Document Title Reference Number Lead Officer Author(s) Ratified by Care Coordination (Incorporating Care Programme Approach (CPA)) Policy NTW(C)20 Executive Director of Nursing and Operations Liz Bowman Care Coordination Development Lead Trust wide Policy Group Date ratified October 2015 Implementation Date October 2015 Date of full implementation October 2015 Review Date October 2018 Version number V05.2 Review and Amendment Log Version V05 Type of change Review in context of new MHA COP Date V05.1 Update Mar 16 V05.2 Update Jan 17 This policy supersedes the following document: Description of change Section 1.4 update to include explicitly Mental Capacity Act 5 statutory principles and five overarching principles in the Mental Health Act 1983 Code of Practice 2015 Section 8 update to more explicitly incorporate collaboration and involvement in decision making incorporating requirements of Mental Capacity Act and Mental Health Act 1983 Code of Practice 2015 Section 21 and 22 Additional guidance re transfers with NTW and where NTW staff are lead professionals ( required by Serious Incident action plan) Additional guidance re medication Inclusion of CC-CPA-PGN-11 Clinical Care Pathways/Packages PGN Update within sections 8.12 and 11.14 - Any medication allergies (whether new or existing) must also be documented Reference Number NTW(C)20 - V05.1 Title Care Coordination (Incorporating Care Programme Approach)
Care Coordination (Incorporating Care Programme Approach (CPA)) Section Contents Page No. 1. Introduction 1 2. Purpose 2 3. Definitions/Abbreviations of terms used 3 4. Duties and Responsibilities 3 5. Assessment and consent to share information 4 6. Role and responsibility of the lead professional 8 7. Enhanced needs (Care Programme Approach - CPA) 10 8. Care planning 13 9. Review 16 10. Risk assessment and management 17 11. In-patient admission and discharges 19 12. Care coordinator roles and responsibilities 21 13. Responsibilities of members of the care team 23 14. Legislative framework 23 15. Involving carers 25 16. Young carers 26 17. Children 26 18. Safeguarding adults 27 19. Public protection 27 20. Community and criminal justice collaboration 28 21. Service users who move within NTW 28 22. Service users who move outside NTW 30 23. Service users who go missing 31 24. Identification of Stakeholders 31 25. Equality impact assessment 32 26. Training 32 27. Implementation 32 28. Monitoring and compliance (Appendix C) 33 29. Fair blame 33 30. Policy leaflets for care coordination and care programme approach 33 31. Fraud, Bribery and Corruption 33 32. Associated documentation 33 33. References 34
Standard Appendices attached to policy document A Equality Analysis Screening Tool 36 B Communication and Training Needs Information 38 C Audit/Monitoring Tool 40 D Policy Notification Record Sheet - click here Document No: Appendices listed separately to policy Description Issue Issue Date 1 Possible strategies for professionals responding to service users who want to withhold consent to share need to know information from other professionals 2 Possible strategies for professionals when service users exercise their right to withhold consent to share need to know Information with Carers Review Date 1 Oct 15 Oct 18 1 Oct 15 Oct 18 3 Seven golden rules for Information Sharing 1 Oct 15 Oct 18 4 Northumberland Tyne and Wear NHS Trust minimum approved tools to record the outcome of the assessment of risk 1 Oct 15 Oct 18 Leaflet hyperlinked to Patient Information Centre (PIC): Title A4 Care Coordination including Care Programme Approach (CPA) Leaflet A4-Large Print Care Coordination including CPA Leaflet A5 Care Coordination including CPA Leaflet PIC Version V08 Issue 1 V08 Issue 1 V08 Issue 1 Uploaded to Intranet Policy Page PIC Ratified Date PIC Review Date Sep 16 Sep 16 Jul 18 Sep 16 Sep 16 Jul 18 Sep 16 Sep 16 Jul 18
PGN No: Hyperlinked to Intranet Practice Guidance Notes (listed separate to policy) Title Version Issue Date Review date CC-CPA- PGN-01 Practice Guidance Adults (Adult services Planned and urgent care, Forensic Mental health and Specified Specialist services) V03 - Issue 4 Mar 16 Feb 18 CC-CPA- PGN-02 Practice Guidance Older People s Services Planned and Urgent Care V03- Issue 2 Mar 16 Mar 18 CC-CPA- PGN-03 Practice Guidance Learning Disability (LD) Services Planned and Urgent Care V04 - Issue 2 Mar 16 Oct 18 CC-CPA- PGN-04 Neuro-rehabilitation Framework V02- Issue 1 Nov 16 Nov 19 CC-CPA- PGN-05 Improving Access to Psychological Therapies (IAPT) V01 Nov 14 Nov 17 CC-CPA- PGN-06 Learning Disabilities Admissions (within LD- Urgent Care only) V03 Issue 2 Dec 15 Oct 18 CC-CPA- PGN-06.1 Learning Disabilities Services -Planned and Urgent Care Management of Epilepsy (within LD only) V03 Issue 1 Dec 14 Dec 17 CC-CPA- PGN-07 Chaplaincy Services V03 Issue 1 Mar 15 Mar 18 CC-CPA- PGN-08 Self Discharge against medical/clinical advice V03 Issue 1 Feb 15 Feb 18 CC-CPA- PGN-09 CC-CPA- PGN-10 CC-CPA- PGN-11 Transitions V01 Issue 1 Working with Private Practitioners V01 Issue 1 Clinical Care-E-Pathways and Packages V01 Issue 1 Jun 15 Jun 18 Aug 15 Aug 18 Mar 16 Mar 19
1 INTRODUCTION 1.1. Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW) and its partner agencies of Gateshead Social Services, North Tyneside Adult Services, Newcastle Social Services, Northumberland Care Trust, South Tyneside Social Services and Sunderland Health Housing and Adult Services are committed to the principle that all service users referred to secondary mental health and learning disability services should have access to high quality, evidence-based mental health services. 1.2. The approach of each organisation to individuals care and support puts that individual at the centre and promotes social inclusion, wellbeing 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. Each organisation and its staff recognise the individual as a person first and service user second. This approach is underpinned by shared Values and Principles and is encompassed by the term Care Coordination. 1.3. Care Coordination ensures that the requirements of the National Service Framework for Mental Health (September 1999) and the Department of Health guidance Refocusing the Care Programme Approach (2008) and Effective Care Coordination in Mental Health Services Modernising the Care Programme Approach(1999) are met by mental health and learning disability services within the Trust and their partner agencies. 1.4. Statement of Values and Principles Assessment and Care planning views a person in the round seeing and supporting them in their individual diverse roles and the needs they have 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 opinions to deliver valued, appropriate, equitable and co-ordinated care Northumberland, Tyne and Wear NHS Foundation Trust 1
