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.

  • 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 coordinate 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

9 beyond the limits imposed by their difficulties’ (Repper & Perkins 2003). The Guiding Statement on Recovery (NIMHE 2005) identifies six potential meanings:
  • Returning to a state of wellness
  • Achieving a personally acceptable quality of life
  • A process or period of recovering
  • A process of gaining or restoring something
  • Obtaining usable resources from apparently unusable sources
  • Recovering quality of life and winning satisfactions in disconnected circumstances 3.7 Whatever the goals of the individual service user and those around them, approaches supporting people to work towards recovery involve changing orientations and behaviours, abandoning a negative focus and developing positive restoration, rebuilding, reclaiming or taking control of one’s life. 3.8 Recovery Approach: Recovery means services and individual workers emphasising positive approaches. The NIMHE Guiding Statement sets out 10 principles for the delivery of recovery-oriented mental health services:
  • The service user decides if and when to begin the recovery process and directs it
  • The mental health system must be aware of its tendency to promote dependency. Service users need to be aware of the negative impact of codependency.
  • Service users recover more quickly when hope is encouraged, enhanced or maintained; they have work or meaningful activities; their spirituality is taken into account; their culture is understood; their educational needs as well as those of significant others are identified; their social needs are identified; they are supported to achieve their goals
  • Individual differences are valued
  • There is a holistic approach including psychological, emotional, spiritual, physical and social needs
  • treatment and care is integrated and includes medical/biological, psychological, social and values based approaches
  • Clinicians and practitioners emphasise ‘hope’ and have the ability to develop trusting relationships
  • Clinicians and practitioners focus on strengths and assets
  • Service users are given support to develop a plan focusing on wellness, treatments and supports that facilitate recovery and resources that will support the recovery process
  • Family, partners and friends are involved. The service user should define who they wish to involve
  • Services are delivered in people’s local area and cultural context
  • There is community involvement - as defined by the service user (Adapted from NIMHE 2005) 3.9 HoNOS (Health of the Nation Outcome Scales): Supporting recovery involves focusing on outcomes and monitoring progress over time. As part of this process the Trust uses outcome scales developed by the Royal College of Psychiatrists as part of the Health of the Nation Strategy:
  • HoNOS for adults
  • HoNOSCA for children and young people
  • HoNOS 65+ for older adults

10 Guidance on the use of these scales is set out in paragraphs 7.22 – 7.24. Equalities, Diversity & Diverse Needs & Roles 3.10 The Trust serves a diverse population. Spiritual, racial, cultural, sexuality, gender, ability, socio-economic and physical health differences should be identified, respected, and steps should be taken to combat any disadvantage people experience as a result of them. 3.11 The Trust has supplemented the network of legislation on discrimination and race relations with a series of policies and projects designed to support diversity and promote anti-discriminatory practice.

Some of the most significant are the Trust’s Core Values statement, the Single Equality Scheme 2008/11 and the Cultural Competency statement.

Personalisation and Self-Directed Care 3.12 National policy requires health and social care to move increasingly towards personalisation, offering services which are available when people want them, are tailored to the individual and give service users more choice and control. This vision is set out in numerous policy documents including Refocusing CPA, Putting People First (DH 2007) and High Quality Care For All (DH 2008). Implications include more emphasis on self directed care, increasing use of direct payments for social care and the development of personal budgets for individual care packages.

Partnership, Long-Term Engagement and Continuity of Care 3.13 CPA is based on partnership working between service users, carers and care workers. Continuing working relationships are more important than isolated CPA review meetings. This means:
  • everyone involved should be kept informed unless there are clear reasons why information cannot be shared. If information cannot be shared the reasons for this should be clearly recorded
  • care plans and services should be based on agreement, wherever possible
  • any disagreements should be clearly recorded, setting out reasons for actions taken
  • Care Co-ordinators/lead professionals should ensure the level of contact service users need is maintained consistently
  • If care is transferred to a different area, service or type of care, teams and Care Co-ordinators/lead professionals should ensure that the responsible teams and professionals are clearly identified at all times, any disruption of care packages is minimised, service users and carers are involved and kept informed and necessary contact is maintained User and Carer Involvement 3.14 Effective CPA requires service user and carer involvement. This applies at the individual level, where service users and carers should be fully involved in planning and delivery of care and support. It also applies at service level and in Trust-wide activity, where the Trust is committed to developing service user and carer involvement in CPA activity and in general. Users and carers have been involved in developing this policy and the forms and training programme accompanying it.

