Transcript Document

How to Find Your Way Around…
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CARE PROGRAMME
APPROACH
CARE PROGRAMME APPROACH
Learning Outcomes
By the end of this Care Programme Approach lesson you know how to:
• Clearly describe the role of the Care Co-ordinator
• Clearly describe the role of the Lead professional
• Identify areas for change in supporting effective CPA implementation within
their workplace
• Articulate what "values based practice" means and how it influences the role of
the Care co-ordinator
• Reflect on strengths and areas for further development as a care co-ordinator
• Be able to identify transition points where there are potential threats to the
continuity of care
• Outline the elements of a comprehensive assessment
• Identify the importance of "whole systems" approaches in the role of CPA care
co-ordinator
• Understand the rationale for reviews and state the maximum frequency
• Recognise the importance of keeping accurate records
"The vision is that there is ‘an NHS that gives patients and the
public more information and choice, works in partnership and has
quality of care at its heart. Quality is defined as ‘clinically
effective, personal and safe'." Lord Darzi, 2008
Introduction
Lord Darzi,
In 1991 the Care Programme Approach was launched by the Department of Health. It
was the principal strategy for the provision of mental health services within the
community. This was reinforced in 'Building Bridges' in 1995. Our Health, Our Care,
Our Say set out the vision for the NHS to deliver services which are fair, personalised,
effective and safe. In many ways mental health services can claim to lead the way in
delivering such an approach across health and social care.
In 1999 the Mental Health National Service Framework set out the recommendations for
how services should be delivered. The focus since that time has increasingly moved
towards personalisation, emphasising the need to look at the individual and addressing
equalities, tackling social inclusion and promoting positive risk management.
Public Service Indicators have been set to improve
housing and employment opportunities for people
with severe mental illness.
The Care Programme Approach (CPA) is at the
centre of the personalisation focus, supporting
individuals with severe mental illness to ensure that
their needs and choices remain central in what are
complex systems of care.
The most recent changes to CPA came about in
2008 in Refocusing the Care Programme Approach:
Policy and Positive Practice Guidance. The changes
aimed to remove the bureaucracy attached to CPA,
whilst ensuring that services are provided within a
set of Values and Principles.
The most recent changes to CPA
In 2007 a consultation document in relation to CPA was released. The focus was to remove
the perceived bureaucracy of CPA and to have just one level for CPA.
The outcome of this consultation culminated in the publication of the Refocusing the Care
Programme Approach: Policy and Positive Practice Guidance.
Those who responded to the consultation were keen to have the Principles as set out in the
National Service Framework for Mental Health; Effective Care Co-ordination in Mental Health
Services and more recent mental health documents.
The changes are based around a core set of values and principles, linked into personalisation,
recovery and the 10 Essential Shared Capabilities.
There will only be one level of CPA, and those not subject to CPA will be classed as non CPA.
CPA or non CPA ?
There is only one level of CPA within the Trust. Those people who
do not have the characteristics of CPA will be considered NonCPA.
The decision to put in place the support mechanisms of CPA will
be made following a comprehensive assessment of needs and risk
or following a review of a persons mental health.
Characteristics used to decide if CPA support is needed
Severe mental disorder (including personality disorder)
with high degree of clinical complexity
Current or significant history of severe
distress/instability or disengagement
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 e.g.
• exploitation e.g. financial/sexual
• financial difficulties related to mental illness
• Dis-inhibition
• physical/emotional abuse
• cognitive impairment
• child protection issues
Presence of non-physical co-morbidity e.g.
substance/alcohol/prescription drugs
misuse, learning disability
Experiencing disadvantage or difficulty as a result of:
• Parenting responsibilities
• Physical health problems/disability
• Unsettled accommodation/housing issues
• Employment issues when mentally ill
• Significant impairment of function due to mental
illness
• Ethnicity (e.g. immigration status; race/cultural
issues; language difficulties; religious practices);
sexuality or gender issues
Multiple service provision from different
agencies, including: housing, physical care,
employment, criminal justice, voluntary
agencies
Currently/recently detained under Mental
Health Act or referred to crisis/home
treatment team
Significant reliance on carer(s) or has own
significant caring responsibilities
The following key groups will automatically be considered to require the support of CPA
those:
• Who have parenting responsibilities
• Who have significant caring responsibilities
• With a dual diagnosis (substance misuse)
• With a history of violence or self harm
• Who are in unsettled accommodation
• Who are subject to Supervised Community Treatment (SCT)
• Who have Guardianship under the Mental Health Act (Section 7)
If service user within these key groups are not supported through CPA, the decision and reasons
not to include them MUST be clearly documented in care records.
