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Assessment and care of children and young people with mental health needs who are placed in an acute general hospital ward policy

Contents

1 Policy summary

This policy details the processes in place to access the support of the children and adolescent mental health services (CAMHS) Crisis team and roles and responsibilities if a young person requiring assessment of their mental health needs is admitted to an acute general ward.

2 Introduction

Children and young people with acute mental health needs may need admission to hospital for assessment and treatment. Acute general hospital wards (typically a paediatric ward) are often the first location for admission. Clinical colleagues from children and adolescent mental health services (CAMHS) have a pivotal role in working with the acute general hospital ward multi-disciplinary team (MDT) to assess, plan and co-ordinate care for these children and young people.

Out of hours response is provided by CAMHS Crisis team in the first instance for young people up to the age of 18 years of age. For young people near 18 years of age, the adult crisis team may be involved in the assessment and discharge planning, working jointly with CAMHS Crisis team.

3 Purpose

The purpose of this policy is to clearly set out best practice guidance and children and adolescent mental health services (CAMHS) requirements for the assessment and care of children and young people who are admitted to an acute general hospital ward with mental health needs.

When any child or young person has been admitted to an acute general hospital ward with associated emotional and mental health issues, be that planned or unplanned; they, their parent, carer or legal guardian and the admitting ward colleagues should have clarity regarding the roles and responsibilities of CAMHS and the nature and frequency of contact that can be expected.

This policy aims to support colleagues to:

  • maintain the safety and well-being of the child or young person through a timely assessment, risk assessment and care and crisis plan
  • provide ongoing assessment, care and support to the child, young person or family and the acute hospital ward during prolonged admission
  • provide a consistent approach and have clarity regarding their roles and responsibilities for the care of children and young people admitted to an acute general hospital ward with mental health needs.

3.1 Definitions and explanation of terms used

Definitions
Term Definition
FACE risk assessment Functional analysis of care environments (FACE) is an abbreviation of the name of the company that produce several toolkits to assess risk and needs in health and social care.
BMI Body mass index
SOP Standard operating procedure

4 Scope

This policy applies to those patients who have not yet reached
their 18th birthday and are therefore defined as children and young people and covers:

  • those children and young people who have been referred to trust services but whose needs and level of risk have yet to be assessed
  • those children and young people who have been accepted by children and adolescent mental health services (CAMHS) and whose level of risk has been assessed and or has changed

This policy applies to all clinical colleagues in CAMHS, who as part of their work will assess children and young people (as defined in the scope) who have been admitted to an acute general hospital ward with associated mental health concerns.

Whilst it is recognised that this policy will predominantly apply to CAMHS, colleagues from adult services may also be involved in the assessment of children and young people and therefore should be aware of the content.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure

5.1 Quick guide update this section when policy review complete to make it specific to this policy

5.1.1 Consent

  • Obtain consent from the patient to access relevant personal information.
  • Refer to relevant Mental capacity Act (MCA) guidance where there are concerns regarding capacity.
  • Ensure that consent is gained for confidential information within any written correspondence to be shared with others, for example, when letter is sent to GP, parents or school.
  • Ensure that assessment of capacity, Gillick competence and consent gained or refused is recorded on the patient record as part of assessment and clinical contact.

5.1.2 Referral

  • Children and adolescent mental health services (CAMHS) single point of access: 03000 218996
  • Eating disorders single point of access (trust wide): 01302 566980

5.1.3 Best practice guidance regarding self harm

Provide clinical care in line with:

5.2 Best practice guidance self harm and admission to a ward

Provide clinical care in line with:

Sec 1.7.24 of NG225, children and young people who have been admitted to a paediatric ward following an episode of self-harm should have:

  • access to a specialist child and adolescent mental health service (child and adolescent mental health services (CAMHS) or children and young people’s mental health services (CYPMHS)) or age-appropriate liaison psychiatry 24 hours a day
  • a joint daily review by both the paediatric team and children and young people’s mental health team
  • daily access to their family members or carers
  • regular multidisciplinary meetings between the general paediatric team and mental health services

5.3 Response by local child and adolescent mental health services within working hours

Normal working hours are defined as Monday to Friday 9am to 5pm hours see appendix C.