11 Mental Capacity 3.15 Adults with mental health problems or learning disabilities may not always have capacity to make decisions for themselves. Effective CPA working requires that, in line with the principles set out in the Mental Capacity Act 2005, every practicable step to help someone make a decision must be taken, and any act done, or decision made, for or on behalf of a person who lacks capacity must be done, or made, in their best interests. 3.16 Full guidance on capacity issues and the law affecting them is set out in the MCA Code of Practice (DCA 2005), the Deprivation of Liberty Safeguards Code of Practice (MoJ 2008) and the Trust Mental Capacity Act Guidance.

Safety and Positive Risk Taking 3.17 Any action involves a degree of risk and people often learn most effectively from taking chances, even if they lead to failure. CPA and mental health services in general work within the requirements of the relevant National Service Frameworks that services are safe, sound and supportive. Effective care planning requires good risk assessment and clear risk management planning. However, there are times when an appropriate concern to manage risks can make services and service users and carers risk averse and over cautious.

3.18 Positive risk taking aims to support people to take advantage of opportunities and take responsibility for their actions and any consequences by weighing up potential harms and benefits. It involves developing plans using resources available to support service user wishes. It is not about negligence, ignoring potential risks or acting dangerously. It involves:
  • thorough assessment to identify potential consequences and ways of minimising potential harm
  • making sure everyone has enough information to make informed decisions
  • working from service users’ strengths and focusing on developing them
  • ensuring risk decisions are taken collectively, so that users and carers are supported to explore their options and professionals have adequate support and supervision
  • ensuring that support is available if things go wrong. Principles Underpinning Staffing Arrangements and Ways of Working 3.19 Good CPA practice is supported by staffing arrangements which help services and teams work in ways which support Care Co-ordinators/lead professionals and the CPA process, and ensure staff have the competencies and capabilities they need to work responsibly and effectively and are given adequate support and supervision.
  • 3.20 New Ways of Working: : New Ways of Working for Everyone: A best practice implementation guide (CSIP/NIMHE 2007) sets out advice on mental health services organisation to achieve:
  • Leadership based on competence rather than profession
  • Building team focused working based on debate and collaboration
  • Developing enhanced and changed roles for mental health staff
Redesigning systems and processes to support staff to deliver effective, person-centred care in a way that is personally, financially and organisationally sustainable 3.21 Ten Essential Capabilities for Mental Health Practice: The government The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce (NIMHE 2004) provides a statement of the capabilities needed by all staff in mental health services:
  • Working In Partnership
  • Respecting Diversity
  • Practising Ethically
  • Challenging Inequality
  • Promoting Recovery
  • Identifying People’s Needs and Strengths
  • Providing Service User Centred Care
  • Making a Difference
  • Promoting Safety and Positive Risk Taking
  • Personal Development and Learning 3.22 These capabilities are supported by values and evidence based practice. They interlink with the Knowledge and Skills Framework, the Capable Practitioner Framework and the Mental Health National Occupational Standards, and inform the statement of Care Co-ordinator competencies. Further details are set out in Part 12 : CPA Roles and Responsibilities and Appendix___. PART 4 : STANDARDS USERS AND CARERS CAN EXPECT 4.1 Service users and carers can expect a high standard of care in all their contacts with the Trust. This applies to any contact with the Trust, including informal queries and initial assessments.

4.2 The table below sets out the minimum standards people can expect under CPA or Lead Professional Care arrangements. The only difference between the entitlements of people on CPA and people on Lead Professional Care are practical ones based on the number of professionals they will normally see and their levels of need. Need/Support CPA Lead Professional Care Professional Support Support from CPA Care Co-ordinator (trained, part of job description, coordination support recognised as significant part of caseload) Support from professional(s) as part of clinical/ practitioner role. Lead professional identified.

