BOARD OF DIRECTORS MEETING 10 th August 2016

Transcription

1 BOARD OF DIRECTORS MEETING 1 th August 216 Open BoD Item Ref No: 6 TITLE OF PAPER Mental Health Reconfiguration Update TO BE PRESENTED BY Dr Rachel Warner, Medical Director Richard Bulmer, Service Director ACTION REQUIRED To report progress and information OUTCOME To review paper and agree any defined next steps in the ongoing mental health reconfiguration projects. TIMETABLE FOR DECISION Feedback to be given in the meeting LINKS TO OTHER KEY REPORTS / DECISIONS Links to community developments and estates strategy LINKS TO OTHER RELEVANT FRAMEWORKS BAF, RISK, OUTCOMES ETC NHS Constitution: Patients Public Staff HSE MH Act Equality Act 21 IMPLICATIONS FOR SERVICE DELIVERY AND FINANCIAL IMPACT CONSIDERATION OF LEGAL ISSUES Not Applicable Author of Report Lisa Johnson, Deputy Director Designation Inpatient Directorate Date of Report 1/8/216 C:\Users\jeanineh\Documents\Board of Directors\216\8 August 216\6(1) Open BoD August Summary sheet mental health reconfiguration update doc

2 Report to: BOARD OF DIRECTORS SUMMARY REPORT Open BoD Item Ref No: 6 Date: 1 th August 216 Subject: From: Mental Health Reconfiguration update Dr Rachel Warner, Medical Director Richard Bulmer, Service Director 1. Purpose For Approval For a collective decision To report progress To seek input from For information Other (please state below) x x 2. Summary The attached paper provides an update about projects in acute care and rehabilitation. This includes the closure of Rowan ward resulting in a three acute ward model. It also includes the development of the single site for inpatient rehabilitation at Forest Close, Pinecroft Ward has now closed with services relocated. The paper also provides quality and performance data including information on acuity. 3. Next Steps To continue with the reconfigurations in acute care and rehabilitation services. Monitoring of both quality and performance data will continue with updates provided as agreed / requested. 4. Required Actions To review information provided, discuss and agree next steps. 5. Monitoring Arrangements This will continue to be monitored through the Mental Health Reconfiguration Programme Board, chaired by the Medical Director, Business Planning Group and the Executive Directors Group. The Efficacy and safety of the services will continue to be monitored through existing governance structures. In addition to this the changes will be audited to assess the overall impact. 6. Contact Details Richard Bulmer Richard.bulmer@shsc.nhs.uk C:\Users\jeanineh\Documents\Board of Directors\216\8 August 216\6(1) Open BoD August Summary sheet mental health reconfiguration update doc

3 Open BoD Item Ref No: 6 Mental Health Reconfiguration Update 29 th July 216 1

4 Contents Page 1. Introduction 1 2. Summary of progress 1 3. Activity and acuity data 6 4. Directorate Staff wellbeing and sickness Service user feedback and outcome measures Risk and mitigation Next steps Finance Items of note or concern 18 Appendix a. GANNT Chart 19 Appendix B cluster descriptions 2 2

5 1. Introduction The Inpatient Directorate are continuing to develop its programme of reconfiguration across acute care and rehabilitation services. The aims of the reconfiguration is to deliver as much care as possible in the community with admissions to hospital only taking place when absolutely necessary and for the shortest time clinical appropriate to meet the needs of the service user and also to avoid the need for out of city rehabilitation placements. This paper provides updates on this programme of reconfiguration, identifying key milestones, finances, performance, risk and mitigation, challenges and next steps. It includes a summary of the progress with phase 1 of the changes in acute care and rehabilitation including the closure of Pinecroft and Rowan Wards. This has enabled the agreed investment 2. Summary and updates from last report Award Nominations In May 216 the Directorate submitted nominations to the Positive Practice in Mental Health awards for a number of categories including Acute care pathway, Partnership working and Mental wellbeing of staff. We are very pleased to have been shortlisted to the final three for both the Mental well-being of staff and Acute care pathway categories. This is against what has been identified by the collaborative chairs as a high standard across the country. In more detail our Transforming Acute Mental Health Care in Sheffield nomination included details about reduction in length of stay, development of the crisis house, bed management meetings, the new PICU. The nomination also focussed on how we have eliminated out of town admission for acute care due to lack of capacity. The nomination also highlights how our strategies for acute and rehabilitation services have been developed and implemented The nomination for Whole team approach to staff support in CERT included details of the role of Psychology in order to work alongside MDT, deliver direct psychological assessment, aid risk management and positive risk taking, case formulation and working with the staff team in reflective practice. We will hear about the outcome of the awards in the autumn of 216. Acute inpatient care including Dovedale The reconfiguration strategy for acute care includes a plan to provide acute inpatient hospital provision from the Longley Centre site. Phase 1 of the Longley Centre development has now been completed and the PICU is open. The next stage is to design the rest of the Longley unit and agree what is based there as well as the plan for moving services into that site. 3