Out of hours are defined as after 5pm and weekends or public bank holidays.

5.4 Child and adolescent mental health services response to referrals made by admitting children and young people to wards in acute hospital settings

All children and young people placed on a paediatric or acute general hospital ward who require a mental health assessment will be seen within 24 hours of receipt of referral, or when medically fit.

Referrals will be assessed as urgent if a young person has been placed on a paediatric or acute hospital ward as a result of:

  • active self-harming and requires treatment
  • is actively suicidal (has a plan and intent)
  • has significant, rapid weight loss and is less than 70% body mass index (BMI), where the weight loss has been ruled out as being caused by a physical health cause
  • is exhibiting active psychotic symptoms or unusual thought processes which are causing them to act in a manner which poses a risk to themselves or others

There are local working instructions with local acute hospitals to be adhered to within working hours. These are held in local services.

5.4 Referral

Referrals are expected to be received from the relevant ward at the earliest opportunity to enable the children and adolescent mental health services (CAMHS) to plan. Referrals should be made by telephone to the CAMHS single point of access team on 03000 218996.

Eating Disorders team

5.4.1 Receipt of referrals

All referrals received by children and adolescent mental health services (CAMHS) single point of access are directed to the CAMHS Crisis team.

5.4.2 Monitoring of referrals

The leadership team of the CAMHS Crisis team will be responsible for collating referral data and information regarding all admissions to the acute hospitals.

5.4.3 Triage

Triaging is a clinical function which aims to assess and categorise the urgency of the referred mental health related problem. This role will be performed by the CAMHS Crisis team on receipt of the referral

CAMHS will support the acute general hospital by offering advice and triage or assessment to support decision-making regarding the safe discharge of children and young people.

5.4.5 Intoxication by drugs and, or alcohol

Alcohol and drug intoxication may influence a person’s mental state presentation and may imitate or mask symptoms of an underlying mental disorder.

The presence of alcohol and, or drug intoxication does not preclude early assessment, although it may indicate the need for further assessment or assessment when the person is declared medically fit and no longer intoxicated or under the influence of drugs.

Consideration whether the child or young person has the capacity to consent to an assessment, due to being under the influence of alcohol or drugs at the point of request, needs to be taken account of. Equally the level of disturbance to the child or young person’s presentation and associated risk should be a critical consideration.

The Mental Health Act: Code of Practice 2015 (14.56) makes reference to the role of the approved mental health professional (AMHP) and states:

  • “Where patients are subject to the short-term effects of alcohol or drugs (whether prescribed or self-administered) which makes interviewing them difficult, the AMHP should either wait until the effects have abated before interviewing the patient or arrange to return later. If it is not realistic to wait because of the patient’s disturbed behaviour and the urgency, the assessment will have to be based on whatever information the AMHP can obtain from reliable sources. This should be made clear in the AMHP‘s record of the assessment.”

5.5 Consent and parental responsibility

Parental responsibility means the rights and responsibilities that parents have in law for their child, including the right to consent to medical treatment for them, up to the age of 16 in England.

Where a child is cared for by local authority children’s services parental responsibility lies with children’s social care as corporate parent.

The valid consent of a child or young person will be sufficient authority to carry out a mental health assessment, additional consent by a person with parental responsibility will not be required.

5.5.1 Valid consent

A child under 16 must have competence and a young person aged 16 and over must have the mental capacity to make the particular decision. They must have sufficient relevant information to make that decision and not be subject to any undue influence when doing so.

Unlike adults, the refusal by a competent child or young person with capacity may or can in certain circumstances, be overridden by someone with parental responsibility or an order of the court.

It is good practice to involve the child or young person’s parents and, or others involved in their care in the decision-making process, if the child or young person consents to information about their care and treatment being shared.

5.5.2 Children under 16

Children under 16 should be assessed to establish whether they have competence to make a particular decision at the time it needs to be made.  The test for children under 16 is determined by considering whether they are “Gillick competent” (appendix D Gillick competence).

