SCHEDULE 2 THE SERVICES A. Service Specificatin Service Specificatin N. Service C11/S/a Child and Adlescent Medium Secure Cmmissiner Lead Prvider Lead Perid 12 mnths Date f Review 1. Ppulatin Needs 1.1 Natinal/lcal cntext and evidence base Secure adlescent inpatient mental health prvisin represents a highly specialist resurce which shuld be cnsidered in the cntext f a range f universal, specialist and highly specialist services fr children and yung peple in England. Such services shuld include thse prvided nt nly by health but als children s scial care, educatin, the yuth justice system and ther agencies. Within the cntext f mental health prvisin fr children and yung peple, secure frensic inpatient care shuld frm part f a clearly defined and crdinated care-pathway which minimises the need fr changes f lcatin but ensures that transitins fr yung peple between such settings and ther cmmunity r residential envirnments (r vice versa) are adequately supprted and prvided fr. Prviders f secure in-patient care shuld be crdinated natinally t ensure equity f access and prvisin fr yung peple irrespective f their gegraphical lcatin r ther circumstances. There are fur security levels currently available within in-patient mental health care in England t allw management f different levels f risk presented by yung peple under 18: medium security, lw security, psychiatric intensive care (PICU) and pen units (als knwn as Tier 4 units). The first three f these types f setting are knwn as secure in-patient units. All secure child and adlescent facilities prvide a range f physical, prcedural and relatinal security measures t ensure effective treatment and care whilst prviding fr the safety f individual yung peple, ther patients, staff and the general public. Medium secure settings accmmdate yung peple with mental and neurdevelpmental disrders wh present with the highest levels f risk f harm t thers including thse wh Page 1 f 19
have cmmitted grave crimes. In such settings there are prescribed stringent levels f physical security and high levels f relatinal and prcedural security. Yung peple admitted t medium security generally have significant lengths f stay frm mnths t years. Lw secure settings accmmdate yung peple with mental and neurdevelpmental disrders at lwer, but nevertheless significant levels f physical, relatinal and prcedural security. Yung peple in such settings may belng t ne f tw grups: thse with frensic presentatins invlving significant risk f harm t thers and thse with cmplex nn-frensic presentatins principally assciated with challenging behaviur, self-harm and vulnerability. Yung peple admitted t lw secure settings generally require significant lengths f stay frm mnths t years. Psychiatric intensive care units (PICU) fr yung peple allw fr cntainment f shrt-term behaviural disturbance which cannt be cntained within an pen adlescent inpatient unit. Levels f physical, relatinal and prcedural security wuld be similar t thse in lw security but there wuld be fewer facilities (e.g. educatinal and recreatinal settings) t supprt a yung persn ver a sustained perid f time as is the case within medium and lw secure units. The decisin t admit t any secure service will need t be based n a cmprehensive risk assessment and detailed cnsideratin as t hw identified risks can be managed safely within adlescent secure inpatient settings. The majrity f yung peple admitted t secure services are either in cntact with the welfare care system and/r the criminal justice system and may be in the middle f cmplex civil curt matters r charged with r cnvicted f criminal ffences. Adlescent medium and lw secure services play a significant key rle in assessing a yung persn s ability t participate in curt (civil and/r criminal) prceedings and prvide imprtant advice t curts regarding welfare pathways and specific criminal curt matters. This service specificatin relates specifically t adlescent medium secure mental health services fr yung peple up until the age f 18 years with mental disrders including neurdevelpmental disrders and cnduct disrders (hencefrth referred t in this dcument as mental disrders ). 1.2 Prevalence The ppulatin f England frm the mid-2012 census published by the Office fr Natinal Statistics was 53,493,700 and the number f 10-18 year lds was 5,617,300. NHS England cmmissin a range f secure adlescent beds via the 10 Mental Health Hubs respnsible fr the direct cmmissining f specialised mental health services. The spectrum f secure adlescent beds cmmissined includes adlescent psychiatric intensive care (PICU), adlescent lw secure services, and medium secure prvisin within the Natinal Secure Frensic Mental Health Service fr Yung Peple (NSFMHSfYP). There are currently six cmmissined medium secure adlescent units which prvide a ttal f 100 beds. 1.3 Natinal Plicy Secure mental health in-patient services are currently prvided by a range f NHS and independent sectr prviders. Between 2002 and 2013 adlescent medium secure services were cmmissined by the NHS n a natinal basis as a Highly Specialised Service fr the ppulatin f England fr yung peple aged up t 18 years (and in sme cases up t 19 years depending n clinical and/r educatinal needs). Since 01 April 2013 the services have been cmmissined lcally via NHS England and Page 2 f 19