6 The closure of Rowan Ward took place ahead of schedule, releasing the funds to improve staffing levels on the remaining wards, increase 136 funding as well investments in community provision. We are progressing with the plan to create single site for acute care at the Longley Centre. The initial stage of the phase 2 capital development at the Longley Centre is to recruit a design team (architects, project management, quantity surveyor and mechanical / engineering). The recruitment of the design team is underway. The recruitment process for this is following the Fusion 21 framework and consisted of a two day process made up of an engagement event to score based on values and a technical interview on day 2. This event was predominantly attended by staff and service users as well as being part of the recruitment process this time was used to gather feedback about how the Longley Centre should be designed. There will now be a stage two interview. Once recruited the design team will work with us and start by drawing up designs for the building which will then be used to recruit the contractors. Rehab update The plan to create a single site for inpatient rehabilitation at the Forest Close site has been delivered ahead of schedule. This included the closure of Pinecroft ward at the Longley Centre. There have been no out of city placements due to lack of capacity and we are continuing to return those still in out of city placements back in Sheffield. There are currently 18 people out of city units. This is ahead of our timeline plan and we are on track to have only 6 people out of city by the end of the financial year. The building works have now been completed at Forest Close which have enabled all inpatient rehabilitation to now be based on that site. Pinecroft ward moved from the Longley Centre to the Forest Close site on the 6 th June 216. Away days are being carried out for staff and these have been well received.. Quality and Dignity surveys are being carried out to gather service users feedback and this form is being amended so that it is suitable for CERT. We are also working with our service user lead Richard Fletcher to review this along with SUEMU. 4

7 The current position against forecast for service user location in the rehab system is below: Out of city CERT Forest Close Actual (27 +2 in reach) 31 Planned Current financial position and prediction (rehab): Current expenditure Forecast financial year expenditure 263,865 (over*) Breakeven ** The current over expenditure is due to a disinvestment of funds and CIPs, as well a revision of timetable for service user return. The delay on returns was due to building work and MoJ restrictions. The end of year prediction is that finance will breakeven with full CIP achievement. A timeline for these projects is included in Appendix A. 5

8 3.Activity and acuity data 3.1 Admissions, Length of stay and occupancy a. Admissions Acute admissions Acute admissions Jun 13 - Jun 16 Admissions UCL LCL Acute includes Stanage, Burbage, Maple and Rowan (until April 216). Admissions remain constant but there have been no spikes in admission numbers per month there are still sometimes weeks with higher admissions which can put more pressure on occupancy levels. Dovedale admissions Admissions Dovedale Jul 13 - Jun 16 Admissions UCL LCL The admissions to Dovedale have reduced over time, with the range reducing from 12 to 4 down and is now 3 to 7 per month. 6

9 3.1 b Length of Stay Acute Inpatient - Length of Stay (Adult Acute) Length of Stay UCL LCL Acute includes Stanage, Burbage, Maple and Rowan (until April 216). There has been a slight increase from February 216 onwards. We will continue to monitor this to get to the overall aim of 31 days. Length of stay Dovedale 25 Inpatient Length of Stay (FI) Length of stay UCL LCL This has often been above 1 days and has varied over time. Although this still remains above the 1 day mark, some consistency has occurred. There has however been a reduction in the last few weeks and this continues to be 7