5.5.3 Consent to the care regime during admission

The decision whether the child or young person consents to their care regime, or if it amounts to a deprivation of liberty, must be kept under regular review. A significant factor to be considered is the scope of parental responsibility and the level of supervision, for example, what is usual for a young child would not usually be an acceptable restriction for a 17-year-old. This is particularly significant where for example the risk assessment and care plan indicate that close observation or supervision is required (for example, to manage risk to self and, or others).

5.5.4 Deprivation of liberty

In determining whether a person with parental responsibility can consent to the arrangements which would, without their consent, amount to a deprivation of liberty, children and adolescent mental health services (CAMHS) should advise the admitting ward multi-disciplinary team they will need to consider and apply developments in case law following “Cheshire West” and may need to seek safeguarding or legal advice in respect of individual cases to ensure the care of the child is delivered within the appropriate legal framework (colleagues can refer to the trust Mental Capacity Act (2005) Deprivation of Liberty (DoL) policy) and specially the following sections.

5.5.4.1 Children under 16

If a child under 16 is not under a formal care order, his or her parents can authorise a deprivation of liberty in the exercise of parental responsibility regardless of the child’s mental capacity, for example, in hospital.

If a child under 16 is under a formal care order, for example, looked after child under an interim or final care order who are deprived of their liberty the deprivation will need to be authorised by the family court, for example, foster home, children’s home, residential special school, boarding schools.

5.5.4.2 16 and 17-year-olds

The courts have now confirmed that for 16 and 17-year-olds who are not under a formal care order and are deprived of their liberty and lack capacity to consent to the arrangements (or do have capacity and refuse) that those with parental responsibility cannot give valid consent. The deprivation will therefore have to be authorised by either:

  • Mental Health Act (1983)
  • Court of Protection

For children and young people that are 16 and 17-year-olds who are “looked after” under an interim or final care order who are deprived of their liberty the deprivation will need to be authorised by the Court of Protection, for example, foster home, children’s home, residential special school, boarding schools, further education colleges with residential accommodation.

Children and adolescent mental health services (CAMHS) colleagues should seek advice and guidance as required though clinical and managerial supervision, the trust Safeguarding team, the trust’s Mental Capacity Act lead (where appropriate) and via the CAMHS on call manager out of hours.

Approved mental health professionals will also have access to legal advice via the local authority.

5.6 Assessment prerequisites

The admitting ward colleagues are required to:

  • confirm who has parental responsibility
  • assess the competence, capacity of the child or young person to consent to and participate in a mental health assessment
  • obtain consent for referral and, or discuss with children and adolescent mental health services those rare cases where consent cannot be secured to ensure the child or young person is assessed within the appropriate legal framework
  • agree a suitable time for assessment and make all attempts to have a person with parental responsibility present for any child or young person being assessed if appropriate
  • ensure a member of the ward team is available to provide a handover of reliable clinical information to inform the assessment
  • confirm that the child or young person is medically fit for assessment having excluded toxicity or organic pathology as a cause of the presenting problem

For the purpose of this policy, “Medically fit” is described as having completed all tests and treatment pertinent to the physical presenting problem and being suitably alert to participate in the assessment as in 5.4.5 and 5.8.

5.6.1 Assessment pathway, attending the ward following admission

It is the responsibility of the Crisis team to conduct a mental health and risk assessment on the paediatric or acute general hospital ward in their locality irrespective of the child’s usual place of residence.

In the event that the child or young person has an allocated care coordinator or children and adolescent mental health services (CAMHS) lead professional, and they are available to undertake an assessment they may accept responsibility to do this themselves within the agreed timescales.

Assessment should be undertaken by a single clinician except in exceptional circumstances where there is a complex presentation.