The care and support of services users will always be informed by an understanding of the Mental Capacity Act and the application of the Acts 5 statutory principles o A person must be assumed to have capacity unless it is established that they lack capacity o A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success o A person is not to be treated as unable to make a decision merely because they makes an unwise decision o 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 their best interests o 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 as effectively achieved in a way that is less restrictive of the person s rights and freedom of action The care and support of services users who are detained under the Mental Health Act 1983 will always take into consideration the five overarching principles set out in the Mental Health Act 1983 Code of Practice published 2015 o Least restrictive option and maximising independence o Empowerment and involvement o Respect and dignity o Purpose and effectiveness, and o Efficiency and equity. 2. PURPOSE 2.1 This policy sets out the principles and framework for assessment and care planning for adults receiving mental health or learning disability services within the Trust and its partner agencies where there is shared care. 2.2 It includes the requirements of C(90)23/LASSL(90)11 Effective Care Coordination in Mental Health Services Modernising the Care Programme Approach (1999) and DOH guidance Refocusing CPA(2008) ensuring that Northumberland, Tyne and Wear NHS Foundation Trust 2
the requirements of the National Service Framework for Mental Health Standard 4 is met and contributes to Standard 6. 2.2 This policy will be supported by practice guidance for NTW staff / integrated teams and where appropriate information sharing agreements. 3 DEFINITIONS OF TERMS USED AMHP Approved Mental Health Professional CPA Care Programme Approach CPAA Care Programme Approach Association DOH Department of Health GP General Practitioner HoNOS Health of the Nation Outcome Scale IMHA Independent Mental Health Act Advocate LA Local Authority LPA Lasting Power of Attorney MAPPA Multi-agency public protection arrangements MCA Mental Capacity Act MDT Multi Disciplinary Team MH Mental Health SARN Summary of Assessments of Risk and Need SCT Supervised Community Treatment SPOC Single Point of Contact UHR Unified Health Record Trust/NTW Northumberland, Tyne and Wear NHS Foundation Trust 4 DUTIES 4.1 The Chief Executive on behalf of the Trust retains ultimate accountability for the health, safety and welfare of all service users, carers, staff and visitors; however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy 4.2 Directors and all managers at all levels in the Trust and its partner agencies are responsible for ensuring the policy and relevant practice guidance is applied consistently and appropriately in their area of responsibility. 4.3 The Trust corporate governance arrangements relevant to this policy are shown in the diagram page 4 Northumberland, Tyne and Wear NHS Foundation Trust 3
Trust Board NTW Quality and Performance Committee NTW Trust wide Patient Safety Group 4.4 NTW Operational Group s Quality and Performance group are responsible for the agreement of the tools to support risk assessment and clinical recording including on the electronic care record within the directorate. These decisions are ratified by NTW Patient Safety Group and Quality and Performance Committee ensuing that the agreed tools and the process for use are reflected in this policy and associated practice guidance notes. 4.5 The Care Coordination Development Lead has responsibility for the Trust wide implementation, development and expansion of care coordination standards to incorporate new legislation, standards, targets and professional practice requirements through policy development and the provision of expert professional advice to senior managers, service users, carers, managers and colleagues liaising with other agencies as appropriate to each directorate 4.6 All staff are responsible for ensuring they meet their professional standards of recording within their organisations/directorates documentation and for applying this policy and relevant practice guidance in their practice with service users and their families. 4.7 A consultant psychiatrist (or associate specialist) should always be involved in the care of all service users who express delusional beliefs involving children or might harm a child as part of a suicide plan. 5 ASSESSMENT AND CONSENT TO SHARE INFORMATION 5.1 Assessment and planning should aim to meet the service user s needs and choices and not just focus on what professionals and services can offer. It should address a person s aspirations and strengths as well as their needs and difficulties. Trust and honesty should underpin the engagement process to allow for an equitable partnership between services users, carers and providers of services. Northumberland, Tyne and Wear NHS Foundation Trust 4