Service user self-directed care, with support.

Assessment A comprehensive multidisciplinary, multi-agency assessment covering the full range of needs and risks A full assessment of need for clinical care and treatment, including risk assessment, complemented by assessments by other agencies where appropriate

13 Fair Access to Care Services (FACS) Assessment An assessment of social care needs against FACS eligibility criteria (plus Direct Payments) An assessment of social care needs against FACS eligibility criteria (plus Direct Payments) Written Care Plan Comprehensive formal written care plan: including risk and safety/contingency/crisis plan Clear understanding of how care and treatment will be carried out, by whom, and when (can be a clinician’s letter) Review of Needs On-going review, formal multi-disciplinary, multiagency review at least once a year but likely to be needed more regularly On-going review as required Review of Need for CPA/Lead Professional Care At review, consideration of continuing need for CPA support Continuing consideration of need for move to CPA if risk or circumstances change Support & Assistance Increased need for advocacy support Self-directed care, with some support if necessary Carers Involvement and Support Carers identified and informed of rights to own assessment.

Agreed arrangements for carer involvement.

  • Carers identified and informed of rights to own assessment. Agreed arrangements for carer involvement. PART 5 : THE CPA PROCESS Care Pathways 5.1 There are numerous potential CPA care pathways, but core CPA procedures apply to everyone in secondary mental health care. People may enter care through in-patient or community services and through any service group, and may transfer from one point to another. Where there are differences between service groups these are set out in the Appendices to this policy. Components of the CPA Process 5.2 CPA comprises
  • Referral: In most settings anyone can refer someone to mental health services, including carers and service users themselves. Local services will agree a single referral point. Separate arrangements for CAMHS are set out at Appendix ___
  • Initial Assessment: Deciding whether someone needs help from secondary mental health services and whether they should be on CPA or Lead Professional Care – or whether there’s an emergency that needs immediate action.

Assessment: A comprehensive multi-disciplinary assessment of the person’s needs for health and social care and any risks they face.

  • 14 Assessment is an ongoing process which involves constant monitoring of any changes in needs. Assessments will be integrated where possible; in some circumstances assessments carried out separately by different agencies will be combined.
  • Care Plan: A written document identifying who is involved, setting out agreed plans for meeting the person’s needs, managing risk and a crisis and contingency plan setting out ways of responding if some of the care plan cannot be delivered or if there is a crisis. Care plans should be developed over a period of time, in collaboration between users, carers and professionals. Service users and carers should be supported to draft their own care plans where possible
  • Review: Regular reviews to ensure that agreed actions are being carried out, to decide whether the care plan needs to be adjusted and whether someone still needs the type of care they are receiving, and whether they need additional or reduced support. Timescales 5.3 All actions should be started at the earliest possible dates. The table below sets out minimum standards for completion. Workers will aim to improve on these timescales wherever possible: Community Services In-Patient Services Initial Contact
  • Within 48 hours of referral
  • Day of admission Initial Assessment
  • No later than 5 days after referral
  • No later than 2 days after admission Risk Assessment
  • No later than 5 days after referral
  • No later than 5 days after admission
  • Prior to leave or discharge
  • Review no later than 12 months Core Assessment
  • No later than 28 days after referral
  • No later than 28 days after referral Initial Care Plan and Services
  • No later than 28 days after completion of core assessment
  • No later than 28 days after completion of core assessment Care Coordinator/Lead Professional Allocation
  • No later than 14 days after assessment
  • Identify need/request community service – community allocation No later than 14 days after request Initial ‘Choose & Book’ Appointment
  • No later than 11 weeks after referral
  • No later than 11 weeks after referral CPA/Lead Professional Care Plan
  • No later than 12 weeks after referral
  • No later than 2 weeks after admission Care Plan distribution
  • No later than 2 weeks after review
  • No later than 2 weeks after review
  • 15 Carers Assessment (where indicated)
  • No later than 6 weeks after carer identified
  • Review no later than 12 months
  • During admission
  • Review no later than 12 months CPA Review
  • No later than 12 weeks after referral
  • Review at least every 12 months
  • No later than 10 days after admission
  • Not more than 2 calendar weeks before discharge Lead Professional Care Plan Review
  • At least every 12 months
  • N/A Recording 5.4 Local administrative arrangements must ensure documentation can be produced and distributed promptly within the agreed timescales. All stages in the CPA process should be recorded:
  • in the appropriate clinical notes
  • on the appropriate Trust and social care databases
  • using standard forms and other agreed documentation where appropriate 5.5 The table below identifies agreed forms/documentation to be used at each stage in the CPA process, showing which forms are used in each service group. Further guidance on electronic CPA, information management and service user and carer access to information is set out in Part 8: Care Plans.