The CAMHS clinician that conducts the assessment will:

  1. complete a functional analysis of care environments (FACE) risk assessment (as a minimum) for all children or young people seen. The purpose of the assessment is:
    • to determine whether the young person is mentally fit for discharge to an agreed community setting and will no longer pose an unacceptable level of risk to themselves and, or others
    • to establish a risk management plan for young people deemed fit for discharge
    • to establish if parents or carers are able to implement the support and risk management plan
    • to determine the risk management plan for a young person not deemed fit for discharge
    • to ensure the risk assessment and risk management plan is clearly communicated and recorded in the young person’s file on the ward and also the CAMHS electronic patient record (EPR)
  2. adopt a collaborative approach to care and risk planning ensuring the child or young person, parent or carer and or legal guardian are involved and agree to the plan in consultation with the admitting ward where continued admission is agreed
  3. inform the admitting ward’s multi-disciplinary team or manager where the child or young person, parent or carer are not in agreement with the care plan or risk management proposed
  4. record a clear plan of care in the child or young person’s file on the admitting ward at the point of assessment and ensure this is shared with the child or young person, parent or carer and or legal guardian (appendix E)
  5. record the full assessment and outcome in the child or young person’s file on the admitting ward and also onto the CAMHS electronic patient record or SystmOne)
  6. issue the child or young person and their family, with a summary of their care plan and contact numbers if they have any concerns
  7. contribute to multi-disciplinary or multi-agency decision-making and discharge planning for the child or young person:
    • where this is at the point of initial assessment this is typically undertaken by the assessing clinician as the CAMHS representative (with support from CAMHS team manager, pathway lead or consultant psychiatrist as required)
    • where admission has been prolonged (for example, over 72 hours) or the presentation is more complex (for example, safeguarding concerns, elevated risk factors) CAMHS will ensure the most appropriate CAMHS representatives attend any discharge planning meetings convened by the acute general hospital, see 5.7 and 5.7.1
  8. add a face-to-face contact to their colleague calendar
  9. take on the role of care co-ordinator (for those cases with no current allocated care coordinator or CAMHS lead professional) and ensure that they are allocated on the care network (SystmOne). Care coordinators are allocated as part of community care approach (CPA) and lead professionals usually non-community care approach framework
  10. care programme approach (CPA) policy
  11. complete a first contact “current view” form
  12. communicate the outcome of the assessment within 5 working days in writing to the child or young person’s GP as a minimum, copies of this letter should be sent to the child or young person and, or their legal guardian in accordance with the healthcare record keeping policy
  13. where there are identified safeguarding concerns and, or the child or young person has an allocated social worker, the details of the assessment or outcome and risk management plan should be shared with the allocated social worker in accordance with trust or local safeguarding children board policies
    • Children and adolescent mental health services (CAMHS) crisis clinicians will assess all young people up to the age of 18 years. For young people nearing 18 years of age the locality access and liaison teams may conduct assessments without CAMHS clinicians or in conjunction with CAMHS crisis clinicians, where there are complex presentations that may require adult mental health specialists. Where a young person aged 16 to 18 years and has been admitted to a general hospital ward and an assessment is deemed necessary to be a joint assessment this will be completed by the CAMHS night shift crisis clinician and the Access and Liaison team worker. Refer to the above standard operating procedure for full details of the assessment arrangements.
    • A FACE risk assessment and assessment document should be completed for all children and young people who have been assessed. This should be uploaded to SystmOne or emailed to the locality team within 24 hours as per trust policy.
    • The locality CAMHS team and allocated worker must be informed of any assessment the following morning via a task on SystmOne if a patient is already open to a locality CAMHS team.
    • Correspondence to the child or young person, parent or carer and or legal guardian and GP will be followed up by the locality team within 1 working week. This will not be the responsibility of the assessing out of hours clinician. In line with consent and confidentiality policy this must be gained to ensure that information is permitted to be shared with external professionals and agencies and parents if the patient is above the age of 16 years.
    • Following an out of hour’s assessment, the clinician is responsible for handing over the information to the relevant team the next day or as soon as practicably possible. Information about children or young people who are already known to service should be passed to the lead clinician or handed over to the day working colleagues within CAMHS Crisis team for further actions and or follow up to be completed. Where a patient is open to a locality CAMHS worker, they should be notified and provided with handover or if they are not available, the clinical lead or team manager for the relevant team.
    • For those children or young people who are “looked after” ensure that there is liaison with the relevant local authority throughout the assessment and decision-making process.
    • The following handover process should be adhered to for those children and young people who are presenting to service for the first time or are not currently in receipt of a service.
Rotherham

