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Assessment, care and treatment in mental health and learning disability services policy

Contents

1 Policy summary

This policy outlines the trusts flexible, responsive and personalised approach to a high-quality and comprehensive assessment, care planning and co-ordination of care in line with the community mental health framework for adults and older adults, but also taking into account the diverse nature of the trust and expanding this guidance across Inpatient and learning disability services.

The policy sets standards for the allocation of key workers, and their role in the ongoing care and review of patients, including the involvement of family carers and significant others.

2 Introduction

The Community Mental Health Framework for Adults and Older Adults (opens in new window) sets out a new approach in which place-based and integrated mental health support, care and treatment are situated and provided in the community. This will be for people with any level of mental health need.

The Framework proposes replacing the care programme approach (CPA), while retaining its sound theoretical principles based on good care coordination and high-quality care planning.

People with any level of mental health need will be able to access support, care and treatment in a timely manner and from wherever they seek it, whether from their GP, from a community service, through online self-referral, other digital means or another route. There will be a “no wrong door” approach to accessing care.

People with the highest levels of need and complexity will receive a coordinated and assertive community response.

The trust will deliver specific parts of this model in line with specific commissioning arrangements; however, its core delivery will be the primary care network mental health team (PCN MHT) and secondary care including specialist services.

3 Purpose

This policy sets out a flexible, responsive and personalised approach to a high-quality and comprehensive assessment, care planning and co-ordination of care in line with the community mental health framework for adults and older adults.

4 Scope

This policy is applicable to all colleagues working across the trusts adult and older adult mental health and learning disability services.

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

The CPA will continue to be used in the following services:

  • prison services
  • adult secure services
  • adult eating disorders specialised commissioning
  • deaf mental health services for adults
  • obsessive compulsive disorder and body dysmorphic disorder
  • perinatal mental health
  • specialised commissioned LD and autism

Colleagues should refer to the trusts CPA policy

for further guidance.

5 Procedure

The Mental Health Framework is based on five broad principles:

  1. The delivery of high-quality, safe, meaningful and intervention-based care which helps people to recover and stay well, coupled with documentation and processes that are proportionate and enable delivery.
  2. A named key worker for all patients with a clearer multidisciplinary team (MDT) approach to both assessment and meeting the needs of patients, to reduce the reliance on individual practitioners and to increase resilience in systems of care, allowing all to make the best use of their skills and qualifications.
  3. High-quality co-produced, holistic, personalised care and support planning for people with severe mental health needs, with patients actively co-producing brief and relevant care plans with colleagues, with active input from non-NHS partners where appropriate including social care (to ensure Care Act compliance), housing, public health and the voluntary, community and social enterprise (VCSE) sector.
  4. Better support for and involvement of carers to provide safer and more effective care. This includes improved communication and services proactively seeking carers’ and family members’ contributions to care and support planning.
  5. A much more accessible, responsive and flexible system in which approaches are tailored to the health, care and life needs, and circumstances of an individual, their carer(s) and family members.

5.1 Quick guide

5.1.1 Assessment

  • Assessment is biopsychosocial and forms part of the integrated team approach to assessment.
  • Assessments should be collaborative.
  • Assessment will be supported by the DIALOG+.

5.1.2 Care plan

  • All care and support plans are genuinely co-produced, personalised, and of a high quality.
  • Patients should be encouraged to be owners of the information within their care plan.
  • Care plans should include flexible and revisable timescales for review.

5.1.3 Safety

  • Assessment of risk forms part of a wider assessment, and that safety planning is built into the wider care planning process.
  • A personalised approach to managing risk is a key part of the personalised care and support planning process.

5.1.4 Key worker

  • For people with more complex needs, who may require interventions from multiple professionals, one person will have responsibility for coordinating care and treatment.
  • The key worker role may be carried out by any registered health or social care professional.
  • Allocation of a key worker should take into consideration clinical need in addition to patient choice, gender, cultural and religious needs.

5.1.5 Review

  • Regular reviews will monitor and evaluate the effectiveness of the care plan and focus on how the needs of the patient can continue to be met.
  • Review frequency should be determined by need and through collaboration with the patient and their representatives. however a review should take place at least once every 12 months.
  • Any major change in the patient’s mental health should prompt a review.
  • Reviews should be supported by patient reported outcome measures (proms) and clinician Reported Outcome Measures (CROMs).

5.2 Key principles of the Community Mental Health Framework

The Community Mental Health Framework outlines a flexible, responsive, and personalised approach to care.