they are nw therefre reginally cmmissined. They cntinue t prvide services n a natinal basis and perate as a natinal clinical netwrk (the NSFMHSfYP, discussed in mre detail belw). Future in Mind (2015) emphasised the need fr imprved care fr children and yung peple in crisis s they are treated in the right place, at the right time and as clse t hme as pssible. This includes implementing clear evidence-based pathways fr cmmunity-based care, including intensive hme treatment where apprpriate, t avid unnecessary admissins t inpatient care hwever, there is a recgnitin that there will always be sme children and yung peple wh require mre intensive and specialised inpatient care. The key t cmmissining the right type f care, in the right places is t adpt a whle system cmmissining perspective..this shuld address the rle f pre-crisis, crisis and step-dwn services alngside inpatient prvisin.. 1 Anther key natinal is NHS England s Five Year Frward View fr Mental Health 2, it sets ut pririties fr children and adlescents mental health. An assciated implementatin plan has been published. 3 2. Outcmes 2.1 NHS Outcmes Framewrk Dmains & Indicatrs Dmain 1 Dmain 2 Dmain 3 Dmain 4 Dmain 5 Preventing peple frm dying prematurely Enhancing quality f life fr peple with lng-term cnditins Helping peple t recver frm episdes f ill-health r fllwing injury Ensuring peple have a psitive experience f care Treating and caring fr peple in safe envirnment and prtecting them frm avidable harm The service is required t mnitr clinical utcmes. As a minimum the service will use utcme measures as indicated in QNIC ROM, including: 1. Clinical measures SDQ (self-reprt, parent/carer and teacher), HNOS-CA, HNOS-Sec and CGAS. These measures will be cllected n admissin, every six mnths and at discharge. These utcme measures will be reprted n bth a natinal and individual service 1 https://www.gv.uk/gvernment/uplads/system/uplads/attachment_data/file/414024/childrens_mental_health.pdf 2 https://www.england.nhs.uk/mentalhealth/taskfrce/ 3 https://www.england.nhs.uk/wp-cntent/uplads/2016/07/fyfv-mh.pdf Page 3 f 19
basis. 2. Educatin prviders will prvide the fllwing data: English and Maths attainment level n entry and discharge using pints values A measure f wider prgress and wellbeing in educatin, in additin t academic prgress, t be cmpleted each academic term, such as the Every Child Matters Teacher and Student Assessment. This measure shuld be agreed and implemented by all units in the medium secure netwrk. 3. Parent / carer and yung persn feedback On yung peple and carer s experience f the service will be rutinely sught as described in sectin 3.2. The means by which this feedback is cllected shuld be agreed and implemented by all units in the medium secure netwrk. Services will be required t submit evidence f achievement f utcme measures as defined in the standard cntract. This will include the measures as utlined abve plus additinal measures that will be reviewed annually. 3. Scpe 3.1 Aims and bjectives f service The cre bjectives fr adlescent medium secure mental health services are t: Assess and treat mental disrder; reduce the risk f harm a yung persn pses t self and thers; supprt recvery; prmte adlescent develpmental tasks and aid rehabilitatin. Have a particular functin in managing high risk behaviurs that cannt be managed in less secure settings. Operate as a clinical managed netwrk (NSFMHSfYP) that supprts: - a crdinated single referral and admissin pathway int individual settings and acrss the netwrk - a crdinated respnse that evidences equity f prvisin fr the ppulatin f England. Prvide multi-disciplinary teams which are experienced in bth adlescent frensic and child mental health. These teams shuld als have highly develped liaisn skills with an extensive understanding f statutry framewrks and services available fr yung peple with cmplex needs utside f inpatient prvisin. Prvide a range f specialist treatment prgrammes delivered either individually r within grups with the aim f safely reintegrating the yung persn int the cmmunity r ther secure r specialist prvisin. Prvide an exemplary cmprehensive service fr all eligible referred yung peple with mental disrders, wh present a significant risk t thers and/r themselves in secure care. Prvide expert multidisciplinary assessments, diagnsis, management and treatment f mental disrder. Prvide expert multi prfessinal assessments f the link in the yung persn between Page 4 f 19
their mental disrder and their high risk behaviurs twards self and/ r thers. Operate within a rbust clinical gvernance framewrk that prmtes multi-disciplinary wrking and the CPA prcess. Prvide an individualised, develpmentally-apprpriate framewrk f care that prvides fr the needs f yung peple and their families. Prvide care in a psychlgically infrmed envirnment in which every interactin has the ptential fr therapeutic value Prvide high quality infrmatin fr patients, families and carers in apprpriate and accessible frmats and media and ensure that all effrts are made t establish gd cllabrative wrking relatinships with parents/carers and thse with parental respnsibility fr the yung persn. Ensure the develpment f gd relatinships with adult mental health and ther services fr adults t ensure timely and planned transitin t such services when a yung persn reaches the age f 18. 