Single point of access team
Rotherham child and adolescent mental health service
Kimberworth Place

Doncaster

Single point of access team
Doncaster child and adolescent mental health service

North Lincolnshire

St Nicholas House
North Lincolnshire child and adolescent mental health service

Trust wide

Children’s eating disorders team

Children and young people currently in receipt of services should be directed to the lead professional or care coordinator. In the absence of the lead professional or care coordinator, the team manager or Crisis team should be informed.

Where psychiatric medical assessment is required, this must be clear within the handover of the case and further information may be required from the appropriate psychiatrist.

5.7 Decision and outcome pathway, discharge of the child or young person into the community

  • Where possible the clinician or care coordinator (where known to the service) will be required to review the child or young person again within 7 working days following discharge, as per National Institute for Health and Care Excellence guidelines (NG225) (2022). This may be sooner dependent upon presenting need and risk factors and may require a joint assessment with a medical team member. Follow-up contact may be in person or by telephone or alternative method as agreed with the young person or family.
  • Where the clinician or care coordinator (where known to the service) is not available to undertake the 7-day review, it is the responsibility of the assessing worker to ensure that the child or young person and parent, carer or legal guardian are clear as to who will undertake this assessment. This may be a member of the Chldren’s Crisis team. Information should be provided to the child or young person and parent, carer or legal guardian as to when and how to contact the service in the interim (crisis card). This should be recorded clearly in the electronic patient record (EPR).
  • Where the 7-day follow-up appointment indicates ongoing care is required the child or young person and their parent, carer or legal guardian must be clear about who is their allocated care coordinator. The care coordinator must be named and allocated by the CAMHS within 10 working days of referral by the admitting ward.

5.7.1 Decision and outcome pathway, where the child or young person is not fit for discharge and remains on the ward

There are occasions where a child or young person may have a brief admission and in more rare circumstances have a prolonged stay in an acute general hospital but also have ongoing mental health needs. This may be due to co-existing or complex physical health needs and or delay in sourcing a suitable place for transfer or discharge. It is essential that the child or young person’s mental health and wellbeing is promoted, and recovery maximised though ongoing assessment and treatment by the local children and adolescent mental health services (CAMHS) during this time.

In circumstances where a young person remains admitted to an acute general hospital by reasons of safeguarding. Laison with trust safeguarding, acute hospital safeguarding teams and children’s social care should be exercised to work towards a timely and safe discharge through discharge planning discussions.

If on assessment the child or young person is not fit for discharge and remains on the ward, the following minimum standards will apply:

  • daily telephone contact with the ward by the care coordinator or crisis team as per the local arrangement is expected. Details of the discussion and any decisions taken must be recorded in the CAMHS electronic patient record.
  • For young person on ward with eating disorder, the plan of contact will be agreed between the ward and the eating disorders team.
  • Daily discussion of cases that are not discharged from the wards will take place within relevant CAMHS crisis and integrated care systems (ICS) team meetings and the CAMHS medical colleagues, as necessary.
  • Face-to-face appointments must take place at no longer than 72 hourly intervals (Monday to Friday) unless agreed otherwise. Where visits are not required at this frequency this must be agreed in liaison with the ward manager or multi-disciplinary team and the reasons documented in the clinical record.
  • CAMHS colleagues will ensure that the ward is provided with a written initial care plan at the point of assessment to include (see appendix E):
    • an outline of the identified problem and core principles of care
    • any observation required, for what purpose and describe how this should be undertaken (for example, frequency, proximity, role of parents, carers or legal guardian)
    • frequency of visits planned by CAMHS workers
    • overview of risk factors or triggers to risk and management plan including safeguarding concerns
    • information where the child or young person, parent, carer or legal guardian do not consent to the care regime
  • This care plan should be reviewed within a maximum of 7 working days and amended or updated as necessary. It should be agreed with the child or young person, parent, carer or legal guardian (and ward colleagues for all children and young people who remain as an inpatient)
  • A written copy of the full CAMHS FACE risk assessment should be shared with the ward within 3 working days for all children and young people who remain as an inpatient
  • CAMHS colleagues will be required to provide support to the paediatric nursing and medical colleagues. They should be clear about the risks and communicate this effectively to the paediatric colleagues highlighting what they should do if the risk changes, both in and out of hours.
  • CAMHS colleagues will be required to progress any referral to tier 4 inpatient services in a timely manner, update the admitting ward with regard to progress and escalate concerns to NHS England regarding delays.
  • CAMHS or admitting ward colleagues should contact the relevant trust’s safeguarding team for advice or support where there is a safeguarding concern. Any safeguarding referrals must be completed at the point of assessment by CAMHS or admitting ward in accordance with trust or local safeguarding children board policies. This will include escalation of concerns where discharge is delayed pending review by another agency, for example, local authority children services or tier 4 providers.

