access team - RDaSH NHS Foundation Trust

Transcription

ACCESS TEAM
LOCAL WORKING INSTRUCTIONS (LWI)
Author(s) Name: Angus McKnight/Paula Thompson
Designation(s): Deputy Assistant Director/Service Manager
Date: 31/08/12
Adult Mental Health Services
Document Change Control
The following is the document control for the revisions to this document.
Version Number
1.0
Date of Issue
30/09/12
Author(s)
Brief Description of Change
Angus
McKnight/ Initial version for review and
Paula Thompson
comment
Issue History
This document has been distributed to the following stakeholders, departments, and
individuals.
Version Number
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Issued to
Graeme Fagan (Deputy Director of Operations)
Sharon Schofield (Deputy Director of Nursing)
Dianne Graham (Asst. Director of Adult Community Services)
Dr Cunnane (Clinical Director/ Consultant Psychiatrist)
Dr Coates (Consultant Psychaitrist)
Dr Aldridge (Consultant Psychiatrist)
Dr. Heighton (Consultant Psychiatrist)
Dr Vishwanath (Consultant Psychiatrist)
Shirleyann Barwick (Access Team Manager, Doncaster Access)
David Simpson (Assistant Team Manager, Doncaster Access)
Doncaster Access Team Staff
Tania Linden (Service Manager)
Yvonne Denly (Team Manager, N. Lincs. Access)
Becki Davis (Assistant Team Manager, N. Lincs. Access)
N. Lincs. Access Team Staff
Rotherham Access Team Staff
Christopher Eastwood (Quality Improvement Team)
Julie Sheldon (Quality Improvement Team)
Emma Butterworth (Quality Improvement Team)
Date
08/10/12
08/10/12
08/10/12
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08/10/12
08/10/12
08/10/12
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08/10/12
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Definition
The following are definitions of terms, abbreviations and acronyms used in this document.
Term
Definition
TABLE OF CONTENTS
Page
1.0
INTRODUCTION AND SCOPE……………………………………………………………………………………….
1
2.0
LAYOUT………………………………………………………………………………………………………………….....
1
3.0
PURPOSE OF LOCAL WORKING INSTRUCTIONS……………………………………………………………
1
4.0
MANAGEMENT STRUCTURES AND PROFESSIONAL ROLES…………………………………………..
2
4.1
Service Manager (Band 8a)……………………………………………………………………………….
2
4.2
Consultant Psychiatrist……………………………………………………………………………………..
2
4.3
Team Manager (Band 7)……………………………………………………………………………………
2
4.4
Assistant Team Manager (Band 6/7)…………………………………………………………………
3
4.5
Table of Organisation……………………………………………………………………………………….
3
5.0
DEFINITION OF ACCESS SERVICE……………………..………………………………………………………….
3
6.0
SERVICE FUNCTIONS…………………….…………………..……………………………………………………….
4
7.0
AIM(S) OF THE SERVICE………………….……………………..…………………………………………………..
5
8.0
PHILOSOPHY……………………………………….…………………..………………………………………………..
5
9.0
WHO IS THE SERVICE FOR…………………….……………….…..………………………………..…………….
6
10.0 HOURS OF OPERATION………………………….………………….……..………………………………………..
6
11.0 STAFFING…………………………………………………….…………….……..……………………………………….
6
12.0 REFERRAL PROCEDURE…………………………………….…….………..………………………………………..
6
13.0 ACCESS TEAM REFERRAL PATHWAY…………………..……….…..………………………………………….
7
13.1
Stage 1 – Receipt of Referral…………………………..…….……………………………..…………..
7
13.2
Stage 2 – Triage…………………………………………….……………………………….……..………….
7
13.3
Stage 3 – Assessment of Service User…………………………………………….…………………
8
13.3.1
Crisis Assessment………………………………………………………………………………………
9
13.3.2
Urgent Assessment……………………………………………………………………………………
9
13.3.3
Routine assessment…………………………………………………………………………………..
9
13.3.4
Assessment under the Mental Health Act………………………………………………….
9
13.3.5
Assessment of Service users with a Dual Diagnosis……………………………………
10
13.3.6
Assessment ‘Out of Hours’ of 16-18 year olds……………………………………………
11
13.3.7
Assessment of referrals from South Yorkshire Ambulance Service……..……..
11
Stage 4 – Interventions…………………………………………………………….……………………….
11
13.4
13.4.1
Gatekeeping admissions to Inpatient Unit…………………………………………………
11
13.4.2
Doncaster & Rotherham - Crisis Beds (Rethink)…………………………………………
12
13.4.3
Home Treatment Service………………………..…………………………………………………
12
13.4.3.1 Inclusion/exclusion criteria………………………………………………………………
12
13.4.3.2 Treatment Intervention(s)…….………………………………………………………….
14
13.4.3.3 Service user care plan………………………..…………………………………………….
15
13.4.3.4 Traffic light framework…………………………………………………………………….
15
13.4.3.5 Early discharge pathway…………………………………………………………………..
16
13.4.3.6 Facilitating early discharge……………………………………………………………….
16
13.4.3.7 Criteria for determining early discharge from Inpatient unit…….………
16
13.4.3.8 Home treatment follow-up and agreed early discharge……………………
17
13.4.4
Transfer to secondary treatment teams……………………..……….….…………………
17
13.4.5
Transfer to primary care mental health services (IAPT)….………………………….
18
13.4.6
Refer to primary care services………………………………………..….………………………
18
13.4.7
Discharge back to referrer and/or other services……………………..……………….
18
14.0 TRANSFERS/CLOSURES FROM THE ACCESS TEAM…………………………………………..…………..
19
14.1
Transfer/closure following crisis/urgent assessment……..…………………………………
19
14.2
Transfer/closure following routine assessment………………………………………………..
20
14.3
Transfer/closure from Home Treatment service…………….…………………………………
20
15.0 DOCUMENTATION…………………………………………………….....……………………………………………
21
16.0 KEY PERFORMANCE INDICATORS………………………………………………………………………………..
22
17.0 QUALITY ASSURANCE………………………………………………………………………………………………….
23
17.1
Evidence based practice/ NICE guidelines…………………….……..……………………………
23
17.2
Trust quality markers……………………………………………………………….……………………….
23
17.3
Trust policies, procedures and guidelines…………………………………………………………
23
17.4
CQC/MONITOR standards…………………………………………………………………………………
23
17.5
Service user & carer surveys……………………………………….…………………………………….
24
17.6
Staff survey’s………………………………….……………………………….………………………………..
24
17.7
Independent surveys (external agencies)………………………….………………………………
24
17.8
External audit (external agencies)…………………………………………...……………………….
24
17.9
Access team audit………………………………………………………………………….…………………
24
17.10
Feedback/recommendations – compliments, complaints & serious incidents….
25
APPENDICES
APPENDIX A
Access Team Referral Pathway
APPENDIX B
Access Team Administrative Pathway
APPENDIX C
Shift Coordinator Roles and Responsibilities
APPENDIX D
Clinical Triage Risk Decision Guide
APPENDIX E
Dual Diagnosis Pathway – Mental Health & Substance Misuse
APPENDIX F
Dual Diagnosis Pathway – Mental Health & Learning Disabilities
APPENDIX G
CAMHS-Crisis ‘Out of Hours’ Pathway
APPENDIX H
Crisis-Ambulance Crew Contact Algorithm
APPENDIX I
Access Team Assessment outcome Sub-processes
APPENDIX J
Rethink referral documentation for accessing a ‘Crisis Bed’
APPENDIX K
Home Treatment Pathway
APPENDIX L
Home Treatment Administrative Pathway (To be completed)
APPENDIX M
Key Worker - Roles and Responsibilities
APPENDIX N
Agreed Care Plan Template
APPENDIX O
Access Team Template letters
APPENDIX P
Access Team Leaflets:
‘About Your appointment’
‘Your Plan of Care’
‘About Home Treatment’
APPENDIX Q
Audit templates: Full Needs Assessment, Care Plan and Clinical Records
1.0
INTRODUCTION AND SCOPE
This document provides guidance and instruction for people working in the
Access Team across the three localities, Rotherham, Doncaster and N. Lincs.,
where the Trust (RDaSH) provides secondary care mental health services.
2.0
LAYOUT
The Local Working Instructions (LWI) provides a high level summary of the
pathway (how the service user can travel through the respective Access Teams)
in each of the localities. It then gives more detail about the role, responsibilities
and contribution of staff at each of the stages in the process.
For ease of understanding, these instructions consist of specific sections,
supported by appendices that identify specific and detailed documents referred
to in the main body of the instructions.
3.0
PURPOSE OF LOCAL WORKING INSTRUCTIONS
Local Working Instructions (LWI) are documents that are a key part of the way
management will translate service proposals, Trust policies, procedures and
guidelines into practice. The following Local Working Instructions (LWI) explain
the constituent parts of the Access Team functions that manages the Single Point
of Access (SPA) and Home Treatment (HT) pathways into secondary care services.
Local working instructions are evolutionary and rely on information from staff to
develop, which includes:

The expectation that if staff and line managers feel that the LWI could be
improved, or parts are not achievable due to specific local circumstances,
they contact the procedure authors

