Trust Headquarters, Greater London House, Hampstead Road, London NW1 7QY Tel: 020-3214- 5871 Fax: 020-3214-5892 CARE PROGRAMME APPROACH (CPA) POLICY Document Reference: John Duguid, Acting CPA Compliance Manager Point of Reference: Directorate of Clinical Governance Publication Date: 1 April 2009 Hyperlinks added 1/6/09 Review Date: November 2009 Policy Reference: CPA1 Ratified By: Clinical Governance Committee (20/3/09) Scheduled Amendments: Appendices: To be issued in stages between 1/5/09 and 30/9/09 Signed by … … Medical Director: Chair of the Clinical Governance Management Group Central and North West London NHS Foundation Trust And by … … Chief Executive Central and North West London NHS Foundation Trust

2 CARE PROGRAMME APPROACH (CPA) POLICY : CONTENTS Paragraph Title Page 1.1 PART 1 : INTRODUCTION 5 1.2 CPA & Lead Professional Care 5 1.3 Policy Purpose 5 1.4 Policy Status 5 1.5 Policy Scope 5 1.6 Policy Structure 5 1.7 Terminology & CAMHS Tiers 6 2.1 PART 2 : CONTEXT 6 2.1 Development of CPA 6 2.2 Legal & Policy Context 6 2.5 Refocusing CPA 6 3.1 PART 3 : VALUES & PRINCIPLES 7 3.3 CPA Values and Principles Statement 7 3.4 Putting the Service User at The Centre of CPA 8 3.5 Social Inclusion 8 3.6 Recovery and Focus on Outcomes 8 3.10 Equalities, Diversity & Diverse Needs & Roles 10 3.12 Personalisation and Self-Directed Care 10 3.13 Partnership, Long-Term Engagement and Continuity of Care 10 3.14 User and Carer Involvement 10 3.15 Mental Capacity 11 3.17 Safety and Positive Risk Taking 11 3.19 Principles Underpinning Staffing Arrangements and Ways of Working 11 4.1 PART 4 : STANDARDS USERS AND CARERS CAN EXPECT 12 5.1 PART 5 : THE CPA PROCESS 13 5.1 Care Pathways 13 5.2 Components of the CPA Process 13 5.3 Timescales 14 5.4 Recording 15 6.1 PART 6 : REFERRALS 17 6.1 Receiving Teams 17 6.2 Advice and Consultation 17 6.4 Receiving Referrals 17 6.5 Sharing Referral Information 17 6.6 Urgent/Emergency Referrals 17 6.7 Re-Referrals 18 7.1 PART 7 : ASSESSMENT 18 7.1 Initial Assessment 18 7.6 Secondary Mental Health Services: Criteria 18 7.7 Who Should Be On CPA? 19 7.12 Who Should Have Lead Professional Care? 20 7.15 Comprehensive Assessment 20 7.20 Risk Assessment 21 7.22 Health of the Nation Outcome Scores (HoNOS) 22 7.25 Vocational Needs Assessment 22 8.1 PART 8 : CARE PLANS 23 8.1 Initial Care Plans 23