10 monitored in order to reduce length of stay. Please note the break in the line is due to there not being a discharge in the trimmed information for June Length of stay (ITS) Length of stay UCL LCL The Length of stay on Endcliffe has stabilised to around 3 days from August 215 onwards and benchmarks well nationally. 3.1 c Bed occupancy Bed Occupancy Adult Acute Bed Occ % UCL LCL 8

11 12 Bed Occupancy Older Adult Bed Occ % UCL LCL Due to the reduction in bed number over this period the occupancy levels have increased. We are continuing to work proactively with inpatient and community teams to manage the number of admissions and the length of stay. There have been periods of high occupancy recently on the acute wards, but this has now reduced as of 29 th July 216 it is one bed under for the acute system. We are continuing to work on this to maintain an optimum sustainable occupancy level. 3.2 Emergency Readmissions 15 Emergency Readmissions - Adult Acute and ITS 1 5 readmissions UCL LCL % readmissions There is some variance with this, but this has not exceeded the highest value in the range. 9

12 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Total No of Incidents 3.3 Incidents including Missing Patients 3.3 a Incidents 9 Incidents & Incidents with Harm All Incidents Incidents With Harm UCL LCL Incidents remain fairly constant, however a slight reduction is apparent in the number of incidents with harm All missing person incidences Missing Person Incidences UCL LCL This has reduced but remains within range of the upper and lower control limits. 1

13 percentage (%) Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Missing Persons on MHA Incidences Missing Persons on MHA UCL LCL The data shows varying figures for the numbers of missing patients. However a significant drop in the number of missing patients occurred in January and although a slight increase in February the following months still remain below average for this period. With a reduction in Mar and April and a constant between April and May. 3.4 Mental Health Act MHA acute % of detained patients 68 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 11

14 Percentage (%) This is now 85% of admissions based on bed nights. The increase could be linked to the bed reductions. 8 MHA Dovedale % of detained patients Feb-16 Mar-16 Apr-16 May-16 There has been a slight reduction in the % of detained patients on Dovedale. 3.5 Clusters The tables below show the number of cluster days per service type the 216 have been projected from end May 216 based on bed days to date. Details of the cluster descriptions included in Appendix B. 12

15 Number of Cluster Days Acute Cluster The reductions are likely to be as a result of reduced bed numbers. Number of cluster days Dovedale Cluster The cluster information generally shows a reduction from 214 to 215 in clusters 4 8 and 11-17, apart from cluster 1 which increased in 215 but is expected to drop in 216. The -3 cluster is remain low. 13

16 Jul-214 Aug-214 Sep-214 Oct-214 Nov-214 Dec-214 Jan-215 Feb-215 Mar-215 Apr-215 May-215 Jun-215 Jul-215 Aug-215 Sep-215 Oct-215 Nov-215 Dec-215 Jan-216 Feb-216 Mar-216 Apr-216 May-216 Jun-216 Number of cluster days PICU Cluster The cluster information for 1 generally shows a increase from 214 to 215 followed by an expected decrease in 216. Cluster show a substantial decrease in 215 followed by a rise in Compliments and Complaints Inpatient - Complaints & Compliments Inpatient Formal Complaints Inpatient Oral Complaints Inpatient Compliments The number of complaints has remained fairly consistent over the years. Compliments has varied quarter to quarter. 3.7 Beds of care 14

17 Total beds of care/ occupancy for whole age range acute in and out of city Number of out of town bed nights 211/12 212/13 213/14 214/15 215/ ( due to lack of capacity ) 3.8 Reducing Restrictive Practices The table below shows restrictive practice across all inpatient directorate services. (Rehab, Acute, Forest Lodge and CERT) All Restrictive Practice Instances (physical, chemical and mechanical) All restraint instances Number of Patients restraint 4 2 Rhodri Hannan, Assistant Service Director is working with Kim Parker and other professional leads on the reducing restrictive intervention programme for the directorate. This includes the Safewards programme as well as the specific focussed work on Endcliffe ward (information to be provided by Kim Parker). As a directorate we are developing the metrics for monitoring restrictive intervention such as time spent in seclusion and service user feedback through post incident review. 4. Directorate staff well-being and sickness levels 15