Section 7 of the Mental Health Act 1983 is a provision for Guardianship, all service users who are
subject to this section should be treated as subject to CPA. This also applies to those service users
who are currently liable to detention in hospital for treatment under a Section 3, 37, 47 or 48 of
the Mental Health Act 1983, but who are not subject to any Home Office restrictions, and who are
assessed as presenting a substantial risk of serious harm to self or others, if not receiving suitable
after-care.
For those service users who will be subject to Community Treatment Orders under the Mental
Health Act 2007, CPA will apply.
Service users with complex multiple needs will normally be subject to CPA and will normally receive
services from a number of professionals and agencies over an extended period of time.
Service users who don’t need the support of CPA (non CPA)
Those service users with more straightforward needs; with the involvement of one agency or no
problems with access to other agencies/support. Service users who have recovered from a complex
episode, and who are concordant with treatment and the need for co-ordination support is minimised.
Where assessments of need and risk have determined that the service user does not require the
support of CPA, a Lead Professional should be allocated. It is the responsibility of the Lead Professional
to ensure that the service user is aware of who they are and how to contact them.
Persons classed as non CPA will have a nominated
Lead professional responsible for their care and
Carrying out reviews. If Safeguarding procedures
are instigated for any service user, they must be
transferred onto CPA.
Service users on CPA are likely to have multiple
needs, require more frequent and intensive
interventions, are likely to have had previous
admissions to hospital or be at risk to self or others.
Service users who are under the care of the Assertive Outreach Teams (AOT) Crisis
Resolution and Home Treatment Teams (CRHTT), A Single Point of Access (ASPA), or in an
Acute Mental Health hospital (with the exception of those in hospital for substance/alcohol
detoxification or respite) will automatically be subject to CPA.
Those who are cared for under CPA will have a Care Co-ordinator who is responsible for
their care. CPA applies irrespective of ethnicity, gender, cultural background or disability
Children and Young People:
Where a child/young person has a serious mental health problem, requiring admission to an
Acute treatment/Inpatient adolescent mental health unit (classified as Tier 4) they will be
subject to the Care Programme Approach.
Values based practice and the role of the CPA Care Co-ordinator
All those referred into Secondary Mental Health Services should have the same approach to individual
care and support. These values and principles will apply:
Statement of Values and Principles
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 patient/service user second.
Care assessment and planning views a person ‘in the round’ seeing and supporting them in their
individual diverse roles and the needs they have, including: family; parenting; relationships; housing;
employment; leisure; education; creativity; spirituality; self-management and self-nurture; with the aim
of optimising mental and physical health and well-being.
Self-care is promoted and supported wherever possible. Action is taken to encourage
independence and self determination to help people maintain control over their own
support and care.
Carers form a vital part of the support required to aid a person’s recovery. Their own
needs should also be recognised and supported.
The Codes of Conduct within these professional groups link in with the values based
practice, and it is therefore expected that all staff act within these codes.
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, team work 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.
All Care co-ordinators within SEPT must be professionally
qualified staff. This can be either a Nurse, Social Worker,
Psychologist, Occupational therapist, Psychiatrist or other
professionals who are members of a recognised professional
body.
Making a difference for service users
Staff whilst practising within their professional codes of conduct will ensure that they are compliant with
the SEPT Customer Service Standards:
Making a Difference for customers:
Positive hellos
Be genuinely warm, welcoming and engaging, not cold and clinical
whenever you meet a service user or carer, whether it's for five minutes
or five months.
Positive goodbyes
Customers leave every interaction 100% clear, and positive, about what will happen, why and when and is
never left wondering what's happening and what might happen next.
Jargon free
With customer we need to cut out jargon, buzzwords, acronyms, abbreviations and SEPT speak so people
know what we are talking about.
Smooth handoffs
smoothest handoffs when customers move from one service to another in SEPT and with partners, or
stop receiving services.
In the know
Pro active communication so the customer always knows where they are and is never left wondering
what's happening and what might happen next.
Assessment
An assessment is the gathering of information concerning an individuals mental health and social care
needs, it should recognise the strengths and resiliencies of the person, whilst taking into consideration
the social and cultural context.
