreements, these must be recorded. A CPA review provides the opportunity to reassess/update clustering, risk assessment, HoNOS and social economic factors and review Section 117 aftercare where applicable. If the Patient 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 or any other professional experienced in managing complex mental health issues such as mental health or learning disability social worker. That person is responsible for co-ordinating, the assessment, planning, implementation, monitoring and review of the CPA care plan for the patient whether in hospital or community, and ensuring that all records, including the Trust electronic recording systems are maintained and updated accordingly. Patients who are not considered to need referral to a community mental health team (CMHT) for longer term care, but who are engaged with Crisis Resolution & Home Treatment Team (CRHT) for and likely beyond six weeks, will require the formal CPA process and a CPA Care Coordinator identified from within the CRHT Inpatient Areas All patients who are admitted to a mental health unit will be on CPA. Upon admission, any recorded CPA Assessment information must follow the patient and 14 of 126

16 be updated accordingly. CPA discharge meeting will be organised by the care coordinator before the patient is discharged involving all the professionals, patient and carers wherever possible. At the time of discharge patients can be regarded as non CPA if clinically appropriate and the rationale needs to be clearly documented. Clear reasons should be documented by the inpatient team if discharge CPA was not possible. In such case CPA review should be organised by the CPA Care Coordinator within 28 days following discharge. Following discharge from an adult mental health inpatient unit all patients irrespective of CPA status should receive follow up within 7 days, this will be recorded in the electronic patient record. At the point of discharge from in-patient services, all patients 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 CPA Care Plan or a copy of an e-discharge letter to the GP. W here the latter is used, the patient must be informed that this copy of the e-discharge letter is their discharge plan. A copy of the agreed Discharge Plan/information must be sent to the relevant GP within 24 hours. Discharge plans are not a substitute for the full CPA Care Plan recorded on the Trust Electronic Patient Record (EPR Primary System). However, where the e-cpa Care Plan cannot be updated and produced at the point of discharge, information provided to the Patient including details for the post discharge period must be recorded in a Discharge Plan. This and any other information relating to the discharge must be sent to the CMHT (or where ever discharged) where the e-cpa Care Plan will be amended accordingly. The Patient (and carer where appropriate) should be involved in, and aware of, any changes to the CPA Care Plan. A copy of the updated e-cpa Care Plan should be sent to the relevant GP and must be given to the Patient as soon as it is practical to do so Information Sharing Information sharing should take into account LPT responsibility in relation to Safeguarding Adults and Safeguarding Children. Consideration should be given to referring adults or children who may be victims of abuse within the local safeguarding multi-agency procedures. Staff should refer to the Adult Safeguarding Policy or Children Safeguarding Policy on e-source When there are safeguarding concerns in relation to children, it is important that information is also shared with the relevant children s service area. Health Visitors work with children 0-5 years and school nurses with school age children. Staff can contact the children s safeguarding advice line on or the adult safeguarding advice line on for advice (Monday Friday) Documentation for patients on CPA Through documentation is a must for all patients. It is the responsibility of the care coordinator to ensure the following documentation is completed after each CPA review: 15 of 126

17 a) CPA review form (Appendix 15a) b) Care Plan (Appendix 16) c) Risk assessment tool (Appendix 11) and Therapeutic risk taking (if applicable; Appendix 12) d) Service User Safety Plan (if applicable; Appendix 17) Patients not on CPA and their documentation Patients with SMI who don t qualify for CPA are placed on non CPA. These include patients who are generally seen by only one clinician within mental health services, having mild to moderate risks that can be contained by a single clinician and not needing extensive coordination of care. Through documentation is a must for all patients including those not on CPA, it is the responsibility of the Lead Professional to ensure that these patients are reviewed as a minimum every 12 months and the following documentation is completed : e) CPA review form (Appendix 15a) or the OP Care Plan, non CPA template clinic letter (Appendices 19&20) f) Care Plan (Appendix 16) g) Risk assessment tool (if applicable; Appendix 11) 5.0 Duties within the Organisation 5.1 Trust Board Committees have the legal responsibility for adopting policies and strategies and ensuring that they are carried out effectively. 5.2 Divisional Directors and Heads of Service are responsible for: Ensuring that comprehensive arrangements are in place regarding adherence to this policy and how CPA procedures are managed within their own Department or Service in line with the guidelines in this policy Ensuring that team managers and other management staff are given clear instructions about policy arrangements so that they in turn can instruct staff under their direction. These arrangements will include: o Receiving policies/procedures from the Policy Administrator o Distributing information about new procedures in a timely manner throughout the Division or service to a distribution list will be agreed in advance with local managers Ensuring that all staff have access to up to this policy, either through the intranet or if policy manuals are maintained that the resources are in place to ensure these are updated as required Maintaining a system for recording that policies and procedures have been distributed to and received by staff within the Department / Service and for 16 of 126

18 having these records available for inspection upon request for audit purposes. 5.3 Managers and Team leaders will be responsible for: Ensuring that this CPA Policy and guidance is followed and understood as appropriate to each staff member s role and function This information must be given to all new staff on induction. It is the responsibility of local managers and team leaders to have in place a local induction that includes policies and procedures Ensuring that the staff understand how and where to access current policies and procedures; via Intranet Ensuring that a system is in place for their area of responsibility that keeps staff up to date with the CPA Policy and any recommended training related to it 5.4 All Staff All staff (including seconded staff) should be aware that despite the above responsibilities of senior staff, every staff member has an individual duty of responsibility to ensure that they: Know where to locate the CPA Policy or procedures when necessary Adhere to all Trust Policies and Procedures Attend core mandatory safeguarding training All staff should be aware of how policies and procedures impact on their practice and be able to follow the specified requirements set out. 6.0 Carers 6.1 A key element of CPA is that it recognises the importance of Patients 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. 6.2 Patients have a right to the involvement and support of other people where they wish it. 6.3 Additional to family or friends who care about the Patient and who the Patient may wish to be involved in the CPA process, there will be others who care for the Patient. The partner agencies all recognise the i m p o r t a n c e of supporting carers those who care for people. Staff must actively seek to identify and support carers at all times. 6.4 Recognition should be given to the role of carer as being a valued member of the Care Team network. 17 of 126

19 6.5 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. 6.6 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 have responsibilities to support or signpost carers as required. 6.7 Local Authorities have a legal duty to offer carers who provide or intend to provide care an assessment of their own needs. 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 Patient. Staff undertaking these assessments should be familiar with the law, the national guidance 3 and the local authority s policies. 3 Care and Support Statutory Guidance Issued under the Care Act Staff who are in contact with carers should inform them of their right to an assessment. All carers should be offered a carers pack and carers assessment. Information and resources available via e-source 6.9 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. This is independent from Patient consent Clinicians may at times be working with individuals and have no direct contact with carers but become aware of them through the Patient. Sometimes Patients may not want their carer to be contacted. In these situations staff are advised to explore the Patient 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 Patient still refuses to give their consent, and there is no overriding responsibility in terms of risks then the Patient s wishes must be respected. The rationale for refusing consent must be recorded in the patient s notes. In these situations carers can still be signposted to carers organisations and/or the local authority for support to them The Patient 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 18 of 126

20 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. Staff should always consider if children are present in the patient s life and ask if they are involved in providing any care. The aim should be to provide the right support to the Patient 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. Information regarding children acting as carers must be shared. Refer to e-source for the Adult Safeguarding Policy or Children Safeguarding Policy 6.16 The Carer can share his/her own view and any other information he/she feel is necessary with the care team, regardless of whether the Patient has given permission or not If a Carer requests that information they share with staff is not passed on to the Patient, this request must be respected subject to Information sharing and Consent guidance 6.18 Throughout the CPA processes, staff must be mindful of the needs of the Patient s family/network and where any needs or issues are identified, further reference for guidance may be obtained in other Trust policies: Adult Safeguarding Policy or Children Safeguarding Policy or Domestic Violence Policy are available via e-source 7. Assessment 7.1 All referrals for secondary mental health services in LPT will receive a full, assessment to determine the level of input required to provide appropriate care and treatment for needs identified within the assessment. Agreed Care Pathways and processes must be followed some of which will include assignment to formal CPA processes. An outcome summary of the holistic assessment together with required data collection relating to social economic factors, must be evidenced and recorded within the agreed Trust tools. 7.2 For those Patients requiring the formal CPA process there may be more than one assessor of their health and social needs. These will be recorded into the Core Mental Health Assessment Tool. (Approved by LPT CPA Standards Group) 7.3 The Assessment must involve the Patient, and where appropriate the 19 of 126

21 Carer, as central and active participants in the CPA process. At all times staff must work with focus on best interests of the Patient. 7.4 Assessments must ensure that the Patient s strengths and achievements are identified. 7.5 The Assessment process must contain an assessment of risk (Refer to the LPT Clinical Risk Assessment Policy). Attention must be given in respect to whether or not the Patient fulfils the criteria for registering under the Multi Agency Public Protection Arrangements (MAPPA). 7.6 Appropriate Outcome ratings (HoNOS and/or Clustering; HoNOS CA) will be completed at assessment, upon discharge from an inpatient setting, at six month intervals as appropriate and at significant points in the CPA process or as defined by the Care Pathway. 7.7 During Assessment, detailed information must be collated regarding any issues or needs of family members/dependents safeguarding, children or vulnerable adults (See also ) 7.8 The CPA Assessment should be fully completed once and thereafter updated information must be evidenced with the Review process. 8.0 CPA Care Planning 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 CPA Care Plans must be outcome focused and in an appropriate format for the Patient s requirements. The responsibility of formulating the CPA Care Plan rests with the Care Co-ordinator. 8.2 Dependent upon assessed mental capacity, Patients have the right to be fully involved wherever possible in the formulation of their CPA Care Plan. Service Users must be invited to sign the final formatted version and have the right to be given a copy of the care plan. 8.3 CPA Care Plans must include a crisis and a contingency plan. 8.4 Where there are two Patients 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 Patients may not be on CPA). 8.5 The CPA Care Plan must be recorded on the Electronic Patient Record 20 of 126