3 8.2 Care Plans : Contents 23 8.4 Draft Care Plans 23 8.5 Care Plans 23 8.9 Advance Decisions 24 8.12 Risk Management Plans 25 8.14 Crisis and Contingency Plans 25 8.17 Crisis Cards 25 8.18 Finalising & Distributing Care Plans : CPA 26 8.20 Finalising & Distributing Care Plans : Lead Professional Care 26 9.1 PART 9 : REVIEWS 27 9.1 CPA Reviews and Reassessments 27 9.3 Arranging CPA Reviews 27 9.8 Who Should Attend CPA Reviews? 28 9.9 CPA Reviews: Preparation and Draft Care Plans 28 9.14 CPA Reviews: Running Meetings 29 9.16 Action Following CPA Reviews 30 10.1 PART 10 : ENGAGEMENT 30 10.2 Managing Engagement Difficulties 30 11.1 PART 11 : TRANSFER & DISCHARGE 31 11.3 Transfers Between Areas and Services : General Points 31 11.9 Transfer Procedure : CPA 32 11.18 Transfer Procedure : Lead Professional Care 33 11.19 Discharge from Secondary Services and Transfers Between CPA and Lead Professional Care 34 11.20 Transfers from Lead Professional Care to CPA 34 11.24 Transfers from CPA to Lead Professional Care 34 11.27 Discharge from Secondary Services 35 11.31 Appeal Arrangements 35 12.1 PART 12 : CPA ROLES AND RESPONSIBILITIES 36 12.2 Care Co-ordination: Core Functions and Competencies 36 12.8 Lead Professional Care: Core Functions and Competencies 37 12.10 Care Co-ordination/ Lead Professional Care: Recording 38 12.11 Choice of Care Co-ordinator And Lead Professional 38 12.13 Restrictions on Who Can Be a Care Co-ordinator/ Lead Professional 38 12.14 Service User Choice 38 12.17 Change Of Care Co-ordinator Or Lead Professional 39 12.18 Support for Care Co-ordinators and Lead Professionals 39 12.20 Other Professionals: Team/Ward Managers/ Administrators & Clerical Staff/ Clinicians/ GPs/ Advocates/ Solicitors 39 13.1 PART 13 : CARERS 41 13.2 Identifying Carers 41 13.4 Carer Entitlements 41 13.8 Young Carers 42 13.11 Carers Assessments 43 13.15 Carers Support Plans 43 13.18 Service Users with Caring Responsibilities 44 13.19 Service Users with Dependent Children 44 13.25 Service Users Looking After Vulnerable Adults 45 14.1 PART 14 : INFORMATION 46 14.1 Recording Information 46 14.5 Recording Consent and Information Disclosure 46 14.8 Electronic CPA 47

4 14.9 Confidentiality & Information Sharing 47 14.16 Capacity and Consent 48 15.1 PART 15 : CPA & OTHER FRAMEWORKS 49 15.2 Care and Assessment Frameworks : Summary 49 15.3 Hospital Admission 49 15.4 Hospital Admission Procedures 49 15.6 Hospital Discharge and Aftercare 50 15.10 Section 117 Aftercare 51 15.13 NHS Continuing Healthcare 51 15.16 Children and Young People : The Common Assessment Framework (CAF) 52 15.22 Adult Social Care: Fair Access to Care Services (FACS) 53 15.27 Adult Social Care: Care Management 53 15.30 Older Adults : The Single Assessment Process 54 15.36 People with Learning Disabilities and Mental Health Problems: Person Centred Planning 55 15.41 People with Substance Misuse and Mental Health Problems 56 15.44 The Criminal Justice System 57 16.1 PART 16 : TRAINING 58 16.2 Training Needs Analysis 58 16.4 Staff Training Programme 58 16.6 User and Carer Involvement and Development 58 17.1 PART 17 : GOVERNANCE AND SUPPORT ARRANGEMENTS 59 17.2 Trust-Wide Governance and Support 59 17.4 Service Level Governance and Support 59 17.7 CPA Audit and Action Planning 60 17.11 Policy Review 60 Appendices (to follow between April 09 and September 09) (Provisional titles) Terminology and Abbreviations Background Documents/References/Useful Websites Equality Impact Assessment Index of Forms CPA Timetable In-Pt Admission Checklist In-Pt Discharge Checklist Care Pathway Flowchart Admission to Discharge Flowchart CPA in Adult Services CPA in: CAMHS / Transfer Flow Chart CPA in Older Adults Services CPA in Substance Misuse Services CPA in Learning Disabilities Transfers: to Primary Care Transfers: From Psychology/Liaison Transfers: To & From Prisons Transfers: To & From Secure Units CPA, Psychotherapy and Psychology Services HoNOS

5 CARE PROGRAMME APPROACH (CPA) POLICY PART 1: INTRODUCTION 1.1 The Care Programme Approach (CPA) sets out a framework for assessment, care planning, review, care co-ordination and service user and carer involvement underpinning the delivery of quality mental health services throughout Great Britain. 1.2 CPA and Lead Professional Care: The CPA framework incorporates arrangements for two types of support: • CPA for people with complex characteristics, who are at higher risk, and need support from multiple agencies • Care provided by an identified lead professional for people with more straightforward support needs.

The Trust is adopting the term ‘Lead Professional Care’ for these arrangements.