18 Jul-214 Aug-214 Sep-214 Oct-214 Nov-214 Dec-214 Jan-215 Feb-215 Mar-215 Apr-215 May-215 Jun-215 Jul-215 Aug-215 Sep-215 Oct-215 Nov-215 Dec-215 Jan-216 Feb-216 Mar-216 Apr-216 May-216 Jun-216 Inpatient - Percentage Sickness Absence 12.% 1.% 8.% 6.% 4.% 2.%.% Inpatient Sickness % Trust Wide Sickness % Trust Wide Sickness Target % This table shows sickness levels across the directorate. When looking at data team by team there have been some increase for forest close and maple ward the team most effected by change in the last 6 months. We are continuing to focus attention on support healthy team across the directorate. This includes psychologically informed reflective practice and team away days. The directorates nomination for staff well being has been successfully shortlisted to the final through in the positive practice in mental health awards. This nomination included evidence about reflective practice as well as ways of working in team such as CERT. 5. Service user feedback and Outcome Measures The quality and dignity survey are carried out by service user volunteers managed by SUEMU. The table below show how many of these were completed by month. A total of 127 were completed across the Inpatient Directorate in 215/16 this includes acute and rehab services. May June July August October December 215 November February April May June Lead individuals from the Inpatient SMT along with Richard Fletcher service user volunteer and the leads at SUEMU are meeting to review the contents of the 16

19 questionnaire in order to ensure this is manageable and that we can easily distil the essence of the information for feedback and reporting. As a directorate we want to use the requol as an outcome measure across our acute and rehabilitation services. 6. Risk and mitigation Management The systems for managing the acute care pathway have been further developed. This includes an enhanced monitoring system for Length of stay and anticipated discharge dates. This improved system is enabling us to more effective manage the acute care flow through the wards. We have also implemented and enhance bed management process in order to address the over occupancy on the acute wards. The service user flow meeting is working effectively, providing a forum to increase to the effectiveness of the interfaces wit community services such as home treatment and the crisis house. We are continuing to with rethink and community service to ensure that the crisis house is truly being used as an alternative to acute hospital admission. We are meeting to make recommendation s about how the specification for the crisis house and working practices for the home treatment needs to be in order for the crisis house to be consistently providing a true alternative to acute hospital admission. 7. Next steps 7.1 Acute inpatient care We will continue to engage with staff and service users as the concept and design work develops. This will be through existing forums such as SUNRISE, ward community meetings and Inpatient Forum as well as specific stakeholder events. Our engagement with governors and non executive directors is and will be by update at their meetings plus active inclusion in communication and invites to events and walk rounds. The management of the capital works is being led by Geoff Rawlings and Helen Payne. Geoff is developing a detailed timeline for this work that feeds into the high level reconfiguration GANT chart. Phil Easthope chairs the capital board which this work is feeding into from a financial governance and risk perspective. 7.2 Rehabilitation We will continue to deliver the plan to return service users form out of city. We are also monitoring and developing the pathways out of both inpatient rehabilitation and CERT. The rehabilitation programme is also feeding into the exciting developments for the Recovery College. We will give a summary of progress as part of the next update. The remaining work identified at Forest Close related to Bungalow 3 and a business case is being developed with regards to this. 17

20 8. Finance - Performance re CIP delivery and financial balance The Directorate is reporting a forecast breakeven position at year end and is currently delivering an overspend which is below the expected overspend at this time (see chart below). The Directorate has a fully developed CIP plan of 1,555k. Year to date achievement of CIP is largely in line with expectation ( 92k achieved out of a planned 13k) although the Directorate is confident that the shortfall will be recovered in future months. Achievement of the CIP target is skewed towards the end of the financial year and therefore we would expect to see overspends in the earlier part of the year, offset by savings in the latter part of the year. Run Rate The red line on the chart above indicates the expected level of expenditure at any time in the year, the non-linear expenditure line is due to the phasing of the various CIP targets and cost reduction plans. The blue column indicates the cumulative overspends to date. 18