22 8.6 A copy of the CPA Care Plan will be provided to all personnel in the care Team or network and, with the consent of the Patient, other relevant parties. 8.7 The effectiveness of the agreed CPA Care Plan will form part of ongoing monitoring and discussions between the Patient and their Care Coordinator. 8.8 The Patient has a right to decline involvement in all or any aspect of the CPA Care Planning process. (See also 11.3). 9.0 CPA Reviews 9.1 Review is a structured and flexible process as well as a planned periodic event. It is to discuss/ update the Risk Assessment and if necessary the CPA Care Plan. It also provides the opportunity to capture social economic factors as required by the Trust. 9.2 Frequency of Review: On CPA - every 12 months or as agreed by all parties involved in the care plan taking into consideration Patient choice, complexity of identified needs and planned outcomes and any risk factors. The rationale for this agreement must be recorded Those patients admitted as inpatient for more than 6 months will have CPA reviews once every 6 months. Not on CPA minimum every 12 months 4 UK Care Standards Act Patients 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 Patient, and their Carer if appropriate. 9.4 Every consideration must be given to a request from the Patient or the Carer to hold the CPA Review in a specific venue. 9.5 The CPA Review is the responsibility of the CPA Care Co-ordinator, who must be satisfied that, all professionals as well as other relevant people (dependent upon the Patient s consent), involved in the Patient s care, have had the opportunity to contribute to the Review. 9.6 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. 9.7 At each Review the date of the next Review must be set and recorded in case notes and on Patient electronic system, and as appropriate on the Local Authorities information systems. 9.8 Decisions made and agreed in a CPA Review must not be changed by any individual without full consultation with all other named participants. 21 of 126

23 9.9 The CPA Care Plan must be updated to reflect any change resulting from a CPA Review and a copy given to the Patient 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 9.10 and 10.7). The outgoing CPA Care Coordinator is responsible for updating the records before transferring the case over to the new Care Coordinator W here there is more than one CPA Care Co-ordinator within one household, or residential setting, both should be involved in each of the Patients CPA Reviews and be fully aware of all vulnerabilities and risks identified in each case Section 117 Aftercare is reviewed as part of the CPA Review process. CPA should be used to oversee and manage section 117 Aftercare arrangements where appropriate. It is recognized however that the support for some people who remain entitled to section 117 Aftercare is straightforward and does not require co-ordination and planning across services. Examples of this include where primary care takes on the support or where the person is settled in social care and no longer requiring regular input from secondary mental health services. Where this is the case then this support can be overseen and managed outside of CPA. (Refer to LPT Section 117 Policy guidance) A CPA Review may be a planned meeting or a series of conversations or a more formal meeting. The information/outcomes from the CPA Review should be recorded using the CPA Review template and this should be circulated to identified persons within 14 days of the Review date A planned CPA Review meetings should be allotted dedicated time and not be part of another meeting Part of any review must include a clustering check/reassessment to ensure the patient is assigned to the appropriate care pathway CPA Care Co-ordinator 10.1 The Care Co-ordinator has responsibility for co-ordinating care, maintaining contact with the Patient ensuring that the CPA Care plan is delivered and 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). and be the person best placed to oversee CPA Care Planning and resource allocation The CPA Care Co-ordinator can be of any discipline depending on capability and capacity 6. Generally the following will not usually be identified into the role: Support Treatment and Recovery (STR) W orkers General Practitioners 22 of 126

24 Unqualified/unregistered health or social care workers 10.4 Care Co-ordination should form part of the job description with co-ordination support recognised as a significant part of the caseload Best practice is that Care Co-ordinator competencies (Appendix 5) should be completed and recognised as part of job specifications There will be one person identified and agreed to act in the role of CPA Care Co- ordinator, irrespective of input from more than one service within LPT. (Appendix 6) 10.7 No qualified member of a service, organisation or discipline is exempt from being allocated the role of CPA Care Co-ordinator Following the assessment outcome where the Patient is placed on CPA, a CPA Care Co-ordinator must be agreed and assigned immediately and registered on patient electronic system Patients assessed to have the greatest level of need should be assigned a CPA Care Co-ordinator with the most skill and experience A choice of CPA Care Co-ordinator gender should be offered to Service Users who are known to have encountered sexual abuse or violence. 5 Effective Care Co-ordination: Modernising the Care Programme Approach October Refocusing the Care Programme Approach: DoH March 2008 page 36 7 Refocusing the Care Programme Approach: DoH March 2008 page Change of Care Co-ordinator will be by agreement of the care team and will follow a CPA Review if possible and full handover of care between the 2 Care Coordinators or the Care Co-ordinator and lead professional or vice versa. (see also 10.7 and 10.11) 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 Patient 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 Patient the formal CPA process must be followed consistent with practice 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 should occur to cover periods of annual leave or sickness: Care Co- ordinators must arrange for crisis and contingency plans to be 23 of 126

25 amended to include details of the person to be contacted by the Patient and awareness shared with the Patient Service Interface 11.1 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 patient from Community and vice versa The CPA Care Co-ordinator retains responsibility for maintaining contact with the Patient and Carer (where applicable), throughout the admission stay and must be involved in discharge planning In-patient staff have an important role during the period of crisis which has necessitated a hospital stay. The Patient s pathway should be a collaborative process with all parties working together Service Specific requirements in Learning Disabilities Services, Family &Young Persons Children (FYPC) or Mental Health Services for Older Persons (MHSOP) may determine alternative interface arrangements All In-patient services must inform and involve the appropriate CPA Care Coordinator when leave arrangements for a patient are being made, whether this is planned or unplanned. Specific arrangements to involve the Crisis and Home Treatment Team (CRHT) may be included in the leave plan The support of formal CPA will not discontinue because a patient is discharged from inpatient services. Any such decision will be as an outcome from the pre-discharge CPA Review Process (See also 11.2) and this will be entered into the Patient records Patients on CPA, discharged from in-patient services, must receive follow up care within 7 days of the discharge date 8. Ideally, this should be face to face contact. The Care Coordinator is responsible to ensure this takes place, but will not necessarily be the person carrying out the contact. (This contact must be recorded and outcomed in the RIO diary and in the RIO progress notes) 11.8 Discharge plans for all in-patients who have a severe mental illness 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 9 and planning for this will be the responsibility of the Care Coordinator Each change in the following must be recorded on electronic record systems: CPA Care Co-ordinator/Lead Professional CPA determination Transfer between wards Transfer to another RMO/Responsible Clinician 24 of 126

26 Leave time and date of leaving ward and time and date of return Discharge For those patients who are discharged from a mental health unit through early discharge process within the Crisis Team, the Care Coordinator role will continue temporarily within CRHT, during facilitation of early discharge and follow-up for a Patient who is awaiting allocation of, and a transfer to, an identified CPA Care Coordinator from the locality CMHT/CLDT (Community Learning Disability Team). If the CRHT and/or CMHT/CLDT feel that patient s CPA status can be regraded to non CPA the reasons should be clearly documented and CPA status amended on electronic records and the patient and appropriate professionals informed including general practitioner W here a CRHT member is facilitating early discharge and post discharge follow- up for a Patient 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/CLDT. The maximum time agreed to hold this interim role is seven working days and must be due to extraordinary circumstances rather than routine practice. (CPA Standards Group March 2012) Managers and CPA Care Co-ordinators must be aware of any staff changes that may affect continuity of care delivery, The patient must not be left without a contact in the event of transfer from inpatient to care in the community W here a patient 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. (see also 8.10) (For Protocol for CPA responsibility for OOA Patients monitored by GEM see Appendix 25) 8 9 Safety First: National Confidential Inquiry into Suicide and Homicide by People with mental illness: DoH 2001 Care Programme Approach; Care Co-ordination, core functions and competencies DOH 2008 page A patient who is not on CPA prior to admission (either with a lead professional or with no previous history) must be re-catagorised upon admission as on CPA. In such cases, the admitting nurse or named nurse will take on the role of CPA Care Coordinator temporarily and be recorded as such in all records (Case notes and electronic system). This applies to patients who are not known to services and are admitted to mental health unit Discussion regarding likely post discharge requirements should commence at an early stage of the admission process. The relevant CMHT/CLDT must be informed and advised that a CPA Care Coordinator will be required to take over the role from the ward staff. This role should be identified, the patient and the ward informed prior to an arranged discharge date. All patients on CPA 25 of 126

27 should have pre discharge meeting involving all the professionals, patient and carer. All patients are reviewed prior to discharge if they should continue to be on CPA upon discharge. There should be no instances where a patient is discharged from inpatient services, on CPA, without an identified CPA Care Coordinator in the community to follow on support The electronic and paper records must be updated when there is a change of the identified CPA Care Coordinator Ending the formal CPA process and discharge 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 12.2 Ending the formal CPA process within LPT will be a decision taken within a CPA Review. The Patient 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 Patient and the team will have agreed that self-management of care, self-direction and organisation is appropriate If a Patient (not considered to be detained under the Mental Health Act) requests not to be on CPA and refuses to have any further care under the formal CPA process, reasonable attempts must be 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 and must be recorded on the patient electronic system. The GP must be fully informed Patients and Carer(s) as appropriate, must be given information of how to contact services at a future date if circumstances change At any change of CPA status, the Electronic Patient Record must be updated accordingly. 10 Independent Inquiry into the Care and Treatment of MN. Avon, Gloucestershire and Wiltshire Strategic Health Authority, June Information Sharing 13.1 Further detailed guidance can be referenced in national and local documents Information sharing should be undertaken with the agreement of the patient Where consent has been withdrawn, a Patient s decision can be overridden when there is a concern or a risk of serious harm to either the patient or any other person. W here this is the case, an explanation must be offered to the Patient. (unless by doing this would increase risk to any dependent children 26 of 126