A high-quality and comprehensive assessment means that the level of planning and co-ordination of care can be tailored and amended, depending on:

  • the complexity of an individual’s needs and circumstances at any given time
  • what matters to them and the choices they make
  • the views of carers and family members
  • professional judgment

The patient’s journey will be to access the right care, support and treatment at the right time. The journey should be clear, and patients should not be bounced around the health system.

Patients are to be considered as “step-up”, “step-down” or “move-across” to the most appropriate intervention rather than the notion of referral and discharge, removing the barriers patients currently experience between primary and secondary care.

Where a patient may stop at a destination which is not correct for them, they should receive what clinical and social support can be provided at this stage. Patients should be supported to continue their journey without needing to go back to the original starting point.

In all care for complex needs, the principle of continuity remains critical.

Stepping up people’s care and support or stepping it down to that provided in the local community should be straightforward and seamless, so that people who use services, their carers and families do not feel and experience any gaps or boundaries.

The goal is to empower patients to seeking contact ‘as and when’ needed, aiming to prevent illness or a worsening of symptoms. This should reflect access to care not just when the patient is ill but according to the need to maintain wellbeing. This approach will encourage the patient to maintain individual responsibility for their health, wherever possible and appropriate.

To support the implementation of the framework, the trust has adopted the DIALOG+ model (opens in new window) (developed by East London NHS Foundation trust (ELFT)) across all mental health and learning disability services.

DIALOG+ is the first approach that has been specifically developed to make routine patient-clinician meetings therapeutically effective. It is based on quality-of-life research, concepts of patient-centred communication and components of solution-focused therapy. Research studies in different mental health services and multiple countries have shown that using DIALOG+ can improve patients’ quality of life.

5.3 Assessment

Assessment is biopsychosocial and forms part of the integrated team approach to assessment. Most importantly, assessment is a collaborative process, not only among mental health team members but also with the person and their families, carers and support network.

It relies on communication and respect between individuals, especially professionals from different backgrounds and settings and a mutual understanding about the approach to assessment.

Assessment can be undertaken by different members of the core community mental health service at the point at which a person seeks access, though colleagues must be suitably qualified and experienced. It will vary according to the individual and the complexity of their needs.

Assessment can be a relatively brief initial contact in which an understanding of the person’s current needs and a shared view of an intervention have been developed and agreed with them. The intervention itself may comprise a simple, short advice session that enables the person to obtain help for themselves, or perhaps no further help will be required.

However, for a significant proportion of people there will be an intervention detailed in an agreed personalised care and support plan, developed mutually (subject to the person’s capacity).

Every patient stepped up to the specialist mental health services will be triaged by a qualified mental health practitioner.

Where appropriate an MDT decision will be made regarding the need for any further assessment to establish a treatment plan, or whether advice and guidance or signposting can be offered before the referral is stepped down or moved across. The MDT should be as inclusive as practicable, reaching out to other services that may be involved or offer support to the patient.

Where care is to be provided by a specialist service, a comprehensive biopsychosocial assessment will be commenced.

5.4 Care planning

The type of plan and level of support needed will depend on the person and their individual needs, ensuring that all care and support plans are genuinely co-produced, personalised, and of a high quality, Care Act-compliant and integrated with Mental Health Act section 117 plans where necessary.

In line with the comprehensive model of personalised care (opens in new window), patients should be encouraged to be owners of the information within their care plan, be familiar with its content and feel confident to request reviews and amendments should circumstances change.

Care plans should include the actions that the patients undertake, that carers and or family members might undertake, and the actions services will undertake to support them.

Support services will extend beyond the trust and include colleagues from statuary and non-statuary organisations. Colleagues should refer to the relevant memorandums of understanding (where these are in place) or seek advice from the care group leadership team regarding expectations and escalations where conflict or concern arises.

Care plans should include flexible and revisable timescales for review agreed between the patient their carer or family and support networks where appropriate and the MDT, as opposed to within a long and arbitrary timeframe.

Plans should reflect the patients’ individual needs rather than generic service policies or processes. These should be brief, clear and follow-up on agreed actions.

The care planning process and its outputs should be viewed as fundamental parts of the meaningful care that services seek to provide, rather than a box-ticking exercise, and should be linked to routine outcome measurement.

For people with less complex needs, care plans will be brief and uni professional and where possible should be delivered by the professional or serviced most closely aligned to the patient’s needs. For people with more complex needs, the assessment will be more comprehensive, and may require multidisciplinary input, and interventions are also likely to be multi professional in nature.