5.8 Assessment under the Mental Health Act

There are situations where a child or young person may require, either immediately (urgently) or as part of an assessment (routinely), a Mental Health Act assessment to be carried out. Approved mental health professionals that are employed within the adult access teams will follow the trust agreed pathway for dealing with Mental Health Act assessments including those for children and young people.

Mental Health Act Assessments are divided into unplanned or planned. Unplanned Mental Health Act assessments, where a response is expected that day include the following:

  • section 136
  • section 135
  • section 2
  • section 3
  • section 4

It is less likely that adult mental health practitioners from the adult access team will be included in planned Mental Health Act assessments for children and young people as these should be provided by children and adolescent mental health services (CAMHS) community and tier 4 colleagues however these would include the following:

  • section 5(2)
  • section 2 to 3
  • cases known to the treatment teams such as early intervention in psychosis (including sections 2 and 3, section 135)
  • community treatment orders (Mental Health Act (1983) Code of Practice 19.113)
  • guardianship (under the Mental Health Act, a guardianship order does not authorise any deprivation of the person’s liberty which is different to the Mental Health Act sections which are legal sections for detention)

The Mental Health Act: Code of Practice 2015 (14.56) makes reference to the role of the approved mental health professional (AMHP) and states:

  • “Where patients are subject to the short-term effects of alcohol or drugs (whether prescribed or self-administered) which make interviewing them difficult, the AMHP should either wait until the effects have abated before intervening the patient or arrange to return later. If it is not realistic to wait because of the patient’s disturbed behaviour and the urgency, the assessment will have to be based on whatever information the AMHP can obtain from reliable sources. This should be made clear in the AMHP‘s record of the assessment.”

5.9 Escalation of concerns or conflict resolution

Any colleagues who have concerns regarding the application of this policy or encounters conflict which they are unable to resolve with regard to the care and treatment of a child or young person within the scope of this policy should:

  • raise initial problems with the locality team manager or children crisis team or on call manager out of hours
  • if at this point it cannot be resolved, then the manager or clinical lead will pass the information on to the service manager of children and adolescent mental health services (CAMHS)

If problems still persist and a resolution has not been sought then this will be escalated to the children’s care group director.

6 Training implications

There are no specific training needs in relation to this policy, but the following colleagues will need to be familiar with its contents:

All children and adolescent mental health services (CAMHS) clinical colleagues and any other individual or group with a responsibility for implementing the contents of this policy. Each CAMHS locality team will make the team aware of any new or updated policy via team meetings and ensure this is covered in local induction for new starters.

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through trust wide email.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

Children and adolescent mental health services (CAMHS) colleagues should ensure they maintain their professional knowledge and competence by accessing available training and seeking advice and guidance through clinical and managerial supervision and using the resources available on the trust intranet.