This policy is designed to ensure that both groups receive high quality care and support. The framework is flexible: care and support should be proportionate to need and people may move from one type of support to another at different times. 1.3 Policy Purpose: The CPA framework is designed to support effective clinical care and service user and carer involvement and recovery. Nothing in this policy is intended to obstruct or delay urgent action where this is necessary to ensure safety or the effective provision of services, which should take priority if there is any conflict with procedural arrangements.

1.4 Policy Status: This policy sets out arrangements for the CPA framework in mental health services throughout the Trust. It reflects legislative and national guidance requirements and has been jointly agreed between Central and North West London NHS Foundation Trust and the local authorities of the Royal Borough of Kensington & Chelsea, the London Borough of Brent, the London Borough of Harrow, the London Borough of Hillingdon and the City of Westminster. 1.5 Policy Scope: CNWL is a large Trust providing a wide range of services. CPA structures apply in: • adult mental health services • older adult mental health services • learning disabilities services (CPA is used for people with dual diagnoses of learning disabilities and mental health problems) • prison inreach services (CPA is used for prisoners who would be on CPA if they were in the community) • child and adolescent mental health services (CAMHS) (CPA is used for children and young people receiving in-patient mental health treatment or who are likely to meet CPA criteria as adults) • addictions services (CPA is used for work with people who have substance misuse and mental health problems).

1.6 Policy Structure: The main body of this policy provides core guidance on the operation of CPA across all services and all groups. Specific arrangements for individual services are set out in a series of Appendices. CPA touches all aspects of mental health care and interacts with several other care frameworks. This policy overlaps with most Trust clinical policies and numerous pieces of

6 legislation, codes of practice, policy statements and other guidance. This policy refers to these other documents where appropriate. The electronic version provides hyperlinks for ease of reference where possible.

The policy will be kept under regular review and the core Policy and Appendices will be updated separately as necessary. 1.7 Terminology and CAMHS Tiers: A full list of abbreviations and definitions of specific terms used throughout this policy is set out at Appendix 1. Most services covered use the term secondary mental health services to describe the majority of specialist services provided for people with mental health problems. CAMHS uses different terminology of Tiers 1, 2, 3 and 4, in which Tier 3 describes services usually provided by a multi-disciplinary team or specialist community setting and Tier 4 describes services for the most serious problems, including specialist inpatient centres.

For consistency and simplicity the core policy refers to ‘secondary mental health services’ throughout, but this should be taken to include Tiers 3 and 4 for CAMHS. Detailed guidance on the use of the CPA framework in CAMHS is set out in Appendix _ .

PART 2 : CONTEXT Development of CPA 2.1 CPA was first introduced in 1991. It has developed in line with changes in the law, national policy, the configuration of services and user and carer needs. This version of the Trust’s CPA Policy implements changes introduced in the government’s 2008 guidance Refocusing the Care Programme Approach and other relevant guidance and legislation. Legal & Policy Context 2.2 CPA operates within the network of health, social care, human rights and other legislation governing the provision of mental health services. CPA will normally be compatible with legal duties and responsibilities, but it is guidance rather than statute.

Services must comply with CPA arrangements unless there are clear reasons why they cannot.

2.3 CPA and the delivery of mental health services generally are influenced by numerous policy developments. These include guidance on the operation of CPA itself and guidance and national policy statements on priorities for mental health services. Some of the major themes of this guidance are developing strategies for integrating services, promoting protection, recovery, social inclusion, personalisation and service user and carer engagement and involvement, as well as new ways of working in mental health services. 2.4 A list of relevant Acts, guidance and policy statements is set out at Appendix 2 with hyperlinks to the relevant documents.

Refocusing CPA 2.5 Refocusing CPA guidance (DH 2008) restates CPA principles and practice and presents a new framework to replace ‘Standard’ and ‘Enhanced’ CPA. People with complex needs, or who need support from a number of services, or who are at most risk, are all subject to CPA. Other people, with more straightforward support needs, will still receive care from secondary mental health services, but the term CPA will no longer be used. The Trust is adopting

7 the term ‘Lead Professional Care’ to differentiate this form of care from other situations where the trust is involved in assessment or care management but does not provide continuing secondary mental health services.