Access to personal health budgets (opens in new window) should be explored, which use NHS funding to create an individually agreed personalised care and support plan (opens in new window) that offers people of all ages greater choice and flexibility over how their assessed health and wellbeing needs are met.

5.5 Safety

Evidence shows that the safest care is care that is personalised and highly responsive. Clear themes include:

  • high-quality care planning
  • an understanding of risk and safety as dynamic within a comprehensive assessment
  • meaningful engagement with families and carers
  • communication and information sharing
  • robust record-keeping; and effective multi-agency working

The National Confidential Inquiry into Suicide and Safety in Mental Health (opens in new window) describes how to make approaches to safety personalised and effective, assessments of (changing) personal and individualised risks should not be based on the use of tools and checklists. It is therefore important that assessment of risk forms part of a wider assessment, and that safety planning is built into the wider care planning process rather than being divorced from it.

A personalised approach to managing risk is a key part of the personalised care and support planning process. Once risks are identified, through personalised conversations, options are explored that are relevant to the individual to help mitigate the risk.

Colleagues should refer to the trust clinical risk assessment and management policy (opens in new window) for further guidance.

5.6 Named key worker

The level of planning and coordination of care will vary, depending on the complexity of the person’s needs. For people with more complex needs, who may require interventions from multiple professionals, one person will have responsibility for coordinating care and treatment. This coordination role can be provided by workers from different professional backgrounds and incorporated through the MDT. Some professionals will play a dual role of coordinator whilst also providing discipline specific treatment.

The key worker role may be carried out by any registered health or social care professional. They must be able to support patients with multiple needs to access the services they require and have the professional skills and authority to oversee and coordinate the wider care package.

Allocation of a key worker should take into consideration patient choice, gender, cultural and religious needs.

For patients’ accessing Specialist Services, it is highly likely that a trust colleague is best placed to undertake the key worker role, based on the likely level of mental health support required. Although this should be considered on a case-by-case basis and where there is evidence to suggest that a key worker from a different organisation would benefit the patient this should be pursued. Where a patient is receiving interventions from more than one trust colleague, the key worker should be identified based on who is best placed to fulfil the role. This decision will take need to take into consideration factors such as capacity and scope in addition to professional skill.

Ultimate responsibility for allocating a key worker rest with the team manager for specialist services, who will assume responsibility of the role until a named individual is identified.

Other members of the care team may be required to cover key worker duties temporarily due to colleague absence. This should be clearly communicated to the patient their families, carers and support network and reflected in the electronic patient record (EPR) for wider oversight.

However, there may be a requirement for a change of key worker during an episode of care, either due to patient choice or other circumstances.

If this is a planned event, a formal handover of care should take place between the existing and new key worker, patient, and their representatives. If this is unplanned, the role of key worker will default to the team manager until a new key worker can be allocated. The patient should be notified of the changes and be kept up to date with reallocation. Colleagues should refer to requesting a change of lead clinician policy for further guidance.

During an inpatient admission a patient will be allocated a named nurse in accordance with the trust admission, transfer and discharge manual. Where applicable the named nurse and key worker should work collaboratively to ensure ongoing coordination of care needs.

Carers involvement should be facilitated, whose expertise should be central. Adopting improved whole family approaches as pioneered within social care can increase the effectiveness of planning.

Where a key worker is allocated externally from the trust, the principles of this policy around assessment, safety and care planning must still be followed, and a named individual or point of contact responsible for care delivered by the trust must be identified.

5.7 Reviews

Regular reviews will monitor and evaluate the effectiveness of the care plan and focus on how the needs of the patient can continue to be met effectively, they also provide an opportunity to deliver statutory responsibilities in relation to mental health legislation.

The key worker and care team should tailor reviews to the circumstances of the individual patient taking into consideration individual circumstances such as work, or childcare commitments and travel. Invitees should reflect the patients individual support networks, but where appropriate should extend to the GP and other professionals and services involved in the patients care.

Review frequency should be determined by need and through collaboration with the patient and their representatives, however as a minimum, a review should take place annually to ensure the care plans remains relevant and up to date.

Any major change in the patient’s mental health, personal or social circumstances including admission to hospital, increased risks, withdrawal from care or self-discharge, discharge or upcoming Mental Health Act hearings should also prompt a review.

For patients with children or regular access to children and there is an allocated children’s worker, the worker should be routinely invited to attend.

5.8 Physical health care for people with severe mental illness

NHS England has a programme to improve physical health care for people with severe mental illness, including early intervention, to avoid development of preventable disease. The biopsychosocial assessment should consider the patients physical health. Colleagues should refer to the trusts physical health policy for further guidance and expectations.