The following LWI is expected to evolve significantly from operational
experience and from interaction with future developments of the service
Further revisions of the document are expected as specific aspects of the service
is further developed and documented. It is the intention that this LWI will always
be a ‘live’ document that is responsive to change and builds on the experience
gained in the provision of the service.
Access Team\Operational Policy\v1.0\31.08.12
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4.0
MANAGEMENT STRUCTURES AND PROFESSIONAL ROLES
The Local Working Instruction (LWI) is not the only measure in supporting staff to
carry out their duties. Management supervision, either informally through
answering queries and providing advice or through formal supervision meetings
is also important in ensuring that staff understand and follow the laid down
processes for providing care.
Clear management structures, lines or reporting and clarification of roles add to
the overall assurance regarding delivery of services in the respective Access
Team’s. The posts below describe the key management structures.
4.1
Service Manager (Band 8a)
The Service Manager is responsible for the overall management of the Access
Teams. The role ensures quality assurances and governance processes are in
place. The Service Manager will also oversee the future developments of the
service.
4.2
Consultant Psychiatrist
The consultant psychiatrist in the Access team should be at the forefront of
culture change and seek to use their skills, knowledge and experience to best
effect by concentrating on service users with the most complex needs. Their role
would include:
 Diagnosis
 Prescribing
 Clinical leadership
 Dealing with complex cases
 The doctor-patient relationship
 Medico-legal problems
 Representing the team to other doctors
 Representing the team to management
 Involvement in the training of staff
4.3
Team Manager (Band 7)
The Team Manager is responsible for the day-to-day management of the Access
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Team within a specific locality. They will provide key roles, which include:
 Providing leadership to the team they manage
 Responsibility for quality assurance standards
 Providing supervision
 Oversee staff development and training
 Monitoring and maintaining agreed performance indicators
4.4
Assistant Team Manager (Band 6/7)
The Assistant Manager is responsible for supporting the Access Team Manager in
their day-to-day management and leadership of the respective locality team.
They will undertake any delegated roles and responsibilities identified by the
team manager up to, and including, the roles identified for the team manager.
The Assistant Team manager will also ‘act up’ in the absence of the team
manager (in the event of planned leave or sickness)
4.5
Table of Organisation
SERVICE MANAGER
[Band 8a]
TEAM
MANAGER
[Band 7]
[Rotherham]
CONSULTANT
PSYCHIATRIST
[Rotherham]
ASST. TEAM
MANAGER
[Rotherham]
5.0
TEAM
MANAGER
[Band 7]
[Doncaster]
ASST. TEAM
MANAGER
[Doncaster]
SERVICE MANAGER
[Band 8a]
CONSULTANT
PSYCHIATRIST
[Doncaster]
TEAM
MANAGER
[Band 7]
[N. Lincs]
CONSULTANT
PSYCHIATRIST
[N. Lincs]
ASST. TEAM
MANAGER
[N. Lincs]
DEFINITION OF ACCESS SERVICE
The Access Team, in line with proposals identified in Health Care For All (2008)
and Healthy Ambitions (2008), provides a single point of Access for new referrals
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to all secondary mental health services. For service users currently receiving care
from the community treatment teams it provides additional support and
intervention during times where a service user’s mental health deteriorates to a
point that they are no longer able to manage the service users’ care without the
additional input.
The Team operates three distinct, but interlinked, functions within its day-to-day
operation, Crisis Resolution, Home Treatment and Routine Assessment. The crisis
resolution function will manage all admissions to the inpatient unit offering a
rapid response and assessment. The Home Treatment Team will offer the
possibility of a comprehensive acute psychiatric care at the Service User’s home
or other community facility until their crisis is resolved without resorting to
admission to a mental health unit. For service users who admitted to a mental
health unit, early discharge may be facilitated by the Home Treatment Team at
the earliest opportunity. Lastly a Routine Assessment service to determine the
potential needs of service users who may require input from secondary mental
health services.
This policy provides the operational guidelines under which the Access Team
will provide a safe and evidence based service.
6.0
SERVICE FUNCTIONS
The RDaSH Access Team service comprises of three Access Teams. The services
are locality based according to Local Authority and NHS Commissioning
catchment areas (NHS Rotherham, NHS Doncaster & NHS N. Lincs.). The team
hosts a number of specific functions, which include:

Crisis (emergency/urgent) Assessment

Routine Gateway Assessment

Mental Health Act Assessment

Fair Access to Care (FAC’s) Assessment

Carers Assessment

Home Treatment Service

Criminal Justice Liaison
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7.0
AIM(S) OF THE SERVICE
The aim(s) of the service are:
8.0

To provide access to specialist mental health assessments

To provide Fair Access to Care (FAC’s) Assessments

To provide Mental Health Act Assessments as requested

To provide assessments of carers needs

To simplify the process of accessing secondary mental health services

To provide a multidisciplinary Home Treatment service as an alternative
to hospital admission

To ‘Gate Keep’ all admissions to the acute inpatient unit

To take an active role in the planning process for timely discharge of
service users admitted to inpatient units

To provide treatment in the least restrictive environment as close to
home as clinically possible
PHILOSOPHY
The Access service is based on a belief that rapidly responding to service users
and their support network can facilitate improved outcomes. Risks of
deterioration and harm to self or others can be reduced and this period is an
ideal time to develop positive resolutions to distress.
Mental health problems occur within the greater context of people’s lives and
should not be viewed in isolation from this. Service users have many of the
resources required to lead to recovery and the professional’s role is to support
the development of positive coping strategies and lifestyle changes. Service
users, their relatives, carers, and immediate social network hold the knowledge
of their own situation and are a fundamental part of the assessment, planning
and implementation process.
The key values and principles are:

Maximise recovery, independence, autonomy and social inclusion

Establish a culture which supports the development of each individual’s
coping strategies in order to enable them to regain the fullest control of
their own life

Service user and carer involvement, in particular taking into consideration
their views in decision making and care planning

Enabling service users to contribute to and be responsible for their own
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recovery
9.0

Partnership working

Effective communication and information exchange

Working with other agencies to support service users in their journey
through secondary mental health services

Use of evidence based practices to support delivery of care
WHO IS THE SERVICE FOR
The service will be available to adults (16 years of age and above), who are
assessed to have a serious mental health problem (not categorised by
diagnosis but by the level of disability, caused by their mental health
problems, to their occupational functioning) and are experiencing an acute
episode of mental/emotional distress.
To ensure service users/carers and referrers experience a seamless service, all
out of hours requests for help and support will be handled by the Access
team. However the “outcome” of some “out of hours” crisis assessments, may
result in a referral/transfer to an alternative team/service.
10.0
HOURS OF OPERATION
The Access Team will provide a crisis resolution and home treatment service
twenty-four hours a day, seven days a week, 365 days a year. The Access Team
routine assessment function will run from Monday to Friday 8.30am-5.00pm.
11.0
STAFFING
The Access Team is a multidisciplinary service staffed by professional and nonprofessional grades from both health and local authority, which include:
12.0

Consultant Psychiatrist

Approved Mental Health Professional’s (AMHP’s)

Social Workers

Community Mental Health Nurses

Support Workers
REFERRAL PROCEDURE
Referrals will be made via telephone call, fax, secure e-mail, or in person. All
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referrals will include the following information:
13.0

Concern(s)/reason(s) for referral

Service user demographics

Personal details including contact details

Next of kin/nearest relative

Any risks known to the referrer

Current medication

Any previous mental health history known to the referrer

Any Adult and Child Safeguarding Concerns known to the referrer
ACCESS TEAM REFERRAL PATHWAY
Referrals made to the Access team will follow the following stages:
1. Receipt of referral
2. Triage of referral
3. Assessment of service user
4. Intervention
These steps are outlined in the process map in appendix A (Access Team Referral
Pathway)
13.1
Stage 1 – Receipt of referral
All new, and previously discharged, service user referrals will be registered on to
the electronic recording system (MARACIS) by the administrative staff within the
Access team (see appendix B – Access Team Administrative Pathway). For
referrals from the treatment teams where service users are already registered, a
link is created between the existing referral and the Access Team in order to
allow staff to input into the service users existing electronic record.
All the available information (paper and/or electronic) is then prepared, along
with a tracking record in order to pass on to the next stage of the referral process
which is triage.
13.2
Stage 2 - Triage
The triaging stage is a clinical function which aims to assess and categorize the
urgency of the referred mental health related problem. For the Access team this
role is performed by the ‘shift coordinator’ (see appendix C - Shift Coordinator
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Roles and Responsibilities). The shift coordinators essential function at this stage
is to determine the nature and severity of the mental health problem, to assess
other risks related to possible mental illness, and then determine how urgently
the response is required, these are:
 Emergency – within 4 hours of referral
 Urgent – within 72 hours of referral
 Routine – within 14 days of referral
In order to aid the ‘Shift Coordinator’ with the process of triaging service users
into the most appropriate response the use of a ‘Clinical Triage Risk Decision
Guide’ is provided (see appendix D).
Once the level of urgency has been determined, the service user will be
contacted by phone in order to arrange an appointment to visit and further
assess their needs. In emergency and urgent situations, if the service user does
not respond to phone contact a ‘cold call’ will be undertaken within the
respective timeframes. Where the level of urgency is identified as routine,
unsuccessful attempts to contact by phone on the day, will trigger the creation of
an appointment letter offering a date to be seen within the 14 day period
following receipt of referral.
13.3
Stage 3 – Assessment of service user
The assessment will provide a systematic approach to identifying the service users
problems/difficulties and clinical risks At every level of identified urgency there will
be a need to assess the service user’s health and social care needs. At the
assessment stage the assigned clinician with the service user, and if available
carer and/or family, will conduct a:
 Full Needs/FAC’s Assessment (FNA/FAC’s) – to determine, and seek to
address, both health and social care needs (see appendix for Full Needs/FAC’s
Assessment Template)
 Risk Assessment – to determine the level of risk that the service user may
pose to themselves or to others (see appendix for FACE Risk Assessment
Template)
The completion of the Full Needs/FAC’s Assessment (FNA/FAC’s) and Risk
Assessment documentation will inform the clinician’s decision making as to the
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most appropriate intervention to address the service users present problems.
The Full Needs, FAC’s and Risk Assessments will be recorded on the Trust
electronic recording system (MARACIS) in line with the Trust Record Keeping
Policy.
In certain circumstances, either immediately upon receipt of the referral or
during the assessment process. A service user may raise sufficient concern in
their presentation that it may require a Mental Health Act assessment to be
undertaken (see section 9.3.4 below).
13.3.1
Crisis Assessment (4 Hours)
The crisis assessment function of the team is to provide responsive support to
anyone who appears to be experiencing a mental health crisis, at least until an
assessment has been completed and a clear care pathway agreed or alternative
arrangements have been put into place.
Not all crisis referrals will involve mental health problems which require specialist
psychiatric help, and direction to other more appropriate agencies can follow
assessment.
13.3.2
Urgent Assessment (72 Hours)
Urgent assessments are required when the service user is not yet considered to
be in crisis, but their mental state is serious enough to merit a rapid response in
order to prevent them from becoming an acute mental health problem.
13.3.3
Routine Assessment (14 Days)
The routine assessment function is carried out under the assumption that service
users are not in crisis requiring an immediate or rapid response. However, the
service user does require secondary mental health service intervention in order
to resolve their mental health problems, and will, following assessment expect to
be directed to the most appropriate treatment team.
13.3.4
Assessment under the Mental Health Act
A service user referred to the Access team may require, either immediately or
during part of an assessment (e.g., emergency, urgent or routine), a Mental
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Health Act assessment to be carried out (see appendix A - Access Team Referral
Pathway).
The Access team has Approved Mental Health Professionals as part of its staffing
and they will follow the Trust agreed pathway for dealing with Mental Health Act
assessments (see appendix I – Access Team Sub-processes). Such Mental Health
Act Assessments are divided into ‘unplanned’ or ‘planned’.
Unplanned Mental Health Act Assessments - where a response is expected that
day and include the following:

Section 136

Section 135

Section 2

Section 3

Section 4
Planned Mental Health Act Assessments include the following:
13.3.5

Section 5(2)

Section 2 to 3

Cases known to the treatment teams (including section(s) 2 & 3, section 135)

Community Treatment Orders

Guardianship
Assessment of Service users with a Dual Diagnosis
Potential referrals to the Access team may include service users who present
with a comorbid condition, which is referred to as a ‘dual diagnosis’. The Trust
has two specific policies dealing with the management of service users who have
dual diagnosis (see appendix A – Access Team Referral Pathway), these are:

Dual Diagnosis – Mental Health & Substance Misuse

Dual Diagnosis – Mental Health & Learning Disabilities
The respective policies identify specific processes to be followed by the Access
team for service users presenting with such problems (see appendix E for Dual
Diagnosis Pathway – Mental Health & Substance Misuse & appendix F for Dual
Diagnosis Pathway – Mental Health & Learning Disabilities)
Page | 10
13.3.6
Assessment ‘Out of Hours’ of 16-18 year olds
As part of the interface with Child and Adolescent Mental Health Services
(CAMHS) to ensure effective management of service users aged 16-18 who may
present in crisis ‘out of hours’. The Access team will use the agreed pathway to
manage service users (see appendix G - CAMHS-Crisis ‘Out of Hours’ Pathway)
13.3.7
South Yorkshire Ambulance Service referral (Rotherham & Doncaster)
As part of the interface agreement with South Yorkshire Ambulance Service
(SYAS) to ensure effective management of service users who may present to their
service. If a service user is considered by the ambulance crew that they are not
physically at risk but the service user’s presentation may have a mental health
component, then they will contact the respective locality Access team to discuss
referring the service user on for their attention. The Access team will use the
agreed pathway to manage service users (see appendix H – Crisis-Ambulance
Crew Contact Algorithm)
13.4
Stage 4 - Intervention
Following assessment and identification of the service user’s needs, a decision
will be made as to which is the most appropriate intervention to use to address
these needs (see appendices A and I for information). These interventions
include:
13.4.1

Ward admission (‘Gate Keeping’)

‘Rethink’ Crisis Bed (short-term) – available in Rotherham & Doncaster

Home Treatment Service (Access Team Function)

Transfer to secondary care treatment teams

Transfer to Primary Care Mental Health (IAPT) services

Discharge back to referrer and/or refer to other services (e.g., third sector)
Gate Keeping Admissions to Inpatient Unit
The Access Team’s Crisis Resolution function (CRS) will ‘gate keep’ all inpatient
admissions for informal and detained service users. The rational and purpose of
the admission will be clearly defined and the member of clinical staff perfuming
the Crisis resolution function will:
Page | 11

Complete a Full Needs/Fair Access to Care Assessment (FNA/FAC’s)

Complete the risk assessment document (FACE)

Identify the service users current needs

Identify the service users current level of risk

Rationale for admission to the service user

Identify agreed aims and outcome indicators with timescales to assist with
early discharge

Interventions agreed

Care plan where appropriate
The shift coordinator will coordinate the admission and liaise with the inpatient
services to secure a bed (Acute Care Pathway Standards).
13.4.2
‘Crisis Beds’ (Rotherham & Doncaster)
Provision has been made in Rotherham and Doncaster localities for the Access
Team to access ‘crisis beds’ managed by ‘Rethink’ (see appendix A – Access Team
Referral Pathway, appendix I – Access Team Sub-processes and appendix J Rethink referral documentation for accessing a ‘Crisis Bed’).
13.4.3
Home Treatment
The Home Treatment Team is an alternative to in-patient hospital care for service
users with serious mental health problems offering flexible, home based care, 24
hours-a-day, and seven days per week.
13.4.3.1
Inclusion/Exclusion Criteria
Inclusion Criteria:
That there is an acute episode of significant mental distress and at least one of
the following:
 That the person is at risk of self-harm or harm to others
 Where an assessment under the mental Health act may be/is required
 That there is an immediate risk of the breakdown in the normal family or
support network
 That the individual would benefit from intensive short-term support and/or
crisis management, which would maintain them at home
 The individual is at risk of inappropriate hospital admission and through multidisciplinary assessment at the point of admission a more appropriate
Page | 12
alternative may be initiated
 For in-patients, Early Discharge or Home Treatment could be facilitated by the
provision of short-term intensive support, which would allow for discharge
and the maintenance of the individual at home
 That there are complex needs and the level of disability caused to the person,
is having a detrimental effect on the persons’ ability to function at a level
where hospital admission is being considered
 Where a person is already receiving care from the Mental Health Services but
due to deterioration in their mental state, the presence of relapse signatures
being identified and where the level of input required to maintain this person
in the community is not available from the existing service provision
Exclusion Criteria:
Beyond initial assessment, this service is not usually appropriate for individuals
with the following conditions. In order to focus Home Treatment services on
those with the highest level of need, the Home Treatment service is less likely to
be able to offer intensive support for the following conditions because of the
priority given to serious mental illness, which could otherwise lead to admission
to hospital.
 Mild anxiety disorders
 Primary diagnosis of alcohol or other substance misuse
 Brain damage or other organic disorders including dementia
 Learning disabilities
 Exclusive diagnosis of personality disorder
 Recent history of self-harm, but not suffering from a psychotic illness or
severe depressive illness
 A crisis related solely to relationship issues
Where ambiguity exists around the appropriateness of home treatment it is
better, on the side of caution, to offer the service for a short while during a
period of crisis. It is recognised that the Access Team will be assessing a wide
variety of conditions, some in emergency situations, and the decision to offer
services will be made in response to individual need.
If Home Treatment criteria is met and agreed, then the process of taking the
service user onto caseload is broken down into two distinct phases (see appendix
I - Home Treatment Pathway):
Page | 13

Phase 1 – is the 72 hour extended assessment service provided to both new
and current service users’:
o New service users - will automatically undertake a 72 hour extended
assessment
o Current service users - will have their care plans reviewed with their
care team. Additional components that Home Treatment service will
contribute to, will be agreed and incorporated into the existing, or new
care plan
o At the end of the 72 hour extended assessment period a decision will be
made whether the service user is taken on to Home Treatment
caseload. If they are taken onto the Home Treatment service they will
jointly agree a care plan, which they will be provided with. If the
decision that the service user does not require Home Treatment the
alternatives considered and agreed will be identified and the service
user will be transferred/discharged from the Access Service (see
appendix A for alternative options)

Phase 2 – Accepted into Home Treatment, which will be delivered by a
multidisciplinary Team (MDT) that will provide a range of interventions. The
purpose of Home Treatment service will be agreed with the service user
(and their carer), and reflected in their Wellbeing/Recovery Plan.

There will be a regular review of the service users care whilst under the
Home Treatment service, and the following thresholds will be applied:
o Service users will be reviewed by the Home Treatment multidisciplinary
team (and care coordinator/lead professional if present) every 7 days
o If the service user has been in Home Treatment Service for 3 weeks a
multidisciplinary review will be held, led by the Access Team Consultant
to determine if the Home Treatment service remains the most
appropriate service to meet the service users current needs, or an
alternative service/discharge is required (see appendix K - Home
Treatment Pathway)
o If the service user has been in Home Treatment service for 3 months
and exception report is required and multidisciplinary review called to
review service users on-going care
13.4.3.2
Treatment Intervention
Service users who require the Home Treatment service will be offered practical
support and interventions to achieve resolution of their current crisis whilst
causing as little disruption as possible to the service user (and their carers) life.
These interventions will reflect the needs identified in the extended assessment
and reflected in the agreed care plan, and may include:

Specialist psychiatric assessment and diagnosis
Page | 14
13.4.3.3

Pharmacological treatment initiation and review

Education about mental health and crisis

Identifying and discussing the factors that may contribute to the current
crisis

Advocacy

On-going help, support and explanation to the service user’s family and/or
carers

Brief psychological interventions

Medication concordance

Practical problem solving

Stress management

Practical help with activities of daily living

Supplementing a relapse prevention/crisis plan with the service user, their
carer(s), and their care coordinator/lead professional
Service User Care plan
The Care plan (see appendix N - Agreed Care Plan Template) will detail:
13.4.3.4

The identified need of the service user

The Goals to be met

How to identify that the Goals have been achieved

The actions that will be undertaken to achieve the Goals

Who will undertake the specific actions

The Timeframe for reviewing each goal
Traffic Light Framework
The Home Treatment service will operate a Traffic Light System in terms of
monitoring service user risk:

Service user is considered at high risk (FACE Assessment)

