CARE PROGRAMME APPROACH (CPA) POLICY →
CARE PROGRAMME APPROACH (CPA) POLICY →
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
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 co- dependency.
• 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
12 • 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, co- ordination 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 multi- disciplinary, 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, multi- agency 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 Co- ordinator/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
21 • 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.
22 7.21 Recording: • For most services risk assessments should be recorded on the RA1 Risk Screening Form. The RA2.1 Substance Misuse Form, RA2.2 Self-Harm - Suicide Form, RA2.3 Self Neglect - Vulnerability Form, RA2.4 Violence - Sexual Assault Form, RA2.5 Harm to Children Form, and RA2.6 - Eating Disorders Form are available for more detailed/specific risk information but their use is optional and it is recommended they should only be used where this is necessary to highlight a risk issue • The RA1 Risk Screening Form should be started at the point of referral and completed within 5 days of referral • For CAMHS the CAMHS Risk Assessment form should be used • For older adults the SAP Risk Profile Form should be used • All risk assessment forms used should be kept up to date Health of the Nation Outcome Scores (HoNOS) 7.22 HoNOS (for adults), HoNOSCA (for Children & Adolescents) and HoNOS 65+ (for older adults) scoring can help assess service users’ level of functioning in a range of areas and can be a central part of measuring recovery. A series of scores can help service users and carers review development over a period and help people identify more clearly their strengths and areas they may need more support. At team, service and Trust levels they can be a valuable way of assessing the effectiveness of interventions and types of service which can influence commissioning decisions.
7.23 Managers should ensure that all staff completing scales are appropriately trained. HoNOS/HoNOSCA/ HoNOS 65+ scores should be completed: • At Initial Assessment • On admission to hospital - within a week of admission, at 4 weekly intervals and at discharge • At CPA review for people on CPA • At least annually for people on Lead Professional Care • At discharge from service • At transfer of care • If there is a significant change in circumstances, including working with the crisis team/home treatment team 7.24 Recording: • Scales should be recorded on the HoNOS Form (for adults), HoNOSCA (for Children & Adolescents) or HoNOS 65+ (for older adults) • Service Users in the Community: Care Co-ordinators/Lead Professionals are responsible for ensuring scores are recorded • Service Users in Hospital: Ward Managers are responsible for ensuring scores are recorded.
Vocational Needs Assessment 7.25 Employment, training and other activities promote recovery and social inclusion. Research shows that people with mental health problems have higher levels of unemployment that any other group. Vocational Needs Assessments should be completed as part of every health and social care needs assessment, needs and strengths should be identified and incorporated into care plans.
23 7.26 Vocational support should be embedded in CPA practice in line with the recommendations of the government report Mental Health and Social Exclusion (Social Exclusion Unit 2004). This includes: • establishing employment status on admission to hospital and supporting job retention • promoting involvement of carers and families • identifying lead contacts on vocational and social issues in secondary care teams • strengthening links with key local partners, in particular Jobcentre Plus and education providers • facilitating access to benefits advice and support PART 8 : CARE PLANS 8.1 Initial Care Plans: If referrals are accepted there may be a delay before the allocation of a Care Co-ordinator/lead professional. Initial assessment should identify any priority needs and include initial care plans. Initial care plans and services identified must be in place no later than 28 days after the completion of the core assessment.
Care Plans : Contents 8.2 The care plan specifies arrangements to support the service user in meeting needs identified in the core assessment, the risk management plan and the service user’s wishes. It focuses on the service user’s strengths and promoting recovery and recognises diverse needs arising from cultural and ethnic background, gender, sexuality, and any physical disability or health problem. In some services it will build on care already being provided as part of other care frameworks. Further detail is set out in Part 15: CPA and Other Frameworks and the relevant appendices.
8.3 Care plans should be developed in contacts between Care Co- ordinators/Lead Professionals, service users and any carers who need to be involved. Advocates and interpreters should be involved where necessary. Workers and service users/carers should make their own arrangements about the length of time it will take to complete the care planning process, the number of contacts, whether they are face to face or by telephone, and which venues are used. Draft Care Plans 8.4 Workers, service users and any carer/s involved should work together to develop draft care plans which should identify the service users goals, wishes and current priorities and other relevant circumstances. These should draw on information in the core assessment and risk assessment where appropriate and explain the need for any action/intervention. Care Plans 8.5 For people on CPA, the final CPA Care Plan should be approved at a CPA review meeting. It should clearly state the actions/interventions required. For people on Lead Professional Care, there should be agreement about how and when the final care plan is agreed, provided it is within the necessary
24 timescales. Care Co-ordinators/Lead Professionals should go through these documents with service users identifying needs, the best ways of meeting them, and making arrangements with other professionals/agencies where necessary. 8.6 Care plans: • Specify interventions and intended outcomes • Record actions necessary to achieve the agreed goals • Record who has agreed to take lead responsibility for each action and who else is involved • Identify timescales for achieving or reviewing actions (where possible) • Incorporate risk management plans based on risk assessment • Include plans if the service user loses contact, does not follow the care plan or is in crisis • Include contingency or backup plans if an action cannot be completed or a service cannot be provided • Include details of any advance decisions • If there are disagreements, set out reasons on both sides • Give the date of the next planned review 8.7 Actions should be identified under the headings listed below. If there is no current need in that area, that part of the form should be left blank: Care Plan Action Areas Mental Capacity Legal Issues Mental Health Alcohol and Drug Issues Physical Health Childrens’/Dependents’ Needs Housing/ Accommodation Carers’ Needs Finances and Benefits Relapse Indicators Cultural and Spiritual Needs Risk Management Plan Employment, Occupation, Leisure Contingency & Crisis Plans Daily Living Skills / Self Care Advance Decisions Social/Family Network, Support Unmet Needs 8.8 Recording: • • • • For people on CPA the Care Plan should be recorded on the Trust CPA Care Plan form.
• • • • For people on Lead Professional Care the Trust Care Plan template letter should be used Advance Decisions 8.9 A valid Advance Decision is a legal statement by a service user over the age of 18 in which they can refuse treatment if they lose capacity to do so in the future, either because of a permanent/progressive condition or because they are temporarily unwell. At the time they make the Advance Decision they must have the capacity to make an informed choice, be fully aware of the consequences and accept responsibility for their actions. 8.10 Advance refusals may be legally binding in most circumstances, but they can be overridden if the person is detained under the Mental Health Act. An advance decision may also suggest preferences for any other aspect of care
25 or treatment. These points have no legal force, but they can assist planning an individual’s care or treatment and clarifying their wishes and best interests if they are unable to do so in the future. Further details are set out in the Trust Advance Decision Policy. 8.11 Recording: An entry in a CPA Care Plan may provide a valid record of an Advance Decision, but it is recommended that the Trust Advance Decision Template is used. Risk Management Plans 8.12 The Risk Assessment leads to a Risk Management Plan in the same way that a core assessment leads to a CPA Care Plan or the care plan agreed with a Lead Professional. Care plans and Risk Management Plans must be linked: the actions set out in the risk management plan must be incorporated in the care plan.
8.13 Recording: • • • • For most services the RA3 Risk Management Plan should be used. • • • • For CAMHS the CAMHS RA form should be used • • • • For Older Adults the SAP Risk Profile Form should be used • • • • Details of the action identified should be set out on the relevant care plan • • • • All risk assessments and risk management plans should be regularly reviewed. • • • • The Risk Management Plan should be formally reviewed, signed and dated as part of the preparation for each review meeting (as set out in the Clinical Risk Assessment Policy) Crisis and Contingency Plans 8.14 All CPA and lead professional Care Plans must include Crisis & Contingency Plans.
8.15 Contingency Plans: Specify what should happen if something specified in the Care Plan is not available – for instance if the Care Co-ordinator is not available or a day service closed. This aims to prevent a crisis developing by providing contact details for sources of interim support and identifying who will be involved in trying to make alternative arrangements. 8.16 Crisis Plans: Set out details of early warning signs/relapse indicators/potential risks and identify action to be implemented if there is a crisis – for instance if the service user’s mental health deteriorates. Action should take account of previous experience, the views of carers and advance decisions where relevant. Crisis Plans should include: • Services available and how they can be accessed in a crisis, including out of hours • Anyone the service user might be responsive to and how to contact them • Previous strategies which have been successful • Who should be involved in deciding next steps Crisis Cards 8.17 Service users can choose to use crisis cards if they wish. This should be discussed at each CPA review. A crisis card should give details of who to
26 contact if the service user becomes unwell or has some other crisis. It can also set out the service user’s wishes about treatment in an emergency. Crisis cards should be completed by the service user themselves. Carer/s should be involved if the service user wishes them to be or if the service user lacks capacity (if 16 or over) or competence (if under16). They should be given assistance if they wish it. Changes can be made at any time. Service users should be offered a crisis card: • When they leave hospital • If they have repeated crises requiring intervention • During risk assessment and planning • During discussion of crisis plans • During preparation for CPA reviews Finalising and Distributing Care Plans : CPA 8.18 Care Plans are drawn up between service users, carers and professionals in the period before a formal CPA meeting. The purpose of the CPA meeting is to make any final adjustments and record formal agreement. Service users must always be given the opportunity to read the care plan, add comments or ask for amendments, and sign it.
8.19 Care Plans should normally be available at meetings and users, carers and others involved should be offered a copy of the care plan at the end of the meeting. If necessary this could be a photocopy of a handwritten care plan, which may be typed and sent out later. If the final care plan cannot be ready at the end of the meeting, the Care Co-ordinator should explain when a copy will be received. Care plans should also be given/sent to everyone involved in the care plan, even if they were unable to attend the meeting, unless the service user refuses consent. Care plans must be distributed within 14 days of the CPA meeting. The date on which the care plan has been sent or given to the service user must be recorded on the database. Finalising & Distributing Care Plans : Lead Professional Care 8.20 Care arrangements are agreed between the lead professional, service user and carers as appropriate during the assessment process or in normal appointments. People on Lead Professional Care should be sent a letter using the Trust Care Plan letter template, setting out: • Details of the plan of care • Who the Lead Professional is • Contact details for daytime and out of hours services • What to do in a crisis.
