Mental Health and Learning Disability Services. Sharon Linter Director of Nursing

Title: Purpose: Applicable to: Document Author: Freedom of Information: Ratified by and Date: Care Programme Approach (CPA) Policy To support staff in the implementation of the Care Programme Approach across Cornwall. Mental Health and Learning Disability Services Sharon Axby Zoe Cockbill This document can be released Sharon Linter Director of ursing 7 August 2017 Review Date: February 2020 6 months prior to the expiry date Expiry Date: August 2020 3 years after ratification unless there are any changes in legislation or changes in clinical practice Document library location: Clinical: Clinical Guidelines Related legislation and national guidance: Mental Health Act 1983 Section 2, 3, 25A 37(4) 117 ational Health Service and Community Care Act 1990 Section 42 ational Service Framework for Mental Health 1999 Fair Access to Care Services Guidance on Eligibility Criteria for Adult Social Care May 2002 The Mental Capacity Act (2005) Valuing People Policy DoH 2001 ational Services Framework for Children DoH September (2004) Working together to Safeguard Children Refocusing the Care Programme approach; Policy and Positive Practice Guidance, 2008 Associated Trust Policies and Documents: Clinical Risk Assessment and Management Policy Leave Procedure Guidelines Section 17 Leave of Absence Standards for Health Records Page 1 of 21

Interagency Child Protection Procedures Interagency Protocol to Guide Working at the Interface of Mental Health and Children s Services Safeguarding Adults Learning from Experience Cornwall Partnership HS Foundation Trust Section 117 Mental Health Act 1983 Policy Guidance for the Management of People who lack Capacity and require Health and Social Care Interventions Inpatient Discharge Planning Policy Interagency Protocol for Working at the Interface of Mental Health and Children s Services Review Caseload Protocol Standards for Unified Health and Social Care Records Health Records Carers Policy Person Focused System Policy Information Sharing Protocols Protection and use of Client Information Leaflet Equality Impact Assessment: Training Requirements: The Equality Impact Assessment Form was completed on 30/12/13 CPA training will be delivered through an e- learning package as detailed in the Trust training prospectus. Training will be incorporated into staff induction sessions, team development sessions and individual supervision. It is expected that all staff will continue to develop their awareness and knowledge of CPA as part of their individual professional development. The organisation trains staff in line with the requirements set out in its training needs analysis and published in its Corporate Curriculum. Training which is categorised as statutory or essential must be completed in line with the training needs analysis and Corporate Curriculum. Compliance with statutory and essential training is monitored through the Learning and Development team with monthly manager s reports and staff individual training records twice yearly. Training reports are also submitted quarterly through the Trust Quality and Governance Committee Meeting. Staff failing to complete this training will be accountable and could be subject to disciplinary action. Page 2 of 21

Monitoring Arrangements: Auditing and monitoring are integral components of the CPA and will allow us to monitor the effectiveness of our CPA processes. Local audit should focus on: Service user and carer satisfaction and engagement The use of outcome measures, e.g. HoOS to measure success The integration of risk management into CPA systems Consideration of equality issues The monitoring of this policy will be managed by the CPA Lead for each Service and reported through to the respective Operational assurance group through the auditing of compliance with and effectiveness of the policy. The audit of this policy will take place every year. The professional leads and Operational Managers have the responsibility for dissemination of this policy to local areas, to ensure that staff are aware of and comply with this policy. Implementation: The Chief Operating Officer is responsible for overseeing Trust wide implementation. Inpatient and Community Locality Managers with the help of the Service CPA Leads are responsible for the implementation of the policy within their Services. The CPA Leads monitors compliance and reports this through to the Chief Operating Officer. Page 3 of 21

Version Control Version Date Reviewed Changes By Whom February 2017 Extended 6 months LG April 2017 Review and update Sharon Axby / Zoe Cockbill This document Replaces: CG/017/14 Care Programme Approach (CPA) Policy Page 4 of 21

Contents 1. Introduction... 6 2. Scope... 6 3. Definition of Terms... 6 4. Duties and Responsibilities... 6 5. Process... 7 6. Monitoring and Review... 15 Appendix A Characteristics... 16 Equality Impact Assessment Proforma Initial Screening... 17 Page 5 of 21

