1. Core Care Standards and the Care Programme Approach March 2016

2. CCS & CPA Service - Who we are Wendy Slater CCS & CPA Manager & Carers lead Lynn Dunham CCS & CPA Co-ordinator – Directorate of Nursing & Patient Experience – Based at Walton Hospital We provide support for care standards across the Trust to staff, service users and carers, including information resources, training, website, audit, development of good practice.

3. Why do we have standards?

4. How we got here Mental Health Act 1983 HC90(23) CPA Circular 1990 Valuing People Refocusing the CPA 2008 etc CPA standards: Assessment Care Planning Review Care Co-ordination Discharge/transfer Service User and Carer Involvement CPA may apply to: Any patient accessing specialist secondary mental health services, of any age, who has serious and complex mental health characteristics

5. CPA – who will benefit from it? 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

6. 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: parenting responsibilities; physical health problems/disability; unsettled accommodation; employment issues; significant impairment of function when mentally ill; ethnicity, sexuality or gender issues Safety: – 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

7. Standards for CPA Service users needing CPA can expect: 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 Comprehensive multi-disciplinary multi-agency assessment A comprehensive formal written care plan including management of risk, and direct payments where appropriate Formal multi-disciplinary, multi-agency review at least once a year, but probably more often Carers identified and informed of their right to their own assessment Increased advocacy support

8. 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

9. New CPA & CCS Policy The CCS and CPA policy and procedures have been updated because: The policy was out of date Legislative changes including the Care Act 2014 Out of step with other policies in some areas such as Safety Changes to some of the Core Care Standards, including Risk to Safety Incident reports and recommendations The main changes have been: Enhancing the guidelines on service receiver and carer involvement The removal of sections including non-compliance The expansion of the standards on Care Planning Re-writing the Carers section to reflect the Care Act 2014 and a focus on family inclusive practice Streamlining the standards, and reducing the overall policy length from 40 pages to 20

10. So why Core Care Standards? In 2011 we looked at why CPA wasn't as effective as it could be? Staff, Service users and Carers, and Partners said: – How do services work? – What are the policies and standards – there are lots? – Why don’t they apply to all service users? – We don’t just provide mental health services – what about children, substance misuse and learning disability services? – What should we expect and what are our rights? – How do we find out the latest information? So we got together and worked out our Core Care Standards and Principles

11. Principles

12. 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

13. Core Care Standards Families & Carers Involvement & Choice Assessment Care Planning ReviewDischarge Care Co- ordination Safety

14. 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 and CPA

15. Core Care Standards 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

16. Service User involvement Core Standard: You will be involved as much as you want and are able to be Fully involved in planning and reviewing care (if able to) Given accessible information and choice Offered a copy of their care plan Can involve carers, advocates, friends Treated with dignity, and diversity taken into account Links: Infolink Resource Booklet Care Plan folder Capacity

17. Families and Carers Core Standard: We will work with Families and Carers 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

18. Assessment Core Standard: We will find out with you what your needs are 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 safety safeguarding caring responsibilities informal carers physical health the need for CPA Ensure physical health assessment is completed

19. Care Planning Standard: You will have a clear care plan 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

20. How do you plan care? Spend 5 minutes sharing how you involve people in planning care

21. Review Standard: We will check that things are working for you 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. Review within a month of discharge from hospital Anyone can request a review, service user must be involved, can bring advocate 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 Anyone with identified accommodation needs should have a home visit at least once a year. Review Guidance

22. Care Co-ordination Standard: Your care will be co-ordinated 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: 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

23. Discharge/Transfer Standard: We will make sure your transfer or discharge works well 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 Care Coordinators should liaise with General practitioners when formulating discharge plans for service users with a history of suicide attempt in the previous 12 months, and who have disengaged from services.

24. Keeping yourself and others safe Standard: We will help you and others be as safe as you can be Trust standards and processes for safety and risk assessment, currently moving from FACE to Safety Planning 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: on depression in adults recommends that the quality of interpersonal relationships and living conditions, and social isolation, should be considered on common mental health disorders also emphasises the importance of considering living conditions and social isolation

25. Core Care Standards www.corecarestandards.co.uk

26. Website www.corecarestandards.co.uk Standards Principles News Help What’s on Services Infolink Keeping well PbR Twitter Glossary Language and Accessibility Recovery Centre

27. So what do our standards 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