3.2 Service descriptin / care pathway It is expected that all yung peple will be treated and managed within a whle care pathway apprach where services wrk cllabratively with each ther in rder t ensure that admissin and transfer within the secure pathways and beynd are achieved seamlessly and efficiently. The pathway thrugh care shuld, therefre, be identified early in admissin but may be subject t change depending n develping needs and circumstances. Child and adlescent medium secure mental health services prvide care and treatment t a variety f yung peple but the predminant need fr care and treatment in cnditins f medium security will be related t the yung persn s assessed risk f harm t self and/r thers in the cntext f their mental disrder. The recgnised pathways int adlescent medium secure services are: Stepping up frm lw secure adlescent services. Direct admissin thrugh a criminal curt prcess r frm yuth justice custdial settings. Admissins frm nn-criminal justice and welfare settings including welfare secure units and ther residential and specialist educatinal settings. Admissin frm a PICU; frm the cmmunity r a nn-secure adlescent inpatient unit. Multi-disciplinary wrking and the Care Prgramme Apprach (CPA) prcess will underpin service delivery and the service will need t prvide the fllwing: Admissin under the prvisins f the Mental Health Act 1983. Care in line with welfare principles frm the Children Act 1989 and the 2015 Cde f Practice t the Mental Health Act. A secure envirnment where patients can address their prblems in safety and with dignity. Care that invlves yung peple and their families and carers frm the beginning f the care pathway. Adherence t the Care Prgramme Apprach in accrdance with best practice Page 5 f 19
guidance; invlving patient, referrers, family, carers and ther relevant stakehlders. Onging assessment, which meets the needs f patients thrugh their transitin t discharge. Cmprehensive risk assessment and management. A multidisciplinary apprach t the prvisin f patient care. Physical and mental health care that meets the needs f yung peple. Yung persn-centred individualised evidence-based treatment packages, based upn assessment f need and risk. The prvisin r f apprpriate educatinal services in line with OFSTED statutry requirements and demnstrating particular attentin t the needs f this grup f yung peple. Educatin prvisin shuld be cnsistent acrss the netwrk and will be detailed in the standard cntract. An extensive range f therapeutic, educatinal, ccupatinal and recreatinal pprtunities. The prvisin f activity prgrammes during perids where educatin is nt prvided with a minimum f 25 hurs f meaningful activities per week. Effective, safe, and timely discharge. Specialist prfessinal advice t referrers and ther agencies. In additin, the cmpetencies that are particularly needed t meet the needs f yung peple with a range f cmplex behaviurs are: A cmprehensive multi-disciplinary team (MDT) with a cre team f expert psychiatry, psychlgy (including clinical and frensic cmpetencies), scial wrk, ccupatinal therapy, educatin and nursing prfessinals. Services shuld ensure apprpriate access t ther necessary disciplines (such as speech and language, family therapy etc.). Units shuld wrk t a therapeutic mdel based n the principles f child develpment and attachment that acknwledges the imprtance f relatinships and the key rle f primary caregivers as agents f change. The mdel infrms the wrk f the multidisciplinary team and is an underpinning principle f the nursing wrkfrce in maintaining a safe, therapeutic and develpmentally apprpriate culture within the unit. A cmprehensive multidisciplinary assessment f a yung persn and their wider supprt netwrk will be undertaken. A structured clinical judgement apprach t clinical risk assessment and management will be adpted, and reviewed at regular intervals. The assessment will infrm an individual frmulatin including risks and prtective factrs which will be clearly recrded and shared by the team, the yung persn and their wider system. The therapeutic regime shuld be able t deliver effectively a variety f psychlgical interventins at an individual and grup level and deliver interventins addressing interpersnal relatinships, prblem slving, affect regulatin, mental health in line with the clinical frmulatin. The interventins shuld be flexible and respnsive t the needs f the yung peple. The units will als prvide a spectrum f ffender-related interventins cmmensurate with high risk presentatins. The therapeutic milieu shuld be cmfrtable with a psychlgical understanding f frmulatins. It shuld have a capacity t effectively deliver interventins fr prtracted perids f time and shuld shw a level f resilience capable f dealing effectively with Page 6 f 19
chrnic challenging yung peple with past significant adversity. It shuld als be capable f demnstrating a rbust safeguarding apprach that is able t balance therapy delivery and safety f staff and patients. Interventins shuld draw frm the available evidence base, whilst recgnising the limits f this evidence fr the cmplex client grup. When wrking utside the evidence base, innvative interventins shuld be theretically sund and rbustly evaluated and shuld evidence clinical utcmes and yung persn and carer satisfactin Individual services will prvide an envirnment which meets best practice fr safety, welfare and security and demnstrates a rbust apprach t risk assessment and management embedded in the culture f the individual adlescent medium secure service and the clinical netwrk. Individual services as part f the natinal clinical netwrk will be required t cmplete regular audits thrughut an annual cycle demnstrating the degree t which security within the unit is maintained and reviewed. The clinical netwrk will then reprt annually t NHS England. Individual services are expected t review all serius incidents and carry ut rt cause analysis f serius incidents and near misses s that learning can be disseminated thrugh the natinal netwrk internal security review meetings. Rbust gvernance arrangements need t be in place with regard t cmmunicatin and infrmatin gvernance and all cmmunicatin shuld aim t allw the yung persn access t infrmatin abut their care in a way that is meaningful fr them and enables the prvisin f feedback abut their care. Infrmatin shuld be given t the yung persn and their