28 or vulnerable adult) Information may be shared in respect of police investigations (if appropriate and dependent upon awareness of the responsible clinician or line management) Where a patient 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 Information sharing should take into account LPT responsibility in relation to Safeguarding Adults and Children. Consideration should be given to referring people who may be victims of abuse within the multi-agency procedures 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 Gaps in Service 14.1 Where a deficiency in service delivery is identified which potentially could affect an outcome as identified within a Patient s care plan, a Gaps in Service form (Appendix 21) should be completed and the process contained within it followed 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 Divisional Director is to be alerted to any such deficits by using the relevant template to record the information Monitoring Compliance and Effectiveness 15.1 LPT must have an appropriate central record of all Patients 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 an annual basis and will be included within LPT audit calendar. This audit will be undertaken in conjunction with LPT Clinical Audit Department. The frequency of the audit will be reviewed annually Additional audits may be commissioned by Divisions, Patient Groups or the CPA Chairs or Lead. This should include audits to provide evidence of standards of care being given to Patients not on CPA. 27 of 126

29 15.4 CPA related audits will be reported to the Clinical Effectiveness Group. This Group will seek assurance from Divisional Directors and Service 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 Patient groups as well as by clinicians Services must support clinicians to undertake data collection and receive findings, whether Trust-wide or Service specific 15.8 In addition to the audits referred to above, managers are expected to monitor patient electronic systems data relating to CPA within their teams, by the use of electronic reports. This information should be shared within supervision with care coordinators and also be used as part of caseload management Links to Standards/Performance Indicators This CPA Policy links to Care Quality Commission (CQC) Outcomes 1, 4, 16. An annual CPA audit will be conducted to ensure compliance with all the CPA standards. Requirements All patients 18 or over on CPA for one year or more have a CPA review yearly Self assessment evidence Section 8.2 Process for Monitoring CPA Audit Integrated Quality Performance Report (IQPR) Responsible Individual / Group Managers and Individual Professionals Divisional CPA Practice Groups Trust CPA Standards Group Clinical Quality Group Frequency of monitoring Annual Quarterly Quarterly Quarterly Divisional Score Cards Divisional Clinical Governance Groups Quarterly 28 of 126

30 All patients have CPA level assigned to them Page 6 Definition of Care Coordinator Section Section Section 6.1 CPA Audit Divisional Score Cards Divisional CPA Practice Groups Trust CPA Standards Group Manager and Individual Professional Twice yearly Monthly All patients on CPA age 18 and over are seen by their Care Coordinator six monthly Section 9.1 Section 9.12 Divisional Score Cards Manager and Individual Professional Monthly All patients on CPA aged 18 and over have a Care Coordinator assigned to them Section 9 Divisional Scorecards Manager and Individual Professional Monthly All patients on NON CPA aged 18 and over have a lead professional assigned to them Section Divisional scorecards Manager and Individual Professional Monthly All patients on CPA aged 18 and over have a CPA Care Plan Section Section 7.2 Section 7.5 Divisional Scorecards Manager and Individual Professional Monthly All patients on CPA between ages Section Section 6.1 Divisional Scorecards Manager and Individual Professional Monthly 18 and 69 have had their accommodatio n status recorded. Section 8.1 Divisional Scorecards Manager and Individual Professional Monthly All patients on CPA between ages 18 and 69 have had their employment status recorded. Section Section 6.1 Section 8.1 Divisional Scorecards Manager and Individual Professional Monthly 29 of 126

31 17.0 References and Associated Documentation 1 Care Standards Handbook 2 Writing Good Care Plan NIMHE Guiding Statement on Recovery. (January 2005) 4 Refocusing the Care Programme Approach 2008 page 13 5 Care Act UK Care Standards Act Effective Care Co-ordination: Modernising the Care Programme Approach October Refocusing the Care Programme Approach: DoH March 2008 page 36 9 Refocusing the Care Programme Approach: DoH March 2008 page 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 Independent Inquiry into the Care and Treatment of MN. Avon, Gloucestershire and W iltshire Strategic Health Authority, June Code of Conduct Data 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)/Information Governance LPT of 126

32 Current laws & government underpinning the NHS equality Agenda. Equality Act 2010 A new Equality Act came into force on 1 October The Equality Act brings together over 116 separate pieces of legislation into one single Act. Combined, they make up a new Act that provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act is intended to simplify, strengthen and harmonise the current legislation to provide Britain with a new discrimination law that protects individuals from unfair treatment and promotes a fair and more equal society. The nine main pieces of legislation that have merged are: the Equal Pay Act 1970 the Sex Discrimination Act 1975 the Race Relations Act 1976 the Disability Discrimination Act 1995 the Employment Equality (Religion or Belief) Regulations 2003 the Employment Equality (Sexual Orientation) Regulations 2003 the Employment Equality (Age) Regulations 2006 the Equality Act 2006, Part 2 the Equality Act (Sexual Orientation) Regulations 2007 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 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. 31 of 126

33 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 32 of 126

34 APPENDIX 1: Due Regard Equality Analysis Introduction Initial Screening Template This document forms part of the Trusts Due Regard (Equality Analysis) toolkit which can be accessed here. Leicestershire Partnership NHS Trust has a legal requirement under the Equality Act 2010 to have due regard to eliminate discrimination. It is necessary to analysis the consequences of a policy, strategy, function, service or project (referred to as activity) on equality groups in respect of patients, patients and staff. The analysis has to consider people s protected characteristics 'age, disability, gender reassignment, marriage / civil partnership, pregnancy and maternity, race, religion / belief, sex, sexual orientation. We also include other vulnerable groups who may not be protected under the Equality Act but their needs should be considered. There are several tangible benefits in conducting equality analysis prior to making policy decisions, including: Higher quality decisions as a result of more complete management information Reduced cost as a result of not having to revisit policy that is not fit for purpose Enhanced reputation as an organisation that is seen to understand and respond positively to diversity. Most importantly, through equality analysis we are able to take into account the needs of our different equality groups of staff and patients. Changes being proposed through policy, strategy, transformational programmes or other methods need to be analysed from an equality perspective and the results considered before decisions are made. Where negative impacts are identified, ways to mitigate or minimise them must be put in place. Before starting if you are unfamiliar with doing an Equality Analysis contact the Equality and Human Rights Team for guidance or visit the Due Regard section on the Trust Intranet here. Below is the Due Regard Screening Template which aims to assess the likelihood of a negative impact on an equality group/s. For example, a policy change in financial management systems may be considered major but has no negative impact. The initial screening form needs to be completed to decide if a full Due Regard (Equality Analysis) * should be undertaken. An overview of the various options available are highlighted in a Due Regard fact sheet which includes top tips and a flow chart which can be accessed here. *A full Due Regard (Equality Analysis) makes sure that any negative impacts have been considered and ways to minimize the impact are specified. 33 of 126

35 Due Regard Screening Template Section 1 Name of activity/proposal Review of LPT CPA Policy Date Screening commenced 8 th November 2017 Directorate / Service carrying out the Assessment Name and role of person undertaking Adult Mental Health, Families, Young Persons and Children. Community Services Mark Griffith, LPT CPA Lead this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS: To provide direction and guidance for implementation of the Care Programme Approach OBJECTIVES: To provide high quality and robust care to patients who are on CPA by effective coordination with all services within and outside Leicestershire Partnership NHS Trust. Those not on CPA to be managed utilising the CPA framework taking into account individual needs and risk of individual PURPOSE: To provide choice to patients and carers, fully involving them in developing a personalized care plan PURPOSE: To provide a holistic approach to providing care to patients ensuring that care delivered covers both mental and physical well being Section 2 Protected Characteristic Age Disability Could the proposal have a positive impact Yes or No (give details) There is no bias within the policy There is no bias within the policy Could the proposal have a negative impact Yes or No (give details) NO Gender reassignment There is no bias within the NO 34 of 126

36 policy Marriage & Civil Partnership Pregnancy & Maternity There is no bias within the policy There is no bias within the policy NO NO Race An interpreting and translating service is available if the patients first language is not English NO Religion and Belief There is no bias within the policy NO Sex The policy is equally applicable to all sexes NO Sexual Orientation There is no bias within the policy NO Other equality groups? There is no bias within the policy NO 35 of 126

37 Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B Section 4 No Low risk: Go to Section 4. x It this proposal is low risk please give evidence or justification for how you reached this decision: Update of existing policy conforming to national policy and guidelines Further amended to reflect up to date national policy Signed by reviewer/assessor Mark Griffith, Service Manager Date 8 th November 2017 Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date 36 of 126

38 Appendix 2 Training Requirements Training Needs Analysis Training Required YES X NO Traini ng topic: Type of training: (see study leave policy) Division(s) to which the training is applicable: Staff groups who require the training: Regularity of Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? CPA and Care Planning XMandatory (must be on mandatory training register) Role specific Personal development X Adult Mental Health & Learning Disability Services X Community Health Services Enabling Services X Families Young People Children Hosted Services All staff undertaking the role of Care Coordinator 3 Yearly Clinical Trainers/ Identified clinical staff Yes Yes Where will completion of this training be recorded? X ULearn Other (please specify) How is this training going to be monitored? Monthly record of mandatory training 37 of 126