All people referred to secondary mental health services should receive an assessment of their mental
health and social care needs. This initial assessment:
AIMS TO IDENTIFY THE NEEDS AND WHERE THEY MAY BE MET AND…
MUST INCLUDE ALL ELEMENTS NECESSARY TO MAKE A DECISION ABOUT CPA INCLUSION
Staff should consider the guidance as outlined in 3 Keys to a Shared Assessment in Mental Health CSIP
(2008)
1st Key: Active participation of the service user and carer
2nd Key: A multidisciplinary Approach
3rd Key: Strengths, Resilience's and Aspirations
" Things often go wrong right from the start because carers and families really can't understand how
the person concerned thinks and behaves as they do. Having someone to help them understand at this
early stage, even if they don't agree with it, give a very different basis for subsequent engagement."
A carer 3 Keys to a Shared Assessment in Mental health CSIP, (2008)
Assessment is an on-going process, starting when the person is referred and added to during the episode
of their care.
Key points
Key Points within a comprehensive assessment process are:
1. Collaboration - between mental health practitioners, service user, carers and
important people in the service users life.
2. Within context - of the persons social and cultural norms and values
3. Engagement with the service user, building a therapeutic relationship. Setting out boundaries.
4. Multi disciplinary sharing of information - Avoid repetition - asking service users / those referred the
same questions over and over makes people feel that they have been "assessed to death" (CSIP,
2008)
5. Consent from the service user to seek information from other agencies for example housing. This can
help staff to put issues into perspective.
6. Taking account of health, social and risk domains.
The assessment establishes information regarding the service users needs, finding out as much as
possible to enable the assessor to establish how these affect the persons wider functioning.
The initial assessment establishes with the person the first contact with SEPT NHS Trust and as such must
be carried out using the Trust's service standards.
Information for the assessment will come from a variety of places, this will be the service users, may be
carers, the GP, and other agencies.
The SEPT comprehensive assessment will include:
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Previous history and contact with services,
Medication history
Significant Life Events - both positive and negative
Family background
Lifestyle choices - smoking, drinking alcohol and the use of illicit substances
Financial situation
Social support
Mental state examination
Insight
Physical, sexual or emotional
Current and past risk factors
abuse
Self directed support
Medical history
Parenting and child care issues It is recognised that many people
who come into mental health
Risk to self and others
services may have experienced some
Capacity (as required)
type of violence or abuse. Whilst the
Religious and spiritual needs
Department of Health recommend
Cultural issues
that a question regarding this is
asked during an assessment, this
should not be asked unless staff
have been trained how to deal with
the response.
Other assessment tools
The outcome of the initial assessment may lead onto other more specialised assessments ie
Hamilton, Becks, or other specialists for example psychology, occupational therapy etc., these
assessments form part of the holistic approach to the individuals needs.
Only tools that are evidence based should be used, unless it is part of a research project.
Risk Assessments
All assessments will include a risk assessment, these should be completed using the SEPT approved
documentation.
The risk assessment will include protective factors, violence, abuse, likelihood of maintaining
engagement with care and safeguarding of Adults and Children.
Risk should be based around the principles as outlined in the Department of
Health document "Best Practice in Managing Risk" (DH, 2007)
Role & Responsibilities of the CPA Care Co-ordinator
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Ensure a systematic assessment of the person’s health and social needs is carried out initially
and reviewed when needed (including an assessment of risk and any specialist assessments)
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Co-ordinate the formulation and updating of the care plan in conjunction with the service
user, ensuring choice and help in identifying goals.
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Familiarise themselves with past and present records about the service user, both paper and
electronic
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Ensure that everyone involved understands their responsibilities as defined in the care plan
and agrees to them and is able to deliver.
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Ensure that the care plan is sent to all concerned including the service user and carer (as long
as the service user has consented to others receiving the care plan).
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Ensure that crisis management and contingency plans are
formulated, updated and circulated.
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Ensure that the person is equally involved and has choice, and assist the service user to
identify his/her goals.
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Ensure that carers and other agencies are involved and consulted where appropriate.
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Ensure that the person understands the CPA care co-ordinator role,
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Ensure that the person knows how to contact the care co-ordinator, and who to contact in
their absence;
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Ensure that the person is registered with a GP and that the GP and other primary health care
workers are involved in delivering the care plan where appropriate and regularly informed of
progress.
