Transcript Carers Assessments - Core Care Standards

CPA Standards and update
(CPA Level 1)
April 2015
Why do we have standards?
What do you know about CPA
and Core Care Standards?
Care Programme Approach
• Began: 1991
• Last Updated: 2008
• From: NHS and
Community Care Act
1990
• CPA may apply to:
– Any patient
accessing specialist
secondary mental
health services, of
any age, who has
serious and complex
mental health
characteristics
•CPA standards are based
on the following:
•Assessment
•Care Planning
•Review
•Care Co-ordination
•Discharge/transfer
•Service User and Carer
Involvement
Who needs CPA?
• The decision about CPA is:
• Only made after someone has been accepted by mental health
services
• Ideally made in a multi-disciplinary forum/review
• Based on professional judgement
• Particular groups who need CPA:
• key groups would usually be included: who have parenting
responsibilities; significant caring responsibilities; with a dual
diagnosis (substance misuse); with a history of violence or
self harm; or who are in unsettled accommodation
• Inpatients automatically included.
• People with a learning disability should be included if they are
also accessing specialist mental health services, or have been
admitted under the MH Act
• Any one guideline may be significant enough to indicate
the need for CPA
Guidelines for needing CPA
• Complexity:
– Severe mental disorder with high degree of clinical complexity
– Multiple service provision from different agencies
– Disadvantage or difficulty as a result of:
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parenting responsibilities; physical health problems/disability;
unsettled accommodation; employment issues; significant
impairment of function when mentally ill; ethnicity, sexuality or
gender issues
• Safety:
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Current or potential risks
Current or history of severe distress/instability or disengagement
Non-physical co-morbidity e.g. substance misuse, learning disability
Currently/recently detained under MH Act, or accepted by
crisis/home treatment team
– Significant reliance on carer/s, or has own caring responsibilities
Link: Glossary on CCS website
Standards for CPA
Service users needing CPA can expect:
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The support of a CPA Care Co-ordinator (trained, probably
part of job description, significant part of caseload), who
keeps in contact if they are in hospital or prison
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Comprehensive multi-disciplinary multi-agency assessment
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A comprehensive formal written care plan including
management of risk, and direct payments where
appropriate
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Formal multi-disciplinary, multi-agency review at least once
a year, but probably more often
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Carers identified and informed of their right to their own
assessment
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Increased advocacy support
Mental Health Service Users not needing CPA
Service users with: more straightforward needs, lower risk, and
contact with only one agency (or no problems with access to other
agencies/support) will no longer need CPA, but can still expect:
• An identified lead professional
• That care will be self-directed, with support
• A full assessment of need including risk
• A care plan in the form of a statement of care agreed with
them, which will be recorded in a letter
• On-going review as required, including annually the need for
inclusion in CPA
• Their Carers identified and informed of their rights to their
own assessment
NB After assessment no further formal CPA paperwork needs to
be completed – good record keeping standards apply
So why Core Care Standards?
In 2011 we looked at why CPA wasn't as effective as it should
be?
• Staff said
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Service users and carers said
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What are the standards and where are they?
Why don’t they apply to all our service users?
We don’t just provide mental health services – what about
children, substance misuse and learning disability services?
How do we find out the latest information?
What are the standards?
What should we expect and what are our rights?
How do we find out the latest information?
Partners said:
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How do your services work?
What are your policies and standards?
How do we find out the latest information?
Core Care Standards and CPA
•CPA standards are
based on the following:
•Assessment
•Care Planning
•Review
•Care Co-ordination
•Discharge/transfer
•Service User and Carer
Involvement
•Link:
•‘Care Standards handbook’
•‘Core Care Standards’ booklet
•Core Care Standards
cover the following:
•Assessment
•Care Planning
•Review
•Co-ordination
•Discharge/transfer
•Families and Carers
•Involvement and Choice
•Keeping yourself and
others safe
Core Care Standards
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We will find out with you what your needs are
You will have a clear care plan
We will check that things are working for you
Your care will be co-ordinated
We will make sure your transfer or discharge works
well
• We will work with Families and Carers
• You will be involved as much as you want and are
able to be
• We will help you and others be as safe as we can
Core Care Principles
• We will provide good quality services
• We will treat you with dignity and respect
• We will respect your rights, and make sure you can
access our services
• We will try to help people be as well as they can be
• We will communicate well with everyone
• We will employ staff who know what they’re doing
• We will provide care and support in a place that’s safe
• You will be at the centre of your care and support
• You can tell us what you think about services
• We will safeguard children and vulnerable adults
• We will keep information safe and share it when
needed, and you will have the right information at the
right time
• We will work together with other organisations
Service User involvement
Core Standard: You will be involved as much as you
want and are able to be
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Fully involved in planning and reviewing care (if
able to)
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Given accessible information and choice
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Offered a copy of their care plan
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Can involve carers, advocates, friends
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Treated with dignity, and diversity taken into
account
Links:
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Infolink Resource Booklet
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Care Plan folder
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Capacity
Families and Carers
Core Standard: We will work with Families and Carers
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Identify and welcome carers and families, giving them
information about care, assessment, services etc
Involve them as fully as possible, giving them a chance to
speak to someone separately, and understanding confidentiality
and information sharing
Signpost or refer for help and assessment if needed to
ThinkCarer/Derbyshire Carers Assoc.