5.2 The person undertaking the assessment should explain to the service user that their family, friend or an advocate can support them through the whole assessment if they so wish. 5.3 Everyone referred to secondary mental health and learning disability services should receive an assessment of their needs, with assessment of mental health and risk as an integral component. 5.4 Each organisation s assessment framework must enable an initial assessment of health and social care needs and risk to identify the individual s needs and where they may be met. This will include an assessment of social care needs including enabling of identification National Minimum Eligibility Threshold (NMET) as determined by the Care Act 2014 (including Direct Payments/ Individualised budgets). 5.5 The assessment framework will also enable consideration, as appropriate to the individual, of psychiatric, psychological and social functioning, including: o Impact of medication o Risk to the individual and others o Needs arising from co-morbidity o Personal circumstances including family and carers o Housing needs o Financial circumstances and capability o Employment, education and training needs o Physical health needs o Equality and diversity issues including faith and culture o Social inclusion and social contact and independence 5.6 Assessment should conclude with a robust formulation/summary that synthesises the information collected to articulate why has the service user presented with these particular problems at this particular time in their life. 5.7 Bringing together and considering the significant factors that have contributed to the development of the problem and articulating the service user s hopes and aspirations, expectations of service, and the expectations of others particularly those of Carers. 5.8 Formulation/summary should be current when making a referral to another service/professional so that it enables the reason for such a referral to be clear 5.9 The service user can only benefit from well co-ordinated assessment and planning if there are clear lines of communication between professionals and agencies. Where joint assessment has been undertaken by clinicians/ professionals from different agencies it is crucial that the resulting record is quickly available to both organisations. Northumberland, Tyne and Wear NHS Foundation Trust 5
5.10 The assessment process should incorporate explicit agreement between the clinicians / professionals about the arrangements to make the assessment record available in both organisations electronic record systems. 5.11 This is one of the occasions when it will be necessary to share information about the service user with other professionals and agencies. The service user s consent to disclose information will be routinely sought as part of the assessment process in compliance with the requirements of the DOH Confidentiality NHS Code of Practice 2003and the Data Protection Act 1998. 5.12 Consent to seek and share Information should be discussed agreed with the individual and recorded as part of the initial assessment whenever possible or as soon as is practicable and should be revisited: When indicated by the service user Where information/circumstances demonstrate that the service user has different wishes to those previously recorded During care planning process When mental capacity status changes 5.13 Some service users may not have the capacity to consent, or be able to understand the implications of sharing information. If concerns about the service user s capacity to consent arise, a decision will be made by the decision maker following an assessment of capacity with clear reference to the Mental Capacity Act best interest checklist. 5.14 Some service users may have fluctuating capacity they have a problem or condition that gets worse occasionally and affects their ability to make decisions. It may be possible to put off the decision about their consent to seek and share Information until the person has the capacity to make it. 5.15 As in any other situation, an assessment must only examine a person s capacity to make a particular decision when it needs to be made. Assessment of capacity should involve discussion with relevant members of any multi disciplinary team, carers and/or advocates and will be clearly recorded in the service user s record. 5.16 There may be occasions when it is deemed necessary to share information without consent in accordance with Trust Policy, common law and the Data Protection Act 1998 as appropriate, for example, in circumstances where disclosure is felt to be justified in the public interest e.g. to protect the service user or someone else from harm. This must be explained to the service user, including what information must be shared and with whom, and an appropriate entry made in the record. Appendices 1-3 provide additional guidance. Northumberland, Tyne and Wear NHS Foundation Trust 6
5.17 Where the service user has not given consent to share information with their carer/family members who live with and or support them and there are significant issues of risk there may be justification to share proportionate and necessary information about risk management without consent. 5.18 A lawful disclosure will be justified in circumstances where the appropriate healthcare professional/clinical team are satisfied that, the disclosure of confidential health information is necessary to prevent serious harm or abuse to the service user or another. In such circumstances the disclosure must be limited to that which is necessary and proportionate to the aim in mind. All disclosure considerations, decisions and subsequent actions must be clearly recorded in the service user s health record. Each circumstance / situation is different and advice should be sought from the relevant person in the employing professional s organisation e.g. Caldicott Guardian or Information Governance Lead. 5.19 Assessment outcome 5.19.1 The outcome of the initial and any subsequent assessment should be communicated to the individual (in a way that they will understand), their GP and to the referrer promptly. 5.19.2 If it is agreed that the person s needs are best met by a secondary mental health service, a care plan should be devised and agreed with the service user and, where appropriate, their carer. 5.19.3 Where a service user has straight forward needs and only requires local authority services they will be supported under the relevant social care frameworks and the referral closed on the NTW electronic care record (RiO) 5.19.4 All service users requiring treatment/intervention that includes NTW services, including integrated teams, will have an identified clinician/professional either from NTW or a partner agency who will have responsibility for coordinating and ensuring the delivery of their care. 23 5.19.5 Where a service users assessed needs are not of a high degree of clinical complexity, and they are able to be self directed in their care (with some support) the person coordinating their care is a Lead professional. This Lead professional will be recorded on the NTW electronic care record (RiO). 5.19.6 The term care coordinator is used to describe the person with responsibility for coordinating and ensuring the delivery of care when the service users needs are of a high degree of clinical complexity (defined in section 7) and they require support through enhanced care coordination (CPA). The care coordinator will be recorded on the NTW electronic care record (RiO) Northumberland, Tyne and Wear NHS Foundation Trust 7