39 APPENDIX 3 : Table of indicators for the support of formal CPA process Severe mental disorder, (including personality disorder) with complex health and social needs and/or a learning disability. Current or potential high 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. - Exploitation e.g. financial/sexual - Financial difficulties related to mental illness - Dis-inhibition - Physical / emotional abuse - Cognitive impairment - Child protection issues Previously detained under the Mental Health Act. Subject to Supervised Community Treatment (SCT) Subject to Guardianship under the MHA (section 7) Current or significant history of severe distress / instability or disengagement Presence of non-physical co-morbidity e.g. substance / alcohol / prescription drugs misuse. Multiple service provision from different agencies, including: housing, physical care, employment, criminal justice, voluntary agencies Engaged with Crisis and Home Treatment Team in excess of 6 weeks Significant reliance on carer(s) or has own significant caring responsibilities Experiencing disadvantage or difficulty as a result of: Parenting responsibilities Physical health problems / disabilities Unsettled accommodation / housing issues Employment issues when mentally unwell 38 of 126

40 Appendix 4 : Definition of serious mental illness (DoH SIDDD ) Original DoH national definitions ( SIDDD ) SAFETY History of significant violence, self-harm or self-neglect or at risk of exploitation due to mental illness IN/FORMAL HELP Need for intensive support in the community either from informal carers or from formal services e.g. More than one contact with specialist services per week, involvement of two or more agencies or subject to Section 117 of the Mental Health Act, supervised discharge or a restriction order DIAGNOSIS DISABILITY DURATION Presence of severe mental disorder including psychotic illness, severe neurotic illness, personality disorder, dementia, development disorder Significant impairment of functioning in role performance in one or more of occupation, family responsibilities or accommodation; particularly where this has led to social isolation and/or difficulties with the activities of daily living. Indicators of this may include being in receipt of Disability Living Allowance, being homeless or requiring supported, sheltered accommodation. Length of illness of greater than one year or likelihood of illness persisting; three or more admissions, or aggregate total of oneyear stay, in the past five years. 39 of 126

41 Appendix 5 : Professional Background for a CPA Care Coordinator A suitably-qualified individual with the requisite knowledge and skills to undertake the role of CPA co-ordinator. Normally this will be someone with a professional nursing or social work background. There may be instances where it is agreed that the most appropriate individual to take on the role can demonstrate the expertise required, but is not from a nursing or social work background. Examples may include in substance misuse or therapy services where case managers come from a range of backgrounds, often but not always health. It may be agreed by the members of the relevant care network that the person best placed to co-ordinate sits within drug or alcohol services for example, and it is accepted that this may be appropriate irrespective of professional background. In all such cases, it should be demonstrated that the individual identified as best placed to act in the role of Care Co-ordinator has completed CPA training, has the necessary competencies, and has co-ordination of care defined within their job role. 40 of 126

42 Appendix 6: Care Coordinator competencies These competencies may be used as part of the induction process for new care coordinators, and they will assist with the identification of further learning needs. In addition, they may also be helpful for self-assessment, reflective practice, clinical supervision or audit purposes. 1. Comprehensive Needs Assessment a) Assess mental health b) Identify potential psychiatric and psychological functioning and mental health needs and related issues. c) Identify the physical health needs of individuals with mental health needs. d) Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care. 2. Risk Assessment and Management a) Develop risk management plans to support independence and daily living within the home. b) Assess needs and circumstances and evaluate the risk of abuse, failure to protect and harm to self and others. c) Assess the need for intervention and present assessments of needs and related risks. 3. Crisis Planning and Management a) Work with families, carers and individuals during times of crisis. b) Respond to crisis situations. 4. Assessing and Responding to Carers Needs a) Work in collaboration with carers in the caring role. Yes No Comments or action 41 of 126

43 Yes No Comments or action b) Assess the needs of carers and families of individuals with mental health needs. c) Develop, implement and review programmes of support for carers and families. d) Empower families, carers and others to support individuals with mental health needs. 5. Care Planning for Recovery and Review a) Co-ordinate, monitor and review service responses to meet individuals needs and circumstances. b) Plan and review the effectiveness of therapeutic interventions with individuals with mental health needs. c) Implement, monitor and evaluate therapeutic interventions within an overall care programme. 6. Transfer of Care and Discharge a) Plan and implement transfer of care and discharge with individuals who have a long term condition and their carers. b) Work with others to facilitate the transfer of individuals between agencies or services. c) Consider the known elevated risk around discharge, particularly of self-harm, and ensure safeguards are in place. 42 of 126

44 Appendix 7 : CPA within Divisional Units 7a) CPA and Learning Disability Services Many referrals to the Learning Disability service do not fit the criteria for formal CPA and immediately are non CPA. The information received via the referral process determines service response and which assessment is to be completed. Clinical Care Pathways which have been developed will ensure that CPA and non CPA needs are addressed. A lead professional will always be allocated to open, non CPA cases and details entered onto the patient electronic system. Those with a learning disability who will most likely benefit from the CPA process will be: L.D. plus severe mental illness L.D. plus severe challenging behaviour L.D/Autism associated with challenging behaviour L.D. plus personality disorder L.D. plus substance misuse L.D. plus vulnerability/safeguarding issues L.D. plus forensic issues Or otherwise assessed, including assessment of risk that indicates suitability for CPA. 7b) CPA and Family, Young Persons and Children Services Whilst FYPC must comply with the Trusts CPA policy, there may be certain circumstances where even in complex and high risk cases it is not appropriate to place a patient on to CPA. Due to the age of CAMHS patients there are other formal frameworks which can be employed to ensure the protection and that the right services are being delivered, and that the process of delivery is monitored, i.e. Child Protection Procedures, Child Assessment Framework, Multi- agency meetings, and the standard CAMHS assessments address whole systems issues with families. It is also accepted that all agencies working with this age group are commonly sharing information as normal practice. FYPC staff must remember that age is not an exclusion criteria for CPA and the CPA Determination Tool for new referrals must be completed. Any decision for not placing a patient on CPA must be clearly recorded and filed in the notes. 43 of 126

45 44 of 126

46 7c) Protocol for following CPA process for out-of-area On Admission: Admitting practitioner to establish, is the patient open to a CMHT and whether they are on CPA in the community? Ideally the out of area hospital will have this information at the point of referral, however if this is not the case please contact the Bed Management Team on whereby the CMHT contact numbers can be provided for these details to be confirmed. 1. If the answer is yes the out of area placement needs to inform the CMHT of the admission and provide them the ward details where the patient was admitted and who the named nurse is. 2. If on CPA request that the CMHT send across a copy of the CPA care plan and put these in the patient notes. 3. The out of areas assessment forms and risk assessment need to clearly identify that the patient is on CPA. FIRST CPA/DISCHARGE REVIEW (patient, carer/relative, care co-ordinator/lead professional, GP and any other involved agency must be invited. If any unable to do so then their views must be obtained either verbally or written and documented). 1. Must take place within the first two weeks of admission. 2. Discuss the presenting and known risks and update the risk assessment, consider plan for therapeutic risk taking. Document everything. Discuss: How long is the patient likely to be in hospital for and set a planned discharge date? Is the patient suitable for an Early Discharge Plan with the Leicestershire Partnership Trust Crisis Team prior to discharge? To discuss their referral criteria please contact and select the option for the Home Treatment Team. Does the patient need to be on CPA upon discharge. If not, a clear rationale must be documented. A temporary Care Coordinator needs to be identified from within the team if remaining on CPA. Identify person to complete the 7-day follow-up upon discharge (please note that the Crisis Team can complete a 7-day follow-up for patients but this should not be the only reason for a referral to their team). Identify any barriers to discharge i.e. housing and/or benefits etc. 45 of 126

47 Agree a clear post discharge plan Arrange next CPA\discharge review if required. 3. A copy of the completed review form to be given to all parties involved including The Bed Management Team. Document in the notes or on the CPA review form who copies have been sent too. 4. Discussion to take place about the best method of contacting the community team member regarding leave and discharge arrangements if they occur outside of the CPA review. Establish how weekly contact between the ward and CMHT is best achieved. If in doubt please contact the Bed Management Team to explore who needs to be involved. FIRST CPA/DISCHARGE REVIEW FOR PATIENTS WITH NO COMMUNITY INPUT (patient, carer/relative and any other agencies involved must be invited to attend if any are unable to attend their views must be obtained in writing or verbally and documented). 1. Must take place within the first 2 weeks of admission. 2. CPA review form must be completed. Named nurse to commence CPA review form prior to meeting. 3. Identify the planned discharge date. Identify and discuss any barriers to discharge and whether the patient is suitable for Early Discharge Plan (see previous page for contact number). 4. Discuss at the review whether a referral for a community team is needed and contact the Bed Management Team for specific teams contact details. Referrals need to be completed providing a clear rationale for the referral and the patient s current presentation. 5. A copy of the completed review to be given to all parties involved and documented in the patients notes. DISCHARGE / CPA REVIEW 1. Practitioner to prepare relevant documentation prior to the meeting, involving all relevant persons 2. Ensure risk assessment is discussed and updated. 3. Clarify whether the patient is to be discharged on CPA and that there is a written rationale if not. 46 of 126

48 4. Ensure that a 7-day follow-up plan is in place and that it is documented who will be doing this. 5. Ensure a clear aftercare, crisis and contingency plan is in place 6. Clarify discharge address and GP details 7. Clarify discharge medication and if 14 days is required due to risk issues. 8. Discuss completing an Advance Statement of Wishes or personal safety plan with either the community worker or ward staff? 9. Document the CPA review and ensure that all parties involved receive a copy including the GP. 10. If the CMHT are not present, ensure prior to the review that their views are documented and that they are informed of the outcome of the review either by phone. 7d) CPA and the Dynamic Psychotherapy Service The nature of the therapeutic relationship within the treatment model in this service means that certain local adaptations to the Trust CPA Policy are necessary. The process of both assessment and treatment in psychodynamic psychotherapy is non-directive and is focused on the patient s inner world. It would normally be assumed that referral for psychotherapy implies that a systematic and full assessment of a patient s health and social care needs has already been undertaken within primary or secondary care services. In the event of other, non-psychological needs becoming evident during the assessment, the psychotherapist will discuss with the patient how these might best be dealt with and what, if anything, might make it difficult for the patient to attend to these needs. As the therapeutic relationship is the cornerstone of the work, psychotherapists have minimal contact with relatives and carers, who are not included in assessment or treatment planning for psychotherapy. Because in most instances patients within the service have an in-depth therapy with a single psychotherapist as their sole care plan, without the necessity to coordinate care between agencies, it is unusual for them to require CPA. When other services are involved in the patient s care, it is usually appropriate for another agency to take the lead professional or care coordinator role. (Rationale: it is inappropriate for the psychotherapist to provide care outside of the weekly psychotherapy sessions, and it is usually unhelpful for the psychotherapist to be directly concerned other aspects of the patient s care. 47 of 126