2.6 The Refocusing CPA guidance also includes: • An underpinning statement of values and principles • Initial assessment for everyone referred to mental health services, leading to the decision about inclusion in CPA • A single assessment and care plan to follow the service user through all care settings • A whole systems approach to care planning and delivery based on assessments that see the person ‘in the round’ • Workforce support, including a national training programme • A Care Co-ordinator competencies statement • Measuring and improving quality, with a focus on outcomes and service user and carer experiences • National standards for people included in CPA • National standards for people no longer included in CPA, with less formal procedures for agreeing care plans with service users.

Care plans will be confirmed in letters sent to service users • Requirements to reduce CPA bureaucracy PART 3 : VALUES & PRINCIPLES 3.1 This section sets out the Trust’s policy on the values and principles underlying CPA. Procedures and good practice points for implementing these values and principles are set out in the rest of the core policy and the operational appendices describing the use of the framework in different services. 3.2 Values and principles underlying CPA and practice across mental health and learning disability services are consistent with the principles set out in the Mental Capacity Act 2005, the Mental Health Act 1983 and the Codes of Practice to those Acts, the Human Rights Act 1998 and guidance on Human Rights in Healthcare as well as the principles behind the various National Service Frameworks.

CPA Values and Principles Statement 3.3 Refocusing CPA sets out a new statement codifying the values and principles that have always underpinned good practice in mental health services. The points are integrated and reinforce each other, so that recovery and social inclusion, for instance, are supported by long-term engagement, and vice versa: • The approach to individuals’ care and support puts them at the centre and promotes social inclusion and recovery. It is respectful - building confidence in individuals with an understanding of their strengths, goals and aspirations as well as their needs and difficulties.

It recognises the individual as a person first and a patient/service user second.

• Care assessment and planning views a person “in the round” seeing and supporting them in their individual diverse roles and the needs they have, including: family, parenting, relationships, housing, employment, leisure, education, creativity, spirituality, self-management and self-nurture, with the aim of optimising mental and physical health and well-being.

8 • Self-care is promoted and supported wherever possible. Action is taken to encourage independence and self-determination to help people maintain control over their own support and care. • Carers form a vital part of the support required to aid a person’s recovery.

Their own needs should also be recognised and supported. • Services should be organised and delivered in ways that promote and co- ordinate helpful and purposeful mental health practice based on fulfilling therapeutic relationships and partnerships between the people involved. These relationships involve shared listening, communicating, understanding, clarification, and organisation of diverse opinion to deliver valued, appropriate, equitable and co-ordinated care. The quality of the relationship between service user and the Care Co-ordinator is one of the most important determinants of success.

• Care planning is underpinned by long-term engagement, requiring trust, teamwork and commitment. It is the daily work of mental health services and supporting partner agencies, not just the planned occasions where people meet for reviews. (DH 2008: Section 2) Putting the Service User at the Centre of CPA 3.4 CPA is designed to support individual service users and carers to maintain and increase their independence and manage their own care as far as possible. The emphasis should be on recognising and maximising the user’s strengths, abilities and interests and building on these to encourage growth, development and social inclusion.

CPA processes involve services, users and carers working in partnership, letting service users take the lead wherever possible. As far as possible: • Service users should feel they control and own their care and the arrangements affecting them • Service users should be supported to assess their own needs and safety, with appropriate self-assessment tools and help • Service users should have a say in who their Care Co-ordinator is • Service users should be involved in setting the agendas for CPA meetings and deciding on venues • Service users should be supported to take a lead role in CPA meetings, including chairing • Service users should be supported to take the lead in writing their care plans and negotiating agreement on them.

Social Inclusion 3.5 People with mental health problems and learning disabilities are often excluded from work and training, normal family relationships, proper health care and community life, and can face stigma and discrimination. The effects of this are well documented, for instance in the government report Mental Health and Social Exclusion (ODPM 2004). CPA includes action to promote social inclusion and combat stigma and discrimination. Recovery and Focus on Outcomes 3.6 Recovery: Recovery from mental health problems can mean different things to different people. It can be seen as ‘people with mental health problems…maintain(ing) or rebuild(ing) valuable and satisfying lives within and