5.9 72-hour follow up

Discharge challenge for mental health and community services providers (opens in new window) set out 10 discharge initiatives including that follow up is to be carried out with the person by the community mental health team (CMHT) or crisis home treatment team (CRHTT) at the earliest opportunity and within a maximum of 72 hours of discharge, to ensure the right discharge support is in place.

The trust has adopted this target and it is set out in the admission, transfer and discharge manual, including patient flow and out of hours (OOH) procedures.

5.10 Transfers, moves across and out of area placements

Effective management of transfers, moves and placements is essential to positive patient experiences and continuity of care. These moves may be internal and external, local, and out of area.

Discharges and transfers to other inpatient services should be managed in accordance with the admission, transfer and discharge manual, including patient flow and out of hours (ooh) procedures.

Internal moves from one service area to another (for example, from an adult mental health team to an older people’s mental health team) should be considered according to clinical need, who is best placed to meet those needs, and in conjunction with the wishes of the individual and their families or carers. To assist in decision-making, appropriate guidance should be used or followed, such as the criteria for old age psychiatry services in the UK (opens in new window).

Any such moves should be carried out as part of an individualised clinical review and be care planned for accordingly.

Some trust patients will be admitted to provider units out of area. As the responsible mental health service, the trust must continue to provide input, attend reviews, and be involved in discharge planning. Where a patient is not known to services and does not have an identified worker the responsibility for this rests with the inpatient services.

The patient flow team will also maintain a general oversight and link with the out of area wards, local teams (for example, Community team if a patient needs allocation) and repatriate where necessary. It should remain a priority where appropriate to bring such patients back into our services at the earliest opportunity.

When a patient is to be transferred to another area, it is important that their transfer is planned and organised to facilitate continuity of care with the receiving service.

It is the duty of the trust team to make a referral to the appropriate service and provide relevant information. In complex cases a senior clinician should be involved or have oversight.

The patient should remain the responsibility of the original team until a handover of care can take place. Agreements should be made about any period of joint working or follow-up where this is appropriate. If an out of area service refuses to accept a transfer, this should be escalated through the management structure accordingly to achieve an outcome.

Transfers into the trust from out of area services should be directed to the appropriate trust team. The team manager and consultant psychiatrist from the receiving team should discuss the transfer at the earliest opportunity and if the transfer is accepted, a key worker should be allocated.

The key worker should actively engage with the patient and transferring service to facilitate a smooth transition of care and develop a new care plan.

Where patients transfer between areas, health and social care funding responsibilities are as set out in the who pays? determining which NHS commissioner is responsible for commissioning healthcare services and making payments to providers (opens in new window).

Teams should maintain contact with the responsible commissioner, especially to inform them if one of their patients returns to hospital or if this is being planned.

5.11 Disengagement

The trust has a responsibility to ensure that it delivers safe and effective services and attempts to engage patients in treatment and care. It must also consider the complex mental health needs of its patients’ and the impact that disengagement from services may have on them and their families. Where there are concerns that a patient may be disengaging colleagues should refer to the trust disengagement policy.

5.12 Mental capacity, advance statements and advance decisions

The mental capacity act (MCA) 2005, came into force in October 2007 and provided a legal framework for acting and making decisions on behalf of vulnerable people who lack the mental capacity to make specific decisions for themselves. The MCA provides a statutory framework to empower and protect such individuals. It makes it clear who can take decisions, in which situations and how they should go about this. It also enables people to plan for a time when they may lose capacity.

Colleagues should refer to the trust polices for Mental Capacity Act and advance statements and advance decisions to refuse treatment for further details and guidance.

5.13 Documentation

This section sets out the local documentation requirements for the trust, reflecting the key principles of the Community Mental Health Framework of a tiered and personalised approach.

The digital DIALOG+ (opens in new window) embedded in the trust EPR will be the core document used to assess, plan and review care and will be implemented across all mental health services, providing a consistent approach to information capture and sharing. The DIALOG + will be supplemented by other key documents including clinician reported outcome measures (CROMs), patient reported outcome measures (PROMs) and other national and local assessment tools to enable proportionate assessments tailored to individual need.

Other key information such as MHSDs, CQUIN and national key performance indicators will be incorporated into various templates across the EPR, to support colleagues with capturing this information which in turn supports local and national profiling, direction and investment.