10.1.1 Care group directors

Care group directors are responsible for:

  • the implementation of the policy across the specified care groups
  • the ongoing review of the policy to keep it up to date with current best practice
  • promoting collaborative working between services, in order that the needs of the patient remain at the centre of the process
  • providing reports to the operational management meeting (OMM) on any issues associated with the implementation of the policy
  • provide reports to the mental health legislation operational group of any young people admitted or detained under the Mental Health Act (1983)
  • facilitating effective joint working with internal and external partners and stakeholders

10.1.2 Team managers

Team managers are responsible for:

  • making their colleagues aware of the contents of this policy
  • monitoring the compliance of their colleagues with the contents of this policy
  • facilitating multi-disciplinary team (MDT) discussion to assist decision-making and communication of concern or actions
  • reporting any breaches in relation to this policy

10.1.3 Child and adolescent mental health service crisis team

The children and adolescent mental health services (CAMHS) Crisis team is responsible for:

  • supporting colleagues with the implementation of this policy
  • reporting any breaches in relation to this policy
  • escalating any clinical issues that impact on the delivery of this policy
  • facilitating multi-disciplinary team (MDT) discussion and, or individual supervision to assist decision-making and communication of concern or actions
  • liaising with general hospital colleagues in relation to this policy

10.1.4 All clinical colleagues

All clinical colleagues are responsible for:

  • following the appropriate steps in this policy and informing the team manager where necessary of any issues that impact on the delivery of care as defined within this policy
  • reporting any breaches in relation to this policy

10.2 Appendix B Monitoring arrangements

10.2.1 Compliance with the standards within this policy

  • How: Monitoring of all admissions of under 18-year-olds to a general health ward, review of any complaints, concerns escalated, or action plans that relate to the admission of children and young people to paediatric ward.
  • Who by: Team managers or Crisis team.
  • Reported to:
    • children’s mental health legislation monitoring group
    • escalate to mental health legislation operational group
    • feeds up to the Mental Health Legislation Committee for assurance at the trust board
    • children’s care group governance group
  • Frequency: 6 monthly.

10.3 Appendix C Gillick competency

Mental Health Act: Code of Practice 2015 (19.34 to 19.37).

10.3.1 Establishing Gillick competence?

19.34, children under 16 should be assessed to establish whether they have competence to make a particular decision at the time it needs to be made. This is because in the case of Gillick, the court held that children who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the competence to consent to that intervention. This is sometimes described as being “Gillick competent”. A child may be Gillick competent to consent to admission to hospital, medical treatment, research or any other activity that requires their consent.

19.35, the concept of Gillick competence is said to reflect the child’s increasing development to maturity. The understanding required for different interventions will vary considerably. A child may have the competence to consent to some interventions but not others. The child’s competence to consent should be assessed carefully in relation to each decision that needs to be made.

19.36, when considering whether a child has the competence to decide about the proposed intervention, practitioners may find it helpful to consider the following questions:

  • does the child understand the information that is relevant to the decision that needs to be made?
  • can the child hold the information in their mind long enough so that they can use it to make the decision?
  • is the child able to weigh up that information and use it to arrive at a decision?
  • is the child able to communicate their decision (by talking, using sign language or any other means)?

19.37 A child may lack the competence to make the decision in question either because they have not as yet developed the necessary intelligence and understanding to make that particular decision; or for another reason, such as because their mental disorder adversely affects their ability to make the decision. In either case, the child will be considered to lack Gillick competence.

10.4 Appendix D Mental Capacity Act (2005)

The Mental Capacity Act in general, applies to individuals aged 16 years and over and empowers individuals to make their own decisions where possible and protects the rights of those who lack capacity. Where an individual lacks capacity to make a specific decision at a particular time, the Mental Capacity Act provides a legal framework for others to act and make that decision on their behalf, in their best interests, including where the decision is about care and, or treatment.

10.4.1 Principles of the Mental Capacity Act (2005)

10.4.1.1 Principle one

A person must be assumed to have capacity unless it is established that they lack capacity.

10.4.1.2 Principle two

A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success.

10.4.1.3 Principle three

A person is not to be treated as unable to make a decision merely because they make an unwise decision.