Copies should be sent to the GP. Copies should also be sent to any carers or other agencies involved, with the service user’s agreement. 8.21 The care plan should be reviewed at least annually during normal appointments with the service user. The review should include consideration of whether the needs of the service user have changed, so that he/she should be on CPA or should be discharged to primary care. Larger review meetings and formal CPA care plans are not appropriate.
27 PART 9 : REVIEWS CPA Reviews and Reassessments 9.1 Assessment and care planning are continuous processes for all service users. Regular formal review is built into the process to ensure that everyone involved understands what is happening and what is required of them and that agreed actions are being carried out. Care plans should be flexible enough and communication networks strong enough that many changes can be accommodated without the need for additional formal review meetings, but these should be arranged if necessary.
9.2 Care Co-ordinators/lead professionals and other members of the care team should be alert to any need to review arrangements: • Assessments should be updated whenever necessary • Contingency plans should set out arrangements if the care plan needs minor adjustments • For people on CPA some decisions may need a formal meeting of the care team • For people on Lead Professional Care some significant changes may need a new care plan • Teams should ensure arrangements are in place to respond promptly if needs or circumstances change Arranging CPA Reviews 9.3 Care Co-ordinators are responsible for ensuring CPA reviews are arranged when needed, that appropriate consultation/discussion about arrangements is carried out before they are finalised and that invitations are issued within the agreed times.
9.4 Community CPA review meetings must be held: • No later than 12 weeks after referral for all new patients • No later than 12 weeks after discharge from inpatient facilities • At least every 12 months • If there is a significant change in the service user’s circumstances • Before discharge from CPA or secondary mental health services • Before transfer of care to another mental health service or team • if it is necessary to bring the care team together for any other reason 9.5 In-patient CPA review meetings must be carried out: • No later than 10 days after admission • In the 2 weeks leading up to discharge • During long admissions, at least every 6 months • Before any Mental Health Review Tribunal or Mental Health Act Manager’s Hearing 9.6 A review meeting may be requested by any member of the care team, the service user themselves or a carer. All requests for unscheduled reviews should be considered by the multi-disciplinary team. If it is decided a review is not necessary, the reasons for this must be recorded in the service user’s notes. If a service user or a carer request for a review is rejected the Care Co-ordinator should write to the user and/or carer explaining the decision.
28 9.7 The date of the next review must be agreed between the service user and other members of the care team at each review. • Service users, carers and key members of the care team should be consulted about dates, times, venues and who should be invited • At least three weeks notice should normally be given unless the meeting is so urgent this is not practicable • Invitations should specify the likely duration of the meeting. Review meetings should normally last between 30 minutes and one hour. Special arrangements should be made if it is likely meetings will need to last longer • Staff should ensure that meetings start promptly and service users and carers are not left waiting for professionals • CPA meetings during in-patient admissions should not normally be arranged as part of ward rounds because of the difficulties of managing timekeeping • If cancelling or rescheduling meetings is unavoidable, everyone invited must be informed within 24 hours. The reasons must be explained. Who Should Attend CPA Reviews?
9.8 Attendance at the meeting should be discussed with the service user before invitations are sent out. The people invited should normally include: • The service user • Carer/s (as appropriate) • The care plan team • The GP • Interpreter/s (if necessary) • An advocate (if necessary) • Any others identified by the service user, such as friends Invitations should be sent on the Trust template including a return form for those unable to attend to submit any information needed. CPA Reviews: Preparation and Draft Care Plans 9.9 The purpose of CPA meetings is to review the care plan. As with the assessment and initial care planning process, most of this work should be done between the Care Co-ordinator and service user (and carer/s if appropriate) before the formal meeting: • Most care plans cover too many issues to be adequately discussed in the time available at a CPA meeting • Some people may have difficulty expressing themselves in a formal and potentially large meeting • Many aspects of care plans may need to be considered carefully by the service user and carer, and/or may require significant work before the most effective action can be determined.
9.10 The flexibility of the CPA framework and the focus on a recovery approach mean it is essential that the need for continuing CPA, Lead Professional Care or support in primary care is considered fully at each review. If service users are receiving aftercare under section 117 of the Mental Health Act this will include reviewing the need for this to continue. The CPA Care Plan must state explicitly whether the service user remains subject to section 117 aftercare.
29 9.11 The Care Co-ordinator should contact the service user at least three weeks before the planned CPA meeting to start discussions to agree a draft care plan. This may need several contacts. Contacts should normally be face to face, but telephone or email may be used if this is more practicable. 9.12 Care Co-ordinator responsibilities during pre-CPA contact/s involve working with the service user (and carer/s if appropriate) to: • Ensure the service user (and carer) understands the purpose of the review, offering a CPA information leaflet if appropriate • Review the needs assessment, updating it if necessary • Review the CPA care plan, including the crisis and contingency plans • Identify any issues which need updating or correction • Offer a crisis card • Offer a vocational needs screening assessment • Identify any new areas of need, including any needs for referral to/support from other agencies • Clarify what the service user wants discussed and develop an agenda • Discuss any concerns the service user may have about the meeting • Discuss and try to resolve any contentious issues • Clarify any areas of disagreement • Establish whether there is any specific information the service user does not want shared • Review whether the service user still needs support under CPA • Give the service user a chance to ask more questions about the CPA review and their care in general • Develop joint plans to meet any practical needs The relative importance of some of these tasks will vary between services. Further detail is set out in the relevant appendices. 9.13 Recording: Contacts should be recorded in clinical notes and on the appropriate databases. Draft care plans and the final CPA Care Plan should be completed on the CPA care plan form.
CPA Reviews: Running Meetings 9.14 CPA meetings are held for the benefit of service users and carers and should be run in ways they feel comfortable with and which will maximise their opportunities for involvement. The Care Co-ordinator and service user are jointly responsible for running the meeting, covering the agreed agenda, ensuring everyone involved has an opportunity to participate and keeping to time schedules. Ways of managing this should have been planned in preparation meetings. 9.15 Tasks and who is to take responsibility for them should be formally agreed at the start of the meeting. Tasks include: • Chairing the meeting • Taking notes • Helping the service user finalise the draft care plan or completing it in collaboration with them Service users should be supported to chair meetings if they wish to do so.
30 Action Following CPA Reviews 9.16 Following a CPA meeting the Care Co-ordinator is responsible for: • ensuring the finalised care plan is given to the service user for agreement and signature within 5 working days • ensuring the care plan is entered on the electronic system within 10 working days • arranging for it to be distributed within 2 weeks to everyone who attended the meeting or needs a copy • liaison with anyone involved who needs discussion of their role or clarification following the meeting, including people who may have been unable to attend.
PART 10 : ENGAGEMENT 10.1 CPA arrangements are based on partnership working and positive steps to support service users and maintain engagement. The CPA framework encourages joint work between professionals, service users, carers, and any other agencies or people from the service user’s wider social network who may be involved. Managing Engagement Difficulties 10.2 Responses to difficulties maintaining engagement will be guided by contingency, crisis and risk management plans set out in the care plan, recent contacts with the service user and any information that can be gained from others involved. Any children or other dependents should be considered and it may be appropriate to contact children’s or other local services. In some circumstances it may be necessary to contact the police. The Care Co- ordinator should take responsibility for co-ordinating attempts to re-establish contact. If care managers from other agencies are involved this should be done jointly with clear agreement about who will be taking what action. 10.3 Guidance on responses where service users go missing or cannot be contacted are set out in several Trust policies: • Missing Informal Patient Policy (outlining action to be taken if informal or voluntary patients go missing or fail to return at agreed times) • Retaking An AWOL Patient From Locked/Private Premises Using Section 135(2) (setting out procedures for applying for warrants to retake detained patients) • Clinical Risk Assessment and Management Policy and Adult Services Procedure (setting out the Trust-wide Clinical Risk Assessment and Management Policy applicable to all services and the Clinical Risk Assessment and Management Procedure applicable to Adults Services) • Prevention of Suicide Policy (setting out procedures for patients at risk of self harm) • Incidents and Accidents Procedure and Serious Untoward Incidents Procedure (providing uniform approaches to the management of Untoward Incidents and Serious Untoward Incidents across the Trust, including near misses) • Supervised Community Treatment Policy (setting out policy and procedures for operating Supervised Community Treatment and Community Treatment Orders)
31 • The CAMHS Risk Assessment 10.4 If contact has not been re-established a CPA review should be held to review the options. Options will include: • • • • identifying whether adjusting any elements of the care plan would improve the situation • • • • Identifying any steps which are still possible to re-establish contact a • • • • Involving other professionals, agencies or carers/family members/other individuals • • • • Agreeing an action plan for periodic attempts to re-establish contact, unless available assessments indicate this is likely to be counter- productive or increase risks 10.5 Available information should be reviewed to identify risks and potential child or adult protection concerns: • If children are involved and there may be child protection concerns the appropriate agencies should be contacted • If there are adult protection concerns for the service user or any other adults, consideration should be given to using the safeguarding adults procedures.
10.6 If contact with the service user cannot be re-established decisions should be based on the available evidence of need. They should not be discharged unless there is clear evidence they no longer need support from mental health services. This would normally require they have contact with another agency, such as a GP, who can assess their current levels of need. If there are continuing needs for secondary mental health service support they should be designated as ‘out of contact’ and remain nominally linked with the care team to ensure there is some level of continuity if they are contacted successfully or re-referred.
PART 11 : TRANSFER & DISCHARGE 11.1 This part of the policy sets out general guidance applying to all transfers of care and discharges from the service. For both CPA and Lead Professional Care, service users and carer/s (where appropriate) should be involved as fully as possible in decisions about transfer and discharge and kept informed of progress. 11.2 Transfers Between Services: Detailed operational arrangements for transfers of care to and from specific service groups are set out in the relevant Appendices.