The minimum documentation for each tier is detailed below. Assessment tools should be completed over time, building a comprehensive picture of the patients’ needs as trust is built and the patient discloses pertinent information.

Colleagues should aim to capture a comprehensive assessment of the patient within the first 4 weeks, however issues and risks should be considered and planned for as they arise. Where colleagues are struggling to ascertain information, they should document their attempts and continue to add to the assessment as and when information is made available or is divulged.

Tier Document Review (minimum frequency)
CMHTs and learning disabilities DIALOG+ 12 months
CMHTs and learning disabilities Risk assessment 12 months
CMHTs and learning disabilities Goals based outcome, as required
CMHTs and learning disabilities Care plan 12 months
CMHTs and learning disabilities Additional tools as required such as PHQ9, GAD7, CORE10
Primary Care Mental Health Hub team DIALOG+ 6 months
Primary Care Mental Health Hub team Safety plan (where required) 6 months
Primary Care Mental Health Hub team Recovery plan 6 months
Primary Care Mental Health Hub team Goals based outcome, as required 6 months
Primary Care Mental Health Hub team ReQoL, as required 6 months
Primary Care Mental Health Hub team Additional tools as required such as PHQ9, GAD7, CORE10 6 months
Primary care mental health practitioner roles DIALOG and DIALOG+ Up to 4 sessions

6 Training implications

DIALOG+

  • Employee groups requiring training: All clinical colleagues working within mental health and physical health services
  • Frequency: On commencement of employment with an annual refresher
  • Length of training: For example, 60 minutes
  • Delivery method: For example, face to face training and ESR module
  • Training delivered by: Learning and Development team and ESR
  • Where are the records of attendance held: ESR

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 service users 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 individual’s 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).

8 Links to any other associated documents

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

10.1.1 The trust

The trust has a duty of care to ensure that safe and effective care is delivered across it services. The trust must adhere to the legislative, statutory, and good practice guidance requirements relating to the delivery of patient care.

10.1.2 The chief executive

The chief executive has overall accountability and responsibility for the delivery of safe and effective care within the trust including the adoption of the Community Mental Health Framework. This function is delegated to executive directors and care groups, who are responsible for driving high quality standards of patient care.

10.1.3 Senior manager of the trust

Senior managers of the trust are responsible for the quality of the care delivered by all trust colleagues to ensure patient safety and quality service delivery.

10.1.4 Consultant psychiatrist and the medical team

Consultant psychiatrist and the Medical team are responsible for:

  • implementing this policy and standards effectively
  • fulfilling the duties as outlined in this and other related policies, to the required professional standards of their discipline
  • escalating any issues which may affect implementation to the attention of their line manager
  • informing the relevant line manager when an identified action or intervention cannot be delivered, for example because of resource or availability
  • identifying learning needs and attending relevant training
  • undertaking regular supervision.

10.1.5 Service managers, modern matrons and team managers

Service managers, modern matrons and team managers are responsible for:

  • overseeing and monitoring the implementation of this policy within their areas
  • escalating issues which may affect the implementation of this policy
  • exploring unmet needs escalated to them as brought to their attention, assessing the case, and specifying the action or process to be followed by the service to meet the needs of the patient
  • supporting colleagues to attend any training in relation to this policy
  • ensuring regular audit is undertaken and results acted upon
  • providing regular supervision.

10.1.6 Key workers

Key workers are responsible for:

  • implementing this policy and standards effectively
  • fulfilling the duties of the key worker role as outlined in this and other related policies, to the required professional standards of their discipline.
  • escalating any issues which may affect implementation to the attention of their line manager
  • informing the relevant line manager when an identified action or intervention cannot be delivered, for example because of resource or availability
  • identifying learning needs and attending relevant training
  • undertaking regular supervision

10.1.7 All colleagues

  • implementing this policy effectively
  • escalating any issues which may affect implementation to the attention of their line manager

10.2 Appendix B Monitoring arrangements

10.2.1 The effective implementation of this policy

  • How and who by: National and local targets for mental health 4 week wait.
  • Reported to: Care group, clinical leadership executive board via the IQPR.
  • Frequency: Monthly.

Document control

  • Version: 1.
  • Unique reference number: 1095.
  • Approved by: Clinical policies review and approval group.
  • Date approved: 3 December 2024.
  • Name of originator or author: Chief nursing information officer.
  • Name of responsible individual: Chief nurse.
  • Date Issued: 19 December 2024.
  • Review date: 31 December 2026.
  • Target audience: Trust wide.

Page last reviewed: January 17, 2025
Next review due: January 17, 2026

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