21 The forecast assumes that the CIPs are delivered as expected, and the Directorate acknowledges that there is a medium risk to this as the CIP delivery is heavily weighted towards the later stages of the financial year. However the Directorate is assured at this stage that the appropriate level of management is in place to ensure delivery as planned. 9. Items of note or concern No out of city admissions due to lack of capacity Comprehensive plan for reducing restrictive interventions including safewards and the Endcliffe pilot to be developed by end of August 216 Ligature business case to reduce risks concern over recent incidents of ligature 19

22 Appendix A Gantt chart Inpatient Directorate Transformation Programme Board - Key Workstreams and High Level Project Milestones Lead/s Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Onwards No. 1 Longley Centre Development Shorlist Potential design teams Engagement event to score design candidates on values Technical interviews of design team Work to begin with design team drawing up designs for the Longley Centre Engagement forums through out design period Contractors to be recruited and appointed Trust Project team to be identified Project meetings Project documents to be drafted and maintained Implementation plan Defining prinicples for site at Longley Centre Agree the services / facilities to be at the Longley Centre Agreeing construction phases Construction phases Opening events GR/HP GR/ PE/GR GR /AS GR /AS /AS GR GR GR GR /AS No.2 Acute Care Reconfiguration Building works deleopment - overseen by Geoff Rawlings GR Wider communication plan - Jane Harris lead JH Agree services and facilities to be based at Longley Centre Complete equality Impact assessment / Site visit with regard to accessibility LIZ J Communication plan about the Longley moves /AS Consultation process with staff Consultation process with carers and families Engagement forums and events AS collaboration with community services Wider commuication (all stakeholders) Implementation plan GR/ Project Documents developments GR/ Naming strategy - stage 2 /AS Defining requirements for acute wards KP/LC/ Defining requirments for 136 suite KP Link with developments of PDU MF/GB/KT/ Defining requirements for ECT Suite /AB Defining requirements for Dovedale ward /LC/KP/IW Agree plans regarding cook from fresh HP/LIBBY J Defining requirements for MHA inc tribunal rooms /CD Design and agree about communal spaces HP/GR//KP Defining requirement for Chaplincy / Spirituality / Prayer room SR/ Risk assessment and plan for the sequencing of moves /LC/RB Moving of ward 1 Moving of ward 2 Moving of ward 3 Moving ward 4 No.3 Decommissioning of vacated wards / spaces Rehabilitation Strategy þ Work to be completed on B1, B1a and B2 Service user and carer consultation Staff consultation completed Creation of the single site for intensive rehabilitation at the Forest Close site Pinecroft to move to Forest Close site Business case to be submitted for works to B3 Pathway plan to be monitored Out of city, Forest Close, CERT and Other. CERT up to agreed caseload Short trerm care beds, plan to be implemented JS Rehab system of monitoring service user flow linked to contracting and finance projections designed GR /RB RB GR RB GR DK 2

23 Appendix B CLUSTER NUMBER Variance CLUSTER DESCRIPTIONS Despite careful consideration of all the other clusters, this group of service users are not adequately described by any of their descriptions. They do however require mental health care and will be offered a service. Common Mental Health Problems (Low Severity) This group has definite but minor problems of depressed mood, anxiety or other disorder but they do not present with any distressing psychotic symptoms. Common Mental Health Problems (Low Severity with greater need) This group has definite but minor problems of depressed mood, anxiety or other disorder but not with any distressing psychotic symptoms. They may have already received care associated with cluster 1 and require more specific intervention or previously been successfully treated at a higher level but are re-presenting with low level symptoms. Non Psychotic (Moderate Severity) Moderate problems involving depressed mood, anxiety or other disorder (not including psychosis). Non-psychotic (Severe) This group is characterised by severe depression and/or anxiety and/or other increasing complexity of needs. They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks. Non-psychotic Disorders (Very Severe) This group will be severely depressed and/or anxious and/or other. They will not present with distressing hallucinations or delusions but may have some unreasonable beliefs. They may often be at high risk for Nonaccidental self injury and they may present safeguarding issues and have severe disruption to everyday living. Non-psychotic Disorder of Over-valued Ideas Moderate to very severe disorders that are difficult to treat. This may include treatment resistant eating disorder, OCD etc, where extreme beliefs are strongly held, some personality disorders and enduring depression. Enduring Non-psychotic Disorders (High Disability) This group suffers from moderate to severe disorders that are very disabling. They will have received treatment for a number of years and although they may have improvement in positive symptoms considerable disability remains that is likely to affect role functioning in many ways. Non-Psychotic Chaotic and Challenging Disorders This group will have a wide range of symptoms and chaotic and challenging lifestyles. They are characterised by moderate to very severe repeat deliberate self-harm and/or other impulsive behaviour and chaotic, over dependent engagement and often hostile with services. CLUSTER REVIEW PERIODS (maximum) 6 months INDICATIVE EPISODE OF CARE 12 weeks 8-12 weeks 15 weeks weeks 6 months 4-6 months 6 months 6-12 months 6 months 1-3 years 6 months 3 years + Annually 3 years + Annually 3 years + 21