Transfers Between Areas and Services : General Points 11.3 Transfer of care will normally be necessary if someone moves out of the catchment area for a specific team or their needs are better met by a different service group. 11.4 If a service user moves from one area to another the team for the new catchment area should be notified immediately. Sufficient details must be provided in case they need to respond to an emergency situation, particularly if a service user is under 18 or is caring for children under 18 (Trust Policy on Child Protection).
32 11.5 If a service user moves to a permanent address within the Trust area, his/her care will be transferred to the team covering the new address or aligned with the new GP. If local services are GP aligned local protocols should specify arrangements where service users change GPs. 11.6 Team/Service Responsibility: Arrangements should always make it clear which team or service has lead responsibility for providing the service. The transferring team maintains responsibility for providing care and services until the agreed transfer date. Necessary services or treatment must not be refused or delayed because of doubts about who should be providing them. If there are any delays in the process or if distance or other factors mean it is not practicable for the existing team to continue providing services the two teams should liaise to agree interim or transitional arrangements, involving team managers, service directors and/or other senior managers if necessary. 11.7 Roles: Care Co-ordinators/Lead Professionals are responsible for coordinating individual transfers until care is accepted by another team/service. Team managers and where necessary service directors and other senior managers are responsible for facilitating transfer processes and consulting with counterparts to ensure transfers are timely, consistent and well managed.
11.8 Urgency and Practicability: The procedures set out below represent good practice which should be followed unless there are exceptional circumstances. Teams should liaise to agree necessary action in the best interests of the service user and carer/s involved if service users need urgent support or move too far away from their original area for these arrangements to be practicable. Transfer Procedure : CPA 11.9 Transfer decisions should normally be made at a formal CPA review meeting and be recorded in the CPA care plan. If urgency makes this impracticable the necessary documents must be completed as soon as possible. 11.10 The Care Co-ordinator from the transferring team should confirm receiving team/service referral arrangements (local protocols will identify the appropriate referral point for each team/service): • The Care Co-ordinator should write to the receiving team/service setting out the reasons for transfer, highlighting any urgent information and enclosing transfer documents (listed below) • The receiving team should identify a new Care Co-ordinator and contact the transferring Care Co-ordinator to arrange a transfer CPA meeting • Service users and any carers should be consulted about arrangements for transfer CPA meetings as for any other meeting • The transferring and receiving team should liaise to clarify and agree any issues around funding or continuity of service provision before the transfer date • Dates for transfer of care should be agreed within four weeks of the transfer request. Transfer of care should normally take place at a formal CPA meeting. (If transfers are taking place to services outside the Trust area it may be useful to explain that these are the standards the Trust works to).
33 11.11 Guidance on transfer arrangements for specific groups is set out in the relevant appendices. 11.12 Good Practice Point: The new Care Co-ordinator should meet with the service user, any carers and the transferring Care Co-ordinator before the transfer date to start developing a working relationship and discuss the draft care plan. 11.13 Transfer Documents: Transfer requests must be accompanied by up to date: • Basic Details information • CPA care plan including details of current medication • Comprehensive needs assessment • Risk assessment • FACS assessment • Medical report and/or discharge summary/ies • Any other significant reports - occupational therapy, psychology, etc. • Details of any services which will be continuing after transfer/providers • Details of any advance decision/s Once a transfer date has been agreed the Care Co-ordinator should complete a closing/transfer summary, which should be available at the transfer CPA meeting.
11.14 Transfer CPA Meetings: Advice in Part 9: Reviews on preparing draft care plans, arranging CPA meetings, venues, who to invite and service user and carer involvement also applies to transfer CPA meetings, subject to any adjustments necessary because of change of area. Invitations should be sent out at least three weeks before the date of the meeting. 11.15 Attendance: Particular consideration should be given to who should attend. This may include people who would not normally attend, but can provide useful information or advice, such as pharmacists. The new Care Co- ordinator and the transferring Care Co-ordinator (or exceptionally a practitioner who knows the service user) must attend, unless alternative arrangements are agreed between the service user/carer/s and the two teams.
11.16 Transfer Care Plans: The receiving team is responsible for completing and distributing the CPA care plan. The care plan should be based on the needs assessment and cover the same headings as any other CPA care plan (paragraph 8.7). If the former care plan included provision for continuing services the new care plan must clarify how the related needs will be met and what the review arrangements will be. 11.17 Disputes: If a dispute between teams cannot be resolved, the relevant Service Director/s will arbitrate to ensure a decision is reached. Transfer Procedure : Lead Professional Care 11.18 The transferring Lead Professional should write to the receiving professional, enclosing appropriate reports, past care plan letters and an up to date risk assessment. Responsibility is not transferred until the receiving professional
34 has accepted the referral in writing. The receiving professional should confirm acceptance within four weeks of the referral. Discharge from Secondary Services and Transfers between CPA and Lead Professional Care 11.19 Whether someone is on CPA or receiving care under Lead Professional Care, the level of their care should be considered at each formal review. Any decision to transfer someone from CPA to Lead Professional Care or vice versa must: • Be discussed with the service user and carer/s involved, so far as practicable • Take account of a formal review of the needs assessment and risk assessment Transfers from Lead Professional Care to CPA 11.20 If a need for increased support is identified the Lead Professional is responsible for: • Reassessing the level of risk and need • Ensuring the proposed transfer is discussed with the user and carer (where appropriate) • Contacting the appropriate team or managers to request transfer to CPA and allocation of a Care Co-ordinator • Ensuring transfer documentation is updated 11.21 The Lead Professional maintains responsibility for overseeing care arrangements, in co-operation with other teams/agencies as necessary, until CPA arrangements are established and a Care Co-ordinator is in place. A CPA meeting should be arranged following the procedure set out in Part 9 : Reviews. The Lead Professional should attend the first CPA meeting unless there is formal agreement between the service user, any carer/s and the team accepting CPA responsibility.
11.22 Documentation: The CPA Care Plan should be agreed at the first CPA meeting and distributed as set out in Part 8 : Care Plans. 11.23 Good Practice Point: The new Care Co-ordinator should meet with the service user, any carers and the transferring lead professional before the transfer date to start developing a working relationship and discuss the draft care plan. Transfers from CPA to Lead Professional Care 11.24 Any decision that someone no longer needs the support of CPA, but still needs support from secondary mental health services should be confirmed in a formal CPA meeting: • Arrangements should be planned with the service user and any carer/s as part of the normal preparations for a CPA meeting • An appropriate Lead Professional should be identified • Transfer documentation should be updated as set out in paragraph 11.13 • A CPA meeting should be arranged. The Care Co-ordinator and Lead Professional should both attend
35 • The final CPA Care Plan should specify Lead Professional Care arrangements. The Contingency and Crisis plans should specify action/who to contact if additional support is needed. 11.25 Transfer from CPA to Lead Professional Care will not end entitlement to any other services that are being provided unless the service user is formally assessed as no longer needing them. This will include aftercare services under section 117 of the Mental Health Act. 11.26 Good Practice Point: The new lead professional should meet with the service user, any carers and the transferring Care Co-ordinator before the transfer date to start developing a working relationship and discuss the draft care plan.
Discharge from Secondary Services 11.27 Any decision that someone no longer needs the support of secondary mental health services should be confirmed in a formal meeting – either a CPA meeting or a meeting with the Lead Professional as appropriate. Discharge from secondary care should be planned: • Service users and any carer/s should be given at least four weeks to consider the proposal before a decision is finalised and should be advised of their appeal rights if they disagree with the final decision • The GP and any other professionals involved should be sent a letter at least four weeks in advance explaining proposed discharge arrangements 11.28 If service users have childcare responsibilities or vulnerable dependents these needs should be explicitly addressed. It may be appropriate to discuss options with Child and Adolescent Mental Health Services (CAMHS), social services departments, the local CAF lead or other agencies. 11.29 The final Care Plan (whether it is a CPA Care Plan or a Lead Professional Care Plan) should include: • Crisis and Contingency plans specifying action/who to contact if additional support is needed • Details of how to re-refer to secondary mental health services • If appropriate carer/s assessment/s should be updated and circulated • Details of any continuing needs and how they are to be met • Details of any entitlement to care under section 117. The care plan should state clearly whether the service user no longer needs section 117 aftercare or whether there are continuing needs and how they will be met. 11.30 Good Practice Point: The Care Co-ordinator/lead professional should meet with the GP, service user, any carers before the transfer date to discuss discharge arrangements and hand over information.
Appeal Arrangements 11.31 If a service user disagrees with a decision about transfer between CPA and Lead Professional Care or discharge from secondary care, they can appeal to the relevant Team Manager. • Appeals may be verbal or written • Appeals can be accepted from carers, advocates or anyone else involved with the service user
36 • If the service user has mental capacity (for those aged 16 or over) or competence (for those under 16) the service user should normally indicate that they support the appeal • If the appeal is from a third party and is based on child protection concerns or other risk issues there is discretion to accept an appeal without the service user’s consent • If any information is to be provided to third parties the service user should normally be asked to give written consent, unless they lack capacity or competence.
Any professional should provide any advice or assistance necessary to help a service user or their representative submit an appeal request. 11.32 The Team Manager should make arrangements for the service user to have their needs re-assessed by another member of staff from within or outside the team. The outcome of this assessment should be discussed with the clinical team in the first instance and then given to the service user in writing, with an explanation of their rights to complain if they are unhappy with the decision or the way it has been made.
PART 12 : CPA ROLES AND RESPONSIBILITIES 12.1 Competencies and working arrangements for services, teams and individual practitioners are supported by principles set out in guidance on New Ways of Working (CSIP/NIMHE 2007) and the Ten Essential Capabilities for Mental Health Practice (NIMHE 2004). These are linked to the requirements of the Knowledge and Skills Framework, the Capable Practitioner Framework, the Mental Health National Occupational Standards, and related guidance, all of which inform the statement of Care Co-ordinator competencies. Care Co-ordination: Core Functions and Competencies 12.2 Care Co-ordination: Care Co-ordinator competencies are set out in government guidance ‘Care Co-ordination: Core Functions and Competencies’ (DH 2008) which are incorporated in Care Co-ordinator job descriptions. Details are set out in Appendix _ .