6 ROLE AND RESPONSIBILITY OF THE LEAD PROFESSIONAL 6.1 The role of Lead Professional can be undertaken by Medical Staff, Qualified Nurses, Non-medical prescribers, Qualified Social Workers, and Qualified Allied Health Professionals, who are suitably experienced and skilled, under appropriate supervision, to be able to assess service users. Where there is only a single NTW clinician delivering care, with no involvement from partner agencies they will be the Lead Professional. 6.2 A lead professional from one of the statutory agencies will be agreed where there are several clinicians/professionals responsible for delivery different elements of care. Explicit agreement between the clinicians/professionals will be made about the arrangements to make the care plan record available in both organisations electronic record systems 6.3 The lead professional will ensure that: The service user s previous consent to seek and share information is discussed and updated as needed In partnership with the service user and (with consent or on a best interest basis) carers any other significant care provider, develop a clear understanding of how care and treatment will be carried out, by whom, taking into consideration any existing Advance Statement or Advance Decision to refuse treatment The agreed care and treatment (care plan) is recorded as required by their organisation. Trust staff can record using a clinical letter that meets the standards set out in the practice guidance relevant to the lead professional s directorate Where a service user is subject to 117 after care this is recorded in their care plan and logged as required by their organisations electronic care record Where a service users has service(s) funded under Continuing Care care this is recorded in their care plan and logged as required by their organisations electronic care record Provide advice and signposting to the service user to enable them to access other agencies/support to meet their needs, facilitating referrals if needed A central record of care is maintained as required by their organisation. A copy of the current care plan is always offered to the service user The service user is offered copies of letters as outlined in the Trust s NTW(O)22 - Sharing letters with service users policy Northumberland, Tyne and Wear NHS Foundation Trust 8
A copy of the current care plan is sent to the person s General Practitioner (GP) and any other significant care provider, including carers, if appropriate Ensure that the care plan and risk assessment is subject to on-going review as required, involving the service user and any other significant care provider, including carers In partnership with the service user and any other significant care provider, including carers, consider at each review whether a service user s needs have changed, and if there is need for intensive care coordination support HoNOS (Health of the National Outcome Scale) ratings will be completed at significant points of change within the care pathway and at any event, at least once a year as part of the formal review process. This requirement will be implemented in a staged approach linked to the implementation of clustering within NTW Documenting the review as required by the lead professional s organisation. Trust staff can record using a clinical letter that meets the standards set out in the practice guidance relevant to the lead professional s directorate Documenting the review as required by the lead professional s organisation. Trust staff can record using a clinical letter that meets the standards set out in the practice guidance relevant to the lead professional s directorate 6.4 Service users who do not have enhanced needs can expect: That the lead professional, through discussion and negotiation with them and others, will ensure that a comprehensive, written Care Plan is developed and agreed taking into consideration any Advance Statement or advance decision to refuse treatment Their Care Plan to be clear and easy to understand and includes o Outcomes that they have determined o Crisis arrangements including if needed risk management o Who is doing what and when o Where applicable that they are subject to 117 o Where applicable the service(s) funded under Continuing Care Northumberland, Tyne and Wear NHS Foundation Trust 9
That any disagreement they have with any part of the Care Plan will be recorded To know who their Lead professional is and what role that person will play in their treatment and care To have the role of their carers recognised, and supported To be offered a copy of their care plan 7 ENHANCED NEEDS (Care Programme Approach - CPA) 7.1 Where a service user has more complex needs and characteristics, then enhanced Care Coordination incorporating the requirements of CPA will be the framework used to deliver continuous care for vulnerable people who may require intensive intervention or long term support. 7.2 For service users who are adults and accessing mental health services complex needs and characteristics are:- Severe mental disorder with high degree of clinical complexity Current or potential risks including suicide, self harm, harm to others, relapse history, self neglect, non-concordance, vulnerable adult, adult/child protection Current or significant history of severe distress/instability or disengagement Non-physical co-morbidity e.g. substance/alcohol misuse, learning disability Multiple service provision from different agencies Currently/recently detained under Mental Health (MH) Act, or referred to crisis/home treatment team Significant reliance on carer/s, or has own caring responsibilities Disadvantage or difficulty as a result of: o o o o o o parenting responsibilities physical health problems/disability unsettled accommodation employment issues significant impairment of function when mentally ill ethnicity, sexuality or gender issues Northumberland, Tyne and Wear NHS Foundation Trust 10