Know who your local Carers Champion or lead is
Offer support plan if needed
Triangle of Care
Links:
•Carers Handbook & Information folder
•Infolink Families and Carers
•Sharing information with families and carers
•Who Cares? quarterly carers newsletter
•Carers Contact Card
•Carers Emergency Card
Assessment
Core Standard: We will find out with you what
your needs are
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Each person who is referred to specialist mental health services will
have a systematic assessment of their needs carried out by a
qualified mental health worker (following triage if appropriate)
Include contributions from all
Consider
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safety
safeguarding
caring responsibilities
informal carers
physical health
the need for CPA
Ensure physical health assessment is completed
Care Planning
Standard: You will have a clear care plan
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Based on the current assessment of their needs
Using principles of recovery and wellbeing
Written in plain language
Details how and by whom the needs will be met
Service user involved in designing the plan and understands it
Includes responsibilities, outcomes, unmet needs, crisis and
contingency arrangements
Copies to all including service user, in an accessible format
Should include (where relevant): medication management,
self-directed care, service users and carers involvement,
support for parenting, safeguarding etc.
Links:
• Care Plan Folder
• ‘Writing Good Care Plans Booklet’
• My Recovery Plan
Review
Standard: We will check that things are working for you
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All service users will have their care plan reviewed
systematically and regularly, at least every year, in a way that
ensures that all those involved can contribute effectively, and in
a way that reflects their needs.
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Review within a month of discharge
from hospital
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Anyone can request a review, service user must be involved,
can bring advocate
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Date of next one set at this one
Remember - A review is a process, not necessarily a single meeting
N.B. Medication should be reconciled every 12 months
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Anyone with identified accommodation needs should have a home visit at
least once a year.
Review Guidance
Care Co-ordination
Standard: Your care will be co-ordinated
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All mental health service users will have a care co-ordinator or
lead professional who will be responsible for co-ordinating their
care
Qualified health or social care professional employed by health
or social care, ‘best placed’, whose role continues if in hospital
(or in prison)
Service users will:
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know how to contact them
have a choice of care co-ordinator which takes account of any cultural or
religious needs, or gender preferences due to damaging experiences of
abuse or violence.
Be involved in the care process
Named Deputy Care Co-ordinator identified
Link:
Responsibilities of the Care Co-ordinator or lead professional
Discharge/Transfer
Standard: We will make sure your
transfer or discharge works well
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Co-ordinated and planned
Written plan (detailing any follow-up and review) copied to the
service user (and carer where relevant)
Jointly agreed and signed plan if entitlement under s.117 of
the Mental Health Act
Enhanced care package if recent risk of suicide
Review before any discharge/transfer
Follow-up within 7 (or 2) days for those on CPA discharged or
on leave from hospital
Keep a record of which documents are transferred to whom
Keeping yourself and others safe
Standard: We will help you and others be as safe as you can be
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Trust standards and processes for safety and risk assessment, currently FACE
Types of safety issues would include: self harm; self-neglect; suicide; violence;
bullying, domestic violence, substance misuse, vulnerability to abuse or neglect,
sexual exploitation, moving and handling, infection control, physical health, and falls.
Therapeutic or positive risk-taking can also be used to help people to develop new
skills and opportunities.
Care plans should include:
management of risk and focus on safety
crisis and contingency plans
a plan for follow up if there is disengagement from the service and a problem
has been identified
sharing information with relevant people
NICE guidance:
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on depression in adults recommends that the quality of interpersonal relationships and living
conditions, and social isolation, should be considered
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on common mental health disorders also emphasises the importance of considering living
conditions and social isolation
Core Care Standards
www.corecarestandards.co.uk
Website
www.corecarestandards.co.uk
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Principles
News
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So what does that look like?
Everyone who uses our services has:
• an assessment of their needs
• involvement in putting their care plan together
and the chance to have someone to support
them
• a copy of a written care plan
• safe and effective care that focuses on wellbeing
and recovery, and recognises physical health
needs as well as mental health needs
• involvement in a review of their care at least
once a year
• the needs of their carers and family recognised
• safe and effective transitions and discharge
What do you know about CPA
and Core Care Standards
- the answers
For more information please contact:
• Wendy Slater/Lynn Dunham
• Core Care Standards and CPA
[email protected]
• [email protected]
• 01246-515974