12.3 Co-ordinating Care: The Care Co-ordinator role is to develop, monitor and review care plans for people on CPA in partnership with the service user, carer/s and other professionals/agencies involved. This includes: • Co-ordinating core assessment • Co-ordinating risk assessment and management • Crisis and contingency planning and management • Co-ordinating assessment of and responses to carers’ needs • Care planning and review • Co-ordinating communication and information sharing to support the care plan, including keeping service users, carers, other professionals/agencies and GPs informed of developments • Supporting service users, advocating on their behalf with other agencies where necessary • Facilitating self-directed support • Co-ordinating transfer of care or discharge The Care Co-ordinator is responsible for ensuring assessments and care plans are maintained and updated. They should Identify any needs which
37 cannot be met and communicate any unresolved issues to the appropriate managers. 12.4 Maintaining Contact: The Care Co-ordinator is responsible for ensuring continuity of care and regular contact with the service user is maintained. This includes: • Maintaining contact with the service user and any carers and other agencies involved • Maintaining contact and care co-ordination responsibility and providing co-operation and assistance during specialist interventions including Mental Health Act assessments and Crisis Resolution /Home Treatment Team involvement • Maintaining contact with the service user during hospital admissions and working with service users, carers, in-patient staff and other teams/agencies to plan discharge • When service users are discharged from hospital, ensuring there is face- to-face contact within 7 days. If contact is not possible or only telephone contact can be made the reasons must be documented.
• If service users have been at high risk, seeing them within 48 hours and ensuring more intensive care is offered in the three months following discharge and for as long as necessary. • If service users are in prison, maintaining contact, keeping track of their whereabouts and expected release dates, liaising with mental health staff working with them in prison, and continuing to support carers involved • If cases are transferred or discharged to primary care, maintaining responsibility until transfer/discharge arrangements are completed 12.5 Frequency of contact: Care Co-ordinators must arrange contact to prepare draft care plans during preparation for CPA review meetings and during the period immediately after discharge from hospital. Frequency of other contact should be proportionate to identified needs and should be agreed as part of the care plan. Contact arrangements should balance respect for service users’ and carers’ privacy and right to family life with safe and effective care co-ordination.
12.6 Contact Details: Care Co-ordinators must: • Ensure the service user and carer/s know how to contact the Care Co- ordinator and who/where to contact out of hours or if the Care Co- ordinator is not available • Arrange for someone to deputise if they know they are going to be absent • Ensure clear written information is given to all involved explaining how to contact professionals/agencies responsible for aspects of the care 12.7 Contributing to Other Care Frameworks: The Care Co-ordinator is responsible for ensuring requirements of other care systems are met where necessary, including care management, Fair Access to Care Services (FACS) assessments and other procedures specific to particular services. Lead Professional Care: Core Functions and Competencies 12.8 Lead Professionals work to professional standards and core competencies set by their professional bodies, legislation and individual contracts. 12.9 The lead professional role includes:
38 • Co-ordinating core assessment, including assessing risks and assessment against local authority FACS criteria where appropriate • Agreeing a care plan with the service user and carer/s (as appropriate) recorded in a letter to them, including crisis and contingency plans • Providing the level of contact and support agreed • Facilitating self-directed care • Liaison and communication with carer/s and other agencies/professionals involved, subject to the agreement of the service user where appropriate • Maintaining continuing review, including reviewing the need for inclusion in CPA or transfer to primary care • Identify carer/s and inform them of their rights to their own assessment Care Co-ordination/Lead Professional Care: Recording 12.10 Care Co-ordinators/lead professionals are responsible for ensuring assessment and care planning documents and clinical notes are kept up to date, sent to the appropriate individuals within the required timescales, and appropriate data is entered on the relevant databases promptly. They are also responsible for ensuring details of their caseloads and contacts are kept up to date on the relevant databases.
Choice of Care Co-ordinator and Lead Professional 12.11 The Care Co-ordinator should be the person who is best placed to oversee care planning and delivery. They do not have to be the professional providing most care. The lead professional should be the person taking lead responsibility for the person’s treatment and care. 12.12 Care Co-ordinators/lead professionals can be from any discipline depending on capability and capacity. They will usually be: • Community Mental Health Nurses • Social Workers • Occupational Therapists • Psychiatrists • Psychologists • Psychotherapists Restrictions on Who Can Be a Care Co-ordinator/Lead Professional 12.13 Care Co-ordinators can be from the independent or voluntary sector, but this must be by local agreement or commissioning and take into account the competencies needed for the role and relevant issues around accountability, access to information and resources, data entry and audit. Lead Professionals should not be from the independent or voluntary sector. The following workers cannot be Care Co-ordinators or lead professionals: • GPs • Support Treatment and Recovery (STR) workers • Unqualified or unregistered health or social care workers • Welfare Rights workers Service User Choice 12.14 Choice of Care Co-ordinator/lead professional should be discussed with the service user and carer/s as appropriate. Gender, culture and ethnicity
39 specific requests should be met where possible within the limits of resources. Choice of gender may be a crucial factor in the development of a therapeutic relationship with people who have experienced sexual abuse or violence. Cultural or religious factors should be taken into account, though the worker does not have to be from the same racial, cultural or religious group as the service user and choice must not be used to support discrimination. If requests cannot be met decisions should be explained to the service user. Service users should be offered assistance in requesting support from an advocate, PALS worker or using the complaints procedure if requested. Further details are set out in the Trust policy ‘Choice of Professional’ 12.15 Other Factors also need to be taken into account: • The worker’s experience, training and qualifications • The level of input required • The worker’s relationship with the service user, if there is one already • The worker’s current caseload • Allocation should take place within 14 days of the initial assessment decision that someone needs to be on CPA Consideration should be given to joint care co-ordination in complex cases or if maintaining continuity of care or frequent contact is particularly importance. 12.16 Care Co-ordinators or lead professionals must not be assigned without their knowledge. They should have reasonable choice in accepting cases and there should be negotiation if there are concerns about the allocation of cases. Team managers must maintain an efficient system of caseload management to ensure fair and manageable caseloads. Change of Care Co-ordinator or Lead Professional 12.17 Reasons for any change should normally be discussed with the care team and the service user and carer/s in accordance with service user choice arrangements outlined in paragraph 12.4 : Service User Choice. Relevant documentation should be updated before hand-over, including the core assessment, risk assessment and care plan. The outgoing Care Co-ordinator should complete a Closing/Transfer Summary. Where appropriate a CPA meeting should be held or there should be a joint meeting between the service user, any carer/s, and the outgoing and incoming Care Co-ordinators. Support for Care Co-ordinators and Lead Professionals 12.18 Care Co-ordinators/Lead Professionals must be given the authority and support to: • Monitor the care plan being provided • Co-ordinate the delivery of the care plan • Arrange reviews • Access resources • Access other members of the person’s care team directly. 12.19 Team managers and others involved must ensure that Care Co- ordinators/Lead Professionals have access to adequate support, supervision, training opportunities and administrative assistance. Other Professionals
40 12.20 The Care Co-ordinator/lead professional has a central role in the CPA framework, but all professionals involved in any aspect of CPA have a duty to do what they can to ensure arrangements operate effectively, safely and support recovery. Particular officers/disciplines have specific roles. The roles and responsibilities of officers beyond individual team levels are outlined in Part 17: Governance. 12.21 Team/Ward Managers: Responsible for: • allocating work to team/ward staff • ensuring Care Co-ordinator/lead professional roles are allocated promptly • monitoring the operation of CPA procedures at team/ward level, ensuring they are followed and reviews are conducted within appropriate timescales • monitoring the quality of care plans and care provision within the team • ensuring administrative procedures are adequate • ensuring there are cover arrangements if workers are absent • providing support and supervision • liaison with other teams/agencies/services as appropriate. 12.22 Administrators & Clerical Staff: Responsible as agreed at individual/team/local level for CPA and database administration and general administrative support.
12.23 Clinicians: Psychiatrists, mental health nurses, social workers, occupational therapists, and other disciplines where appropriate are organized into care teams around each service user, crossing clinical team boundaries where appropriate and including agencies/professionals outside the Trust. Each clinician in a care team is responsible for • supporting the service user and carer/s in ways agreed in the care plan • delivering or supporting parts of the care plan as agreed • ensuring the Care Co-ordinator and other members of the care team as appropriate are kept informed of developments • supporting the Care Co-ordinator to oversee the care plan 12.24 GPs: Responsible for continuing medical care in the community. GPs cannot always attend CPA review meetings but they should always be invited. The Trust ‘CPA: invite letter to GP template’ should be used to assist GPs in sending a brief report to contribute to the review. If service users want reviews held in GP surgeries, staff must try to accommodate this in conjunction with GPs/practices. GPs should always be sent a copy of the care plan.
12.25 Advocates: Independent advocacy can help service users get the best from the CPA process. There are statutory rights to advocacy under Mental Capacity Act 2005 and the Mental Health Act 1983 and staff have a duty to inform service users of these rights. The Trust supports the extension of advocacy services to everyone who wants one. Staff should: • co-operate fully with advocates, subject to normal confidentiality procedures • provide service users and carers with information about how to contact advocacy services whenever appropriate • provide whatever assistance they can to help arrange advocacy. Advocates working with service users should be invited to CPA and other relevant meetings and should be involved in drawing up draft care plans.