family r carers abut the unit they are referred t prir t admissin and all infrmatin and feedback frm service users shuld cntribute twards future service develpment. Individual services, in line with natinal netwrk recmmendatins, are expected t ensure that rbust systems are put in place t gather patient, family and stakehlder rganisatin feedback. This shuld be gathered by a variety f means and include feedback mechanisms that are independent frm the service. This shuld include: scial grups in wards; therapeutic interventin prgrammes; discharge questinnaires; patients self-reprts n care and treatment; advcacy supprt grups; discussin with families and cnsultatin with referrers, cmmissiners and ther stakehlders The abve is nt meant t be an exhaustive list f feedback systems but rather the minimum necessary. There shuld be clear evidence f hw the service has acted n feedback t imprve patient, family and stakehlder experiences. Age-apprpriate independent advcacy (including independent mental health advcacy) services are t be prvided thrugh sub-cntractual arrangements. Advcacy services and are required t cmplete regular activity reprts n service prvisin thrugh service review meetings highlighting yung peple s feedback and any areas requiring actin. Page 7 f 19
Individual services, in line with the natinal netwrk shuld have clear prcesses that practively cnsider safeguarding issues bth n an individual patient basis and als that allw fr the management f any patient interactin difficulties. This shuld include evidence f apprpriate (Level 3) safeguarding children training fr all frntline staff, and dedicated input frm a scial wrker. Each unit shuld have an identified safeguarding lead within the service wh will be a senir pint f cntact in relatin t any safeguarding cncerns and wh can liaise beynd the unit as necessary with regard t such matters. Care Pathway The service n a natinal basis will prvide safe, effective and crdinated clinical care acrss the different stages f a clearly defined care pathway. The invlvement frm lcal/catchment area services in the yung persn s care and treatment, thrughut the admissin and transfer/discharge, is essential. This must be maintained thrugh effective cmmunicatin and invlvement in clinical reviews via an identified care crdinatr frm the yung persn s hme area and an identified scial wrker in line with s.117 requirements. There shuld be clse cmmunicatin between the lcal care crdinatr and lcal cmmissiners and case managers. Other imprtant lcal/catchment area services may include: adult mental health, yuth ffending / prbatin teams, educatin, and third sectr rganisatins. a. Referral Yung peple will nrmally be expected t be referred t medium secure services frm the fllwing surces: Adlescent lw secure inpatient services Inpatient Tier 4 prvisin ( pen adlescent units and PICUs) Yuth Justice System (frm curts r transfer frm Yung Offender Institutins (YOI), Secure Training Centres (STC) r Secure Children s Hmes (SCH) Secure children s hmes where the yung persn is detained n welfare grunds Cmmunity child and adlescent mental health services (including adlescent assertive utreach services, early interventin in psychsis services and cmmunity child and adlescent frensic teams) Residential care settings (including children s hmes and specialist educatinal placements) via senir child and adlescent mental health prfessinals. The NSFMHfYP medium secure clinical netwrk shuld cnsider all referrals fr mental health inpatient care frm yuth justice settings (curts and custdial units) and determine the level f security required. In general, a yung persn frm such settings is likely require medium security but n rare ccasins it may be mre apprpriate fr them t be admitted t a lwer level f security. Referrals can be made t any f the units within the NSFMHSfYP medium secure clinical netwrk. Referrals shuld be made via the NHS England CAMHS Inpatient Natinal Referral Frms All referrals are discussed at a weekly NSFMHSfYP referrals meeting with input frm all services (held via videcnference) when, if apprpriate, the referral will be allcated t a specific unit fr assessment. This allcatin will be made based n available treatment, gegraphy, and current capacity t admit. The NSFMHSfYP cannt cver the cuntry fr acute psychiatric emergencies. Hwever, services are ften able t prvide a rapid respnse (within days) t help cntribute t the assessment and Page 8 f 19
management f imminent risks f harm t thers as relevant t yung peple wh present with mental health cncerns. There is currently a ne-ff fee fr assessment, t be paid by the patient s CCG. All ther health csts assciated fllwing admissin will be met by Natinal NHS England cmmissining arrangements. Services shuld facilitate early discussin f ptential referrals, and encurage clinicians t make cntact prir t referral. In general cnsideratin fr medium secure prvisin will be undertaken in agreement with CAMHS lcal t the patient s hme area. b. Initial Assessment Admissin t medium secure inpatient settings must be carefully cnsidered by bth referrer and the ptential medium secure service. There must be gd prir cmmunicatin and assessment by bth parties. Repeated assessments fr the same yung persn in relatin t a single referral must be avided and the clinical netwrk must ensure that arrangements are in place t prevent this. The initial assessment will be carried ut by members f the multidisciplinary team (t include a psychiatrist and nurse) frm the medium secure service where pssible jintly with the referrer. This assessment shuld include active invlvement f a yung persn s family r carers. All medium secure services are required t