10.4.1.4 Principle four

An act done, or decision made, on behalf of a person who lacks capacity, must be done, or made, in their best interests.

10.4.1.5 Principle five

Before the act is done, or the decision is made, regard must be had to whether the purpose of the act or the decision can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

It is important for professionals to be aware that individuals with a mental disorder do not necessarily lack capacity. The assumption should always be that a patient has capacity unless it is established otherwise in accordance with the Mental Capacity Act.

10.4.2 Patients lacking capacity

A person lacks capacity in relation to a matter if, at the material time, the person is unable to make a decision for themselves in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

The above definition contains both a “diagnostic test” and a “functional test”. The diagnostic test determines whether the individual has an impairment of or a disturbance in the functioning of the mind or brain. The impairment or disturbance can be temporary or permanent, but if it is temporary, the decision-maker should justify why the decision cannot wait until the circumstances change.

The functional test determines whether the individual is unable to make the specific decision in question themselves because of the impairment or disturbance. Both tests must be satisfied for an individual to be deemed to lack capacity to make the specific decision in question at the material time.

A person is unable to make a decision for themselves if they are unable to do any one of the following:

  • understand information which is relevant to the decision to be made
  • retain that information in their mind
  • use or weigh that information as part of the decision-making process
  • communicate their decision (whether by talking, sign language or any other means)

As capacity relates to specific matters and can change over time, capacity should be reassessed as appropriate over time and in respect of specific treatment decisions. Decision-makers should note that the Mental Capacity Act test of capacity should be used whenever assessing a patient’s capacity to consent.

Best Interests is a core principle that underpins the act. In brief, it stresses that any act done, or decision made on behalf of an individual who lacks capacity, must be done or made in their best interests. This principle covers all aspects of financial, personal welfare, health care decision-making and actions.

Everything that is done for or on behalf of a person who lacks capacity must be in that person’s best interests. The act provides a checklist of factors that decision-makers must work through in deciding what is in a person’s best interests. A person can put his or her wishes and feelings into a written statement if they so wish, which must be considered by the decision maker. Also, carers and family members have a right to be consulted. In order to document and structure this process in a formal and clear way, the trust in collaboration with the local authority have developed a best interest checklist pro forma (form Mental Capacity Act 2) as a means of ensuring that all the statutory requirements are covered

Colleagues should also refer to the trusts’ Mental Capacity Act (2005) policy.

10.4.3 Younger people

The act applies to people of 16 or over who lack capacity to make their own decisions. Most of the provisions of the act apply to young people of 16 and 17-years-old. Decisions relating to treatment of young people of 16 and 17 who lack capacity must be made in their best interests in accordance with the principles of the act. The young person’s family and friends should be consulted where practicable and appropriate. However, a person needs to be 18 or over to make an advance decision.

The Children Act (1989) covers the care and welfare of children in most situations. The Mental Capacity Act applies to children under 16 years in two ways:

  • the Court of Protection can make decisions about the property and affairs of a child where it is likely that the child will lack capacity to make those decisions when they reach 16 years old
  • the criminal offence of ill treatment or neglect applies to children who lack capacity
  • recording assessments of capacity and best interests decisions
  • decision-makers should ensure that where a mental capacity assessment is undertaken, the evidence is recorded on the MCA1 questionnaire on SystmOne and where the young person lacks capacity the record of actions taken to make a best interest decision should be recorded on an MCA2 questionnaire

10.4 Appendix E Initial care plan and risk overview following assessment of a child or young person on an acute hospital ward


Document control

  • Version: 4.
  • Unique reference number: 365.
  • Approved by: Clinical policies review and approval group.
  • Date approved: 7 January 2025.
  • Name of originator or author: Nurse consultant.
  • Name of responsible individual: Medical director.
  • Date issued: 20 January 2025.
  • Review date: 31 January 2028.
  • Target audience: All clinical colleagues within children and adolescent mental health services (CAMHS) and as appropriate, colleagues from adult mental health services (crisis or access teams), approved mental health professionals (AMHP) from local authorities.

Page last reviewed: January 20, 2025
Next review due: January 20, 2026

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