7.3 For service users who are older adults and accessing older peoples services complex needs and characteristics are:- Severe mental disorder ( including functional mental health needs) with high degree of clinical complexity Significant risk to self or others/rapid onset of symptoms requires immediate assessment and treatment Needs require a period of inpatient care Mental Health needs are having significant impact on activities of daily living and requires prompt assessment and interagency treatment plan Current or potential risks including suicide, self harm, harm to others, relapse history, self neglect, non-concordance, vulnerable adult, adult/child protection Current or significant history of severe distress/instability or disengagement Non-physical co-morbidity e.g. substance/alcohol misuse, learning disability Multiple service provision from different agencies Currently/recently detained under MH Act, or referred to crisis/home treatment team Significant reliance on carer/s, or has own caring responsibilities Disadvantage or difficulty as a result of: o parenting responsibilities o physical health problems/disability o unsettled accommodation o employment issues o significant impairment of function when mentally ill o ethnicity, sexuality or gender issues 7.4 For service users who are adults with a learning disability Enhanced Needs (CPA) applies to all service users Who are inpatients Who have active, complex mental health problems that require multiple professional involvement from the Trust Northumberland, Tyne and Wear NHS Foundation Trust 11
Who have severe challenging behaviour Behaviour can be described as challenging when it is of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion. Severity can be described as requiring multiple professional involvement from the Trust Service users with Severe challenging behaviour will usually also meet one or more of the following criteria; o o o o high risk of home/placement break down high family/staff distress multi agency work is required there is conflict and/or a lack of shared understanding of the service user s needs and no agreed formulation of needs and associated care / Behaviour Support plan o o o o o there is a history of multiple placement breakdowns there is a high risk of harm to self or others transition between services is complex significant changes in support e.g. loss of significant staff High use of PRN and/or restraint/restrictive practice/limited access to usual activity 7.5 In all instances the guidance is not exhaustive and there is not a minimum or critical number of items on the list that should indicate the need for enhanced Care Co-ordination. Professional experience, training and judgement should be used in using this list to evaluate which service users will need this support. 7.6 The exception being that all service users subject to Community Treatment order (CTO), or subject to Guardianship under the (MH) Act (section 7) status should be supported by enhanced care coordination (CPA) and the requirements set out in each organisation's policies. A care coordinator will be identified; this may or may not be the responsible clinician. Northumberland, Tyne and Wear NHS Foundation Trust 12
7.7 Service users with enhanced needs can expect: To have a Care Coordinator To have access to health and social care services through one systematic assessment of their health and social care needs That the Care Coordinator, through discussion and negotiation with them and others, will ensure that a comprehensive, formal written Care Plan is developed and agreed taking into consideration any Advance Statement or advance decision to refuse treatment Their Care Plan to be clear and easy to understand and include outcomes that they have determined That any disagreement they have with any part of the Care Plan will be recorded on that Care plan To know who their Care Coordinator is and what role that person will play in their treatment and care To have the role of their carers recognised, and actively supported To have information on how risks will be assessed and managed To have clear crisis arrangements agreed in their Care Plan To know who is doing what and when, to have this clearly stated in their Care Plan, including their comments, and be offered a copy To be offered copies of letters as outlined in the Trust s NTW(O)22 - Sharing letters with service users policy To have the Care Plan reviewed regularly and changed if necessary with their active involvement, including being informed of their right to request a care coordination review at any time To have access 24 hours and 7 days per week to information and services To have access to information in a way they can understand in an accessible format appropriate to their needs, including information about their condition and/or treatment, the risks of the treatment and information about available alternatives 8 CARE PLANNING 8.1 The standards and requirements of care planning are applicable regardless of whether the service user has enhanced needs or not. Northumberland, Tyne and Wear NHS Foundation Trust 13