give infrmatin abut available treatments and facilities t the yung persn, parents, carers and thers with parental respnsibility prir t admissin. Fllwing the assessment, the assessing medium secure service will discuss the case with the NSFMHSfYP referrals meeting. This meeting will determine whether the yung persn fulfils the criteria fr admissin. The utcme f this discussin will be prmptly cmmunicated t the referrer. Fllwing assessment and discussin at the NSFMHSfYP referrals meeting, a full reprt in line with agreed standards will be prvided by the assessing medium secure service. The relevant NHS England CAMHS Inpatient Natinal Referral Frms shuld als be cmpleted by the assessing medium secure service. If it is cncluded that the yung persn des nt meet the criteria fr admissin, the assessing service shuld feed this back verbally and within the assessment reprt t the referrer. In particular, such feedback shuld include advice n management f risk f harm t thers. c. Pre-admissin The admitting medium secure service shuld infrm the yung persn, parents (and thers with parental respnsibility), carers, scial care, relevant CAMHS clinicians, and cmmissiners that the yung persn has been accepted fr admissin. All shuld als be kept updated regarding timescales fr admissin. The arrangements fr admissin will be jintly agreed by the current placement and the admitting medium secure service. There shuld be clear verbal and written cmmunicatin regarding admissin arrangements, with particular fcus n nursing handver. Page 9 f 19
The admitting medium secure service shuld prvide written and verbal infrmatin t the yung persn, parents and carers and scial care abut the service, facilities and available treatments prir t admissin. d. During admissin There is sme degree f verlap between admissin criteria fr adlescent medium and lw secure services. This shuld be brne in mind by clinical teams fllwing an admissin t a medium secure setting and at each case review cnsideratin shuld be specifically given as t whether the yung persn is apprpriately placed. Such cnsideratin shuld take int accunt the principle f ffering the yung persn the least restrictive ptin in terms f their care Each adlescent medium secure mental health service will perate 24 hurs a day, 365 days per year and will prvide care that meets the fllwing standards in delivering service: Each yung persn will have their wn bedrm. Each yung persn will have a Respnsible Clinician. The nursing mdel f care will be based n the primary nurse mdel, where every patient will have a named nurse wh will be respnsible fr their day t day nursing needs. The patient will als have a Care Crdinatr allcated within the medium secure service, which will c-rdinate the care fr the individual within the Care Prgramme Apprach (CPA) framewrk. The verall mdel f care will be thrugh a Multi-Disciplinary Team (MDT) apprach cnsisting f psychiatrists, psychlgists, ccupatinal therapists, scial wrkers and nurses, in accrdance with standards and guidelines utlined by the Quality Netwrk fr Inpatient Care (QNIC). Each patient will: Be reviewed by the MDT at least weekly. Have a cmprehensive up t date MDT care plan and risk assessment develped by the MDT cllabratively with the yung persn and, if apprpriate, their family in accrdance with best practice guidance. Have a named practitiner psychlgist wh will undertake needs based assessment and cntribute t a multidisciplinary risk assessment t develp a frmulatin and use this t identify the apprpriate psychlgical treatment prgramme n either an individual r grup basis Have a named ccupatinal therapist wh will undertake a full ccupatinal therapy assessment and will deliver an apprpriate prgramme. Speech and language assessment may be required and where this is nt prvided within huse, there shuld be defined agreements t ensure this can be accessed in a timely fashin during the curse f the yung persn s admissin. Have a named scial wrker within the unit wh will liaise with the yung persn s lcal Scial Care Children s Services t ensure the prvisin f a full scial care service t the patient, family and carers. Have access t the Independent Mental Health Advcates (IMHA) and, where Page 10 f 19
applicable, Independent Mental Capacity Advcates (IMCA), wh will assist by undertaking the direct advcate s rle. Receive three culturally apprpriate meals per day. The fd will be prepared in accrdance with NHS Natinal guidelines n nutritin and variety. Have their religius and cultural needs met. Have their rights under the Mental Health Act 1983 explained. Have their physical healthcare needs met thrugh a full range f primary healthcare and dental interventins that include health prmtin and physical health screens. Yung peple will be prvided with a structured day including a minimum f 25 hurs per week f structured activity acrss three dmains: Leisure: Educatin: Develpmentally apprpriate and specifically care planned activities prvided n and ff the ward such as, art, drama, dance, music, gym, sprts and grup games. All yung peple are expected t participate in educatinal studies t imprve their educatinal attainment. Yung peple shuld have educatin prvided in accrdance with the Natinal Curriculum. The prvider will liaise with partners t make sure recmmendatins f Care and Treatment Reviews are undertaken and must ensure that educatinal needs cntinue t be met. Where apprpriate (when a child r yung persn has a Educatin Health and Care plan, r statement f special educatinal need (where this has nt yet been cnverted) r is receiving SEN supprt, the prvider will ensure that the child r yung persn cntinues t access the educatin and supprt specified within their plan. This may smetimes require a review r revisin f the plan. Therapeutic Interventins: Frmal assessment and mnitring f mental state; Assessment f clinical risks and develpment f management plans; Management f physical health care; Prescribing and mnitring f drugs and their side effects in line with NICE guidance; A brad range f psychlgical interventins (which may be delivered at an individual, grup and systems level). These interventins shuld be sequenced accrding t need and readiness, and delivered within a develpmentally sensitive framewrk. Offence specific therapeutic interventins (which may include prgrammes fr sex ffending, fire setting, aggressin reductin) if indicated by the assessment f risk and need; Occupatinal therapy; Page 11 f 19