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Maintain regular contact with the service user and monitor their progress, whether at home
or in hospital.
If a service user who remains vulnerable refuses to take part in the CPA process, all steps should
be taken to find out why, and to continue to attempt to engage them;
Partial or full disengagement or non concordance with prescribed treatment, should trigger an
immediate multidisciplinary review of the service users needs and risks.
Maintain regular contact with people who have been sent to prison (including face-to-face contact
where possible) and liaise with mental health staff working within the prison, in order to provide
continuity of care. It is vital to be aware of any changes in location within the prison estate and likely
release dates, so that proactive care can be planned for their release. In this situation, contact with
and support for carers should also continue.
Consider the need for advocacy for the service user, or carers if appropriate; and make them aware of
any advocacy or self-advocacy schemes;
Organise and chair (where appropriate) CPA reviews at appropriate timescales, ensuring that
everyone involved in the service users care are invited, consulted and informed of any outcomes.
Explain to the service user, relatives and carers what the CPA process is and make them aware of their
rights and roles;
Identify unmet needs and communicate any unresolved issues to the appropriate managers, through
the appropriate systems;
Ensure that other care systems requirements are met where necessary including consideration of
local eligibility criteria in respect of social care needs, this includes care management, person centred
planning (PCP), single assessment process (SAP), health action planning (HAP) and children’s
assessment framework (CAF)
Consider and explore direct payments with eligible service users and carers with the aim
of promoting their independence
Take responsibility for ensuring continuity of care, using home visits, repeat
appointments, etc. providing clear written instruction on how to contact team members
responsible for aspects of the care are made available to everyone who may need them.
Have face-to-face contact with the service user within a week of discharge from inpatient
care. However, follow-up, preferably face to face, should be within 48 hours for service
users who have been at high risk of suicide prior to admission with a more intensive
provision of care in the first three months after discharge.
Inform the out of hours Emergency Duty Team (EDT) and CRHT on the same day of any
concerns that may warrant an out of hours assessment. This data should be recorded on
the Trust CIS and where appropriate Local Authority information system.
Complete Daily diary sheets to reflect contacts
Where Safeguarding procedures are in operation it is the responsibility of the care
coordinator to ensure that the investigating officer (where this is a different allocated
professional) is kept informed of information pertinent to the case. The care coordinator
is also required to attend all strategy and other review meetings appropriate to the
procedures and / or investigation.
Offering and either undertaking carer’s assessments, or delegating this duty to another
member of the Multi disciplinary Team. This will include recording in the service user’s
notes where a carer’s assessment has been offered but declined.
The CPA Care co-ordinator has responsibility for co-ordinating care, keeping in touch with the service
user, ensuring that the care plan is delivered and reviewed appropriately.
The complexity of the CPA Care Co-ordinator role in any person’s case will
reflect the complexity of that individual’s needs and risk. The primary role
is of co-ordination and communication.
As professionals, CPA Care Co-ordinators are responsible for actions within their own sphere of
responsibility they should:
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Be clear about where their role starts and ends
Be clear about the role of others involved in the care and
Communicate concerns, risk factors and changes to everyone involved
Consider all elements of the service users circumstances and take action where indicated.
It is not the intention that the care co-ordinator necessarily is the person that delivers the majority of
care. There will be times when this is appropriate, but other times when the actual therapeutic input
may be provided by a number of others, particularly where more specialist interventions are required.
This approach supports the principles of New Ways of Working, which aims to use the skills of all in the
most appropriate, effective and efficient manner.
Roles and Responsibilities of the Lead Professional
Duties and responsibilities of the Lead professional
The Lead professional will be the worker taking lead responsibility for the person’s treatment and care
when the person has been assessed as not needing the support of CPA.
The Lead Professional is responsible for:
• Ensuring that needs and risks have been assessed
• Making sure that all care prescribed is delivered
• That records are maintained in line with Trust and professional standards (i.e.: NMC, GSCC, GMC
etc.,)
• Making sure that the service user knows who to contact in a crisis
• Ensuring that service users are aware of who to contact if the lead professional is not available
• Ensure that any carers are aware of their rights to an assessment
• Maintaining accurate records
• Ensures that the service user is aware that entitlement to services will not be removed by not
being supported under CPA
• Review the service user’s progress on a regular basis
• Encourages the service user to move towards self directed support
• Inform the person of the availability of advance statements should they wish to utilise them
• Maintain appropriate liaison with others involved in the person’s care to ensure continuity of
care
Who can be a CPA Care Co-ordinator or Lead Professional?