8.2 Care planning should be a collaborative process with all service users as much as is possible. To help someone be involved and make decisions all possible and appropriate means of communication and providing relevant information should be tried. 8.3 If the service user and the professionals supporting them disagree over any element of the care plan the approach should be one of discussion and compromise whenever possible. Where disagreement remains the care plan should record this. 8.4 Where a service user does not have the capacity to make decisions in respect of any aspect of the care plan then a best interest decision, within the framework of the Mental Capacity Act 2005 will be undertaken 8.5 For service users who do not have enhanced needs, the record of the care plan should be recorded as expected by their lead professional s employing organisation, for NTW staff this can be in the form of a clinical letter. 8.6 For service users who do not have enhanced needs, if there is a requirement for a period of intervention from another professional to meet additional need this does not automatically equate the enhanced needs. Complexity not the number of professionals should be the guiding factor. 8.7 For service users who have enhanced needs the record of the care plan should be as expected by the employing agency of their Care Coordinator. 8.8 Regardless of the level of need of the service user, where there is multiagency involvement, it is crucial that arrangements are made to ensure that the care plan record is quickly accessible to both organisations. 8.9 Where a service user is assessed as lacking the mental capacity to consent to their care and treatment and/or admission, consideration should be given to the care plan and if this amounts to a deprivation of the person s liberty. Where it is considered that a deprivation of liberty may be occurring For example if the person is not free to leave and is under continuous supervision and control as defined by the Supreme Court Ruling (March 2014) appropriate authority should be sought, this could be from the Mental Health Act or the Mental Capacity Act/Deprivation of Liberty Safeguards (detailed in the Trust s policy NTW(C)36 - Deprivation of Liberty Policy. 8.10 The care plan will identify the service user s health and social care needs and goals, promoting recovery and wellbeing, preventing deterioration/ relapse, and the resources, and actions by individual members of the care team, including the service user and carer and any Lasting Power of Attorney (LPA) or court appointed deputy (as appropriate) to meet those needs. 8.11 The care planning process should ensure that service users (inpatient and community) are offered an annual physical health check (either at their GP or a clinic), and, if required, support them with accessing this. Northumberland, Tyne and Wear NHS Foundation Trust 14
8.12 Where the care plan includes medication it will identify the prescriber, where medication is obtained from, instructions for administration, how monitoring will be undertaken and that screening is offered/undertaken in line with conditions and medication as appropriate. For further information about the monitoring required, please refer to relevant shared care guidance (link to intranet page); the Trusts, NTW(C)38 - Pharmacological Therapy Policy, practice guidance notes, (PGNs) or NTW(C)29 Trust standard for the assessment and management of physical health policy, PGN, AMPH-PGN-06 - Antipsychotic Physical Health Monitoring. Any medication allergies, (whether new or existing) must also be documented. 8.13 The service user will be offered information about the medication including benefits and side effects. 8.14 Where a service user is subject to 117 after care or has service(s) funded under Continuing Care this should be recorded in their care plan. 8.15 Service users must always receive a copy of their care plan unless they have explicitly stated that they do not wish to receive a copy. Where there are difficulties in ensuring understanding, the Care Coordinator/Lead professional will explore alternative means and accessible formats (pictorial, Braille) to ensure service user or carer understand the content of the care plan. 8.16 If it is identified that there could be an increased risk for the service user to receive a copy of their care plan, a clinical decision must be made not to offer a copy of the Care Plan and this decision recorded in the service user s health record. 8.17 Copies of the care plan should be given to the service user s GP and any other significant care provider, including carers, if appropriate. 8.18 Care plans should routinely include arrangements for setting out, measuring and reviewing specific outcomes. An outcome focus can help to improve understanding of the impact of services on the lives of people who use them; give assurance that treatments and care provided are producing results; and ensure that outcomes related to treatment, care and support are monitored on an on-going basis. 8.19 The desired outcomes should be explicitly agreed with the service user and carer(s) at the beginning of the care process and include service user defined outcomes so that the plan is personalised to the service user. 8.20 Care plans should routinely include a crisis plan and where appropriate a risk management plan incorporating trigger factors/relapse indicators specific to the service user. The crisis plan should clearly specify the respective responsibilities of all members of the care team including the service user in response trigger factors/relapse indicators and to increasing levels of risk. Northumberland, Tyne and Wear NHS Foundation Trust 15
8.21 If there is doubt about the service user s capacity to consent in relation to any aspect of care or treatment, as recorded on the care plan, an assessment of capacity in relation to that aspect of treatment should be completed and recorded in the health record. The Decision maker in relation to each/any specific aspect of the care plan must weigh up all the information in order to determine what decision is in the person s best interests. 8.22 Where a significant decision is being considered in relation to a patient without capacity a formal assessment of capacity should be completed in line with Trust or relevant Local Authority Policy on the Mental Capacity Act 8.23 Where a Welfare Lasting Power of Attorney is in place the attorney needs to be consulted on all matters relating to the person s care and treatment. Unless the Welfare LPA specifies limits to the attorney s authority the attorney will have the authority to make personal welfare decisions and refuse treatment (except life-sustaining treatment unless the LPA specifies this) on the person s (donor s) behalf. Any Advance Decision or Statement should also be taken into consideration. 