24 First Episode Psychosis This group will be presenting to the service for the first time with mild to severe psychotic phenomena. They may also have depressed mood and/or anxiety or other behaviours. Drinking or drug-taking may be present but will not be the only problem. Ongoing Recurrent Psychosis (Low Symptoms) This group has a history of psychotic symptoms that are currently controlled and causing minor problems if any at all. They are currently experiencing a period of recovery where they are capable of full or near functioning. However, there may be impairment in self-esteem and efficacy and vulnerability to life. Ongoing or recurrent Psychosis (High Disability) This group have a history of psychotic symptoms with a significant disability with major impact on role functioning. They are likely to be vulnerable to abuse or exploitation. Ongoing or Recurrent Psychosis (High Symptom & Disability) This group will have a history of psychotic symptoms which are not controlled. They will present with severe to very severe psychotic symptoms and some anxiety or depression. They have a significant disability with major impact on role functioning. Psychotic Crisis They will be experiencing an acute psychotic episode with severe symptoms that cause severe disruption to role functioning. They may present as vulnerable and a risk to others or themselves Severe Psychotic Depression This group will be suffering from an acute episode of moderate to severe depressive symptoms. Hallucinations and delusions will be present. It is likely that this group will present a risk of Non-accidental self injury and have disruption in many areas of their lives. Psychosis & Affective Disorder (High Substance Misuse & Engagement) This group has enduring, moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles and co-existing Problem drinking or drug taking. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired. Psychosis and Affective Disorder Difficult to Engage This group has moderate to severe psychotic symptoms with unstable, chaotic lifestyles. There may be some problems with drugs or alcohol not severe enough to warrant dual diagnosis care. This group have a history of non-concordance, are vulnerable & engage poorly with services. Cognitive Impairment (Low Need) People who may be in the early stages of dementia (or who may have an organic brain disorder affecting their cognitive function) who have some memory problems, or other low level cognitive impairment but who are still managing to cope reasonably well. Underlying reversible physical causes have been rule out. Cognitive Impairment or Dementia Complicated (Moderate Need) People who have problems with their memory, and or other aspects of cognitive functioning resulting in moderate problems looking after Annually 3 years Annually 2 years + Annually 3 years + Annually 3 years + 4 weeks 8-12 weeks 4 weeks 8-12 weeks 6 months 3 years + 6 months 3 years + Annually 3 years + 6 months 3 years + 22

25 2 21 themselves and maintaining social relationships. Probable risk of self neglect or harm to others and may be experiencing some anxiety or depression. Cognitive Impairment or Dementia Complicated (High Need) People with dementia who are having significant problems in looking after themselves and whose behaviour may challenge their carers or services. They may have high levels of anxiety or depression, psychotic symptoms or significant problems such as aggression or agitation. The may not be aware of their problems. They are likely to be at high risk of self-neglect or harm to others, and there may be a significant risk of their care arrangements breaking down. Cognitive Impairment or Dementia (High Physical or Engagement) People with cognitive impairment or dementia who are having significant problems in looking after themselves, and whose physical condition is becoming increasingly frail. They may not be aware of their problems and there may be a significant risk of their care arrangements breaking down. 6 months 3 years + 6 months 3 years + 23