In a community focused mental health service it is appropriate that the CPA care coordinator/Lead
Professional are community based staff.
The role and responsibilities of the CPA care coordinator will usually be undertaken by a member of staff who
is registered with a professional body; this will be a Nurse, Social Worker, Occupational Therapist,
Psychologist or Doctor.
The role of Lead professional may be undertaken by a member of staff who is registered with a professional
body; this includes Doctors, Social Workers, Nurses, Occupational therapists, Arts Psychotherapists or
Psychologists.
Risk Assessment
Risk is classified as the likelihood of something happening with either beneficial or negative consequences for
someone (Sainsbury Centre for Mental Health, 2000)
RISK ASSESSMENT
Risk assessment is the gathering of information and analysis of the potential outcomes of the identified
behaviours. Identifying risk factors of relevance to an individual and the context in which they may occur. This
process requires linking historical information to current circumstances to anticipate possible future change.” (p
2 Sainsbury Centre, 2000)
TYPES OF RISK
Risk is generally categorised into:
RISK TO SELF: suicide, self harm, substance misuse, neglect
TO OTHERS: violence, aggression, abuse, neglect, children, carers, service providers
FROM OTHERS: vulnerability, exploitation, physical, sexual or emotional abuse, domestic violence.
PHYSICAL HEALTH: nutrition, substance misuse, co-existing medical conditions, confusion, falls, memory
impairment, wandering
DISENGAGEMENT: from services
NON CONCORDANCE: with prescribed treatments, (these may be medications, therapy or attending clinic
appointments)
POSITIVE RISK: this is the balancing of the potential benefits and potential harm, resources, resilience,
coping and self management
PREDICTION
Whilst risk cannot be predicted with 100% accuracy, this does not meant that a risk assessment should
not be carried out. Measures to manage risk need to be based on a comprehensive risk assessment and
risk management.
Risk assessment should include a structure and sensitive interview
with the service user and where appropriate carers. Efforts should
be made to ascertain the service user’s own views about their
trigger factors, early warning signs and other vulnerabilities and
the management of these.
Risk assessment should be used to establish whether a care plan
should include specific interventions for the short term
management of the risks.
SEPT risk assessments cover various aspects of risk
As follows:
RISK…..
• of injury to self / others through moving and handling
• of disengaging
• to self / health through severe self neglect
• of violence OR harm to others
• to children (any risks in this area staff should immediately
• of suicide
refer to safeguarding procedures)
• of deliberate self-harm
• of abusing others
• of accidental self-harm
• of sexually inappropriate behaviour
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Risk of sexual vulnerability
Risk of being exploited
Risk of substance misuse
Risk of committing arson
Risk of other offending behaviour
Risk of non compliance with treatment and care
Assessment of risk covers:
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the history of previous incidents,
the frequency these have happened,
the severity,
how long ago,
patterns,
mental state (delusions, hallucinations, ideas,
threats); emotions, statement of intent; degree of
planning (needs tracking)
A CONSIDERATION OF RISK FACTORS:
• age
• gender
• family history
• housing,
• employment
• physical health,
• diagnosis
• substance misuse
TRAINING FOR RISK ASSESSMENT AND RISK MANAGEMENT
All qualified professional staff are required to attend the Trust training in Risk Assessment and management on
a 3 yearly basis.
For further information from the Department of Health on risk look at the following documents.
Independence, Choice and Risk (DH, 2007)
Best Practice in Managing Risk (DH, 2007)
Care Planning and personalisation
“What is a care plan?
A care plan is:
• A record of needs, actions and responsibilities
• A tool for managing risk
• A plan which can be used and understood by carers, service users, and other agencies as well as
colleagues in a crisis.
• Based on a through assessment of need
• A multi professional, multi agency endeavour
• Co-ordinated by the care co-ordinator
• Produced in the most appropriate forum
• Shared with those who are part of it
A care plan has outcomes so everyone can see what we expect to achieve, We can establish if our support
and interventions are appropriate for the service user.
Helps the service user to work towards their goals, and helps them to recognise the achievements they are
making. The written record of a plan of action negotiated with the service user to meet their mental health and
social care needs”. (Buck et al., 2008)
All care plans should be personalised to meet the individual needs of each person.