49 Similarly, since the goal of psychotherapy is first to contain the patient s disturbance within the therapeutic frame and then to move towards increasing autonomy and responsibility for their own world, it is usually inappropriate for the psychotherapist to be involved with the patient s external world or to prepare contingency plans other than the weekly provision of psychotherapy.) Where patients are on CPA, because of complex needs or high levels of risk, they will require the input of a number of professionals. In these circumstances, psychodynamic psychotherapy may form part of the care package; however, the neutrality and preservation of therapeutic boundaries required by the therapeutic model preclude the psychotherapist from taking the role of Care Coordinator, so it is necessary that another professional involved in the care package is likely to be the best placed person to assume the role. In order to safeguard the therapeutic boundary, it will not generally be appropriate for the psychotherapist to attend case conferences or be in open communication with other members of the care team, but each situation is considered in its unique circumstances, in conjunction with the supervisor, the clinical director and/or consultant psychotherapist, as appropriate. For patients on formal CPA, communication with the care coordinator may be helpful prior to therapy, or at the point of a change in CPA status (i.e.at CPA Review). This will help to establish, clarify and agree the boundary between the psychotherapy service and the rest of the care team that will be in the best interests of the patients When agreed at a CPA Review that CPA and input from other services is no longer required, and input from the Dynamic Psychotherapy service is to continue, there must be agreement on the identification of the new lead professional. This must be recorded in the notes and on patient electronic system and the patient fully informed. In all cases, whether on CPA or not, any risk information which may affect the safety of the Patient or another person, must be shared with the care coordinator or lead professional where this person is based in another service. 7e) CPA and Therapy Services for People With Personality Disorder It is acknowledged that personality disorder is commonly associated with developmental problems with attachment issues, so consequently the way that individuals are transferred between services providing continuity of provision is essential for safe and effective transition between services. National guidance and the Trust CPA policy states that the CPA care co-ordinator should be the person who is best placed to oversee the CPA care plan. As the therapies offered, within Therapy Services for People with Personality Disorder, vary in intensity and length and are group based it is acknowledged that staff providing therapy may not be the person best placed to do this. The therapeutic frame of group therapy prioritises interpersonal learning occurring, in the here and now in the group situation, which may not always uncover issues pertinent to CPA, such as housing, finances, safeguarding etc. Therapists convening CPA meetings with only some individual patients in the group, can 48 of 126

50 skew the therapeutic relationships with the group in an unhelpful way, for instance creating envy, creating an identification with the sick role to gain staff attention, damaging the evenly suspended attention that the therapist holds for the group as a whole. NICE guidance for BPD states that community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder. In those instances where the therapy service provides group therapy for an individual but does not hold CPA care co-ordination, and where it is agreed that it is appropriate, staff from this service will be part of the care network and be involved with CPA reviews. The principle that any change in CPA care co-ordination or lead professional is by agreement requiring a full handover between them is acknowledged 7f) CPA and Huntington s Disease Services Whilst the HD service complies with the trusts CPA policy there are specific referrals that do not fit the criteria for screening for CPA. These include:- Northampton HD Advisory Service. If there is a need for CPA this is carried out by Northampton Mental Health Services Clients that are pre symptomatic of HD and wish to take part in Enrol HD research Clients at risk of HD who require a psychiatric assessment as part of the care pathway for genetic testing. Most of these clients, although not all are one off assessments. All other clients within the HD service will be screened for CPA. 49 of 126

51 Appendix 8: CPA and Risk Assessment Training CPA Training: CPA training will be half a day face to face training which is mandatory to all staff who join the Trust in mental health. CPA update training will be once every 3 years thereafter which can be either face to face or via e-learning. Risk Assessment Training: This will be half a day face to face training and is mandatory to all staff in mental health and learning disabilities service. Risk assessment update training will be once every 2 years thereafter which is again face to face. CPA training and risk assessment training should be attended by psychiatric social workers who are involved in the assessment and care planning patients with mental health issues. The CPA training and Risk Assessment training should be attended by psychiatric social workers who are involved in the assessment and care planning of patients with severe mental illness. Monitoring: All training will be recorded on ULearn and will be monitored by each of the directorates, CPA practice groups and the CPA Standards Group. Training Resources: The CPA and risk assessment training dates and trainers will be co-ordinated by CPA Lead. The CPA lead will liaise closely with risk training lead in reviewing the content of the CPA and risk assessment training. For risk assessment training the content will include scenarios based on serious incidents in the previous months from all the directorates. There will be a pool of trainers delivering the CPA and risk assessment training in the Trust. See Appendix 2 for training needs analysis. 50 of 126

52 APPENDIX 9 : Advance Statement of Wishes/Advance Decisions/Lasting Powers of Attorney WHAT IS IT ADVANCE DECISIONS (to refuse treatment) Oral or written decision to refuse medical treatment, in advance, if a person loses capacity in the future. Treatment cannot be demanded. ADVANCE STATEMENTS (of wishes) Expression of a person s wishes or preferences (as stated or written by the patient). Can cover many things including treatment preferences, childcare, accommodation and clarification of who to share information with. LASTING POWERS OF ATTORNEY A person gives authority to another to make decisions on their behalf. WHO MAKES DECISION? Patient Clinicians should take wishes into account but do not have to follow them if considered not appropriate Attorney AGE LIMIT 18 None 18 CAPACITY Need capacity to make Need capacity to make Need capacity to make. Personal welfare LPAs can only be used when donor lacks capacity. Property and affairs LPAs can be used even though donor still has capacity. LEGALLY BINDING? Yes takes effect as if person had capacity. NO Yes if registered at office of Public Guardian KEY POINTS Must be valid and applicable If refusing life sustaining treatment then formalities must be complied with, e.g. in writing Will be superseded by LPA made subsequently Can be overruled if the person is detained compulsorily under the MHA when treatment could be given compulsorily under Part IV When new MHA in force AD will be able to be used to refuse ECT. Not legally binding 2 different types Personal Welfare Property & affairs Attorney must exercise powers in best interests of patient Attorney cannot consent to or refuse treatment for a mental disorder in respect of a patient detained under the MHA. Jill Mason, Partner and Lead of the Healthcare Law and Mental Health Team at Mills and Reeves Solicitors 51 of 126

53 Appendix 10(a): Core Mental Health Assessment Form - Adult and MSHOP Core Mental Health Assessment Client PATIENT DO NOT USE, Test (Mr) Date of Birth 5 Jun 1974 NHS Number Date/time Presenting Situation Click Here For Guidance -This section is for 'presenting complaints' and 'history if present illness'. - It is not sufficient to say 'patient thinks there are no problems" since it is possible that a very ill psychotic her view on the original referral and concerns that others may have presented. -Present a coordinated history taken from patient and informants as a coherent whole, taking all perspectives into view. The expectations of the patient and family from this assessment can also be covered here. -First list all the chief complaints with duration of each. -Duration of untreated psychosis if relevant (onset of psychosis to start of antipsychotic medication). - In the history, detail every complaint, how it developed, how it stands now. - Whether the symptoms have had an acute or gradual onset. -In the history also mention if there have been any stressors of significance. - Mention socio occupational functioning and impact of symptoms on the same i.e day to day work/function. - Mention biological symptoms sleep, appetite, energy, sexual drive. 52 of 126

54 RISK FACTORS: - Have there been any acts or thoughts of harm towards self or others in the present episode? - Is the patient neglecting self-care or health? Are there indications of poor nutritional/fluid intake? - Are there symptoms which might affect the patient s judgement and impact on thoughts of harm to self or others? (example feelings of hopelessness may lead to suicidal thoughts, persecutory delusions may lead to the patient targeting the perceived persecutor, a manic patient may take impulsive risks leading to misadventure, overvalued ideas of body image in eating disorders may lead to patient putting health at risk, is the patient safe to drive?) - If there have been acts of harm towards self or others, details surrounding the act need to be takenwhat were the triggers, did the patient act on provocation or out of the blue, was he/she under influence of alcohol or drugs? - Take corroborative history from other sources to establish the validity of the history. Patient may deny risky behaviour but family may have other views. Include client/carer perspective; background of current episode; precipitating factors; treatments / interventions during current episode. Mental Health History Past Mental Health History Click Here For Guidance - Past history of contact with mental health professionals (to include mental health facilitators and IAPT in primary care and secondary psychiatric services. Remember to ask about CAMHS contact). - Past psychiatric admissions. - Past history of DSH and suicidal attempts. - Past diagnoses if available. - Also include all past treatments, concordance with the same and response- medication, psychotherapy, 53 of 126

55 other interventions. RISK FACTORS: Past history of risky behaviours is a reliable indication of future risks. If a patient has behaved in a certain pattern during an episode in the past, possibility of repetition of a pattern needs to be considered. For example self-harm/suicidal attempt every time a relationship breaks down, neglecting self-care and health, social isolation during every psychotic episode etc. This section is also useful in establishing triggers to an episode, work on early relapse markers to prevent an episode from becoming florid and stop it in the early stages. Associated risks become reduced automatically. Include previous symptoms, behaviours, diagnoses and interventions; admissions including those under the MHA; history of risk to self and others. Family Mental Health History Click Here For Guidance... - Family history of mental health problems/issues - Are they still with services - What kind of treatments they responded to - Family history of suicide, drug and alcohol abuse - If any of the above are not present, it is still worth mentioning the negative history, i.e. there is no family history of suicide, drug or alcohol problems etc RISK FACTORS: - Family history of suicide, mental illness and drug & alcohol abuse impact on risk. They show the genetic vulnerability of the patient and also influence early experiences which would have an impact on their personalities and coping styles 54 of 126