1. Introduction The Care Programme Approach (CPA) was introduced in England in 1990 to provide a framework for effective mental health care for people with severe mental health problems. The main principles of the CPA are: Assessment of a person s health and social needs Formulation and implementation of a care plan to meet the service user s assessed needs A named individual responsible for co-ordinating the care called the CPA care co-ordinator Regular reviews of the care plan Service user and where appropriate carer involvement Multidisciplinary / multi agency working. The principles of the CPA are relevant to service users of all ages and includes people with learning disabilities who also have mental health problems. The aim of this policy is to support staff in the implementation of the Care Programme Approach across Cornwall. The document is based on national guidance detailed in Refocusing the Care Programme Approach; Policy and Positive Practice Guidance (DOH 2008). 2. Scope This policy describes the procedure and framework for implementing the Care Programme approach across the Trust. This policy applies to all staff working for, or on behalf of the Trust in Mental Health and Learning Disability Services. 3. Definition of Terms CPA The term CPA is used to describe the Care Programme Approach used in Cornwall Partnership HS Foundation Trust (CFT) when there is an identified mental health need to assess, plan, review and co-ordinate the range of treatment, care and support needs for people who have complex characteristics. o CPA The term o CPA will be used to describe the system of provision of mental health services to those with more straightforward needs receiving services from CFT. Some of these patients will be held on a Low Intensity caseload and managed by the clinical support services in each locality. FACS Policy guidance on Fair Access to Care Services (FACS) provides councils with an eligibility framework for adult social care for them to use when setting and applying their eligibility criteria. 4. Duties and Responsibilities The Trust Board is responsible for ensuring that all corporate support is made available to assist in the implementation of this policy. The Chief Operating Officer is responsible for overseeing Trust wide implementation of this policy. Page 6 of 21

Operational managers (both inpatient and community) are responsible for the implementation of policies, procedures and practice that promote the principles of the Care Programme Approach. Care Co-ordinators are responsible for ensuring all the appropriate assessments are completed including the Core Assessment and up-dated as necessary and entering them on the Electronic Record. If eligible for CPA, all appropriate documentation should be completed the care plan updated electronically and delivered subject to regular review. Care Co-ordinators are responsible for ensuring that patient data relating to the Mental Health Minimum Data Set (MHMDS) is complete and that the service user and carer, where appropriate, has been given a copy of the Care Plan All CFT staff members are responsible for ensuring: o They comply with both this CPA Policy and the CPA practice guidance document o They undertake the training required of them to be competent in using the Care Programme Approach urse Consultants in each CFT Service will function as the CPA Lead be responsible for assisting the respective management teams with implementation of the Care Programme Approach. 5. Process 5.1 Personalised Mental Health Care: Statement of Values and Principles The approach to individuals care and support puts them at the centre and promotes social inclusion and recovery. It is respectful building confidence in individuals with an understanding of their strengths, goals and aspirations as well as their needs and difficulties. It recognises the individual as a person first and patient/service user second. Care assessment and planning views a person holistically seeing and supporting them in their individual diverse roles and the needs they have, including: family; parenting; relationships; housing; employment; leisure; education; creativity; spirituality; self-management and self-nurture; with the aim of optimising mental and physical health and well-being. Self-care is promoted and supported wherever possible. Action is taken to encourage independence and self determination to help people maintain control over their own support and care. Carers form a vital part of the support required to aid a person s recovery. Their own needs should also be recognised and supported. Services should be organised and delivered in ways that promote and co-ordinate helpful and purposeful mental health practice based on fulfilling therapeutic relationships and partnerships between the people involved. These relationships involve shared listening, communicating, understanding, clarification, and organisation of diverse opinion to deliver valued, appropriate, equitable and co-ordinated care. The quality of the relationship between service user and the CPA care co-ordinator is one of the most important determinants of success. Care planning is underpinned by engagement, requiring trust, teamwork and commitment. It is the daily work of mental health, Page 7 of 21