The person is at the centre and the care plan belongs to them not to the health or social care professional. It
has been widely recognised that Personalisation means looking at the person as an individual and
recognising that there are a variety of issues that affect a person’s mental health.
These include their social care needs, social networks, cultural beliefs and economic factors. The person has
strengths and preferences, and generally knows what they need and how those needs can be best met.
People can be responsible for themselves and can usually make their own decisions about what they
require, but we need to provide information and support to enable them to do this effectively. Person Centre
planning was an approach formally introduced in the 2001 Valuing People Strategy (DH, 2001) for people
with leaning disabilities.
This has similar aims to personalisation as the focus is on supporting
individuals to give choice and control to live as independently as possible.
Whole Systems approach and CPA
Organisations can be complex, and working across different agencies can mean even more confusion for both
professionals and service users.
CPA is about making care pathways for service users easier to understand and to navigate.
As a Trust we should:
• make sure that the appropriate information is passed on whenever necessary. this can help avoid people
having to repeat information
• Work with other agencies to agree ways of working together that make life easier for a service user rather
than creating obstacles and barriers to getting the help they need.
• Make sure that all service users are made aware of the services that may be available to them so they can
have the greatest choice possible.
• Make sure that Community teams work closely with the ward teams when someone needs to be admitted to
hospital.
• Work closely with the primary care team (GP surgery and other community services) to help people
understand and take full advantage of the services on offer, for example IAPT
Care plans should be written with service users, in a language that they will understand, taking into
consideration the social support networks they currently have, or have depended on in the past. These will
include family, carers, friends, work, leisure activities, culture, religion etc . We know that social networks can
have a powerful and positive effect in helping people recover.
SEPT - MANDATORY TRAINING
We must ensure that the relationship between the service user and professional does not inhibit the growth
and personal development of the individual, but helps to lead the person back to the greatest level of
independence possible
The care co-ordinator has a pivotal role in helping an individual navigate complicated care systems and provide
continuity, but there is also a need for systems and structures to be in place at strategic and organisational
level to support this. This whole system approach to care planning and delivery should aim to promote and coordinate care, and support activity across the individual’s life domains and circumstances. A number of
approaches and mechanisms can help with this:
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Improved information sharing between agencies
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Improving local shared provider agreements with primary care, housing and employment agencies, and
drug and alcohol agencies
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Commissioning for a range of services to meet
of unmet need.
service users’ and carers’ needs, including the recording
Effective Local Strategic Partnerships and Local Area Agreements to facilitate planning across agencies. Key
PSA targets include the proportion of adults receiving secondary mental health services in settled
accommodation, and in paid employment, as well as several for children and young people.
Protocols and arrangements for working between different assessment and planning systems, such as:
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The Single Assessment Process for older adults, An older person’s combined mental health, physical health
and social care needs can be highly complex and involve several assessments, necessitating a coordinated
and focused service response across disciplines and agencies. Any one of those agencies may already be
managing that person’s care and the person does not necessarily always require a lead co-ordinator from
mental health services, although others may.
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When an older person’s needs are met and managed predominantly in primary and social care, and they
have a mental health need which is not complex or which is without significant risk, secondary mental health
care will form part of the overall assessment and care plan and care management. Mental health
assessments, care plans and reviews will be communicated to the identified person taking the lead in
management. These people will be managed as non CPA.
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When a person’s mental health and social care package is complex, predominantly mental health-related
and meet the criteria for CPA, their care will normally require care co-ordination using CPA and a mental
health care coordinator should be allocated. SAP can provide information and inform assessment – the CPA
will provide the specialist care planning, review and health and social care provision.
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Person Centred Planning and Health Action Planning: Individuals with a learning disability should also
access annual health checks which inform the Person-centred Health Action Plan (HAP). Any assessment
undertaken by secondary mental health services should form part of this HAP and not be seen as separate.
If the individual does not have a HAP on referral to the secondary mental health services it would be the
time to initiate one with the learning disability services and GP.
Criminal justice
It is vital that relevant information accompanies the offender/service user during transition through the offender
pathway and that both CPA care co-ordinators and Offender Managers have a sound understanding of both the
health and criminal justice systems. Care Co-ordinators will usually retain their role, but will need to liaise with
the prison service to organise CPA reviews.