9 REVIEW 9.1 The standards and requirements of the review process are applicable regardless of whether a service user has enhanced needs or not. 9.2 The record of the review (regardless of level of need) should be as expected by the Lead professional s Care Coordinators employing agency. 9.3 Regardless of the level of need, where there is multi-agency involvement, it is crucial that arrangements are made to ensure that the review record is quickly accessible to both organisations. 9.4 The review of a care plan must be regarded as an ongoing process, the frequency of meeting being led by the needs of the service user. The review will be undertaken by the Care Coordinator/Lead Professional involving the service user, any identified carer and all those professionals involved in an individual s treatment or care. 9.5 Every review should consider whether a service user s needs have changed and the impact (if any) of changed need on: Whether they may need/may no longer need to be supported at enhanced level Any 117 eligibility Any service (s) funded under Continuing Care 9.6 As a minimum a formal review will take place once a year. This formal review will usually involve a meeting of all concerned in a setting where the service user feels comfortable. Northumberland, Tyne and Wear NHS Foundation Trust 16
9.7 It is expected that NTW staff/la staff with integrated teams will lead on the completion of clustering at significant points of change within the service user s care pathway and as part of every review. 9.8 If a full multidisciplinary meeting will prevent service user s participation this will be documented and the review will be undertaken by the Care Coordinator/Lead Professional meeting with the service user and any identified carer, with other members of the care team contributing to the process through the Care Coordinator through the provision of written reports. 9.9 A review will be undertaken in the event of a sudden relapse or following any major change in the service user s circumstances including significant changes to risk or if significant concerns are expressed by carers/family/ significant others. 9.10 Every formal review should consider whether a service user s needs have changed and the impact (if any) of changed need on: Whether they may need/may no longer need to be supported at enhanced level Any 117 eligibility Any service (s) funded under Continuing Care 10 RISK ASSESSMENT AND MANAGEMENT 10.1 Risk assessment is a dynamic and ongoing process in the provision of care and treatment to all service users. It is a multi disciplinary responsibility and the outcome of risk assessment should be formally documented using the minimum approved tool and recording required by each organisation (see Appendix 4). 10.2 A consultant psychiatrist (or associate specialist) should be directly involved in formulating risk assessment(s) and management plan(s) for all service users who express delusional beliefs involving children or might harm a child as part of a suicide plan (including multi-agency planning via the safeguarding process where applicable). 10.3 This involvement should be whenever risk assessment is required and should be formally documented using the minimum approved tool and recording required by each organisation. 10.4 Effective risk assessment should include exploration of any risk with carers and family members who live with and/or provide care to support the service user. Risk assessment is required: o As part of initial assessment/ongoing assessment/ reassessment Northumberland, Tyne and Wear NHS Foundation Trust 17
o When admitting and discharging from hospital and as part of planning and agreeing leave o As part of community or inpatient care coordination or MDT reviews o When there are major changes to presentation/personal circumstances or following an incident o When alerted by carers / relatives to their concerns. e.g. about changes to presentation / personal circumstances / an incident o When referring service users to other professionals teams/service providers to ensure that there is a shared understanding of current risks to inform the referral process. o When transferring service users to other teams/service providers to ensure that there is a shared understanding of current risks to inform the transfer process. o When alerted by other members of the care team about major changes to presentation/personal circumstances / an incident 10.5 Practice guidance details the Trust s approved minimum risk assessment tools for each directorate. 10.6 Risk management plans are an integral part of the Care Plan that will be developed when the level of risk is significant, serious, or serious and imminent. 10.7 Risk management plans should be developed, whenever possible, collaboratively with the service user and their carer/family members who live with and or support them recognising the service user s strengths. Circumstances in which you may need urgent extra help (including, if relevant, what you notice that indicates you are becoming unwell/means your problems are becoming worse/ may put yourself or others at risk 10.8 Where there is multi-agency involvement it is crucial that arrangements are made to ensure that risk assessments and risk management plans are quickly accessible to both organisations. Northumberland, Tyne and Wear NHS Foundation Trust 18