learning disability services and supporting partner agencies, not just the planned occasions where people meet for reviews. 5.2 Refocusing the Care Programme Approach All individuals receiving treatment, care and support from secondary mental health and specialist learning disability services are entitled to receive high quality care based on individual assessment of the range of their needs and choices. Service users with complex needs and / or who are at most risk, should receive a higher level of care co-ordination support. For these people the CPA process will be used. For service users with needs that are not complex and can be met by one discipline and less at risk the o CPA process will be used. The characteristics of presentations that should be considered for CPA are shown in Appendix A. 5.3 o CPA o CPA will apply where following assessment relating to mental health and/or learning disability needs, it is identified that the service user has: eeds that are not complex and can be met by one discipline Lower risk Contact with only one agency or no problems with access to other agencies / support Whether a service user needs the support of CPA or not should not affect their entitlement to services under FACS. Where a service user has straightforward needs and has contact with only one agency then an appropriate professional in that agency will be the person responsible for facilitating their care. The formal designated paperwork for care planning and the review processes for this service user group is not required. However a statement of care agreed with the service user should be recorded in the clinical records and copied to the GP and other relevant and agreed parties. This could be done in any clinical or practice notes, or in a letter, and this documentation will constitute the care plan. 5.4 Assessment All service users who have been accepted by CFT mental health services and learning disability services will have a thorough assessment of their health and needs including a risk assessment, carried out by a qualified professional. Mental health services will also assess social care needs. This assessment will involve the service user and where appropriate their carer as central participants in this process. Page 8 of 21

5.5 Care Clusters and Pathways (Please refer to CFT care pathways) Document Reference Code: CG/017/17 As part of the assessment of care, service users living with a mental health condition and receiving care from CFT Mental Health Services, will be assigned a care cluster. This enables clinicians to provide targeted and specific interventions within a care pathway, to support recovery. Each care pathway has a range of treatment options which will be considered in the formulation of the CPA care plan and the necessary review intervals, which MUST be aligned to the CPA review dates. 5.6 Role of the Care Coordinator The person who is best placed to oversee care planning and resource allocation will take on the role of care coordinator. It is not expected that Consultant Psychiatrists, clinical psychologists or other medical staff act as CPA care coordinator for Service Users. There may be occasions when the service user clinical need means that care coordination may sit with psychology. The care coordinator is responsible for the following:- Coordinating the delivery of evidence based interventions by the appropriate professional; the care coordinator is not always the best person for delivering the care. Keeping appropriate level of contact with the service user and primary care as required. Contact should be within a minimum period of 8 weeks unless care planned and agreed. Advising the other members of the care team of changes in the circumstances of the service user, which might require review or modification of the care plan. Keep the care plan and contingency plan up to date together with other involved clinicians and ensure all documentation is kept in line with record keeping policy. To ensure that the carers receive a carers assessment from team. Takes the lead in ensuring the risk assessment is reviewed and updated. To attend any statutory required meetings. 5.7 CPA process in In-patient Units. The Consultant and the ward urse will be responsible for ensuring that an initial assessment is carried out for all service users admitted to in-patient beds under their care. This should identify the service user s general health and social needs and should happen as soon as is practical after admission. The Consultant, ward urse and Care Co-ordinator will be responsible for identifying at an early stage when a service user s discharge should be arranged. This will usually be agreed at the Clinical / Ward review. The ward urse will take the lead in organising the CPA discharge planning meeting, liaising with the Care Co-ordinator and ensuring that all members of the clinical team involved in aftercare are invited in good time to attend the meeting. The views of members of the clinical teams to be involved in aftercare, who are unable to attend, should be sought and fed into the meeting. A full record should be made of the CPA discharge planning meeting on the electronic record. There are occasions when service users are placed in out of area specialist placements / hospital. CFT employ staff who retain the care co-ordinator role when our patients are in specialist placements, e.g. the Community Forensic Service remain as Care Co-ordinators for patients that are in specialist Page 9 of 21