41 12.26 Solicitors: Solicitors can give service users legal advice and represent them. Solicitors should be invited to CPA and other relevant meetings if the service user requests it. A solicitor’s role in a CPA or any other related meeting or contact is to represent their client. Any concerns about the conduct of solicitors, communication with them or disclosure of information should be discussed with managers. Advice may be sought from Trust solicitors in complex cases. PART 13 : CARERS 13.1 Carers often provide the most consistent support for service users and can be essential in maintaining their health and wellbeing and promoting their recovery. Carers can make important contributions to care plans and assessments and should be fully involved wherever possible. Carer involvement should be agreed with services users as appropriate, if necessary with negotiation to clarify any information the service user does not wish to be disclosed. Caring can also be a demanding role and this should be acknowledged by professionals.
Identifying Carers 13.2 Service Users on CPA or Lead Professional Care: Assessments should review the social and family network around each service user to identify anyone who provides unpaid practical and/or emotional support and whose caring may have an impact on their own lives. Caring arrangements can change and should be reviewed regularly, particularly during the care plan review and draft care planning process. 13.3 Regular and Substantial Care: Legislation gives particular entitlements to people providing ‘regular and substantial’ care. The meaning of ‘regular and substantial’ care is not always straightforward. The Trust expects staff to use a broad definition of caring, recognising: • Caring includes practical care and support, such as personal care, preparing meals, looking after the home, shopping, laundry, paying bills etc • Caring includes emotional care and support • Caring is not just about how much time is given to caring activities - the impact of being a carer fluctuates over time, and can be affected by other circumstances affecting the carer • Carers may still continue to provide commitment and emotional support when a service user needs little practical help, or practical help is provided by paid homecare workers or residential services • Service users will often have more than one carer Carer Entitlements 13.4 Unless the service user has capacity or competence and withholds consent, anyone identified as a carer for someone receiving care from mental health or learning disabilities services is entitled to: • Be part of the care team of someone on CPA • Be given information about the condition and/or treatment, the risks of the treatment and available alternatives • Be involved in preparing care plans
42 • Be invited to review meetings and be involved in making arrangements for review meetings • Have their involvement acknowledged and described in service users’ CPA care plans 13.5 Whatever the views of the service user, anyone identified as a carer is entitled to: • The opportunity to contact or meet professionals without the service user present • Support to express their views and raise any concerns • An explanation of the role of the CPA Care Co-ordinator • Be told who to contact in an emergency • Be given information about CPA and care planning • Be given information about ‘out of hours’ support • Continuing support in their caring role • Be told they have a legal right to an assessment of their caring, physical and mental health needs, repeated at least annually • Their own written support plan, implemented in collaboration with them • Request a review of their support plan at any time 13.6 Carer Confidentiality: Carers have the same rights to confidentiality as anyone else and information provided by carers should be protected, unless the carer consents to it being disclosed or disclosure is necessary. Professionals may need to negotiate consent over a period of time. Further details are set out in paragraphs 14.9 – 14.15 and in related Trust policies. 13.7 People Who Are Not Currently Receiving Services: Carers are entitled to request an assessment whether or not the person they care for is known to local services or has declined an assessment or service. If people self-refer requesting a carers’ assessment, details should be taken as for any other referral. Details should be taken of the person cared for, any information that they have a mental disorder, and details of the carer and the type of support they are providing. Other investigations such as contacting the GP should be carried out if necessary. A decision about whether to offer an assessment should then be taken. If it is decided not to offer an assessment a written explanation should be sent to the person making the referral. Young Carers 13.8 Young carers are children and young people under the age of 18 who provide practical, personal or emotional care to another family member. At times this may involve taking on parenting responsibilities for younger siblings. Young carers should receive adequate support to minimise any adverse effects of their caring responsibilities and to ensure they have adequate opportunities for education, leisure and friendship, as appropriate to their normal development.
13.9 The general carers entitlements set out in paragraphs 13.4 – 13.5 apply particularly to young carers: • Workers must ensure young carers have access to carers’ assessments so that the full range of their needs is assessed and a support plan offered • Care Co-ordinators should normally undertake this assessment, involving others as needed
43 • Assessors need to be aware of services available to young carers locally and provide appropriate information about the service user’s condition and about services and support available • Young carers should always have access to crisis numbers both within and out of hours • Interventions should not reinforce the role of the child as a carer. 13.10 Interventions to support the parenting roles of adults are likely to be helpful in ensuring a child’s welfare or development is not impaired. Further detail is set out in paragraph 13.19: Service Users with Dependent Children. Carers Assessments 13.11 Anyone identified as a carer should be offered a carers assessment. Workers should explain the possible benefits and outcomes and encourage carers to participate in assessments.
13.12 Conducting Carers Assessments: the service user’s Care Co-ordinator will normally take the lead in ensuring the Carers Assessment is carried out. Sometimes respecting confidentiality or ensuring there are no concerns about potential conflicts of interest will mean it is more appropriate for this to be done by another worker or another service. • Carers should be given the choice of completing the assessment form on their own or with the level of support they wish. • It may be useful to involve someone from a carers’ organisation to act as an advocate.
13.13 Joint Assessments: Each carer should be given an opportunity to discuss their needs separately from those of the person for whom they care or anyone else involved - if assessments are conducted with other carers or anyone else this should be each carer’s choice: • It may be appropriate to involve other relatives, close friends or the service user - they may have useful ideas about the pressure the carer/s are experiencing. • groups of individuals (such as families) may be able to provide assistance. It may be appropriate to conduct a group assessment All identified carers should be recorded, but a single assessment and care plan can be devised and implemented as long as it covers all areas necessary.
13.14 Carers Who Decline Assessment: Carers are entitled to decline an assessment. The reasons should be explored where possible to clarify any misunderstandings. The offer of an assessment is a formal recognition of the carers’ role as part of the care team. Declining a formal assessment does not mean the carer is unwilling to engage in the process of care, does not want information or advice, or that they should not be informed about resources that might be useful to them. Assessment should be offered again at appropriate intervals.
Carers Support Plans 13.15 Support planning is a collaborative process focusing on the individual needs of the carer. Workers do not assume clinical responsibility for carers, but should support access to other resources and provide advice and information.
44 Liaison with primary care teams, voluntary and other statutory agencies are an important part of ensuring that the care plan is implemented. 13.16 Depending on the carer’s circumstances and what emerges from the assessment, the support plan should include some or all of: • Information about the needs of the service user, including information about medication, side effects and support services available • Action to meet defined contingencies • Information about what to do and who to contact in a crisis • What will be done to meet the carers own mental and physical needs and how it will be provided • Action needed to secure advice, support or assistance with income, housing, education, training, leisure, employment issues and general health issues • Arrangements for any short term breaks • Arrangements for social support including access to carers’ support groups • Arrangements to support carers if they need to reduce or relinquish their caring role • Information about appeals or complaint procedures • Date/arrangements for review (maximum period 12 months) • Any areas of need that cannot be met by current service provision should be recorded as ‘unmet need’ in the same way as in service users’ care plans It is not necessary to repeat points if they are covered in the service user’s care plan which has been given to the carer. A copy of the carer’s support plan should be sent to their GP, with the carer’s consent. 13.17 Recording: Carers Assessment and Support Plan forms should be used. Entries in clinical notes and the relevant databases should record: • Any offers of carers assessments • Details of every carers assessment • If carers assessments are declined and reasons, if given • Carers’ assessments and related documentation should be filed in the section of the service user's file marked Third Party Information. Service Users with Caring Responsibilities 13.18 Service users may have caring responsibilities of their own. These should be identified in assessments and appropriate support should be identified in care plans. Children or vulnerable adults who are looked after by a parent or carer with some form of mental disorder will not necessarily suffer adverse effects, but there is likely to be some impact.
Service Users with Dependent Children 13.19 Service users with parenting responsibilities should normally be on CPA. If a thorough assessment concludes that they only need support on Lead Professional Care the reasons for this should be clearly documented. The position and the need for support under CPA should be reviewed regularly. More detailed advice is set out in Trust guidance Considering the welfare of children whose primary carer has mental health needs.
45 13.20 Child Protection: If there are concerns about harm or potential risk to a child, local authority child safeguarding services must be contacted as soon as possible for further guidance. Staff have a duty to share concerns relating to child protection with appropriate agencies, and should be aware of the multi-agency nature of child protection work. All professionals should be familiar with local child protection procedures and know how to obtain specialist advice quickly. Trust employees have a responsibility to consider risk to children and should request formal assessment from children’s services as appropriate. Further details are set out in the CNWL Child Protection Policy. If children’s services do not consider concerns warrant their formal involvement, Trust workers should consider the need for referral to alternative agencies offering support to parents. Further advice is available from managers/supervisors and the Trust Named Nurse for Child Protection and/or Named Doctor for Child Protection.
13.21 Referrals: Details of dependent children and family circumstances must be recorded as part of basic referral information. Any agencies which are already involved must be identified and it may be necessary to contact them for background information. It may also be necessary to provide details of the referral if this is in the best interests of the child/ren. If no other agencies are involved it may be appropriate to make referrals to children’s services or other agencies. 13.22 Assessment: Parental roles must always be considered in assessments with the aim of supporting and enhancing parenting capacity. It may be necessary to involve other agencies in joint assessments or request parallel assessments of other aspects of the family situation.
13.23 Care Plans and Reviews: All care plans for service users looking after children or young people should record any support that is necessary in this area. Staff should be aware of services to support parenting and liaise with them to arrange assistance where appropriate. If no support needs are identified this should be clearly indicated on the care plan. Allocated workers from children’s services such as Health Visitors, social workers and voluntary sector staff involved with the family should be invited to CPA reviews, subject to agreement with the service user, and should be sent copies of the care plan. There should be clear arrangements about which agencies/individuals should be contacted in the event of an emergency.