Health prmtin (physical and mental health) and relapse preventin; Vcatinal wrk activities as apprpriate. Other therapeutic interventins that may include family therapy, music therapy and art therapy. Graded prgramme f sectin 17 leave (where apprpriate). Care planning and CPA Yung peple shuld have a cmprehensive care plan and risk assessment develped by the MDT cllabratively with the yung persn and, if apprpriate, their family in accrdance with best practice guidance. All care planning shuld fllw a recvery and utcme prcess, shuld be embedded in the Care Prgramme Apprach (CPA) and frm the crnerstne f delivery f an effective care pathway thrugh secure care. Linking with ther prcesses Patients shuld have a designated cmmissiner in line with respnsible cmmissiner guidelines. Medium secure services shuld supprt case management frm NHS England case managers. All patients shuld have a cmmunity Care Crdinatr linked t cmmunity CAMHS team lcal t the patient s hme area wh will remain updated thrughut the admissin perid and is expected t remain invlved with the yung persn s care. Fr restricted patients, adlescent medium secure services will need t ensure cmpliance with the Ministry f Justice requirements. Fr yung peple wh are subject t input frm the Yuth Justice Services, reviews f rders including remand reviews shuld be facilitated and may be undertaken jintly with CPA reviews. Fr yung peple in the care f lcal authrities, Lked After Children (LAC) Reviews must be facilitated and may be undertaken jintly with CPA reviews. e. Future care planning and discharge Cnsideratins in secure care pathway planning Care pathway planning shuld always invlve balancing the relevant needs f the yung persn, including: The immediate risk psed by the yung persn t themselves and/ r thers Ministry f Justice r curt-rdered restrictins Specialist treatment needs which cannt be met in lwer security settings The Mental Health Act 1983 (as amended 2007) principle f least restrictiveness The yung persn s vulnerabilities, including ptential destabilisatin by multiple transitins Placement stability and cntinuity f care the yung persn s and their family s needs including access t and prximity t hme and ease f access t family Page 12 f 19
In planning future care pathways there shuld be active cnsideratin f balancing the principles f management in the least restrictive envirnment and reducing transitins fr yung peple. On ccasins, where it can be clearly demnstrated that it is in the best interest f the yung persn, it may be mre apprpriate in the cntext f their lnger term future care pathway, fr a patient t cntinue t receive treatment in a medium secure service rather than experience transitin t a shrt-term less secure placement. Discharge The discharge / transfer f a yung persn frm medium secure inpatient care will be dictated by the nature f their mental health difficulties, their risk prfile, and their identified needs. All yung peple shuld be supprted in taking an active rle in their discharge planning. Recgnised discharge rutes include discharge / transfer t the fllwing settings: Adult secure (lw, medium r high) r pen inpatient services, including rehab services Adlescent lw secure r pen inpatient services Cmmunity mental health services (cmmunity CAMHS r adult CMHT) Scial care residential settings, including secure welfare placements Specialist educatinal settings Family hme Supprted living r ther cmmunity placement Custdial placements (Yung Offender Institutin, Secure Training Centre, Secure Children s Hmes, adult prisns) Services are required t actively invlve the catchment area services frm the patient s hme area and ensure that they hnur their statutry respnsibilities (e.g. via sectin 117 f the Mental Health Act) in supprting discharge. This shuld include input frm: Pst 18 care pathway Mental health services (CAMHS and/r adult mental health as apprpriate) Scial care services (children s scial care and/r adult scial care) Educatin and training prviders In rder t ensure gd age transitin planning, when a yung persn in an adlescent medium secure service is a minimum f six mnths frm their 18 th birthday, the Respnsible Clinician in the medium secure service shuld liaise with lcal services, including the Respnsible Cmmissiner, t ensure that the relevant transitin prcesses fr mental health and scial services are initiated, including access assessment fr adult secure prvisin. In certain cases identificatin f yung peple likely t require specialist prvisin at the age f 18 is pssible at an earlier juncture and gd practice wuld require that such needs be signalled earlier. In sme cases yung peple are required t stay beynd their 18 th birthday fr cmpletin f adlescent specific treatments. The maximum extended inpatient perid will nt exceed the yung persn s 19 th birthday and the view f the respnsible cmmissiner in the yung persn s CCG shuld be sught six mnths prir t the yung persn s 18 th birthday t cnfirm arrangements. Page 13 f 19