16 Adult Services CAMHS Older Adults Advice/Consultation Case notes where appropriate Case notes where appropriate Case notes where appropriate At Referral Basic Details Start core assessment Start risk assessment Basic Details Face 1 Contact Assessment Start risk assessment Initial Assessment Health & Social Care Needs Assessment Contribute to CAF Initial Assessment Face 2 Overview Assessment Core Assessment Health & Social Care Needs Assessment By agreement with Child & Education Care Managers By Older Adults Care Managers CPA Care Plan Care Plan Care Plan Care Plan Lead Professional Care Plan Template Care Plan Letter None Template Care Plan Letter Carers Assessment Carers’ Assessment and support plan Carers’ Assessment and support plan Carers’ Assessment and support plan Learning Disabilities Addictions Offender Care Advice/Consultation Case notes where appropriate Case notes where appropriate Case notes where appropriate At Referral Basic Details Basic Details Initial Assessment Brief Initial Assessment Brief Initial Assessment Full Needs Assessment By local authority social workers Health & Social Care Needs Assessment Care Plan Learning Disabilities Care Plan AOCD CPA Care Plan (V2) Care Plan Lead Professional Care Plan Template Care Plan Letter AOCD Care Plan Template Care Plan Letter Carers Assessment Carers’ Assessment and support plan Carers’ Assessment and support plan Carers’ Assessment and support plan

17 PART 6 : REFERRALS Receiving Teams 6.1 The appropriate team to receive referrals in each area/service should be set out clearly in local protocols. If referrals are misdirected the receiving team should immediately identify the appropriate referral point, re-direct the referral and advise the referrer. Advice and Consultation 6.2 Mental health services can provide a valuable function in giving advice and information which can help professionals and members of the public decide whether a situation they may be facing involves a mental health problem and whether it would be useful to refer it to secondary mental health services for further assessment.

People contacting services can remain anonymous if they wish, but they should be advised that if they describe a situation where someone is likely to come to harm and they provide enough identifying information, it may be necessary for services to take some action. 6.3 Recording: Contacts from people seeking advice or consultation should be recorded in clinical notes and on databases, if necessary using identifiers based on whatever information is available, if names and addresses are not known. They are outside the CPA framework and should not be treated as referrals.

Receiving Referrals 6.4 For most services referrals can be received from professionals, organisations or members of the public including potential services users and carers. CAMHS arrangements are set out at Appendix . Referrers should be asked to provide an outline of the concerns and enough information to identify individuals and other agencies involved. Sharing Referral Information 6.5 GPs should be identified wherever possible. GPs should be informed if they do not already know about the referral. Third party referrers should be told that referral details will be disclosed to the person referred unless there are reasons disclosure might be harmful or against best interests.

Considerations for specific service groups are set out in the relevant appendices. Urgent/Emergency Referrals 6.6 Initial information gathering will help services determine whether referrals present emergencies needing urgent response. Local protocols set out arrangements for involving Crisis/Home Treatment teams and arranging hospital admission and/or assessments under the Mental Health Act. If referrals raise child protection issues local child protection services must be contacted immediately in accordance with local procedures. In some circumstances it may be necessary to contact the police or advise referrers to do so.

Additional considerations for specific service groups and guidance on other agencies which may need to be contacted/involved are set out in the relevant appendices.