Face-to-face contact is carried out daily or more frequently

Minimum of 2 qualified staff will always undertake visits

The care plan is reviewed and updated daily

The electronic record (MARACIS) updated daily

Service user is considered at moderate risk (FACE Assessment)

Face-to-face contact is carried out every 1-3 days

A qualified member of staff will undertake visits
Page | 15
13.4.3.5

The care plan is reviewed after 3 days

The electronic record is updated at each visit

Service users is considered at low risk (FACE Assessment)

Face-to-face contact carried out between 4-6 days

Qualified or unqualified staff can undertake visits

The Care plan is reviewed after 7 days at review

The electronic record is updated after each visit

Plans are in place for preparing discharge
Early Discharge Pathway
Early discharge means discharging the service user from an inpatient unit at a
time earlier that would have occurred if the Home Treatment service was not
available, and the service user is still part of an acute episode of care.
13.4.3.6
Facilitating Early Discharge
This Is a core function of the Access Team’s Home Treatment function. The Home
Treatment staff will liaise on a daily basis with the inpatient unit staff to identify
all service users suitable for early discharge as they will be aware of all inpatients
through the ‘Gate Keeping’ process.
Where a service user is identified as suitable for early discharge there must be
face-to-face contact with the service user within 24 hours prior to being
discharged from inpatient unit, and within 48 hours of the discharge, and an
agreed discharge plan in place.
13.4.3.7
Criteria for determining early discharge from inpatient unit

A clinically appropriate period without incident (i.e., violence or aggression)

The absence of, or greatly diminished suicidal intent (identified through risk
assessment documentation)

The absence of, or greatly diminished risk to others (identified through risk
assessment documentation)

On general observations

Service users’ whose medication regime can be managed in a home
treatment setting

The service user has capacity, can give informed consent and agrees with the
discharge plan
Page | 16
13.4.3.8
13.4.4

Service users’ cares and/or family have been consulted and support this
decision

Full multidisciplinary agreement (MDT) with plan of care

Inpatient agreement with proposed plan
Home Treatment follow-up/agreed early discharge

Discuss with relevant consultant

Attend formulation/discharge meeting

Liaise with named nurse/care coordinator/Treatment Team and any other
specialist services

Identify care plan needs for home treatment episode

Ensure service users’ care and/or family opinion/views is obtained and
recorded in electronic record (MARACIS) at all stages

A member of the Home Treatment staff will be allocated as Key Worker, but
the service will take a team approach to all cases. The ‘Key Worker’ will take
responsibility (see appendix M - Key Worker - Roles and Responsibilities) for
the planning and delivery of care, along with organising reviews in
conjunction with the care coordinator (if currently known to secondary
services)

Ensure a Home Treatment plan is in place and a discharge date is. A copy of
this plan is to be made available to the service users’ care network that has
been identified on the electronic recording system (MARACIS) (see appendix
M – Key Worker - Roles and Responsibilities)
Transfer to Secondary Care Treatment Teams
Following assessment it may identified that the service user does require
secondary mental health service intervention in order to resolve their mental
health problems. In this instance they will be directed to the most appropriate
treatment team.
To determine which treatment team is the most appropriate one to address the
service user’s needs, the Full Needs/FAC’s and risk assessment information will
be used to help inform the completion of the Mental Health Cluster Tool (MHCT).
Completing the tool will provide a ‘cluster number’ (1-17) and to the specific
treatment team that offers treatment interventions for that cluster number.
Secondary Care Treatment Team
Community Therapy Team
Intensive Community Therapy Team
Cluster(s)
2, 3 & 4
5, 6, 7 & 8
Page | 17
Early Intervention Team
10
Social Inclusion Team
11
Recovery Team
12 & 13
Assertive Outreach Team
16 & 17
Service user transfers are carried out through bi-weekly meetings between the
Access Team manager and Treatment Team managers. Service users identified as
requiring secondary care interventions are discussed, agreed and signed off by
the respective treatment team manager.
13.4.5
Transfer to Primary Care Mental Health Services (IAPT)
Following assessment it may be apparent that the service users’ needs will not
require intervention from secondary service, and completion of the Mental
Health Cluster Tool will support the decision that Primary Care Mental Services
(IAPT) are the most appropriate service to treat the service user. The Mental
Health Cluster Tool in these instances will identify service users as clustering at a
‘1’.
Service user transfers are carried out through weekly meetings between the
Access Team manager and the Primary Care Mental Health manager. Service
users identified as requiring Primary Care Mental Health Team (IAPT)
interventions are discussed, agreed and signed off by the Primary Care Mental
Health team manager.
13.4.6
Refer to Primary Care Services
If, after an assessment the service user’s identified needs would be best served
by available Primary Care Services then a referral will be made to the relevant
service in order for the individual to receive the most appropriate intervention.
13.4.7
Discharge back to referrer and/or refer to other services (e.g., third sector)
There will be occasions, following the full needs assessment where the outcome
concludes that there is no specific mental health problem and/or need requiring
an intervention from Primary or Secondary mental health services, primary care
service, or third sector services. In these instances the service user will be
referred back to the service that originally made the referral, along with
Page | 18
information explaining this conclusion.
14.0
TRANSFERS/CLOSURES FROM THE ACCESS TEAM
At the intervention stage of the referral pathway (see appendix A – Access Team
Referral Pathway) a decision will be made on what intervention is required for
the service user once they have been assessed. The intervention may take the
form of:

Internal transfers – within the ‘whole system’ of secondary services

External referrals/transfers:
o To other agencies (e.g., Local Authority, or Third Sector)
o To primary care mental health services
o To primary care services (e.g., GP’s)

Discharge with no further input from any services
In each instance the original referrer will receive a letter informing them of the
intervention chosen.
14.1
Transfer/Closure following Crisis Assessment
Following assessment, and at the intervention stage of the referral process (see
appendix A – Access Team Referral Pathway), where it has been identified and
agreed with the service user that they do require further input from secondary
services then the service user will either be:

Identified as requiring Ward admission and this is facilitated via ‘Gate
Keeping’ function

Identified as requiring a ‘crisis bed’ (Rotherham & Doncaster) and supported
by Home Treatment service

Identified as requiring Home Treatment service

Identified as requiring treatment interventions from one of the treatment
teams. The appropriate treatment team is identified using the Mental Health
Clustering Tool (MHCT) and transfer agreed with the identified secondary
care treatment team (see appendix I – Access Team Assessment Outcome
Sub-processes)
Following assessment and at the intervention stage of the referral process,
where it has been identified and agreed with the service user that they do not
require further input from secondary services then the service user may be:
Page | 19
14.2

Referred on to another agency that is

Referred on to Primary Care Mental Health services

Referred back to their GP

Discharged from services
Transfer/Closure following Routine Assessment
Following assessment, and at the intervention stage of the referral process (see
appendix A – Access Team Referral Pathway), where it has been identified and
agreed with the service user that they do require further input from secondary
services then the service user will either be:

Identified as requiring Ward admission and this is facilitated via ‘Gate
Keeping’ function

Identified as requiring a ‘crisis bed’ (Rotherham & Doncaster) and supported
by Home Treatment service

Identified as requiring Home Treatment service

Identified as requiring treatment interventions from one of the treatment
teams. The appropriate treatment team is identified using the Mental Health
Clustering Tool (MHCT) and transfer agreed with the identified secondary
care treatment team (see appendix I – Access Team Assessment Outcome
Sub-processes)
Following assessment and at the intervention stage of the referral process,
where it has been identified and agreed with the service user that they do not
require further input from secondary services then the service user may be:
14.3

Referred on to another agency that is

Referred on to Primary Care Mental Health services

Referred back to their GP

Discharged from services
Transfer/Closure from Home Treatment Service

Planning for discharge from the Home Treatment service will being early, the
expectation is that the service users identified care plan goals will have been
met

Prior to withdrawal from home treatment the ‘Key Worker’ will arrange a
discharge planning meeting prior to closure