13.24 Other Agency Procedures: Care Co-ordinators/Lead Professionals should prioritise attendance at child protection case conferences, and where possible attend other meetings relating to children. If attendance is impossible they should supply reports, in accordance with information sharing protocols. Other Trust-based professionals involved should also be prepared to supply reports if requested, subject to information sharing protocols. Service Users Looking After Vulnerable Adults 13.25 If service users live with or care for vulnerable adults this: • Should be recorded during the referral process • Should be identified in assessments, along with details of existing support arrangements and any other agencies involved
46 • Be addressed in care plans with a view to supporting the service user in their caring role. There should be referrals to/liaison with other agencies where appropriate and crisis/contingency plans should be identified 13.26 Staff should be familiar with local safeguarding adults arrangements and should request a protection of vulnerable adults case conference if there are concerns. Any decision to use safeguarding adults procedures should normally be a multi-disciplinary one taken after discussion within the care team. In urgent cases it may be necessary to contact the police. Managers should ensure arrangements are in place for staff to have immediate access to advice and support in urgent situations.
PART 14 : INFORMATION Recording Information 14.1 Accurate and up to date recorded information supports assessment, care planning, decision making, recovery and safety. It can also reduce duplication and help avoid the need for service users to repeat information to a number of professionals. 14.2 Trust policy is to work towards a position where all information is merged with the Trust database and is available electronically. Until this is achieved all information should be recorded in patient notes/files and entered as appropriate on relevant databases.
14.3 Records should be kept of all contacts. Records should be concise, factual and accurate. Jargon and abbreviations should be avoided. Any opinion recorded should be clearly identified as such. Records should identify the professional involved, their role/job title and the date and time. Services should specify locally who is responsible for recording information in different circumstances. 14.4 Service users, carers and other individuals should be told what information is kept. When appropriate they should be asked if they consent to its disclosure. The Trust leaflet Your Information may help service users, carers and others understand information recording and confidentiality issues. Recording Consent and Information Disclosure 14.5 Anything affecting the use of confidential information must be recorded in clinical notes and on any document/s it applies to: • Any consent to share information must be clearly recorded • Any decision to disclose information without consent must be recorded in clinical notes and on any document/s it applies to. The reasons for making the decision must be set out clearly • If individuals have placed restrictions on disclosing information this must be clearly specified wherever that information is kept or recorded • If individuals lack capacity (for those 16 or over) or competence (for under 16s) this should be clearly recorded, together with details of anyone with authority to consent on their behalf. Further details are set out at paragraphs 14.16 – 14.19 Guidance on disclosure of information without consent is set out in paragraph 14.14.
47 14.6 Access Rights: Anyone is normally entitled to be told what information is held about them and professionals should assist people where they can. Service users and carers have legal rights to access information held about them under the Data Protection Act 1998. Service users, carers and any organisation or member of the public also have rights to request information under the Freedom of Information Act 2000. Requests received under these Acts should be discussed with the local Subject Access Co-ordinator. Further details are set out in the Trust Access to Health Records Policy and Procedure.
14.7 Information Security: Information kept on paper and electronic records must be stored securely. When information is communicated verbally and by post, internal mail, email or fax, efforts should be made to ensure it is only received by people it is intended for. Electronic CPA 14.8 Patient details, assessments, care plans, contacts and care team details must all be entered promptly on the Trust database and appropriate details must be recorded on relevant local authority databases. Printed care plans should be from the database record.
Confidentiality & Information Sharing 14.9 This section summarises considerations in handling confidential information. Fuller details are set out in the Trust Consent Policy, the Policy on Compliance with the Data Protection Act (1998), and The Clinical Records Management Policy. 14.10 Safe and effective operation of CPA procedures depends on openness and ensuring relevant information is shared between people who need it and available when it is needed. Some of this information is confidential. The need to share information to provide effective care, and to involve users and carers fully, will sometimes conflict with duties to respect the confidentiality of personal information.
14.11 Any information provided by an individual is confidential unless that person has indicated that it is not. Any documents or electronic records which identify individuals are health and social care records and are confidential. 14.12 Confidential information should be protected, but it can be disclosed with consent and/or if disclosure is necessary. Professionals may need to negotiate consent over a period of time. It should be explained to individuals that the normal expectation is that information will be shared with other people involved unless the individual withholds consent. .
14.13 The principles are: • Individuals should normally be asked for consent before any information they have provided is disclosed • Individuals can consent to disclosing all or only some of the information provided • Individuals can consent to disclosing information for some purposes only
48 14.14 Confidential information may sometimes be shared without formal consent or if formal consent has been withheld. Any decisions to disclose information without consent should normally be taken collectively by the care team, involving supervisors and managers where appropriate, seeking legal advice if necessary. Individuals should be told about any decisions to share information unless telling them would increase the risks of harm occurring. • Anyone who may be at risk of direct harm should be informed of this risk • Professionals and other agencies working with particular service users should be kept informed of any relevant risk information • Information may be given to an external agency if this is in the public interest • Information may need to be disclosed to protect children or vulnerable adults • Information must be given to comply with the law, a court order or a police investigation (advice should be sought if there is any uncertainty) • If someone lacks capacity to consent information may be disclosed in their best interests (further details are set out in Trust guidance on the Mental Capacity Act) 14.15 Carers: Sharing information can be crucial for carers. If consent to sharing information with a carer is withheld and the circumstances do not justify disclosure without consent, professionals should offer any information which might help the carer understand mental disorder, treatments, the relevant law, or anything which might help or support them in their caring role, even though individual diagnosis or other personal details cannot be shared. They should explain sensitively to carers why they cannot share information, with awareness that this may be distressing for the carer. Carers’ rights to confidentiality are set out in paragraph 13.6.
Capacity and Consent 14.16 Anyone over the age of 16 is assumed to have capacity to give consent and make decisions for themselves unless a formal capacity assessment has determined otherwise. 14.17 Adults Lacking Capacity: Information should be shared in their best interests, taking account of any wishes expressed at a time when they had capacity. Further details are set out in Trust guidance on the Mental Capacity Act. 14.18 Children and Young People: Under 16s who are Gillick competent and young people aged 16 or 17 are entitled to make decisions about the use and disclosure of information they have provided in confidence in the same way as adults.
14.19 Decisions to disclose information to parents and others with parental responsibility are complex and depend on a range of factors, including: • the child or young person’s age, developmental level, maturity and ability to take into account the future as well as the present • the severity of a mental disorder and the risks posed to themselves and others • the degree of care and protection required • the relationship with the parents and the degree of the parents’ involvement in their care
49 • the current competence of the child or young person to make a decision about confidentiality (adapted from MHA Code of Practice, 36.79). PART 15 : CPA & OTHER FRAMEWORKS 15.1 This section outlines the relationship between the CPA framework/procedures and other assessment and planning frameworks. CPA should be integrated with other frameworks as far as possible. Assessments, care plans and reviews should not be duplicated. CPA describes the process used in delivering care in mental health services. It is not a gateway to other services. Assessments to establish entitlement to other services, such as social care, are legally separate, although they may be carried out at the same time as CPA assessments and may use the same assessment documents, which can have multiple uses.
Care and Assessment Frameworks : Summary 15.2 If initial assessment establishes that someone needs care from secondary mental health services, there will be decisions about whether they should receive care under CPA or Lead Professional Care. This does not automatically mean they need any other services. Needs for other services are assessed under whichever framework is appropriate for the group they belong to: • Children and young people (up to the age of 18) are assessed by children’s services and under the Common Assessment Framework for Children and Young People (CAF) • Adults (over 18) – including adults with substance misuse and physical health problems as well as mental health problems - are assessed under Fair Access to Care Services (FACS) • Older Adults (over age 65) are assessed under the Single Assessment Process (SAP) • People with learning disabilities are assessed under Health Action Planning (for health services) and Person Centred Planning (for housing, education, employment and leisure).
Hospital Admission 15.3 Anyone admitted to hospital with mental health problems should normally be on CPA. If they are not currently in contact with services there should be a full assessment of need and the CPA process should normally be commenced. If they have been receiving Lead Professional Care their care should be reviewed to decide whether they should receive care under CPA. The principles of the CPA process set out in Part 12: CPA Roles & Responsibilities apply to in-patients in the same way as for any other service users, except for the adjustments identified below.
Hospital Admission Procedures 15.4 Wards should inform the relevant community team of all admissions to ensure that communication is established, the CPA process can be facilitated and discharge planning is started from the point of admission:
50 • If service users are already in contact with services the Care Co- ordinator/Lead Professional should maintain contact with the service user throughout the admission • If service users are not currently in contact with services the relevant team should identify a Care Co-ordinator/Lead Professional within 14 days of a request • The hospital key/primary nurse will act as Care Coordinator until a community team worker is in place • A draft care plan should be developed/updated (as appropriate) before a CPA review meeting is held on the ward • A CPA review meeting should be held within the first 10 days of admission and in the two weeks before discharge • Additional CPA review meetings should be held as necessary. In long admissions, a CPA meeting must be held at least every 6 months. • Times and dates of CPA review meetings should be arranged by the Care Coordinator in consultation with the service user, any carer/s, ward staff and others involved • CPA meetings should be separate from ward rounds wherever practicable • The Care Co-ordinator should attend ward rounds whenever possible and must attend CPA meetings • The Care Co-ordinator must be involved in care planning and should take the lead in discharge planning 15.5 Recording: • The relevant CPA documentation for the service should be used • If nursing care plans are used to itemise in-patient care arrangements these add detail to the CPA care plan and must be compatible with it. Hospital Discharge and Aftercare 15.6 Service users who are discharged should normally remain on CPA unless it is clear and agreed in a formal review meeting that their needs can be met by either Lead Professional Care or primary care services. If it is proposed to discharge someone to primary care the procedure set out in paragraphs 11.27 – 11.30 should be followed.
15.7 Carers and other providers of services should be kept fully informed of leave arrangements, discharge dates and discharge planning arrangements, subject to confidentiality arrangements. 15.8 7 Day Follow Up: All service users discharged from hospital, whether on CPA or not, must be followed up within 7 days of discharge. Follow up means face to face contact. If this is not possible, telephone contact must be made and reasons for not seeing the patient must be recorded in the notes. If contact cannot be made team managers should contact Service Directors outlining the reasons.
15.9 Post-Discharge CPA Meeting: All service users on CPA should have a CPA meeting within 12 weeks of discharge from hospital. All service users under Lead Professional Care should have a meeting within 12 weeks of discharge where their care plan and post-discharge arrangements, including any need for care under CPA, are reviewed.