forensic placements and the Out of County Care Co-ordinator acts a care co for Out of county patients in specialist placements such as low secure, locked rehab, PD units etc. When people are on leave from our inpatient units the care co (if one has already been allocated) will remain, this also applies if someone is sent on leave from an Out of county placement. 5.8 The Care Plan The care plan is a record of needs linked where appropriate to HoOS domains, with associated actions and responsibilities that are written in an accessible and jargon free-way. The care plan should be based around the needs of the service user and not around the ability of the service to provide. A service user s care plan will be based on a thorough assessment of their health needs (and for mental health services social care needs also), including risk factors identified during the assessment process. The care plan provides a summary of the total care being provided to the service user. Care plans for all service users on CPA should include details on what to do in a crisis and a contingency plan with specific actions to offer additional support the service user. The care plan should be shared with the patient and a copy should be made available to them, with an entry on Rio to confirm that the patient has been issued a copy of their care plan. 5.9 CPA Reviews (*including Individual Packages of Care IPCs and CHC) CPA reviews are designed to monitor and evaluate the effectiveness of the care plan and focus on how the needs of the service user can continue to be met. CPA reviews will be conducted at intervals set out in each care pathway or within 6 monthly intervals. During the CPA review, the current care cluster if applicable should also be reviewed. The CPA review incorporates our statutory responsibilities to provide and review aftercare for mental health service users subject to section 117 of the Mental Health Act 1983. *Care Coordinators will be allocated to service users who receive Individual Packages of Care (IPCs). Their function will be to assess the clinical care and treatment plan and review the quality and cost of the care package being provided and whether the service users needs continue to be met. 5.10 Electronic CPA and Electronic Recording of Care Process It is a mandatory requirement that all clinicians and practitioners document all data and events, including those which relate to CPA. This important action ensures that 24 hours, 7 days a week secure access to information by relevant staff is available enabling safe and effective delivery of care. 5.11 Carers CFT is committed to supporting individuals who provide unpaid support for people with a mental health need. The Trust recognises such carers as partners in the care of people in recovery from Page 10 of 21

mental illness and promotes the standards and interventions described in the Triangle of Care (Carers Trust 2013)Effective support for carers is both an essential and crucial part of any care plan for a person with a mental illness. In many instances carers are taking primary responsibility of care for the person they support. As part of the CPA process, all carers should be offered a carers assessment to identify and where appropriate, support them in meeting these needs. ( see Carers Policy /010/11) It is acknowledged that the statutory duty for carers assessments for people aged 65 and over and service users with a learning disability, rests with Cornwall Council, however CFT practitioners are required to assess the well-being needs of carers supporting people living with dementia as described in statement 7 of the ICE Dementia Standard QS1: Carers of people with dementia are offered an assessment of emotional, psychological and social needs and, if accepted, receive tailored interventions identified by a care plan to address those needs. (ICE 2010) 5.12 Advance Decisions The Mental Capacity Act 2005 came into force on October 1 2007 and affects the way people make decisions about their future care if they lose mental capacity. This includes decisions on whether they want life-saving treatment and to participate in research. If the person wishes to refuse medical treatment in the future, they should make their wishes known by making an 'advance decision' (previously known as an 'advance directive'). This is made when the person still has capacity and is used if they're not able to make the decision themselves at the time of the proposed medical treatment. Creating an Advance Decision may bring some reassurance to service users regarding their future healthcare. An advance decision is legally enforceable providing it has been drawn up using the right guidance. This includes: The person drawing up the advance decision must have had capacity at the time. The person must be 18 years or over at the time of the decision and fully understand any consequences of not accepting a treatment The wording of the advance decision has to be relevant to the person s medical circumstances The advance decision must be clear and unambiguous The advance decision must have been intended to apply in the situation that has arisen The advance decision must be written and witnessed by at least one person who is over the age of 18. There is a minimum requirement of information that the advance decision should contain. 5.13 Advance Statement of Wishes An advance statement is a written statement that conveys a person s preferences, wishes, beliefs and values regarding their future care. The aim is to provide a guide to anyone who might have to make Page 11 of 21