11 IN-PATIENT ADMISSION AND DISCHARGES 11.1 Prior to or on admission the referring person, as a minimum, must supply the admitting ward with a copy of the assessment and risk assessment that led to the admission, if this is not already on the Trusts electronic care record (RiO). If the service user is compulsorily admitted, this will comprise relevant section papers and assessments including the Approved Mental Health Professional (AMHP) assessment. 11.2 If the service user is already known to secondary mental health or learning disability services, on the Trusts electronic care record (RiO) there should be: most recent assessment most recent risk assessment (including any keeping children safe assessments) current care plan and any risk management plan 11.2.1 This will be available either because it has been directly recorded into the Trust electronic care record or through the uploading of partner agencies documentation. 11.3 On admission or at least within 24 hours of admission, service users should have a physical examination as outlined in the Trust s NTW(C)29 - Trust Standard for the Assessment and Management of Physical Health Policy. 11.4 Each in-patient admission, regardless of time elapsed, is a separate episode. A full assessment of need including risk assessment will be undertaken for each episode of care. 11.5 If the service user is not admitted under the Mental Health Act and is assessed as lacking capacity an urgent and standard application to deprive the patient of their liberty must be completed. The MHA CoP ch13.49-13.62 provides specific guidance in relation to the appropriate legal framework to implement when a patient lacks capacity. 11.6 The first Multi-disciplinary/care coordination review must be held within 7 days of the admission. The Multi Disciplinary Team (MDT)/Care Coordination review, including the consultant, will complete and document a full review of the patient s care needs resulting in a plan of care and where appropriate; referrals to other agencies/services. 11.7 All service users admitted to an inpatient ward will have enhanced needs on admission 11.8 If the service user is known to the service and has a Care Coordinator, this arrangement will be confirmed at this review. Northumberland, Tyne and Wear NHS Foundation Trust 19
11.9 For those service users who are new to the service, or who have been previously supported by a Lead professional, the Care Coordinator will be arranged at the review via liaison arrangements with community services or from within the inpatient reviewing team. This is to ensure that identified needs and arrangements that may take some time to put in place are initiated early. 11.10 All service user s will have a pre-discharge meeting involving the service user carers and/or advocates as appropriate, who in partnership with the multidisciplinary team, including the Care Coordinator or Lead Professional, community staff and other relevant external agencies, will review the service users needs including reassessment of risk, whether their needs continue to be at enhanced level and formulate a discharge care plan a copy of which should be offered to the service user and any carer as appropriate. 11.11 For all service users a discharge care plan will identify the service user s needs for their immediate discharge and successful reintegration into the community. The care plan will make particular reference to their immediate needs, support in the first week of discharge and the subsequent 3 months. 11.12 Consideration should be given to the planned future care regime for patients lacking capacity. If it is likely to amount to a deprivation of liberty then discharge planning should include identifying who will make the appropriate applications to authorise any future deprivation 11.13 A consultant psychiatrist (or associate specialist) should be directly involved in formulating the discharge risk assessment and management plan for all service users who express delusional beliefs involving children or might harm a child as part of a suicide plan (including multi-agency planning via the safeguarding process where applicable) 11.14 For service users with enhanced needs the care plan will also include: Financial issues (if appropriate) Medication changes including who is the prescriber, where medication is obtained from, instructions for administration, how monitoring will be undertaken and where appropriate Depot clinic/ Clozaril clinic, follow-up. The service user will be offered information about the medication including benefits and side effects. Any medication allergies (whether new or existing) must also be documented. Any physical health needs Out-patient appointments Social requirements A Risk Management Plan that recognises and builds on protective factors Northumberland, Tyne and Wear NHS Foundation Trust 20
A crisis plan 7 day follow up by whom and where and action to be taken if the service user does not attend Explicit information relating to services provided under Section 117 (where applicable) Statement on best interest if any aspect of the care plan concerns client without capacity in relation to that area of intervention 11.15 If a Service user is being discharged under order Community Treatment Order the requirements set out in the Trust s NTW(C)47 - Community Treatment Order Policy must also be met. 12 CARE COORDINATOR ROLES AND RESPONSIBILITIES 12.1 Consent must always be sought from a professional prior to them being identified as a Care Coordinator. Under no circumstances must any professional be stated as Care Coordinator without negotiation and agreement. 12.2 The role of the Care Coordinator should usually be taken by the person who is best placed to oversee case management and resource allocation and can be of any discipline depending on capability and capacity. 12.3 The Care Coordinator will have the authority to coordinate the delivery of the care plan and ensure that this is respected by all those involved in delivering it, regardless of the organisation of origin. 12.4 However, it is not the intention that the Care Coordinator is necessarily the person that delivers the majority of care. There will be times when this is appropriate, but other times when the therapeutic input may be provided by a number of others, particularly where more specialist interventions are required. 12.5 For people who have had damaging experiences of sexual abuse or violence, choice of gender of the Care Coordinator may be a crucial factor in establishing trust and a therapeutic relationship. 12.6 The Care Coordinator will: Ensure the service user s involvement in the process of decisionmaking Ensure where appropriate, any carer s involvement in the process of decision- making Northumberland, Tyne and Wear NHS Foundation Trust 21