51 Section 117 Aftercare 15.10 Anyone who has been detained in hospital under treatment sections 3, 37, 47 or 48 of the Mental Health Act 1983 (MHA) is entitled to aftercare under section 117 of MHA. The relevant NHS and local authorities have a duty to provide whatever after-care services are assessed as necessary. Further details are set out in the Trust Section 117 Aftercare Policy and Procedures. 15.11 Everyone receiving section 117 aftercare should be on CPA: CPA provides the framework required for planned and managed care. All services provided under section 117 must be reviewed at each CPA review and identified in care plans. If the service user no longer needs some of the services provided this should be agreed in a CPA review with the service user and carer’s involvement as appropriate. If the service user no longer needs any of the services provided it may be appropriate to terminate section 117 aftercare. This must be agreed jointly between the Trust/PCT and the local authority in accordance with the Trust policy.
15.12 Recording: • Entitlement to section 117 aftercare must be noted in all care plans, recorded in appropriate databases and services received must be identified • Any decision to change or terminate services provided under section 117 must be recorded in care plans, appropriate databases and confirmed in writing to the service user, carer (where appropriate), GP and any other professional/s or agencies involved in the service user’s care. NHS Continuing Healthcare 15.13 If people have primary health care needs which are likely to continue indefinitely they may be entitled to NHS Continuing Healthcare, a complete package of care arranged and funded by the NHS. Assessment for Continuing Healthcare is independent of assessment for CPA/Lead Professional Care and entitlements under CPA are not a ‘gateway’ to Continuing Healthcare funding. However, anyone whose level of need makes them eligible for Continuing Healthcare would normally need care under CPA. 15.14 Anyone who has substantial health and social care needs should be screened for NHS Continuing Healthcare eligibility as part of the CPA/Lead Professional Care assessment process. If screening indicates that a full Continuing Healthcare assessment is needed this will require further specialist assessments. The Care Co-ordinator/Lead Professional is normally responsible for requesting these assessments and co-ordinating the submission of evidence in accordance with local procedures. 15.15 Recording: • The Decision-Support Tool for NHS Continuing Healthcare should be used • CPA care plans should record Continuing Healthcare assessment and eligibility status • Assessments and outcomes should be recorded in clinical notes and on the relevant databases
52 Children and Young People : The Common Assessment Framework (CAF) 15.16 Assessments under the Common Assessment Framework (CAF) establish whether a child or young person is ‘in need’ or ‘at risk’ and requires multi- agency support. A ‘lead professional’ (normally outside mental health services and different from the lead professional under Lead Professional Care) is selected from the agency which is likely to provide most support to the family. 15.17 If children/young people have mental health needs then the ‘lead professional’ would make a referral to Child & Adolescent Mental Health Services (CAMHS) who would conduct further assessment/s and provide necessary care. Many children and young people with relatively straightforward mental health needs will continue to be supported under CAF arrangements with supplementary input from CAMHS. These children and young people will not be covered by the CPA framework. 15.18 CPA arrangements will be used for children and young people over the age of 14 who: • have a first episode of psychosis and are seen in Early Intervention in Psychosis services • are admitted to specialist child and adolescent in-patient or residential units. This includes secure children’s accommodation, Forensic CAMHS Units or Young Offenders Institutions if CAMHS are involved • need transfer to adult mental health services. In this situation CPA reviews should be held from age 17 and should include both adult and CAMHS team representatives. CAMHS will not work with young people over the age of 18 • If children/young people from outside the Trust are placed within CAMHS Tier 4 accommodation within CNWL services, there should be mutual negotiation and agreement between CNWL services and the placing bodies. Normally the CPA policy for the referring Trust will be followed. 15.19 Lead Responsibility: Responsibility must always be clear: • If the child/young person is outside the CPA framework, the children’s service lead professional will be responsible for managing their care, with support from CAMHS workers and other agencies as appropriate • If the child/young person is on CPA, the Care Co-ordinator will be from mental health services and will have responsibility for co-ordinating mental health care. They should work closely with the CAF lead professional • If young people are transferring from CAMHS to adult services the transition process should start at age 17. Services may agree a period of joint working to ease transition. A clear transition date should be agreed for transfer of lead responsibility, which should pass to adult services no later than the service user’s 18th birthday, though joint working may continue beyond this date. 15.20 Further details and the agreed transfer protocol from CAMHS to adult mental health services are set out in Appendix _ .
53 15.21 Recording: • CAF documentation used by the relevant local agencies should be used in all cases. The CAF Form takes the place of any other assessment form. CAMHS agencies will use local formats to record additional assessment information. • If children and young people are on CPA then Trust CPA Care Plans and Risk Assessment forms should be used. General health and social care assessments will be recorded on the CAF form • Data should be entered in relevant trust and local authority databases Adult Social Care: Fair Access to Care Services (FACS) 15.22 All social care eligibility for adults (over 18) is assessed under Fair Access to Care Services (FACS) arrangements. FACS assesses a range of presenting needs and categorises risks of difficulties as non-applicable, low, moderate, substantial or critical. Each local authority sets the threshold at which it will provide services, based on local priorities.
15.23 FACS assessments cover any need an adult may have and are independent of assessment for secondary mental health services. Both are about identifying needs, so people who need secondary mental health care are likely to meet FACS criteria, but there will be many people who need social care but do not have mental health problems, learning disabilities or substance misuse problems. There may also be some people whose mental health problems make them eligible for local authority services, but do not need secondary mental health care.
15.24 Neither assessment should influence the other. Being on CPA is not a ‘gateway’ to local authority services or any other services. 15.25 Good Practice Point: CPA assessments and FACS assessments are separate but if they are both being carried out by the same service they should be completed at the same time. FACS assessments should be updated as part of the CPA review process. 15.26 Recording: The relevant local authority FACS form should be used. Assessment details should be entered on the relevant local authority database.
Adult Social Care: Care Management 15.27 Care management is the process for providing social care to all vulnerable adults. If someone needs secondary mental health or learning disabilities services, then care management arrangements, the CPA framework and care co-ordination/Lead Professional Care will normally be fully integrated. CPA and Lead Professional Care arrangements will include assessment and provision of social care under the NHS and Community Care Act 1990. The Care Co-coordinator will normally also take on the role of Care Manager. 15.28 Exceptions: Provision of secondary mental health/learning disability care is based on level of need and current address. Care management responsibilities are based on social care need and ordinary residence. In most cases these will be parallel, but there are some exceptions:
54 • Review Cases: If people with mental health problems need social care input but do not currently need secondary mental health services they will not be on CPA or Lead Professional Care. Social care will be funded and monitored/reviewed by secondary mental health services • Placements: If people are placed away from their borough of ordinary residence, CPA or Lead Professional Care will be transferred to their new area. Transfer arrangements are set out in paragraphs 11.3 – 11.18. The placing borough maintains responsibility for funding and monitoring the placement and arranging any subsequent placement. Secondary mental health services from the original area will be responsible, using local placements monitoring arrangements where appropriate. • Out of Area Admissions: If people are admitted out of area (usually to a specialist or forensic unit) CPA responsibilities are taken on by the unit they are admitted to, but the local authority they are ordinarily resident in retains care management responsibilities. Secondary mental health services from the original area may need to provide input to support discharge and aftercare planning and fund any placement. If patients are detained this may also involve providing evidence/information to tribunal and hospital managers’ hearings under the MHA. Detailed arrangements should be negotiated between the teams/units involved. 15.29 Recording: • All care management input should be recorded in clinical notes and on the appropriate Trust and local authority databases • Different service groups will use their own assessment forms. For adults, the Adult Health & Social Care Needs Assessment and CPA Care Plan records both mental health and social care needs for adults. For other services, core mental health assessment forms will be combined with assessment forms for other relevant frameworks, eliminating duplication where possible • Reviews and any other social care activity should use the relevant local authority forms/documents • If people are on CPA and receiving social care in the same area (i.e. most people) social care provision should be reviewed as part of the CPA review process • If people are placed out of area, CPA documentation for the area they are in should be used • Out of area placement monitoring should use the placing authority’s monitoring forms.
Older Adults : The Single Assessment Process 15.30 The Single Assessment Process (SAP) is the framework for assessing and planning all care for older adults. Further details of the relationship between SAP and CPA are set out at Appendix _ . 15.31 Primary/Social Care: Older adults whose mental health needs can be adequately supported by primary care and social care will not need secondary mental health services. Social care will be provided through SAP care management arrangements. 15.32 Lead Professional Care: Older adults who need secondary mental health services but whose needs are straightforward and do not include significant risks will have a lead professional from mental health services who will be
55 responsible for overseeing clinical/mental health care. Care Managers will be responsible for developing and monitoring the main care plan through SAP arrangements. The Care Manager and lead professional should communicate and keep each other and any carer/s or other agencies informed about treatment arrangements and the overall care plan, subject to usual confidentiality considerations. 15.33 CPA: Older adults who have complex and predominantly mental health related needs/care packages will normally be on CPA and will have a Care Co-ordinator from mental health services. The Care Co-ordinator will be responsible for developing a CPA care plan in collaboration with the service user and any carer/s involved. Care will be reviewed under the CPA framework set out in Part 5: The CPA Process and Part 9: Reviews. Assessments and risk assessments will be carried out within the SAP framework.
15.34 Transfers from Adult to Older Adults Services: Decisions about transferring care from adult to older adult services should be based on the service user’s needs. If needs continue to be better met by adults services, care should not be transferred. Some conditions such as early onset dementia are more appropriately cared for within older adult services and it may be appropriate to transfer care whatever the service user’s age. 15.35 Recording: • All mental health services input should be recorded in clinical notes and on the appropriate Trust databases • Assessments should use the SAP form. Risk assessments should use the SAP Risk Profile Form. FACS assessments should continue, using the FACS form.