decisions in their best interest if they have lost the capacity to make decisions or to communicate them. A statement of wishes is unlike an advanced decision in that it is not legally binding but anyone who is making decisions about your care must take it into account. Examples could be: how you want any religious or spiritual beliefs you hold to be reflected in your care where you would like to be cared for, for example at home or in a hospital, a nursing home, or a hospice how you like to do things, for example if you prefer a shower instead of a bath, or like to sleep with the light on concerns about practical issues, for example who will look after your dog if you become ill 5.14 Section 117 Aftercare (Please refer to the CFT Section 117 Procedures) Section 117 Aftercare is an integral part of CPA. All service users who fulfil the criteria for S117 will be included, i.e. those who have been detained in hospital under Sections 3, 37, 47 or 48 of the Mental Health Act (MHA) 1983. At each CPA review meeting, the appropriateness of Section 117 aftercare continuing must be considered. 5.15. Supervised Discharge From April 1996 an amendment to the Mental Health Act included a provision for supervision of mentally disordered patients in England and Wales who, on leaving hospital after detention for treatment (under S3, 37, 47 and 48) all receive aftercare services under S117. 5.16 Guardianship and CPA People on Guardianship Orders (Section 7 MHA) should also be in receipt of CPA. 5.17. Transfer of responsibilities of care For service users on CPA, all decisions about transfer to another CHMT or other service, within the Trust, must be made at a CPA review meeting. For service users subject to other processes of Care a review meeting should be held where planning for management of transitions can take place. Prior to the transfer the Care Co-ordinator should ensure that the following has been agreed The receiving team / service has identified a Care Co-ordinator (if applicable). Appropriate services have been set up with the receiving team / service to meet the service user s needs, before a transfer takes place Effective communication has taken place and detailed information has been made available to the appropriate professionals in the receiving team/service. Page 12 of 21

The Service User and Carer have been kept up to date and involved in the transfer process. It has been acknowledged by professionals that the transition process can be destabilising and unsettling and must be monitored and managed as such. All such decisions will be communicated in writing to the service user, their carer, if appropriate, the GP. The transfer of a young adult from CAMHS services is important and there is a separate Trust policy Please see Interagency Protocol for working at the interface of Mental Health and Children s Services 5.18 Service User Discharge (Please refer to Cornwall Partnership HS Foundation Trust Discharge Planning Policy) Information should be shared with all appropriate agencies on discharge or transfer. This should Include: The latest Care Plan and completed Contingency plans, and relevant copies of correspondence or events from the electronic and paper record. The GP should always be informed and where appropriate other involved agencies. Care plans must take into account the heightened risk of suicide in the first three (3) months following discharge/transfer of care and must outline contact to be made within the first 48 hours by an agreed member of the clinical team. In addition 7 day follow up arrangements are:- For adults regardless of age best practice would be a face to face contact or if not possible or practical, telephone contact with the client within 7 days of discharge from the ward. 5.19 Loss of Contact with Services If it becomes clear that contact with a service user has been lost, a review meeting should be held to consider the next steps. Each member of the team should make every reasonable effort to reestablish contact. Consideration should be given to contacting the following: carer / family, service user s GP, local A&E departments and community teams in other Trusts. The Care Co-ordinator will take responsibility for co-ordinating this. 5.20 Refusal to Maintain Contact This procedure applies to service users under the care of the Trust whose whereabouts and physical wellbeing is known and who have made it clear that they refuse to engage with services. Refusal of engagement should rapidly be discussed with the Service User, also within the MDT and communicated to the GP. An assessment of the risks that the service user presents to him / herself Page 13 of 21