  • 18 Re-Referrals 6.7 If a service user is re-referred within a month of being discharged from secondary mental health services the team that closed the case should normally resume responsibility.
  • If it is necessary for them to be transferred to another team or service the original team is responsible for co-ordinating the transfer process (as set out in Part 11 : Transfer & Discharge).
  • If they require urgent support the original team is responsible for coordinating/commissioning this, liaising with other services where necessary.
  • PART 7 : ASSESSMENT Initial Assessment 7.1 All referrals should be assessed to:
  • decide whether they need support from secondary mental health services
  • gather enough information to decide whether the service user needs CPA or Lead Professional Care. Initial assessment is likely to produce more information than is necessary to make these decisions. This is completely appropriate. 7.2 Needs for secondary mental health services and allocation for CPA or Lead Professional Care are independent of needs for other services and CPA is not a gateway to other services. Information supporting other assessments may be drawn from the same contacts with service users, but assessments should be carried out according to whichever criteria are appropriate for that service and recorded on the relevant forms. Further details are set out at Part 15: CPA & Other Frameworks.

7.3 If people do not need secondary mental health services involvement the referrer, service user and carer/s (as appropriate) should be informed as soon as possible, with recommendations for alternative care where appropriate. 7.4 Recording: Initial assessments should be recorded on the appropriate core assessment form/s for the service (as set out in paragraph 5.5). This is used to record information collected later as part of a comprehensive assessment and can be added to or amended throughout the service user’s contact with mental health services. There is no need to complete parts of the form where information is either not available or already set out on accompanying assessment form/s in use for some service groups (further details are set out in Part 15: CPA & Other Frameworks and the relevant appendices).

7.5 Good Practice Point: Needs may be identified if cases are not best dealt with by secondary mental health services. Wherever possible alternative sources of support/assistance/advice should be identified. Referrals should be made to other agencies if necessary/appropriate.

Secondary Mental Health Services: Criteria 7.6 Secondary mental health services work with people with a mental disorder whose needs cannot appropriately be met in primary care. This includes people with a diagnosis of personality disorder. Further details are set out in

19 the National Service Frameworks, NICE guidelines and the NIMHE guidance Personality disorder: No longer a diagnosis of exclusion (NIMHE 2003). Who Should Be On CPA? 7.7 CPA should be used if people have more complex needs, are at most risk or have mental health problems compounded by significant disadvantage.

Decisions about whether a particular individual should be on CPA require clinical discretion, guided by indicators set out in the government guidance Refocusing CPA. Government guidance is that CPA should be used if any of the indicators apply, unless there are clear reasons why Lead Professional Care or primary care is more appropriate.

7.8 Indicators suggesting people are likely to need CPA are:
  • Severe mental disorder (including personality disorder) with a high degree of clinical complexity
  • Current or potential risk(s), including: − Suicide, self harm, harm to others (including history of offending) − Relapse history requiring urgent response − Self neglect/non concordance with treatment plan − Vulnerable adult, adult/child protection issues − Exploitation, for instance financial/sexual − Financial difficulties related to mental illness − Disinhibition − Physical/emotional abuse − Cognitive impairment − Child protection issues
  • Current or significant history of severe distress/instability or disengagement
  • Presence of non-physical co-morbidity including substance/alcohol/ prescription drugs misuse, learning disability
  • Multiple service provision from different agencies, including: housing, physical care, employment, criminal justice, voluntary agencies
  • Currently/recently detained under Mental Health Act, on Supervised Community Treatment or Guardianship, and most people subject to S.117 MHA or referred to crisis/home treatment teams
  • Significant reliance on carer(s) or has own significant caring responsibilities
  • Experiencing disadvantage or difficulty as a result of: − Parenting or other caring responsibilities − Physical health problems/disability − Unsettled accommodation/housing issues − Employment issues when mentally ill − Significant impairment of functioning due to mental illness − Ethnicity (such as immigration/asylum seeking status; race/cultural issues; language difficulties; religious practices); − Sexuality or gender issues (DH 2008) 7.9 Service users on CPA must be allocated a Care Co-ordinator. Further details about allocating Care Co-ordinators and their roles are set out in Part 12: CPA Roles and Responsibilities.