• People receiving Lead Professional Care will have care plans setting out their mental health care, using the Trust Care Plan letter template. These will supplement the main care plans developed with care managers using formats approved by the local authority. • People on CPA will have a single care plan setting out all their care needs. The CPA Care Plan form should be used. People with Learning Disabilities and Mental Health Problems: Person Centred Planning 15.36 Care for people with learning disabilities is primarily provided under local authority care management arrangements and a network of person centred planning: • person centred plans: addressing housing, education, employment and leisure • health action plans: addressing health needs, led by an identified health professional • vocational plans: led by Connexions for young people • housing plans: including joint housing/community care assessment • communications plans (where the person has communications needs) 15.37 CPA will be used for anyone who has a dual diagnosis of learning disabilities and mental health problems.
• If people have significant mental health problems they will be on CPA.
56 • If service users are cared for as in-patients at the CNWL Kingswood Centre Learning Disabilities Service and followed up by an intensive support team of CNWL staff, they will be on CPA • Where service users have more straightforward mental health needs and are primarily seen within community teams run by PCTs and local authorities, use of the CPA framework will be as agreed between CNWL Learning Disabilities Services and separate PCTs/local authorities. Person centred plans and related plans should still be used, but they should contribute to developing a CPA care plan.
15.38 Care Co-ordination: Negotiations over the use of CPA by community learning disabilities services should aim to ensure community teams provide care coordinators. If service users are admitted to in-patient care at the Kingswood Centre Learning Disabilities Service without a community care coordinator the key in-patient nurse or intensive support worker will act as Care Co-ordinator during the admission. 15.39 Recording: • A learning disabilities CPA care plan will be used. • Risk assessment should be recorded on the standard Trust Risk Assessment/Risk Management forms • FACS assessments should be recorded using the local authority FACS form • Leaflets tailored to the needs of people with learning disabilities are available 15.40 Further details are set out in Appendix _ . People with Substance Misuse and Mental Health Problems 15.41 People with problematic drug and/or alcohol use and mild to moderate mental health problems will have their mental health needs met within alcohol and drug services. The substance misuse key worker will act as lead professional and will develop a care plan to meet substance use, mental health and other needs.
15.42 People with problematic drug and/or alcohol use and severe mental disorder should be on CPA. Mental health services should allocate a Care Co- ordinator and take the lead in providing and reviewing care. Substance misuse services should contribute to the CPA process and the care plan. There should be regular communication between substance misuse and mental health workers, service users and carer/s, subject to usual confidentiality considerations. 15.43 Recording: • All input should be recorded in clinical notes and on the appropriate Trust databases • Assessments should use the assessment form for the relevant service. • For people receiving Lead Professional Care the Addictions and Offenders Directorate (AOCD) Care Plan should be used • For people on CPA the CPA Care Plan should be used
57 The Criminal Justice System 15.44 CPA/Lead Professional Care should be used for all offenders with mental health problems who need secondary mental health services. The principles used to decide whether people need CPA/Lead Professional Care in the community should be used in prisons. Prisoners, whether remanded or sentenced, often move between prisons, and can move to different areas/regions at very short notice. This can pose significant challenges to continuity of care and appropriate information sharing. 15.45 Known service users who are arrested/in custody: • The police should contact the relevant service/Care Co-ordinator as soon as they have information that an arrested person is a service user. Services should provide whatever support and assistance they can to the service user and the police; local arrangements should be set out in local inter-agency protocols • Information necessary to ensure adequate care and risk management should be shared with appropriate agencies • Programmes of treatment should continue in prison wherever practicable • Community Care Co-ordinators/Lead Professionals should maintain contact with service users who go to prison wherever practicable • Care Co-ordinators/Lead Professionals should maintain contact with prison healthcare/mental health services to support continuity of care • Care Co-ordinators/Lead Professionals should assist transfer to and from NHS hospitals where necessary • Care Co-ordinators/Lead Professionals should provide assistance to support transfers to other prisons, pre-release planning, and aftercare provision • Care Co-ordinators should ensure any Section 117 MHA arrangements are understood and incorporated in pre-release planning • Prison in-reach staff may act as Care Co-ordinators if appropriate 15.46 Prisoners whose need for mental health services is identified in prison: • Inmates whose needs would warrant CPA in the community should start on CPA in the prison • Prisons should have mechanisms to identify prisoners who are, or should be, on CPA • Where appropriate prison in-reach staff may act as Care Co-ordinators • Prisons should identify the appropriate local services and involve them in pre-release planning • Services/teams who are contacted about prisoners who may be entitled to local services when released should offer appropriate support to prison mental health services and should attempt to start engaging prisoners before release where appropriate • Released prisoners with mental health problems will normally need CPA care • If prisoners have learning disabilities arrangements should link with Person Centred/Health Action Plans 15.47 Team managers and professionals working with offenders should ensure they understand criminal justice arrangements and procedures and should seek specialist advice if necessary.
58 PART 16 : TRAINING 16.1 The Trust is committed to supporting continuous professional development for all workers associated with it. The CPA process, including lead professional support for people on Lead Professional Care, is supported by a Trust-wide training programme, supplemented by local training as necessary. CPA Training will be developed in consultation with service users and carer representatives. Wherever possible training will be delivered with the participation of service users and carer representatives. 16.2 Training Needs Analysis: The Trust-Level CPA Steering Group and the Service-based CPA lead officers will conduct an annual training needs analysis to identify training priorities in the light of: • Legislation, national guidance and objectives • Trust-level objectives/priorities • Issues raised by service users and carers • Issues raised by teams, services, individual workers and in appraisal and supervision • Lessons emerging from monitoring, audit, inquiries and complaint- monitoring 16.3 Programme Development: CPA training programmes will be developed in co-operation between the Trust-wide CPA Steering Group, the Training and Development Department, the various directorates, local CPA steering groups and in consultation with user and carer groups and representatives. Staff Training Programme 16.4 All new staff employed by the Trust take part in an induction programme which will include a session on CPA. Local managers will be responsible for ensuring that new staff who are not directly employed by CNWL receive induction in CPA practice and principles.
16.5 Continuing training will be aimed primarily at supporting staff in carrying out their CPA responsibilities, working to support safety and recovery and promote user and carer involvement. Training will focus on particular roles within CPA – Care Co-ordinators/lead professionals, managers, community- based staff, ward -based staff, administrative and clerical staff. Training will be available in a variety of formats to cater for different staff needs. Training will be primarily aimed at local services/team levels to address local priorities; this will be supported by a range of centrally delivered sessions where staff can compare local practices and learn from experiences elsewhere in the Trust. The training programme will be kept under regular review. Wherever appropriate CPA principles will be incorporated into training sessions in other topics. An outline of the training programme is set out at Appendix ___. User and Carer Involvement and Development 16.6 CPA development work will integrate with Trust-wide service user and carer activities to develop service user and carer input into the CPA training and development process and support service users and carers involved in delivering training activities.
59 PART 17 : GOVERNANCE AND SUPPORT ARRANGEMENTS 17.1 The basic unit of CPA is the care team around each service user or, for those under Lead Professional Care, the relationship between the service user, lead professional and any carer/s involved. CPA policy and quality of care are overseen by a network of governance and support arrangements. Trust-Wide Governance and Support 17.2 Committee/Group Structure Committee/Group Responsibilities Trust Board Strategic direction and performance Clinical Governance Committee Approval of CPA policy, quality of care CPA Steering Group Leads on policy and procedure development and implementation Performance Management Committee CPA performance (Monitor targets and Key Performance Indicators) Clinical Risk Management Group Risk management and policy Acute Care Forum In-patient CPA Clinical Audit Group CPA audit arrangements Operational Management Team Operational oversight Bureaucracy Busting Group Inter-departmental/cross service group co- ordination and streamlining Officers 17.3 CPA encompasses a wide range of issues and all Trust officers carry responsibilities for some aspects of CPA. Officers with specific CPA duties are: CPA Compliance Manager CPA policy, procedures, compliance and training CPA Training Co-Ordinator CPA training and development Service Level Governance and Support 17.4 Local CPA Implementation/Steering Groups: Comprising representatives of local in-patient and community teams, rehabilitation services, professional leads, user and carer representatives. Responsible for local implementation, policy and procedure monitoring and compliance, local CPA audits, developing action plans in response to audit findings, developing local training needs analysis, supporting good practice. Local groups report to the Trust- wide CPA Steering Group.
17.5 Service Directors/Clinical Leads: Supporting service teams/clinicians in operating CPA and Lead Professional Care to deliver optimum care and promote recovery and involvement. 17.6 Service Group CPA Leads: Local implementation, monitoring, development and support.
60 CPA Audit and Action Planning 17.7 The Trust will conduct a Trust-wide audit of CPA implementation on an 18- month cycle, supplemented by a programme of local audits led by local teams and local CPA Steering Groups. The Trust will support CPA audits carried out by user group organisations. 17.8 Trust-wide CPA Audit: The Trust-wide CPA Steering Group will advise on the content of audits and ensure they examine the quality of care provided and that it conforms with national and Trust-wide objectives. CPA audits will be integrated with procedures for Care Quality Accounts and will be informed by the findings of the National Patient Survey. In particular CPA audits will address: • user and carer involvement • needs assessment • care planning • crisis and contingency planning • risk assessment and risk management plans • review arrangements • transfer and discharge arrangements • carers’ assessments • numbers of carers offered assessment/reassessment • numbers of carers who have been given a copy of their carers’ support plan 17.9 Electronic Audit: Audit functions can increasingly be performed using electronic databases. The databases currently support monitoring of CPA registers for each practitioner and monitoring of seven-day follow up arrangements for people discharged from hospital. The Trust will work towards further integrating audit development with electronic databases. 17.10 Action Plans: Each service area is responsible for developing an action plan to address any shortcomings identified in CPA audits.
Policy Review 17.11 CPA policy is very influenced by developing national objectives for mental health and learning disabilities services. This policy and the various appendices will be kept under regular review and updated as necessary.