3.3 Ppulatin cvered The service utlined in this specificatin is nly relevant t individuals wh are the cmmissining respnsibility f NHS England. The ppulatin cvered includes yung peple liable fr detentin fr mental disrder under the Mental Health Act in need f child and adlescent medium secure care. This ppulatin includes yung peple with specific cultural needs and special needs such as deafness, blindness r ther physical disabilities and it als includes yung peple with neurdevelpmental disrders with r withut a learning disability. Child and adlescent medium secure mental health services will need cmpetences in the assessment and treatment f yung peple with such special needs. Many f these will receive apprpriate treatment fr their primary mental disrders in mainstream medium security with nly minr adjustments t the care prvided. In particular, services shuld have the skills and training (r t access such skills and training prmptly) t meet the cmmunicatin needs fr all yung peple with and withut special needs grups. There may be times when apprpriate specialist advice r cnsultatin (fr example frm the natinal Deaf CAMHS) shuld be sught. When adjustments t child and adlescent medium secure facilities are nt sufficient t enable adequate cmmunicatin, equality f utcmes, r participatin in the day t day activities r when a specialist treatment is needed then treatment in a specialist service will be required. This is f particular relevance t yung peple with a learning disability, wh are likely t require admissin t a specific learning disability medium secure unit t ensure equality f utcmes. 3.4 Any acceptance and exclusin criteria and threshlds Acceptance Criteria The yung persn is under 18 years f age at the time f referral AND: The yung persn is liable t be detained under either Part II r Part III f The Mental Health Act AND: The yung persn presents a significant risk* t thers f ne r mre f the fllwing: AND: Direct serius vilence liable t result in injury t peple Sexually aggressive behaviur Destructive and ptentially life threatening use f fire There is clear evidence prir t referral that serius cnsideratin (and testing where apprpriate) f less secure prvisin will exceed the ability f available mental health services t meet the needs f the yung persn. * It is nt necessary that the referred yung persn shuld be facing criminal charges fr these risk behaviurs, but it is necessary that there shuld be reliable accunts available f such behaviur. Page 14 f 19
Imprtant cnsideratins Yung peple with mental disrder wh present a grave danger t the general public (which may include sme high risk yung peple wh may have n ffending histry, as well as thse wh have been charged with r cnvicted f specified vilent r sexual ffences under Schedule 15 f the Criminal Justice Act 2003) shuld be referred t the NSFMHfYP (medium security) rather than lw security. Yung peple wh are directed t cnditins f security under a Restrictin Order by the Ministry f Justice (s.49 MHA); t include a yung persn in custdy (remand r sentenced) OR have has been sentenced by a Crwn Curt t a Restrictin Order (s.41 MHA) shuld be referred t the NSFMHfYP (medium security) rather than lw security. On very rare ccasins yung peple with particularly severe presentatins which may include prlnged self-harm and particularly challenging behaviur wh cannt be managed in any ther setting will be cnsidered fr admissin t medium security Yung peple with brief episdes f disturbed r challenging behaviur as a cnsequence f mental disrder (including neurdevelpmental disrders) are usually mst apprpriately cared fr in PICU. When uncertain, referring clinicians are encuraged t seek advice regarding whether a yung persn wuld be mst apprpriately referred t lw secure r medium secure; this advice can be prvided by senir clinicians within the NSFMHSfYP netwrk. 3.5 Interdependencies with ther services/prviders Child and adlescent medium secure mental health services are part f a spectrum f services whse functin is t meet the needs f yung peple with mental disrders in need f specialist care and treatment in a secure envirnment. Adlescent medium secure mental health services als supprt yung peple in their recvery and rehabilitatin and enable transitins int less restrictive envirnments as sn as pssible. Key partnerships At Natinal Level: NHS England Apprpriate NHS and independent sectr prviders (including Adult Services, Tier 4 services, and lw secure adlescent services). Lcal Mental Health Services (including Tier 3 CAMHS and reginal Frensic CAMHS). Organisatins representing yung peple, their parents and families (eg. Yung Minds) At Reginal Level: Department f Health, Public Health Team, Hme Office, Children and Yung Peple leads Reginal divisin f NHS England Reginal Directrs f Public Health Reginal Children and Yung Peple Health and Well-being Bards Page 15 f 19