20 7.10 There should be continuing assessment to decide if people still need the support of CPA. This should be formally reviewed at each CPA review meeting. 7.11 Recording: A decision to place a service user on CPA should be recorded on the appropriate core assessment form/s for the service, the appropriate databases and in clinical notes. A letter confirming the decision should be sent to the service user, carer/s (where appropriate), the GP and any other agencies agreed. Who Should Have Lead Professional Care? 7.12 Lead Professional Care should be used if people need secondary mental health services but have more straightforward needs.

There should be continuing assessment to decide if they continue to need Lead Professional Care, if their support needs have increased and they need the support of CPA, or their needs can be managed in primary care. This should be formally reviewed when the rest of the care plan is reviewed.

7.13 Service users on Lead Professional Care must have an identified lead professional. Further details about allocating lead professionals and their roles are set out in Part 12: CPA Roles and Responsibilities. 7.14 Recording: A decision to place a service user on Lead Professional Care should be recorded on the appropriate core assessment form/s for the service, the appropriate databases and in clinical notes. A letter confirming the decision should be sent to the service user, carer/s (where appropriate), the GP and any other agencies agreed.

Comprehensive Assessment 7.15 All service users will receive a comprehensive mental health assessment, covering both health and social care needs. In some services this will be the combined result of separate assessments carried out by different agencies. Further details are set out in Part 15: CPA and Other Frameworks and in the relevant appendices. This assessment builds on the initial assessment and should be completed within 28 days of the referral. Assessment is a continuous process: formal assessments should be kept under continuing review and added to and amended as necessary. They should be formally reviewed in the period leading up to any review meeting. 7.16 Assessments should be carried out in partnership with the person (and carer/s where appropriate):
  • Advocates and interpreters should be involved to facilitate this where necessary
  • Assessment should be holistic, covering mental health, physical health, social and psychological needs
  • Assessments must identify service user strengths, skills and abilities
  • Assessments must identify what the service user understands by recovery and what is required to promote it
  • Assessment should take account of service users’ beliefs and opinions about their mental health issues and focus on their needs, hopes, aspirations and choices, not just what the service can provide
  • Assessments must consider the needs of the service user’s family, carers, dependents and/or children
  • If service users lack mental capacity assessments must be conducted in accordance with Trust guidance on the Mental Capacity Act and should establish what is in the service user’s best interests. 7.17 Assessments should address:
  • Mental capacity
  • Psychological, psychiatric, and social needs
  • The effects of personal history, experiences and circumstances, including any experience of violence or sexual abuse
  • Physical health needs
  • Medication and side effect monitoring
  • Family roles, including parenting and other caring roles
  • Self Care and domestic functioning
  • Employment, Education, and Training needs
  • Housing, homelessness and resettlement needs
  • Financial needs, debts and benefits
  • Cultural, racial, gender, religious, spiritual and access needs
  • Communication needs, language and literacy
  • Substance misuse (the Bromley Screening Tool should be completed for all adult service users)
  • The needs of children and/or vulnerable adults
  • Statements of wishes or advance decisions 7.18 Specialist or additional assessments may be indicated and/or requested including:
  • Psychiatric assessment
  • Activities of Daily Living assessment
  • Psychology assessment
  • Carer/s’ assessment
  • Vocational Needs screening form
  • Forensic Risk Assessment
  • Housing agency assessment/s In some services mental health assessments will be complemented by other general assessments. Details are set out in Part 15: CPA and Other Frameworks and the relevant appendices.

7.19 Recording: Assessments should be recorded on the appropriate core assessment form/s for the service. Details for each service area are set out in the relevant appendix. Risk Assessment 7.20 Risk assessment is an essential part of assessment. Like all other forms of assessment it is a continuous process. Trust policy is set out in the CNWL Clinical Risk Policy. Risk assessments and risk management plans should be completed in partnership with service users and carers in the same way as other assessments. They should normally be shared with service users unless doing so would increase risks to the service user or others.

They should also be shared with carer/s where appropriate and with the agreement of the service user. Guidance on Risk Management Plans is set out in Part 8: Care Plans.

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