56 Forensic and Offending History Click Here For Guidance... - History of harm to others and property whether or not that has come to attention of the law. - What charges has the patient faced? - Has there been a custodial sentence? - Are there any ongoing legal cases? - Is the patient remorseful about past events, or does he/she give excuses for behaviour? - First age of violence towards others. RISK FACTORS: - This entire section is relevant for harm towards other and/or property. Include any current charges/probation. Alcohol and Substance Use Click Here For Guidance... - Current use. - Age of starting use. 55 of 126

57 - Change in pattern recently if any. - Cannabis/alcohol. - Class A drugs - Any IV use. - Impact on mental health. - Contact with drug and alcohol services. - Audit tool if appropriate. - Referral to dual diagnosis if being considered- whether patient want to be referred, if not to explore reasons. RISK FACTORS: - Impact on mental health - Impact on physical health (iv use and blood borne diseases) - Patient neglecting physical health, other needs due to alcohol and substance abuse - Patient may undertake other risky behaviours to fund drug habit- stealing, violence, prostitution - Actions in intoxicated states may be impulsive (getting into fights, overdoses, accidents) Include alcohol, tobacco, illicit substances and non-prescribed medication; past and present use; pattern of use; quantities and frequencies; harmful effects; motivation to change. Physical Health Physical Health History 56 of 126

58 Click Here For Guidance- In particular do mention... Click Here For Guidance - In particular do mention obesity/diabetes since they are important for the aspect of metabolic syndrome. - Impact that mental health may have on physical health i.e. nutritional deficiencies in eating disorders or severe depression. - Any illnesses which may impact on prescribing- asthma and beta blockers for anxiety symptoms, kidney or thyroid problems and lithium. - Any illnesses which may manifest as mental illness- hypothyroidism and depression. RISK FACTORS: - Does the patient have ongoing physical health problems which are exacerbated with the mental illness? Include past and current problems; nutrition; continence; sensory impairment; skin integrity; falls; mobility. Is a falls risk assessment required? Ple a s e S e le c t If Yes, complete a falls risk assessment form. Multifactorial Falls Assessment Comments 57 of 126

59 Family Physical Health History Click Here For Guidance... - Family history of diabetes, obesity is particularly important. Current Medication Click Here For Guidance -Use this section for recording all current medication, including non-psychiatric ones. That is important from the view of drug interactions. Include dose and frequency; method of administration; concordance. Allergies Include medication, food and other allergies; nature of reaction(s). 58 of 126

60 Pulse Blood Pressure Weight (Kg) Height (metres) BMI Personal Family History Click Here For Guidance -Childhood and development: - Birth. - Developmental milestones. - Family issues (example parental separation, abuse). - Contact with CAMHS if any. - Contact with social services, was service user in care. - Education and employment history: - List places of education and employment. 59 of 126

61 - Try to highlight consistent problems if any. - Mention bullying if significant. - Relationship History: - Sexual orientation. - First relationship. - Is patient currently in relationship/married. - Summary of relationships. - Domestic violence if relevant. - Premorbid personality: - Describe the person in general terms - Highlight features of personality disorder if present Highlight features of personality disorder if present - This is a very long section. The length of the subsections will vary according to the particular division a patient is being assessed in. For example for a CAMHS patient- the childhood and development is expected to be more elaborate. For an adult patient with personality disorder- premorbid personality needs more elaboration. The chaos in the patient s life may also be reflected in a turbulent relationship history. Keeping the above points in mind, the whole section should read life a continuous life story which gives us a holistic picture of the patient as an individual, apart from mental illness. RISK FACTORS: - This section gives a useful picture of the baseline of the patient before he/she became unwell especially in terms of personality. Features of borderline or antisocial personality, conduct disorder if present, should become apparent in this section. -Did the patient witness violence during upbringing or within relationships? Was he/she a perpetrator of domestic violence? - Are relationships well planned or impulsive? -What are the coping strategies used by the patient to deal with stressful situations? Include childhood and development; relationships with parents and siblings; employment history; significant/sexual relationships; spirituality and culture; hobbies and interests; pre-morbid personality. 60 of 126

62 Have you experienced physical, sexual or emotional abuse at any time in your life? Ple a s e S e le c t Brief details of any disclosure. If not asked, please state reason. Current, Social and Domestic Circumstances Click Here For Guidance... - Current accommodation; who patient lives with. Social History / Care Management - Financial situation. - Benefits. 61 of 126

63 - Social networks/supports. - Contact with children. - The section for names of children and their dates of birth have been taken out since they will not be relevant for the majority of patients. However, if the assessor feels this information is necessary, this is where that should be inserted. RISK FACTORS: - A patient with little support is more at risk in difficult situations compared to one with more supportive networks. - Accommodation, finance are immediate practical factors for the well-being of the patient. - Contact with children, especially less than one year of age to be well elaborated to see whether any risks exist. - This is the section to elicit whether the patient is at risk from other people: risk of exploitation, violence. Include activities of daily living (washing; dressing; laundry; shopping; cooking; household tasks; use of appliances); current care and support network (family and friends; nurse; social worker; home carers; other statutory and voluntary services); environment and accommodation; financial issues (benefits; debt; problems with budgeting; and LPA); caring responsibility (children/other; details of responsibilities including ages of children). Mental State Examination Click Here For Guidance - Appearance and behaviour including eye contact - Speech - Affect or mood/subjective/objective - Thought 62 of 126

64 - Stream (normal, slowed down, accelerated) - Form (eg: loosening of associations, derailment, word salad etc) - Possession (insertion, withdrawal, broadcast) - Content (delusions, overvalued ideas, depressive ruminations etc. Description of anxiety and depressive symptoms) - Perceptual disturbances including hallucinations of all modalitiesperceptual disturbances including hallucinations of all modalities - Thoughts of harming self or others- in the context of psychopathology that has already been elicited. - Insight: what is the patient s perspective on his/her need for help? What does he/she want to see happening? - What does he/she want in terms of treatment? RISK FACTORS: - Particular thoughts/beliefs leading to the patient harming self, others or property would be elicited here. - Beyond direct violence/abuse, illnesses may have other impacts (ex: manic patient who believes he/she is a millionaire gives away all his/her property saying he/she can afford it, psychotic patient accuses boss of putting cameras in his house and loses his/her job.) Include appearance and behaviour; speech; mood; suicidal ideation; thought form; thought content (delusion, overvalued ideas, obsessions); perceptions; cognition; insight. Formulation/Summary Formulation/Assessment Summary including risk summary Click Here For Guidance of 126

65 - This is an overall summary taking into consideration all the key points in the assessment leading to a diagnosis or a summary of problems elicited which need to be treated. - Risks should be especially highlighted. Click here to enter ICD10 diagnosis Click here to enter Cluster Management Plan including risk management plans and physical health monitoring Click Here For Guidance.. - Include medical/social/psychological aspects. - Make a special emphasis on risk and what is being done to address specific risks Any aspect of physical monitoring that the GP needs to be told about as a requirement to carry out example a need for ECG or bloods Has a risk assessment tool been completed as per Trust policy? Ple a s e S e le c t Recovery focused healthy lifestyle plan Any issues with smoking, alcohol, drugs, diet and exercise? 64 of 126

66 Subject to CPA? Ple a s e S e le c t Rationale Click Here For Guidance... - People on CPA are expectedly more complex, have more intense needs, have a number of agencies/services involved requiring co-ordination. If they are less complex, present with less risk, less professionals involved, CPA may not be relevant, though the principles of good practice still remain applicable. Points to consider are: - Complex multiple care needs - Severe mental disorder/illness (including personality disorder) with a high degree of clinical complexity or a learning disability with additional co-morbidity -A high degree of risk - Current or recent application of the Mental Health Act - Current or recent application of the Mental Health Act - Involvement from a range of different agencies - A care plan which would benefit from co-ordination under a formal framework 65 of 126

67 Click here to record CPA status Now complete the Physical Examination form Tick this box to make this form read only Core Mental Health Assessment Version: 1.1 Updated: 31/07/15 66 of 126

68 Appendix 10(b): Core Mental Health Assessment Form used in CAMHS 67 of 126

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79 Appendix 11 (a): Risk Assessment Form Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Risk Assessment Patient Risk Assessment information There exists one or more completed Risk Assessment forms: Yes No Date: Delete as appropriate Risk Incidents History Harm to self e.g. suicide, self-harm, wandering/ falls/ substance misuse/bereavement-loss Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Act with suicidal intent Self-injury or harm Suicidal ideation Self-neglect Other Please specify your reasons for choosing Yes in this category Past History Yes No Not known Harm from others e.g. all forms of abuse including any domestic violence issues, neglect, exploitation Any identified risks? Yes No If Yes, select appropriate factors below Risk of neglect Risk of sexual exploitation Risk of emotional psychological abuse including bullying Risk of unlawful restrictions (e.g. locks on doors, physical restraints, etc.) Risk of physical harm Risk of financial abuse Risk caused by medication / services / treatment Domestic Violence Current Yes No Not known Past History Yes No Not known 78 of 126