(including risks of self-neglect), or others, and their mental capacity to make decisions are required and plans made accordingly. 5.21 Other Reasons for Discharge of Service Users There may be occasions when service users are discharged from Trust Services, whether on CPA or another Care Process or not, when they or their carers remain of the view that they should still receive a service. Such decisions to discharge the service user should only be taken after careful consideration and discussion with the Service User. Robust risk assessment, contingency and safety plans should be completed to support the process to discharge. 5.22 Discharges from CPA When a service user is discharged from CPA following their CPA / Review, this review must be recorded electronically. The service user is discharged from CPA or Care Process when: The service user no longer requires specialist Mental Health Services, Learning Disability, CAMHS and is discharged to the care of his/her GP. The complexity and risk for the service user is reduced. All service user outcomes are met The service user leaves the area and is discharged to the care of services in the new area. The service user has capacity and declines further intervention from specialist mental health services and are not at risk of harming themselves or others or at risk of exploitation. Clinicians should develop a discharge from service care plan which gives details of how the service user can access the services again should they need them in the future. 5.23 Implementation and dissemination Dissemination of this policy will be carried out through the corporate induction programme and yearly training up-dates provided by the Trust s training department. Service Associate Directors are responsible for the dissemination of the policy to their Operational Managers who are responsible for the dissemination and implementation of this policy to their areas. 5.24 Education and Training CPA training will be delivered via an e-learning course and is detailed in the Trust training prospectus. Staff Induction the CPA must be included as part of the induction of all new members of mental health, learning disability and CAMH services staff. It is the responsibility of the local manager to ensure that a new member of staff is adequately inducted to CPA and is familiar with the local approach to the implementation of this policy. Page 14 of 21

Team Development the implementation of the CPA requires effective cross-agency care planning and good systems of communication. Multi-disciplinary team members must understand each other s roles and responsibilities and have opportunities to develop effective working relationships. Individual Supervision staff should use supervision meetings to discuss issues relating to the implementation of this policy. Local managers should use supervision sessions as a means of monitoring whether or not the quality standards relating to the CPA are being met and that the individual staff s practice complies with the CPA policy. Individual Professional Development it is an expectation that mental health and learning disability professionals will be equipped with the skills to work within the framework of the CPA. If a member of staff requires formal training in order to perform the duties expected under CPA this should be addressed as part of the individual s professional development plan. 6. Monitoring and Review All team managers receive regular reports on various aspects of CPA to ensure compliance with targets and data quality. Auditing and monitoring are integral components of the CPA and will allow us to monitor the effectiveness of our CPA processes. Local audit should focus on: Service user and carer satisfaction and engagement Quality and effectiveness of care plans The use of outcome measures, e.g. HoOS to measure success The integration of risk management/safety planning into CPA systems Consideration of equality issues The monitoring of this policy will be managed by the CPA Lead for each Service Line and reported through to the operational assurance group through an annual audit of compliance with and effectiveness of the policy. The OAG will agree actions to be completed where non-compliance is identified. Through the CPA leads, an annual CPA compliance audit report will be presented to the Quality and Governance Committee. Page 15 of 21

Appendix A Characteristics Characteristics to consider when deciding if support of (new) CPA needed (DOH 2008) Severe mental disorder (including personality disorder) with high degree of clinical complexity Learning disability with a high degree of clinical complexity Current or potential risk(s), including: Suicide, self - harm, harm to others (including history of offending) Relapse history requiring urgent response Self-neglect/non concordance with treatment plan Vulnerable adult; adult / child protection e.g. Exploitation e.g. financial / sexual Financial difficulties related to mental illness Disinhibition Physical / emotional abuse Cognitive impairment Child protection issues Current or significant history of severe distress / instability or disengagement Presence of non-physical co-morbidity e.g. substance / alcohol / prescription drugs misuse, learning disability Multiple service provision from different agencies, including: housing, physical care, employment, Criminal justice, voluntary agencies Currently / recently detained under Mental Health Act or referred to crisis / home treatment team Significant reliance on carer(s) or has own significant caring responsibilities Experiencing disadvantage or difficulty as a result of: Parenting responsibilities Physical health problems / disability Unsettled accommodation / housing issues Employment issues when mentally ill Significant impairment of function due to mental illness Ethnicity (e.g. immigration status; race / cultural issues; language difficulties; religious practices); sexuality or gender issues Page 16 of 21