Within SEPT we have Bedford Prison which is a remand prison serving the courts of Bedfordshire and
Hertfordshire, it has the capacity to hold 506 adult and young adult male offenders. (Mullins, 2011). Information
between the Community Mental health Teams and the prison Inreach team should be encouraged to ensure
that continuity of care can be maintained.
National Treatment Agency (substance misuse):
The NTA endorses the CPA framework as an approach to co-ordinating the care of people with a severe
mental disorder and substance misuse problems within mental health services. It acknowledges that substance
misuse treatment providers should contribute to the CPA process where appropriate.
The Common Assessment Framework for Children. It is important that adult’s and children’s services work
together to provide adequate support for parents.
CAMHS - Where the CPA criteria applied is complexity of need, there is theoretically no lower age limit, but it
must be tailored to their requirements It is vital that local protocols are used to agree which system, coordinator, or person is in the lead in the overall care of a child or young person. Where care is shared across
agencies it must be clear who takes the lead on which areas. This is especially important for children and
young people who may have a Lead Professional appointed across agencies. Key issues to take account of in
adapting CPA for CAMHS include:
•
The fact that the needs of children and young people vary and change over time to a possibly greater
extent than adults.
•
CPA will be particularly important when a child or young person is in a secure setting or leaving a secure
setting.
•
Reviews may need to be more frequent for children and young people compared to adults;
•
Reviews and information need to be young-person friendly
•
The more complex inter-agency issues, including youth justice;
•
The need to ensure that the child or young person’s family are involved in the care plan decision making
process;
•
The educational needs of children and young people
•
Young people should be supported in the process
•
The need for clarity by staff about which system to use in which situation
Whole systems approach is about making the journey through health and social care services easier to
navigate for our service users, looking at each person holistically and ensuring that their care is not delayed
because of barriers in the system
Reviews of Care, and outcomes
The review is a point in time to establish if the prescribed treatments are effective and what changes (if any)
need to be made. Reviews can take place at a time when there are particular issues or risks or if the care
coordinator is concerned about the service user. Service users cannot move from CPA to non CPA without a
CPA review. Prior to discharge from an inpatient unit, a CPA review should take place. At this review it is
possible to alter the service user to non CPA.
CPA
All service users who are being cared for under CPA require a formal review at least every 6 months. This
review will include the effectiveness of the care interventions and treatments prescribed. Risk management
plans and care plans will require updating, and those where the same care is to continue should be re printed,
dated and signed by the service user and staff to demonstrate that the care has been reviewed.
Non CPA
For those not subject to CPA, formal reviews will take place at least annually, this review will be carried out by
the Lead professional.
Pre reviews
Prior to the review, service users should be prepared for this review. this is carried out in the form of a pre
review questionnaire, which helps to prompt staff and service users about the areas that they wish to discuss.
HoNOS PBr measures points in care and demonstrates outcomes of various treatment regimes.
In Certain parts of the Trust this is now completed electronically and the results are monitored as part of the
contract with our commissioners. All reviews and HoNOS should also be entered onto the Trust clinical
Information System
Carers Assessments and CPA
Carers Assessment
The law says you have a right to an assessment if you care for someone for 'a substantial amount of time on a
regular basis'. The relevant legislation is the Carers (Recognition & Services) Act 1995 and the Carers &
Disabled Children Act 2000. You may be a carer living with or away from the person you care for, caring full
time or combining care with paid work - you will still have a right to a carer's assessment.
Easy Read version
Carers should:
• Have an assessment of their caring, physical and mental health needs, offered on at least an annual basis.
• Have their own written care plan which is given to them and implemented in discussion with them. This is
defined at the end of the revised carer’s assessment form (Standard 6, NSF for Metal Health 1999)
• The Care Coordinator or assessor must consider a carers’ outside interests work study, or leisure
activities/interests. (The Carers Equal Opportunities Act 2004)
• A Person under the age of 18 who provides support in the context of the above paragraph is defined as a
Young Carer. Where a Young Carer is identified referral to Child and Family Services should be made.
• A Person aged 18 or over who provides support in the context of the above paragraph is defined as an
Adult Carer.
Involvement of an Advocacy Service and/or Translation/ Interpreter Service should be accessed where
required to ensure effective agreement and/or communication between the service user and/or carer and the
MDT. The service user’s needs assessment should prompt staff to carry out a Carers Assessment in line with
the Carers Equal Opportunities Act (2004) and the Carers Recognition & Services Act 1995.
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