80 Other Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Please specify your reasons for choosing Yes in this category Harm to others e.g. aggression, violence, associated criminality, exploitation, abuse, neglect of others Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Sexual assault (including touching / exposure) Violence/aggression/abuse to others and / or property Arson Hostage taking Weapons Risk to children Is the patient/ partner pregnant, are there any children less than one year old in the household who are at risk? Exploitation of others (e.g. financial, emotional) Stalking Risk to vulnerable adults Domestic Violence/ safeguarding Other Please specify your reasons for choosing Yes in this category Past History Yes No Not known Accidents Any identified risks? Yes No If Yes, select appropriate factors below Falls Accidental harm outside the house (e.g. wanderings) Unsafe use of medication Driving/road safety Current Yes No Not known Past History Yes No Not known 79 of 126

81 Other accidental harm at home Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Other Please specify your reasons for choosing Yes in this category Other risk behaviours Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Incidents involving the police Correspondence Phone calls Restricted patient MAPPA Schedule 1 Absconding/escape Visitors Sex offenders Act 2003 Probation Service involvement Theft Other Please specify your reasons for choosing Yes in this category Past History Yes No Not known Physical Health Any identified risks? Yes No If Yes, select appropriate factors below Falls Substance abuse (including smoking and alcohol) Nutrition Current Yes No Not known Past History Yes No Not known 80 of 126

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83 Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Venous thromboembolism (VTE) Memory and Cognitive impairment Long term conditions Allergies Other Please specify your reasons for choosing Yes in this category Risk Formulation and Management Summary Factors increasing risk, factors reducing including support network, risk formation and risk management summary. The factors to be considered are: Substance misuse (e.g. alcohol/drug abuse),risk of losing essential services, major life event, current mental state, patient would be unable to summon help, refusal of services, discontinuation of medication, housing status, patient is unaware of risk, patient s care network is unaware of risk, protective factors (such as family, support network), others. This list is not exhaustive. Assessment Completed by: Date for Review: 82 of 126

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85 Appendix 11 (b): CAMHS Risk Assessment Form Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Risk Assessment Patient Risk Assessment information There exists one or more completed Risk Assessment forms: Yes No Date: Delete as appropriate Risk Incidents History Harm to self e.g. suicide, self-harm, wandering/ falls/ substance misuse/bereavement-loss Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Act with suicidal intent Self-injury or harm Suicidal ideation Self-neglect Other Please specify your reasons for choosing Yes / No / Not Known in this category Past History Yes No Not known Harm from others e.g. all forms of abuse including any domestic violence issues, neglect, exploitation Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Past History Yes No Not known Risk of neglect Risk of sexual exploitation Risk of emotional psychological abuse including bullying Risk of unlawful restrictions (e.g. locks on doors, physical restraints, etc.) Risk of physical harm Risk of financial abuse Risk caused by medication / services / treatment Domestic Violence Other Please specify your reasons for choosing Yes / No / Not Known in this category 84 of 126

86 Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Harm to others e.g. aggression, violence, associated criminality, exploitation, abuse, neglect of others Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Sexual assault (including touching / exposure) Violence/aggression/abuse to others and / or property Arson Hostage taking Weapons Risk to children Is the patient/ partner pregnant, are there any children less than one year old in the household who are at risk? Exploitation of others (e.g. financial, emotional) Stalking Risk to vulnerable adults Domestic Violence/ safeguarding Other Please specify your reasons for choosing Yes / No / Not Known in this category Past History Yes No Not known Accidents Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Falls Accidental harm outside the house (e.g. wanderings) Unsafe use of medication Use of Motorised Vehicles / Road safety Other accidental harm at home Other Please specify your reasons for choosing Yes / No / Not Known in this category Past History Yes No Not known 85 of 126

87 Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Other risk behaviours Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Incidents involving the police Correspondence Phone calls Restricted patient MAPPA Schedule 1 Absconding/escape Visitors Sex offenders Act 2003 Probation Service involvement Theft Other Please specify your reasons for choosing Yes / No / Not Known in this category Past History Yes No Not known Physical Health Any identified risks? Yes No If Yes, select appropriate factors below Current Yes No Not known Falls Substance abuse (including smoking and alcohol) Nutrition Pressure Sores Venous thromboembolism (VTE) Memory and Cognitive impairment Long term conditions Allergies Other Please specify your reasons for choosing Yes / No / Not Known in this category Past History Yes No Not known 86 of 126

88 Risk Formulation and Management Summary Factors increasing risk, factors reducing including support network, risk formation and risk management summary. The factors to be considered are: Substance misuse (e.g. alcohol/drug abuse),risk of losing essential services, major life event, current mental state, patient would be unable to summon help, refusal of services, discontinuation of medication, housing status, patient is unaware of risk, patient s care network is unaware of risk, protective factors (such as family, support network), others. This list is not exhaustive. Assessment Completed by: Date for Review: 87 of 126

89 88 of 126

90 Appendix 12 Therapeutic Risk Taking Tool Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Date of assessment and agreed decision: Details of therapeutic risk being taken: Risk being taken (What has been agreed with the Service User?): Describe the known actions or behaviours which may present a risk: State reasons why it has been agreed clinically appropriate to take this risk: Detail the therapeutic benefits/outcomes for the service user: Detail the protective factors in place/strengths of service user to support the risk taking: 89 of 126

91 Patient Name: Patient Date of Birth: Patient NHS Number: Date of Assessment: Details of crisis/contingency plans in place: How are these to be managed in this specific risk taking situation: Outcome of this Therapeutic Risk Taking exercise: To be reviewed on: (date) By: Persons involved in the discussion and agreed decision for this therapeutic risktaking: (collective accountability); (signatures): Date: Service User signature: Date: Carer signature (if applicable): Date: 90 of 126

92 Appendix 13: Copying Correspondence to Patients Consent Form Name: DOB: I have read the leaflet Copying Care Plans and Correspondence to Patients and would like the following to take place (please delete as applicable): CARE PLAN CORRESPONDENCE to receive copies ---- yes/no to have this posted to me yes*/no yes*/no to be provided with copies at my next appointment yes/no yes/no I would not like to receive my own copies but would like to read this at my next appointment yes/no *Please send documents I have requested be posted to the following name and address: Name: Address: 91 of 126

93 I understand that I am responsible for the safe keeping of any care plan or correspondence that has been given to me. I understand that I must inform my health team in writing if any of the above instructions are to be changed. If the correspondence is being sent to someone else s address, I can confirm that they have agreed to receive the information on my behalf. Signed: Date: 92 of 126

94 Appendix 14: CPA/Non CPA Review Form CPA Review Patient Name: Patient Date of Birth: Patient NHS Number: Date of Review: Venue of Review: Care Co-ordinator/Lead Professional: Invited Participants: Attended Contributed Absent/ Declined Participants summary since last review: Current mental state: Current medication: Care Plan with risk management and crisis plan 93 of 126

95 Risk - changes since last review: Attach the updated Risk Assessment Summary tool. Cluster: ICD 10: Change in CPA status? CPA Status (if not on CPA give rationale) CPA Care Plan amended? Change of diagnosis if any with rationale: Abuse Question asked? Tick appropriate box Yes: Has Patient (and Carer by agreement) been given an updated copy? No: No changes to the Care Plan No, the patient was not asked Yes, the patient was asked Section 117 and CTO Review: Date of next review: Date and change of care co-ordinator: Care coordinator / Lead Professional name and signature: Consultant psychiatrist 94 of 126

96 name and signature: FOR COMPLETION AFTER THE CPA REVIEW MEETING Copies of CPA review sent to DATE SENT to those identified as per instruction Sent by: Signature Print Name 95 of 126

97 Appendix 15: CPA Care Plan Care Plan Patient Name Patient Address Patient Phone Number Patient Date of Birth Patient Gender Patient NHS Number Main Carer Name Main Carer Relation Main Carer Address Main Carer Post Code 96 of 126

98 Main Carer Phone Number Patient Next of Kin Patient Nearest Relative Patient CPA Level Start Date Date of Last Review Date of Next Review Date Care Plan Printed Detained under MHA? Subject to Section 117 Subject to CTO Care Team Details Your Care Co-ordinator is 97 of 126

99 Phone No of Care Co-ordinator This is / These are who to Contact, When and How: During Office Hours Outside Office Hours (evenings, night-time, weekends) Written Information Type Given by Whom Given Date CPA Mental Health Needs Medication Including Purpose and Side Effects Copies of Care Plan Distributed to Date Client 98 of 126

100 Carer Responsible Clinician General Practitioner Community Psychiatric Nurse Occupational Therapist Social Worker Community Learning Disability Nurse Speech and Language Therapist Physiotherapist Crisis and Contingency Plan Who will be Caring for any Dependants? 99 of 126

101 Relapse Indicators / Early Warning Signs Name Signature Date Patient Patient agrees to Carer receiving copy of Care Plan (if applicable) Care Co-ordinator 100 of 126

102 Appendix 15a : Outpatient Care Plan letter template for patients not on CPA IN STRICT PROFESSIONAL CONFIDENCE NOT TO BE DISCLOSED WITHOUT PRIOR CONSENT OF THE SIGNATORY Date: RE: NHS NO: Review Date: AGREED CARE PLAN (Not Registered for Care Programme Approach) Problem summary/diagnosis/icd Code: HoNOS Score/Cluster (date): Recommended Medication: Plan: Healthy Lifestyle Plan (any issues with smoking, alcohol, drugs, diet and exercise): Physical Health monitoring (if any): Lead Professional: Risk Assessment: Crisis Plan: In a crisis during office hours contact Lead Professional on [INSERT NO] or GP. Outside office hours please either contact your out of hours GP service or if you would like to speak to someone for guidance and support, please ring the Richmond Fellowship telephone helpline on This is a telephone helpline run in conjunction with Leicestershire Partnership NHS Trust. Appointment for next review: An Advance Statement has been completed: Risk Summary: GP to Note: Details of Assessment: Mental State Examination: 101 of 126