Reginal Imprvement and Efficiency Partnerships Offender Health Reginal Strategy Bards (implementing Imprving Health, Supprting Justice) Reginal Children and Yung Peple lead fr the Assciatin f Chief Plice Officers (ACPO) Directrs f ffender management Cmmissiner and prvider representatives fr secure establishments Natinal Treatment Agency reginal managers Yuth Justice Bard heads f regin Third sectr rganisatins At Lcal Level: Lcal Authrities (LAs) Lcal Safeguarding Bards & Public Prtectin panels Children s Services Authrities Cmmissiners (LA and Mental Health) Clinical Cmmissining Grups Directrs f Public Health Plice Prbatin Husing Yuth Offending Team (YOT) Third sectr rganisatins Lcal Strategic Partnerships with: - Children s Trust Bard - Lcal Children s Safeguarding Bard - YOT Management Bard - Crime and Disrder Reductin Partnerships - Drug Actin Teams - Lcal Criminal Justice Bard - CAMHS Partnership 4. Applicable Service Standards Best practice guidance in respect f service prvisin within child and adlescent secure mental health services will be prvided thrugh a range f natinally agreed standards, guidance framewrks and legislatin as well as mental health literature assciated with adlescent mental disrders. Medium secure services, like all child and adlescent mental health services are expected t deliver care within best practice guidelines and any newly published mental health strategies that relate t the treatment f children and adlescents with mental health difficulties. Care standards shuld be agreed and crdinated by a natinal medium secure netwrk; prviders will be expected t adhere clsely t such standards. Page 16 f 19
4.1 Applicable legislatin, natinal standards e.g. NICE Care Quality Cmmissin Standards fr Hspitals and relevant guidelines regarding restrictive practices. Mental Health Act 1983 Mental Health Act Cde f Practice 2015 NICE guidelines fr a range f disrders (e.g. psychsis and cnduct disrder) The Natinal Service Framewrk fr Children and Yung Peple and Maternity services (DH 2004) Every Child Matters in the Health Service (DH, 2006) Natinal Service Framewrk fr Mental Health: Mdern standards and service mdels (DH, 1999) New Hrizns fr Mental Health (DH, 2009) Wrking Tgether t Safeguard Children: A guide t inter-agency wrking t safeguard and prmte the welfare f children (DFE March 2015) Standard fr Better Health (DH 2007) Healthy Children Safer Cmmunities (DH, 2009) Human Rights Act 1998 The Children Act 1989 Criminal Justice Act 1998 Criminal Justice Act 2003 Children Act 2004 DH Offender Mental Health Pathway 2005 Mental Capacity Act 2005 Cde f Practice: See Think Act (Department f Health 2010). The Autism Act 2009 The Evidence Base t Guide Develpment f Tier 4 CAMHS (Department f Health; Kurtz, Z April 2009) Prmting mental health fr children held in secure settings: a framewrk fr cmmissining services. Lndn: DH, 2007 Prcedure fr the Transfer frm Custdy f Children and Yung Peple t and frm Hspital under the Mental Health Act 1983 in England (DH, June 2011) Infrmatin Sharing - Advice fr practitiners prviding safeguarding services t children, yung peple, parents and carers (HM Gvernment, March 2015) UN Cnventin n the Rights f Persns with Disabilities (perhaps an verall statement n Human rights issues). Page 17 f 19
4.2 Applicable standards set ut in Guidance and/r issued by a cmpetent bdy (e.g. Ryal Clleges) Quality Netwrk fr Inpatient CAMHS (QNIC) standards Standards fr Adult Medium secure services (CCQI, 2007) Standards fr Adult Lw secure services (CCQI, June 2012) Healthcare standards fr Children and Yung Peple in Secure Settings (Ryal Cllege f Paediatrics and Child Health June 2013) Develping Services t imprve the quality f life fr yung peple with neurdevelpmental disrders, emtinal/ neurtic disrders and emerging persnality disrder (Ryal Cllege f Psychiatrists OP77 June 2011) Interventins fr children at risk f develping antiscial persnality disrder (Reprt t the Department f Health and Prime Minister s Strategy Unit; Utting et al March 2007). Better Mental Health Outcmes fr Children and Yung Peple (CHIMAT). 4.3 Applicable lcal standards The Admissin Criteria and Prcess fllwing referral t the NSFMHSfYP. Terms f Reference and Prcedural Guidelines fr the Natinal Referral Grup Meeting. NSFMHSfYP Security Grup Peer Review Tl (currently in draft). 5. Applicable quality requirements and CQUIN gals 5.1 Applicable quality requirements (further details within Schedule 4 Parts A-C f the cntract ( Quality Schedule ) Clinical standards Adlescent Medium Secure Mental Health Services prvide care and treatment by balancing three principles: as an adlescent service it has t prvide develpmentally apprpriate care attuned t the cmplex needs this ppulatin typically presents with and it needs t facilitate the yung persn s emtinal, cgnitive, mral, educatinal and scial develpment; as a secure service it has t prvide a secure and safe envirnment that can effectively manage high-risk and ften high cst behaviurs and at the same time manage high levels f vulnerability; as a mental health service it has t prvide cmprehensive multi-faceted evidence-based treatments and evaluate their effectiveness. Adlescent Medium Secure Mental Health Services must meet all three f the abve principles t be effective and it wuld nt be acceptable t prvide a secure envirnment that cmprmises the delivery f therapy nr wuld it be acceptable t deliver therapeutic interventins in a manner that cmprmises the safety f its service users and staff. Clinical standards will be specified elsewhere within the cntracting prcess but and shuld be mediated via the natinal Page 18 f 19
medium secure clinical netwrk. Clinical standards can be peratinalised within three dmains: indicatrs by which clinicians and peratinal managers can demnstrate cmpliance with the three principles mentined abve: develpmentally apprpriate care; secure safe envirnment; multifaceted evidence-based treatments a descriptin f the mdel f psychlgically infrmed care which articulates hw the abve principles can be sustained; a descriptin f standards and functins f the multidisciplinary team (MDT) with particular fcus n medical, psychlgical, nursing, ccupatinal therapy, scial wrk, speech and language therapy and educatinal prfessinals grups. 5.2 Applicable CQUIN gals (See Schedule 4 Part D see the cntract) 6. Lcatin f Prvider Premises The Prvider s Premises are lcated at: Page 19 f 19