Equality Impact Assessment Proforma Initial Screening ame of Procedural document to be assessed: Section: Care Programme Approach Policy Clinical: Clinical Guidelines Officer responsible for the assessment: Date of Assessment: Is this a new or existing procedural document? E 1. Briefly describe the aims, objectives and purpose of the procedural document. 2. Are there any associated objectives of the procedural document? Please explain. 3. Who is intended to benefit from this procedural document, and in what way? 4. What outcomes are wanted from this procedural document? 5. What factors/forces could contribute/detract from the outcomes? 6. Who are the main stakeholders in relation to the procedural document? 7. Who implements the procedural document, and who is responsible for the procedural document? 8. Are there concerns that the procedural document could have a differential impact on RACIAL groups? To provide a framework and procedure through which Care is delivered across all Cornwall Partnership HS Foundation Trust Operational areas. To set out Policy and Procedures for all areas of the Care Programme Approach and to set standards for CPA delivery and the delivery of other Care Processes used within Cornwall Partnership HS Foundation Trust. All staff working in Mental Health and Learning Disability Services For CPA standards to be implemented correctly and reviewed appropriately within the Trust Poor understanding of the CPA process leading to inconsistent application across the Trust All staff working in Mental Health and Learning Disability Services The Chief Operating Officer through the Service Line CPA Leads Page 17 of 21

What existing evidence (either presumed or otherwise) do you have for this? 9. Are there concerns that the procedural document could have a differential impact due to GEDER What existing evidence (either presumed or otherwise) do you have for this? 10. Are there concerns that the policy could have a differential impact due to DISABILITY? What existing evidence (either presumed or otherwise) do you have for this? 11. Are there concerns that the policy could have a differential impact due to SEXUAL ORIETATIO? What existing evidence (either presumed or otherwise) do you have for this? 12. Are there concerns that the procedural document could have a differential impact due to their AGE? What existing evidence (either presumed or otherwise) do you have for this? 13. Are there concerns that the procedural document could have a differential impact due to their RELIGIOUS BELIEF? What existing evidence (either presumed or otherwise) do you have for this? 14. Are there concerns that the procedural document could have a differential impact due to their MARRIAGE OR CIVIL PARTERSHIP STATUS? (This MUST be considered for employment policies). Page 18 of 21

What existing evidence (either presumed or otherwise) do you have for this? 15. Are there concerns that the procedural document could have a differential impact due to GEDER REASSIGMET OR TRASGEDER ISSUES? What existing evidence (either presumed or otherwise) do you have for this? 16. Are there concerns that the procedural document could have a differential impact due to PREGACY OR MATERITY? What existing evidence (either presumed or otherwise) do you have for this? 17. How have the Core Human Rights Values of: Fairness; Respect; Equality; Dignity; Autonomy The policy has been written to support staff to implement standards of the CPA. The aim of CPA is to ensure that the care of service users is assessed appropriately and delivered based on the least restrictive principle in a way that is fair and equitable, that respects their wishes and views, maintains their dignity and promotes autonomy. Been considered in the formulation of this procedural document/strategy If they haven t please reconsider the document and amend to incorporate these values. Page 19 of 21

18. Which of the Human Rights Articles does this document impact? What existing evidence (either presumed or otherwise) do you have for this? How will you ensure that those responsible for implementing the Procedural document are aware of the Human Rights implications and equipped to deal with them? 19. Could the differential impact identified in 8 13 amounts to there being the potential for adverse impact in this procedural document? 20. Can this adverse impact be justified on the grounds of promoting equality of opportunity for one group? Or any other reason? If Yes, describe why, and then proceed to a full EIA. The right: To life; ot to be tortured or treated in an inhuman or degrading way; To be free from slavery or forced labour; To liberty and security; To a fair trial; To no punishment without law; To respect for home and family life, home and correspondence; To freedom of thought, conscience and religion; To freedom of expression; To freedom of assembly and association; To marry and found a family; ot to be discriminated against in relation to the enjoyment of any of the rights contained in the European Convention; To peaceful enjoyment of possessions and education; To free elections The Rights considered are integral to CPA policy and procedures. Through appropriate training and development offered by the Trust Y Y Y Y Y Y Y Page 20 of 21

21. Should the procedural document proceed to a full equality impact assessment? If o, are there any minor further amendments that should take place? 22. If a need for minor amendments is identified, what date were these completed and what actions were undertaken O Signed (completing officer) Signed (Service Lead) Date Date Page 21 of 21