103 Opinion: 102 of 126

104 Appendix 15b - CAMHS Outpatient Template for patients on non CPA IN STRICT PROFESSIONAL CONFIDENCE NOT TO BE DISCLOSED WITHOUT PRIOR CONSENT OF THE SIGNATORY Date: RE: NHS NO: Review Date: AGREED CARE PLAN (Not Registered for Care Programme Approach) Problem summary/diagnosis/icd Code: HoNOSCA Score (date): Recommended Medication: Agreed Care Plan (including physical monitoring): Lead Professional: Crisis Plan: In a crisis during office hours contact lead professional on Out of hours to contact GP who will assess the situation and make contact with an out of hours crisis worker if thought to be appropriate Consent and confidentiality discussed and permission to contact and discuss the case with the following professionals was provided. Appointment for next review: An Advance Statement has been completed: 103 of 126

105 Appendix 16: Patient Personal Safety Form for patients on CPA (Attaching to and forming part of a care plan) Name:. Date of birth:./../. Date: /./. ID no:.. When I am well, the following helps me to remain stable: When I am unwell: The following makes me feel safe: The following makes me feel unsafe: The following things need to be taken care of in my personal life: I want the following people to be informed: I do not want the following people to be informed: 104 of 126

106 The following are my usual early warning signs of relapse: This is my plan of action if early warning signs show: This is my plan of how to avoid the above danger situations: This is my plan of how to manage the above danger situations if I can t avoid them: The following are the staff I prefer to work with me when I am unwell: The following are my preferred interventions, treatment approaches, medication etc when I am unwell: The following interventions etc should be avoided when I am unwell. Signatures: Patient: Practitioner: 105 of 126

107 Appendix 17: Covering letter to patient regarding assessment forms/cpa review form which is copied to all relevant professionals (including GP) and carer Dear (Patient) Thank you for attending the..(assessment/cpa review/meeting) on / Please find enclosed the following documents (whichever is applicable): Core Mental Health Assessment Form CPA Review Form Care Plan Personal Safety Plan Risk Assessment Form Should you need to discuss any part of the document please let me know. Yours sincerely Care Co-ordinator/Lead Professional Copy: GP Other professionals 106 of 126

108 Appendix 18 : Outpatient Care Plan letter template for patients on CPA IN STRICT PROFESSIONAL CONFIDENCE NOT TO BE DISCLOSED WITHOUT PRIOR CONSENT OF THE SIGNATORY Date: RE: NHS NO: Review Date: AGREED CARE PLAN ( Registered for Care Programme Approach) Problem summary/diagnosis/icd Code: HoNOS Score/Cluster (date): Recommended Medication: Plan: Healthy Lifestyle Plan (any issues with smoking, alcohol, drugs, diet and exercise): Physical Health monitoring (if any): Lead Professional: Risk Assessment: Crisis Plan: Appointment for next review: In a crisis during office hours contact Lead Professional on [INSERT NO] or GP. Outside office hours please either contact your out of hours GP service or if you would like to speak to someone for guidance and support, please ring the Richmond Fellowship telephone helpline on This is a telephone helpline run in conjunction with Leicestershire Partnership NHS Trust. An Advance Statement has been completed: Risk Summary: GP to Note: Details of Assessment: Mental State Examination: Opinion: 107 of 126

109 Appendix 19: CPA Service gaps GAPS IN SERVICE FORM SERVICE: Adult MHSOP LD CAMHS Spec Serv Other: state which service: Inpatient services Community services Patient Name: Date of Birth: CPA yes no Care Co-ordinator Name: or Lead Professional Name: Please identify the area of deficit and provide detail. Accommodation Appropriate out-of-hours services Transport Employment Leisure Education Culturally appropriate services Day Services 108 of 126

110 Respite Therapies Resources/Organisational (related to delivery of CPA Care Plan) Other(state) Please provide details of Gap in Service, continuing on another page if necessary: ACTION taken by Line Manager: Date: For notes on use of this form see over 109 of 126

111 USE OF THE GAPS IN SERVICE FORM Record any unmet need on this Gaps in Service form. Give as much detail as possible. Related information should also be documented within the CPA Review meeting notes. Scan the form on patient electronic system and send the original to the line manager for action. In the effort to resolve any Gap in Service, a copy of the form should go through the appropriate line management system up to Service Director level for further input. Each level of management should keep a copy of the form and make every effort to resolve the problem. If not resolved by CPA Standards Group to escalate to Clinical Effectiveness Group 110 of 126

112 Appendix 20: CPA Service Gaps Learning Disability Version Gaps in Service Form / 01 /15 Name NHS No.: Date: Care Co-ordinator Tel. No.: Your home Support in the evenings and at weekends 111 of 126

113 Transport Things to do Work Money Medication 112 of 126

114 People working with you Education/College Day Care Respite Other things 113 of 126

115 Appendix 21: The NHS Constitution The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimize errors Support and value its staff Work together with others to ensure a seamless service for patients x x x x x Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance x x 114 of 126

116 Appendix 22: Stakeholder and Consultation CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Dr G Kunigiri Mark Griffith Consultant Psychiatrist and Chair of CPA Standards Group CPA Lead Circulated to the following individuals for consultation Name Jacqueline Burden Heather Darlow Vicki Spencer Tracey Finnamore Richard Holland Ian Redfern Sarah Morris Claire Rashid Teresa Smith Jacqueline Moxon Designation Clinical Governance Lead for AMH & LD Divisional Governance Lead, CHS Clinical Governance & Quality Lead for FYPC Chair, LD CPA Practice Group PIER Team and Co-chair FYPC Practice Group Head of Service, Leicestershire County Council City Social Care Clinical Effectiveness Lead, Quality and Innovation Executive Director, CPA Standards Group RIO project manager 115 of 126

117 Sue Scarborough Dr. Satheesh Kumar Michelle Churchard Fern Barrell Claire Armitage Dr Saquib Muhammad Information Analyst Business Development Medical Director Senior Advisor, Learning Disabilities Risk Assurance Co-ordinator Risk Management Department Lead Nurse, Adult Mental Health Deputy Medical Director 116 of 126

118 Appendix 23 - Protocol for CPA Responsibility for Out of Area Placements monitored by GEM 1. It has been agreed with commissioners and Greater East Midlands Commissioning Support Unit (GEM) where a patient has been placed in an Out Of Area (OOA) Hospital that the care coordinator responsibility will transfer at the point of discharge from Leicestershire Partnership Trust (LPT) to the OOA provider. 2. GEM will attend reviews and monitor placement 3. LPT community staff will be expected to re-engage with the patient at the point the OOA Unit commences discharge planning. 4. The OOA Unit is expected to inform LPT of the date and time of the CPA Meeting where the proposed discharge will be discussed. 5. If the patient is not known to a LPT community services the referral will need to be sent to the Locality Team which covers the patient s last address and registered GP. 6. If the patient is detained under the Mental Health Act and the Section 117 responsibility lies with Leicester, Leicestershire or Rutland and there is a request for a Social Circumstances report the responsibility for this lies with the last community care coordinator (Health or Social Care). If the patient is not known to any community team then a referral should be made to the relevant local authority for completion of the report. 1 st August of 126

119 APPENDIX 24 - Inpatient CPA Process Flow Chart Admission All patients on CPA Refer CMHT to allocate CPN Not allocated inform Team Manager / Service Manager Invite all stakeholders, including GP for CPA meeting in 2 working days. Initial CPA Meeting CPA Disharge Meeting Held within two weeks of admission Invite all stakeholders Put CPA meeting date on RiO Complete CPA review document Complete / update Risk Assessment Circulate CPA review minutes to GP Give copy of CPA review minutes to patient Put CPA meeting date on RiO Invite all stakeholders Complete CPA Review document Complete CPA Care Plan Complete / update Risk Assessment Give copy of CPA Review / Care Plan to patient Copy GP into CPA Review minutes and Care plan Discharge on CPA Discharged on Non CPA Change name of Care Co-ordinator 7 day follow up by Care Coordinator / Early Disharge Team (EDT) if involved Involved with EDT Not involved with EDT Named Ward Nurse contact patient within 48 hours of discharge. Complete 7 day follow up template either face to face or over telephone and send to GP 118 of 126

120 APPENDIX 25 Everyone Counts: Planning for Patients 2014/ /19: Technical Definitions for Clinical Commissioning Groups and Area Teams E.B.S.3: Mental Health Measure Care Programme Approach (CPA) DEFINITIONS Detailed Descriptor: Care Programme Approach (CPA) 7 day follow up. The proportion of those patients on Care Programme Approach (CPA) discharged from inpatient care who are followed up within 7 days. Lines Within Indicator (Units): The indicator is the numerator divided by the denominator, expressed as a percentage. Numerator: The number of people under adult mental illness specialties on CPA who were followed up (either by face to face contact or by phone discussion) within 7 days of discharge from psychiatric in-patient care. Denominator: The total number of people under adult mental illness specialties on CPA who were discharged from psychiatric in-patient care. All patients discharged from a psychiatric in-patient ward are regarded as being on CPA. Data Definition: All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within 7 days of discharge. All avenues need to be exploited to ensure patients are followed up within 7 days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team. Exemption: Patients who die within 7 days of discharge may be excluded, Where legal precedence has forced the removal of a patient from the country, Patients transferred to NHS psychiatric inpatient ward, CAMHS (child and adolescent mental health services) are not included. The 7 day period should be measured in days not hours and should start on the day after the discharge. MONITORING Monitoring Frequency: Quarterly Monitoring Data Source: Unify2 119 of 126

121 ACCOUNTABILITY What success looks like, Direction, Milestones: Achieving at least 95% rate of patients followed up after discharge each quarter Timeframe/Baseline: Ongoing Rationale: Reduction in the overall rate of death by suicide will be supported by arrangement for securing provision by commissioners of appropriate care for all those with mental ill health. To reduce risk and social exclusion and improve care pathways to Patients on CPA discharged from a spell of in-patient care. PLANNING REQUIREMENTS Are plans required and if so, at what frequency? CCG No. Area Team - No 120 of 126

122 Appendix of 126