Agreement for closure to the Home Treatment service will be in discussion
with all professionals involved and a date agreed to transfer back to the
treatment team and care coordinator/lead professional
Page | 20
15.0
DOCUMENTATION
From receipt of referral the Access Team has an administrative pathway that
mirrors the referral pathway and identifies specific documentation that is to be
used as a service user progress through the four stages of the referral process
(see appendix B – Access Team Administrative Pathway, and appendix O - Access
Team Template letters, appendix P – Access Team Leaflets)
STAGE
Receipt of Referral
ADMINISTRATIVE
CLINICAL
 Referral form
 If already known to service
then to inform referrer
send:
o (Template letter A 1)
 Complete section in
‘Tracker document’ (T1)
Triage
 If following triage
assessment referral is not
appropriate then send:
o (Template letter A 2)
 Referral information
 If previously known to
service any previous
documentation
 If telephone contact
successful to arrange
appointment for routine
referrals then send:
o Confirmation
Appointment Letter
(Template letter A 3) &
‘About Your
Appointment Leaflet’
 If telephone contact
unsuccessful for routine
referrals then send:
o Appointment Letter
(Template Letter A5) &
‘About Your
Appointment’ Leaflet
‘Tracker Document’ (T1)
Page | 21
Assessment
 If contact unsuccessful
(emergency. urgent or
routine referrals) then
send:
o Fax letter (Template
Letter A4) to referrer
informing them of
unsuccessful contact
attempt (and GP if not
original referrer)
 If clinical decision indicates
that further appointment
to be offered
o Send Appointment
Letter
 If contact is successful
then staff will
complete:
o Full Needs/FAC’s
(FNA/ FAC’s)
Assessment
o Risk Assessment
(FACE)
o Mental Health
Cluster Tool (MHCT)
o ‘Your Plan of Care’
document to leave
with service user
(Template Letter A5) &
‘About Your
Appointment’ Leaflet
 If attempts to make contact
with service user have
failed then clinical decision
made to discharge from
service then send:
o Discharge letter
(Template Letter A6)
Tracker (T1)
Intervention
 Complete ‘Your Plan of
Care’ to leave with service
user
 Send summary of
assessment to referrer
(Template letter A 7)
 Send ‘Your Plan of Care’
Letter to service user
(Template Letter A8)
 Send survey questionnaire
 Complete Tracker (T1)
16.0
KEY PERFORMANCE INDICATORS
The Access team has a range of performance indicators by which it is measured
Page | 22
and these are:
17.0
KPI
ROTHERHAM
DONCASTER
N. LINCS
Gate Keeping (Ward Admission)
100%
100%
100%
Crisis referrals seen within 4hrs
95%
95%
95%
QUALITY ASSURANCE
The Access Teams in Rotherham, Doncaster, and N. Lincs., are determined to
maintain a high quality service and has a variety of mechanisms to
feedback/update on the quality of its service delivery. with a view to seeking
further improvements, these include:
17.1
Evidence Based Practice/NICE Guidelines
All Trusts are expected to comply with NICE guidance, as implicitly indicated in
the Care Quality Commission (Registration) Regulations 2009. RDaSH has a
responsibility for implementing National Institute for Health and Clinical
Excellence (NICE) guidance in order to ensure that:
 Patients receive the best and most appropriate treatment
 NHS resources are not wasted by inappropriate treatment and
 There is equity through consistent application of NICE guidance/Quality
Standards
17.2
Trust Quality Markers
RDaSH has set three quality markers as it’s priority for services and these are:
Leadership, personalised care plans and
17.3
Trust Policy, Procedures and Guidelines
The Access Team is guided by, and adheres to Trust’s policies, procedures and
guidelines in its day-to-day operations.
17.4
CQC/MONITOR Standards
The external agencies, CQC and MONITOR provide a range of standards by which
it measures the quality of service provided by an agency. These standards are
Page | 23
applied at the team and individual staff level to provide assurances regarding
care delivery at point of contact
17.5
Service User & Carer Surveys
RDaSH performs biannual Service User & Carer surveys as part of its agreed
targets with commissioners. Results from these are incorporated in future
planning of service delivery. Where results indicate the need for immediate
actions to be taken these will be implemented via specific Business Division and
team level action plans.
17.6
Staff surveys
RDaSH undertakes annual survey of staff within it service. The results of these
surveys are returned to the respective business divisions and their respective
teams. Where there are specific areas of concern indicating the need to address
staff concerns, action plans at team level are
17.7
Independent Surveys (external agencies)
The Trust commissions independent surveys of its services, the results of which
are passed on to the respective teams within each business division. Where
scores indicate that there has been a ‘no change’ or a ‘decrease’ in scores the
respective teams will action plan and implement measures to improve the care
delivery highlighted.
17.8
External audit (external agencies)
The Trust (RDaSH) commissions external audits to be carried out on service
delivery and this will include the Access Teams functions e.g., ‘Gatekeeping
admissions’.
17.9
Access Team audit
The Access Teams has also developed a set of ‘in-house’ audit tools to monitor
the quality of staff Full Need’s Assessments, clinical notes, and Home Treatment
care plans (see appendix Q – Full Needs Assessment, Care Plan and Clinical
Records audit templates).
Page | 24
17.10
Feedback/recommendations from compliments, complaints and Serious
Incident Investigations
The Patient Advice and Liaison Service (PALS) manage feedback to the service as
part of any compliment or complaint. Where a formal complaint is raised they
will coordinate its investigation. Recommendations from complaint investigations
are addressed through specific action plans. Compliance is monitored via the
PALS department.
The Adult Business Division Patient Safety Team investigates and/or coordinates
the investigation of Serious Incidents (SI’s). Recommendations arising from
serious investigations are addressed through specific action plans. Compliance
with recommendations and accompanying action plans is monitored by the
Patient Safety Team.
Page | 25
APPENDIX A
KEY
ACCESS TEAM REFERRAL PATHWAY
ADMINISTRATIVE
FUNCTIONS
RECEIPT OF REFERRAL
Referral is received
into team and
registered on
MARACIS system
TRIAGE
ASSESSMENT
Discharge/Transfer Sub-Processes from Access Team
QUALIFIED STAFF REVIEW
REFERRAL
YES
Follow
Safeguarding Policy
EMERGENCY
[4 HOUR RESPONSE]
Crisis referral?
Follow MHA Work
Entry into service
YES
[See appendix for subprocess detail]
YES
YES
Transfer to IAPT/
Primary Care
Mental Health
Services
Discharge to GP/
Primary Care or
refer to other
Services
Learning Disability?
YES
Follow Dual
Diagnosis Policy of
service users with
Mental Health/
Learning
Disability**
YES
[See appendix for subprocess]
NO
YES
YES
[see appendix for subprocess]
MHA Referral?
NO
[72 HOUR RESPONSE]
YES
Urgent referral?
YES
Ward Admission?
NO
Crisis Bed?
NO
Home Treatment?
NO
Secondary care?
NO
IAPT service?
Referral is assessed within
4 hours of receipt of
referral**
NO
NO
URGENT
available in locality)
Transfer to
appropriate
treatment team
identified by cluster
NO
CAMHS/Crisis ‘Out
of Hours Pathway’
Admit to Rethink
Crisis Bed (Where
Admit to Mental
Health Unit (Wards)
Safeguarding?
Specific end point for Access Team
involvement
Decision point
INTERVENTION
Rotherham &
Doncaster Specific
Protocol with
Ambulance Service
Sub-process details of which can be found in
separate appendix
YES
YES
YES
YES
YES
YES
Follow Dual
Diagnosis Policy of
service users with
Mental Health/
Learning
Disability**
MHA Referral?
NO
Dual Diagnosis
referral?
Substance Misuse?
Ward Admission?
NO
Crisis Bed?
NO
Home Treatment?
NO
Secondary care?
NO
IAPT service?
72 hours of receipt of
referral**
NO
YES
NO
YES
Follow Dual
Diagnosis Policy of
service users with
Mental Health/
Substance Misuse**
YES
YES
YES
YES
YES
YES
ROUTINE
[14 DAY RESPONSE]
NO
NO
YES
Follow Dual
Diagnosis Policy of
service users with
Mental Health/
Learning
Disability**
MHA Referral?
NO
Ward Admission?
NO
Crisis Bed?
NO
Home Treatment?
Routine referral?
HOME
TREATMENT
NO
Direct Request for Home
Treatment intervention
from Inpatient Unit/
Treatment Team Staff
YES
14 days from receipt of
referral**
** DOCUMENTATION
· Full Needs Assessment
(FNA) completed
· Risk Assessment
completed
· Mental Health Cluster
Tool (MHCT) completed
YES
Taken onto Home
Treatment caseload
as alternative to
hospital admission
NO
Secondary care?
NO
IAPT service?
NO
APPENDIX B
ACCESS TEAM – ADMINISTRATIVE PATHWAY
RECEIPT OF REFERRAL
LOG ON
MARACIS
TRIAGE
Already in
service?
NO
(Electronic Record)
TRIAGE
REFERRAL
Appropriate?
YES
Crisis?
YES
ASSESSMENT
PHONE
CONTACT
4 HOUR
RESPONSE TIME
Successful?
YES
Arrange
visit
YES
Arrange
visit
INTERVENTION
NO
COMPLETE
COMPLETE
REFERRAL
REFERRAL
FORM
FORM
NO
YES
Arrange to
cold call
A2
A1
Send
Sendletter:
letter:
Access
Access(A1)
(A1)
DOCUMENTATION (FORMS AND/OR LETTERS)
SAFEGUARDING
SAFEGUARDING
REFERRAL
REFERRAL
FORM
FORM
Send
Sendall
all
Referral
Referral
Information
Information
to
totreatment
treatment
team
team
Send
Sendletter:
letter:
Access
Access(A2)
(A2)
NO
PHONE
CONTACT
Urgent?
YES
Rotherham 24Hr
response time
Doncaster/NL – 72Hr
Response time
Successful?
Attended?
YES
Documentation:
Documentation:
Full
FullNeeds
Needs
Assessment
Assessment(MARACIS)
(MARACIS)
Risk
RiskAssessment
Assessment(FACE)
(FACE)
Mental
Health
Mental Health
Cluster
Tool
(MHCT)
Cluster Tool (MHCT)
NO
Arrange to
cold call
A7
A8
Send
Sendsummary
summary
letter
letterto
to
referrer:
referrer:
Access
Access(A7)
(A7)
Send
Send‘Your
‘YourPlan
Planof
of
Care’
Care’to
toService
ServiceUser:
User:
Access
Access(A8)
(A8)
&&
Your
YourOpinion
OpinionCounts
Counts
Form
Form(YOC)
(YOC)
A7
A8
Send
Sendsummary
summary
letter
letterto
to
referrer:
referrer:
Access
Access(A7)
(A7)
Send
Send‘Your
‘YourPlan
Planof
of
Care’
Care’to
toService
ServiceUser:
User:
Access
(A8)
Access (A8)
&&
Your
YourOpinion
OpinionCounts
Counts
Form
Form(YOC)
(YOC)
NO
NO
Routine?
YES
INITIAL PHONE
CONTACT
TO BOOK
APPOINTMENT
Successful?
YES
A4
A5
Send
SendFAX
FAX
letter
letter
to
referrer:
to referrer:
Access
Access(A4)
(A4)
Send
Sendletter
letter
to
toService
Service
User:
User:
Access
Access(A5)
(A5)
Attended?
YES
Documentation:
Documentation:
Full
FullNeeds
Needs
Assessment
Assessment(MARACIS)
(MARACIS)
Risk
RiskAssessment
Assessment(FACE)
(FACE)
Mental
MentalHealth
Health
Cluster
ClusterTool
Tool(MHCT)
(MHCT)
NO
A3
14 Day response
NO
Send
Send
confirmation
confirmation
letter
letterto
to
Service
ServiceUser
User
Access
Access(A3)
(A3)&&
‘About
‘AboutYour
Your
Appointment’
Appointment’
leaflet
leaflet
NO
Clinical
decision to
discharge?
YES
A6
Send
Senddischarge
discharge
Letter
Letterto
to
referrer:
referrer:
Access
Access(A6)
(A6)
A5
TRACKER
Send
Sendletter
letter
to
toService
Service
User
User
Access
Access(A5)
(A5)
Start
StartTracker/
Tracker/
Checklist
Checklist
Input
Inputonto
ontoTracker/
Tracker/
Checklist
Checklistfor
forthis
thisphase
phase
Input
Inputonto
ontoTracker/
Tracker/
Checklist
Checklistfor
forthis
thisphase
phase
Complete
Complete&&Sign
Signoff
offTracker/
Tracker/
Checklist
Checklist
APPENDIX C
ACCESS TEAM SHIFT COORDINATOR – ROLES AND RESPONSIBILITIES
The Shift Coordinator will have the following responsibilities:

Ensuring that the shift is run efficiently and safely

Oversees work assigned to staff to ensure it is completed and that agreed team
practices and procedures are being followed

Ensuring that they are contactable at all times
The shift coordinator will:

Ensure staff rostered on duty are accounted for

Check in with administrative staff for scheduled meetings and daily activities for all
team members

Ensure the general mailbox messages are checked regularly and messages dealt with
in timely manner

Work to agreed safety procedures

Ensure that all shifts are safely covered

Ensure handover starts promptly at agreed times

Check for new referrals and those that have not been contacted and follow-up on
information as required

Ensure all work, including referrals are prioritised

Allocate all pending work, taking into consideration the role of the key worker, skill
mix, gender issues and safety factors

Ensure all staff are given opportunity to take part in handover and planning of the
shift

Ensure all assessments, either accepted or rejected, are discussed at handovers and
no in-between times

Ensure that weekly MDT meeting is organised

Ensure that the team diary is kept visible and ensure entry of important
appointments and task to be carried out

Ensure that ‘patient status at a glance’ (whiteboard) is kept up to date

Assesses workload of staff and if they have to complete intervention summaries,
referrals, etc., allocate as part of the shift

Ensure:
o Attendance at ward rounds
o Attendance at relevant meetings (e.g., CPA reviews)
o Completion of referrals
o Visits are allocated accordingly

Ensure all referrals are tracked and allocated according to the needs of the case and
workload of staff members

Intervene If activities and issues are unclear and make a decision, or if unable to
reach a decision consult with a senior member of staff to intervene
APPENDIX D
CLINICAL TRIAGE RISK DECISION GUIDE
URGENCY
TYPICAL PRESENTATION
RESPONSE TYPE/TIME
ADDITIONAL CONSIDERATIONS
High risk of harm to self or others  Active suicidal ideation with plan/partial plan and/or history
and/or high distress especially in
of suicidal ideation
absence of capable supports
 Rapidly increasing/developing symptom of psychosis and/or
severe mood disorder
 High risk behaviour associated with perceptual/thought
disturbance, delirium, dementia, or impaired impulse control,
including risk of harm to self or others
 Unable to care for self or dependents, or perform activities of
daily living due to acute mental health presentation
 Known service user requiring urgent intervention to prevent
certain relapse
 UndertaKe
clinical
triage,
Information
gather and assess
 4 hours
 Known to services
 Safeguarding issues/concerns
 Physical screening required
Moderate risk of harm and/or  Significant client/carer distress associated with serious mental
significant distress
illness (including mood/anxiety disorder) but not actively
suicidal
 Early symptom of psychosis
 Requires priority face-to-face assessment in order to clarify
diagnostic status
 Known service user requiring priority treatment or review
 Undertake
clinical
triage,
information
gather
and
offer
assessment
 2 calendar days
 As above
 Obtain additional/corroborating
information
from
relevant
others
Low risk of harm in short-term or  Requires specialist mental health assessment but is stable and
moderate
risk
with
high
at low risk of harm in waiting period
support/stabilising factors
 Other service providers able to manage the person until
appointment offered to be assessed
 Undertake
clinical
triage,
information
gather
and offer
assessment
 14 calendar days
 As above
Referral not requiring face-to-  Other services (e.g., GP, Primary Care Services, 3rd Sector
face response from Access Team
services) more appropriate to service user’s current needs
in this instance.
 Symptoms mild to moderate depression, anxiety, adjustment,
behavioural disorder
Refer to Primary Care
Mental Health Service
(IAPT), Primary Care
Services, GP, 3rd. Sector .
Only advice and/or information  Service user/carer requiring advice or opportunity to talk
required, or service provider  Service provider requiring telephone consultation/advice
consultation
 Issue not requiring mental health or other services
Advice and information to
service user/Professional
advice from clinical triage
staff
 GP may request to speak with
from consultant psychiatrist
APPENDIX E
APPENDIX F
MENTAL HEALTH CRISIS PATHWAY – LEARNING DISABILITIES
Who is this pathway designed to support?
Adults with a learning disability who have been identified as having additional complex needs
and are at immediate risk to themselves or others or harm that requires in-patient admission.
Additional complex health needs may include significant difficulties in the following areas:

suicidal intent

mental illness not responding to interventions in community settings

severe challenging behaviours
and may:

require use of legislation

be resistant to treatment

be inter-related to other bio-psycho social needs

require more than one professional and a multi-disciplinary team to meet their needs

require care programme approach (CPA) continued support
Emergency/Crisis Point of Contact
 – 999
Police

If there is an immediate risk to your safety, the safety of others or the service user,
seek emergency support from the police.
What can service users expect?

Assessment of biopsychosocial factors and clarification of diagnosis

Risk assessment and management plans

Pharmacological and psychological based approaches

Planned discharge with a suitable care package
Who can refer to acute specialist learning disability services?
We have an open referral process which includes:

GPs

NHS clinicians

Community learning disability teams

Social services
ASSESSMENT & MANAGEMENT OF RISK GUIDELINES
Key principles



Keep the person safe
Keep other people safe
Keep yourself safe
Indicators of risk
Risk assessment is an on-going process and should always be at the forefront of any
practitioner’s clinical thinking. Be alert for the following:
Referral
 Information on suicide attempts, self-harm threats and threats to others.
 A history of depression and/or psychosis.
 A forensic history.
 Borderline Personality Disorder (BDP).
 Young men and older people are more at risk.
History
 Previous attempts.
 Major life changes.
 Substance misuse problems.
 Recent discharge from inpatient care.
 Serious physical illness.
In session factors
 Threats or plans to harm self.
 Hopelessness / no sense of a positive future.
 Current unmet need / lack of a social network / isolation.
 Mental health practitioner intuition and concern.
Proactive assessment of risk
Ask about the following:






Level of intent: Are there definite plans?
Degree of hopelessness?
Problem solving: Are there alternative ways out – possible solutions?
Social support: Are there people at home? Can these people help?
Access to means: Does the person have access to a means to hurt themselves?
Harm to others: Are other people at home, carers or children at risk from the
behaviour?
ROTHERHAM SCREENING TOOL
Screening Information
(to be done together with Screening Questionnaire)
Name of client:
Date of Screening:
Name of person completing screening:
Information gathered from:
Birth:
Normal Birth:
Yes/No/Don’t Know
If no, what is known about birth difficulties?
Schooling:
Did client have a Statement of Special Education Needs?
If yes, what details are known for why Statement issued?
Did client attend “special” school(s)
If so, which one?
Yes/No/Don’t Know
Yes/No
Current Social Situation:
Work and/or leisure activities:
Does client exhibit any behavioural difficulties?
If yes, what is the nature of these difficulties?
Medication:
Yes/No
Current Skills and Abilities
Client’s personal care skills (e.g., Personal hygiene, dressing, etc.):
Client’s domestic skills (e.g., Cooking, laundry, shopping, etc.):
Can client travel on their own?
Yes/No
If yes, to what extent? (e.g., Safe on roads, knows how to get to familiar or unfamiliar places, etc.):
Can client take care of own money?
If yes, to what extent?
Yes/No
NOW PLEASE MOVE ON TO THE SCREENING QUESTIONNAIRE
Learning Disability Screening Questionnaire Scoring Sheet
Name of client:
Completed by:
Name of respondent:
Date of Birth:
Date of Assessment:
R’ship to client:
Yes
No
1.
Can the client tell the time
(Use picture sheet)
Score = 1
Score = 0
2.
Can the client read?
(Use reading sheet)
Score = 1
Score = 0
3.
Can the client write?
(Read text on writing sheet and ask client to write it down)
Score = 1
Score = 0
4.
Does the client live independently?
Score = 1
Score = 0
5.
Does the client have job?
Score = 1
Score = 0
6.
Has the client had previous contact with learing disability
service?
Score = 1
Score = 0
7.
Has the client had special schooling?
Score = 1
Score = 0
Total score:
Scored items (No. of items answered “yes” or “no”)
Percentage score (Total score divided by scored items multiplied by 100)
Don’t
Know
Score
Telling the Time
Reading
Your views are important to us so please let us know if you have anything to tell us to make our
services better. We will let you know we have received your comment within three days and get in
touch with you as soon as possible/
Writing
THIS MUST BE READ OUT LOUD TO THE PERSON BEING ASSESSED.
DO NOT SHOW THIS TO THEM.
I can get worried when I go to see my doctor. It is helpful to write my questions down before I see him
so that I don’t forget anything important.
DONCASTER SCREENING TOOL
Definition of a learning disability
Learning disability includes the presence of:
• A significantly reduced ability to understand new or complex information, to learn
new skills (impaired intelligence), with;
• A reduced ability to cope independently (impaired social functioning);
• Which started before adulthood with a lasting effect on development
The ‘Valuing People’ White Paper (DoH 2001).
Mental retardation (Learning Disability) is a condition of arrested or incomplete development
of mind, which is especially characterised by impairment of skills manifested during the
developmental period which contributes towards overall development of intelligence, i.e.
cognitive, language, motor and social abilities. Adaptive behaviour is always impaired
though may not always be obvious. (ICD10, WHO, 1992)
Approximately only 2% of the population in the UK have a learning disability.
What isn’t a learning disability but is a learning difficulty?
• Problems with reading, writing or numeracy only.
• Emotional difficulties that may sufficiently have disrupted schooling,
influencing achievement.
• Conditions like Attention Deficit Hyperactivity Disorder (A.D.H.D.) or
hyperactive disorder.
• Asperger’s syndrome and some individuals with Autism (a ⅓ of people with
Autistic Spectrum Disorders do not have a learning disability).
However, you can have a learning difficulty as well as a learning disability.
Exclusion Criteria
People with a learning disability cannot usually have this label and be able to:
•
•
•
•
Independently attend courses and gain qualifications (GCSE O’Levels etc.)
Drive a car (Full UK driver’s licence).
Attend mainstream education without additional support.
Independently carry out complex purchasing (i.e. buying a house).
The term ‘Learning Disability’ does not include someone who has had normal development
until a head injury or accident after the age of 18 years.
There is no true or false answer so always apply caution.
Someone may wrongly present as having a learning disability.
Some conditions or disabilities may affect or mask the diagnosis of a learning disability,
these include:
Physical disability e.g. cerebral Mental Health – this can effect
palsy
adaptive functioning
Sensory disability
difficulties
Challenging
e.g. hearing ADHD
Epilepsy e.g. drugs
intellectual functioning
behaviour
–
e.g.
impairing Personality disorder
These things should be taken into consideration when doing the assessment.
Key points to investigate:
1. Has the person had a diagnosis of a learning disability in any paperwork? (Not
learning difficulties).
2. Does the person have a clinical syndrome likely to be a cause of learning
disability? E.g. Down’s syndrome, see clinical syndromes directory (attachment).
Yes
No
3. Do the person’s records show results of formal assessments, (e.g. WAIS-R,
Leiter etc.)?
Yes
No
4. Has the person been known to:
Learning Disability Health Professionals:
(please tick)
Psychiatrist
Learning disability Nurse
Speech Therapist
Psychologist
Physiotherapist
Occupational Therapist
Have they attended any Learning Disability Hospital such as:
(please tick)
St Catherine’s Hospital
Learning Disabilities Out-Patient Clinic
If you have answered yes to questions 2 or 3 or have ticked any boxes in question 4 – To
clarify diagnosis, it should be possible to contact the professional/ organisation involved.
Did the person go to a special school or have additional support at a mainstream school?
(This does not include support for emotional/behavioural difficulties alone but for
educational difficulties), i.e.
Doncaster Special Schools for children with severe learning disabilities:
Chase / Coppice School
Fernbank / North Ridge School
Cedar / Heatherwood School
Doncaster special schools for children with moderate learning difficulties:
Pennine View School
Stonehill School
5. Has the p e r s o n b e e n statemented? (It m a y b e necessary to ask the relevant
professional for copies of reports)
Yes
No
6.
Adaptive
skills
functioning).
(also
know
as
social
competence
or
social
This must be completed when person is stable i.e. not suffering mental ill health.
skills
Tick the most appropriate box
Fully
independent
(no
help/prompting
needed)
Some
independence
(much
help
and/or
prompting
needed)
Very little or no
independence
Communication
Self care (washing, etc.)
Home living
(domestic skills, e.g. setting the table,
cooking, cleaning, hovering)
Social skills
(relationships, e.g. has one good friend)
Use of community facilities
(e.g. library, recreation facilities)
Self direction
(e.g. structuring your day, setting goals)
Health and Safety
(e.g. understanding of danger)
Reading and Writing
Leisure activities
(e.g. participation in activities)
Work
(ever employed, kind of work)
If there are more than two ticks in the ‘some independence’ column, the person may have
generalised limitations and, therefore, may have learning disabilities (from A.A.M.R. 1992).
NORTH LINCS SCREENING TOOL
APPENDIX G
CAMHS-CRISIS – ‘OUT OF HOURS’ PATHWAY
SERVICE USER UNDER 16 YEARS OLD
SERVICE USER AGE 16 AND ABOVE
REFERRAL FROM EXTERNAL AGENCY
PHONE CRISIS TEAM STAFF ON DUTY
(Mon-Thurs 5pm-9am next day)
(Friday 5pm-Mon 9am)
YES
Crisis Team staff to contact
‘On-Call’ CAMHS Worker to
attend A&E Dept.
Assessment completed by
CAMHS Worker – Next steps
agreed
Is service user under
16?
CRS staff to contact St. Cath’s
Switchboard to ask for ‘On-call’
CAMHS clinician (as they will have
most up to date rota)
NO
Crisis Team Staff to initially liaise
with ‘On-call’ CAMHS Worker
Lynn Eyvbowho will circulate
CAMHS worker ‘On call’ rota
[[email protected]]
YES
Does referral
meet 16-18
CAMHS assessment
Criteria?*
‘On-Call’ CAMHS Worker to
attend A&E Dept.
NO
Assessment to be completed
by Crisis Worker
*Criteria for Joint Assessment:
‘On-call’ CAMHS Worker
Completes their agreed
assessment documentation
CAMHS worker ‘signs-off’ to
CRS staff
[Lone Working Policy]
· Dual diagnosis – mental
health and ASD/ADHD/LD
Joint assessment completed
by CAMHS/Crisis Staff –
Next steps agreed
· Complex safeguarding issues
Assessment completed by
Crisis Worker – Next steps
agreed
· Looked after children with
complex situation
Crisis worker completes
MARACIS CAMHS
Assessment
‘On-call’ CAMHS
Worker Completes
their agreed assessment
documentation
Refer to Local
CAMHS service next
working day
[No MHC cluster required]
APPENDIX H
CRISIS RESOLUTION - AMBULANCE CREW CONTACT ALGORITHM
Ambulance HUB
contact CRS Service
IMPORTANT TO REMEMBER
Ambulance Crews only have
maximum of 10 minutes for you to
make decision
Shift coordinator/
CRS staff takes call
Is service user
currently receiving
a service from
RDaSH?
YES
Is it after 8pm?
YES
Does service user
need to be seen by
CRS staff?
NO
YES
NO
NO
NO
Process as new
referral
Does service user
need to be seen by
CRS staff?
YES
Is service user safe to
be seen at home?
Does service user
refuse to go?
YES
YES
Direct Ambualnce crew to
take service user to A&E
Dept.
Make arrangements to
visit service user at home
Record
events on
MARACIS
NO
Pass service user details on to
admin staff to create new referral
for audit purposes
Does service user
have Care Coordinator/
Lead professional
NO
Send
Send outcome
outcome information
information
to
to GP
GP for
for their
their records
records
Consider MH
Act
YES
Does service user
want to be seen at
home by care
coordinator/lead
professional?
Offer Access team
appointment
YES
Inform care coordinator/lead
professional of contact and
request to visit service user
APPENDIX I
ACCESS TEAM ASSESSMENT OUTCOME SUB-PROCESSES
SUB PROCESS
MENTAL HEALTH ACT
Mental Health Act
Work Entry into
service
ACCESS TEAM
Unplanned?
FURTHER ACTION
· Complete Tribunal Report
· Attend Manager’s hearing
Sufficient AMHP
staff to undertake
Requests?
YES
NO
Admit to Mental Health Unit
WARD
(Wards)
Admit to Mental
Health Unit (Wards)
Complete and send:
· Referral documentation
· Risk assessment
· Inform care coordinator/lead
professional (if known)
Admit to Rethink Crisis Bed
(Where available in locality)
(Where available in
locality)
Complete and send:
· Referral documentation
· Risk assessment
· Inform care coordinator/lead
professional (if known)
· Transfer to appropriate
treatment team identified by
cluster
· Discharge from Access Team
TREATMENT TEAMS
Transfer to
appropriate
treatment team
identified by cluster
IAPT
Admit to Rethink
Crisis Bed
Transfer to IAPT/
Primary Care
Mental Health
Services
· Discharge from Access team
and transsfer to IAPT
· Write to inform GP of
contact with Access Taam
and transfer to IAPT services
GP/PRIMARY CARE
CRISIS BED
[RETHINK]
YES
RESPONSE TODAY
· Section 136
· Section 135
· Section 2
· Section 3
· Section 4
Discharge to GP/
Primary Care
Services
Discharge from service and
write to inform GP of contact
with Access TEam
Use identified Access Team
AMHP’s
Access Local AMHP Rota to
supplement
NO
PLANNED
· Section 5(2)
· Section 2 TO 3
· Case known to team (including
section 2 and 3, section 135)
· Community Treatment orders
· Guardianship
TREATMENT TEAMS
APPENDIX J
Information
Sharing
Protocol
Contents
Page No
1. Introduction
3
2. Scope
4
3. Aims and Objectives
5
4. The Legal Framework
6
5. Data Covered By This Protocol
7
6. Purposes for Sharing Information
8
7. Restrictions on the Use of Information Shared
9
8. Consent
10
9. Organisational Responsibilities
11
10. Individual Responsibilities
12
11. General Principles
13
12. Review Arrangements
14
Signatures and Contact Information
15
Appendix 1: Relevant Legislation
16
Appendix 2: Glossary
22
Appendix 3: Information Sharing Agreement
25
2
1.0
Introduction
1.1
Rethink is committed to working together for the delivery of improved public
services to the people of Doncaster. It is recognised that the lawful sharing of
information between partner agencies is essential to meet these aims.
1.2
The Rethink Information Sharing Protocol has been established to help
support these aims.
1.3
Rethink and the Doncaster Access Team have endorsed this document.
1.4
This document is an Information Sharing Protocol for key organisations in the
Doncaster Crisis Accommodation & Outreach Service. Its aim is to facilitate
sharing of information between the public, private and voluntary sectors so
that the public receive the services they need.
1.5
Organisations involved in providing services to the public have a legal
responsibility to make sure that their use of personal information is lawful,
properly controlled and that an individual’s rights are respected. This balance
between the need to share information to provide a quality service and to
protect confidentiality is often a difficult one.
1.6
The legal situation on the protection and use of personal information can be
unclear. This may lead to information not being readily available to those who
have a genuine need to know. See Appendix 1.
3
2.
Scope
2.1
This Protocol sets out the principles for information sharing between partner
organisations.
2.2
This Protocol sets out the minimum rules that all people working for or with
the partner organisations must follow when using and sharing information.
2.3
The Protocol applies to the following information:



all personal information processed by the organisations including;
electronically such as computer systems, CCTV, audio or in manual
records;
aggregated and anonymised data.
Consideration must be given to other factors such as commercial or business
and sensitive data.
2.4
The Protocol may be extended further to include other public sector, private
and voluntary organisations working in partnership to deliver services.
4
3.
Aims and Objectives
3.1
The aim of this Protocol is to provide a framework for partner organisations to
establish and regulate working practice. The Protocol provides guidance to
make sure the secure information is securely transferred and that information
shared is for justifiable ‘need to know basis. See 6.3 and 11.6.
3.2
These aims intend to:








3.3
By becoming a partner to this Protocol, partner organisations are making a
commitment to:



3.4
Guide partner organisations on how to share personal information lawfully.
Explain the security and confidentiality laws and principles of information
sharing.
Increase awareness and understanding of the key issues.
Emphasise the need to develop and use information sharing agreements.
Support a process, which will monitor and review all data flows.
Encourage a two-way flow of data, where applicable.
Protect the partner organisations from accusations of wrongful use of
sensitive personal information.
Identify the lawful basis for information sharing.
Apply the Information Commissioner’s Code of Practice’s ‘Fair Processing’
and ‘Best Practices’ Standards.
Follow, or demonstrate a commitment to, achieving the appropriate
compliance with the Data Protection Act 1998. See Glossary of
Legislation.
Develop local information sharing agreements that specify transaction
details. See Appendix 3.
All partners are expected to promote employee awareness of the major
requirements of information sharing. Appropriate guidelines will be produced
where required to support this.
5
4.
The Legal Framework
4.1
Principal legislation concerning the protection and use of personal
information, further explained in Appendix 1:




4.2
Other legislation may be relevant when sharing specific information:








4.3
Human Rights Act 1998 – Article 8
The Freedom of Information Act 2000
Data protection Act 1998
The Common Law Duty of Confidence
Children Acts 1989, 2004
Crime and Disorder Act 1998
The Education Act 1996
Health Act 1999
Health and Social Care Act 2001
Mental Health (Patients in the Community) Act 1995
National Health Service and Community Care Act 1990
The Regulation of Investigatory Powers Act 2000
Other standards may be relevant when sharing specific information:



The Caldicott Principles
The NHS Information Governance Framework
The Government Protective Marking Scheme
6
5.
Data Covered By This Protocol
5.1
All personal and anonymised information, as defined in the Data Protection
Act 1998, is covered in this Protocol. Anonymous data should be used
wherever possible.
Personal Information
5.2
The term ‘personal information’ refers to any information held as either
manual or electronic records, or records held by means of audio and/or visual
technology, about an individual who can be personally identified from that
information.
5.3
The term is further defined in the Data Protection Act as:


Data relating to a living individual who can be identified from those data, or
Any other information which is in the possession of, or is likely to come
into the possession of, the data controller – the person or organisation
collecting that information.
5.4
The Data protection Act also defines certain classes of personal information
as ‘sensitive data’ where additional conditions must be met for that
information to be used and disclosed lawfully.
5.5
An individual may consider certain information about themselves to be
particularly ‘sensitive’ and may request other data items to be kept especially
confidential. For example, any use of a pseudonym when their true identity
needs to be withheld to protect them.
5.6
In certain circumstances, although not all, people have a legal right to choose
how their data is used and who may have access to it. As far as possible,
depending on the circumstances under which the data is collected, their
individual wishes should be respected. Any personal information about an
individual should be treated as sensitive.
Anonymised Data
5.7
Make sure that anonymised information does not identify an individual, either
directly or by summation.
5.8
Data about an individual can be shared without their consent in a form where
the identity of the individual cannot be recognised. For example when:


5.9
Reference to any data item that could lead to an individual being identified
has been removed;
The data cannot be combined with any data sources held by a partner to
produce personal identifiable data.
Anonymising data does not remove the duty of confidence.
7
6.
Purposes For Sharing Information
6.1
Information should only be shared for a specific lawful purpose or when
appropriate consent has been obtained.
6.2
Employees should only have access to personal information on a justifiable
need to know basis, in order for them to perform their duties in connection
with the support they are there to deliver.
6.3
Having this agreement does not give license for unrestricted access to
information another partner organisation may hold. It lays the parameters for
the safe and secure sharing of information for a justified need to know
purpose.
6.4
All employees have an obligation to protect confidentiality and a duty to
ensure that information is only disclosed to those who have a right to see it.
6.5
All employees should be trained and be fully aware of their responsibilities to
maintain the security and confidentiality of personal information.
6.6
All staff should follow the procedures and standards that have been agreed
and incorporated within this Information Sharing Protocol and any associated
information sharing agreements.
6.7
Each partner organisation will operate lawfully in accordance with the eight
Data Protection Principles, See Appendix 1.
6.8
Personal data shall not be transferred to a country or territory outside the
European Economic Area without an adequate level of protection for the
rights and freedoms of the data subject in relation to the processing of
personal data.
8
7.
Restrictions On Use Of Shared Information
7.1
Information must only be used for the purpose(s) specified at the time of
disclosure(s) as defined in the relevant information sharing agreement. It is a
condition of access that it must not be used for any other purpose without the
permission of the Data Controller who supplied the data, unless an exemption
applies within the Data Protection Act.
7.2
Additional statutory restrictions apply to the disclosure of certain information.
For example, criminal records, HIV and AIDS, assisted conception and
abortion and child protection.
7.3
It is recognised that individual organisational policies and procedures may
place additional restrictions on the sharing of information. For example,
limitations for the electronic transfer of information where secure
communications cannot be guaranteed.
9
8.
Consent
8.1
Consent is not the only means by which data can be disclosed. Under the
Data Protection Act 1998, to disclose personal information at least one
condition in Schedule 2 must be met. To disclose sensitive personal
information, at least one condition in both Schedules 2 and 3 must be met.
Appendix 1 contains more information and the Glossary may be helpful.
8.2
Where a partner organisation has a statutory obligation to disclose personal
information, then the consent of the data subject is not required. However, the
data subject should be informed that such an obligation exists.
8.3
If a partner organisation decides not to disclose some or all of the personal
information, the requesting partner must be informed. For example, the
partner organisation may be relying on an exemption or on the inability to
obtain consent from the data subject.
8.4
Consent has to be signified by some communication between the organisation
and the data subject. If the data subject does not respond this cannot be
assumed as implied consent.
8.5
If consent is used as a form of justification for disclosure, the data subject
must have the right to withdraw consent at any time. When using sensitive
data, explicit consent must be obtained. In such cases, the data subject’s
consent must be clear. It must cover items such as the specific details of
processing, the data to be processed and the purpose for processing.
8.6
Specific procedures apply when the data subject is under the age of 16 or
they do not have the capacity to give informed consent. In these
circumstances, referral should be made to the relevant policy of the partner
organisation.
10
9.
Organisational Responsibilities
9.1
Each partner organisation is responsible for making sure that their
organisational and security measures protect the lawful use, integrity and
availability of information shared under this Protocol.
9.2
Partner organisations will accept the security classifications on information
and handle the information accordingly.
9.3
Partner organisations accept responsibility for jointly auditing compliance with
the information sharing agreements in which they are involved.
9.4
Partner organisations should make it a condition of employment that its
employees will abide by its rules and policies on the protection and use of
confidential information. This condition should be written into employment
contracts and any failure by an employee to follow the policy should be dealt
with in accordance with the organisation’s disciplinary procedures.
9.5
Partner organisations should make sure their contracts with external service
providers abide by their rules and policies on the protection and use of
confidential information.
9.6
The partner organisation originally supplying the information should be
notified of any breach of confidentiality, or incident, involving a risk of breach
of the security of information.
9.7
Partner organisations should have documented policies for records retention,
maintenance and secure waste destruction.
11
10.
Individual Responsibilities
10.1
Every employee working for the organisations listed in this Protocol:





Is personally responsible for the safekeeping of sensitive information they
obtain, handle, use and disclose – process.
Should know how to obtain, use and share information they legitimately
need to do their job.
Has an obligation to request proof of identity, or take steps to validate the
authorisation of another before disclosing sensitive information.
Must uphold the general principles of confidentiality, follow the rules laid
down in this Protocol and seek advice when necessary.
Should be aware that any violation of privacy or breach of confidentiality is
unlawful and a disciplinary matter that could lead to their dismissal.
12
11.
General Principles
11.1
The principles outlined in this Protocol are legal requirements or
recommended good standards of practice that should be followed equally
across all services.
11.2
This Protocol sets the core standards applicable to all partner organisations
and should be the basis of all information sharing agreements established to
secure the flow of personal information.
11.3
This Protocol should be used together with local service level agreements,
contracts or any other formal agreements that exist between the partner
organisations.
11.4
All parties signed up to this Protocol are responsible for making sure that they
have organisation measures to protect the security and integrity of personal
information and that their employees are properly trained to understand their
responsibilities and comply with the law.
11.5
This Protocol has clear and consistent principles that satisfy the requirements
of the law that all employees must follow when using and sharing personal
information.
11.6
The specific purpose for using and sharing information will be defined in the
information sharing agreements that will be specific to the partner
organisations sharing information.
13
12.
Review Arrangements
12.1
Rethink and the Doncaster Access Team will formally review this
agreement annually, unless new or revised legislation or national
guidance necessitates an earlier review.
12.2 Any of the signatories can request an extraordinary review at any time
when a joint discussion or decision is necessary to tackle local service
developments.
14
Signatures and Contact Information Agreement
We, the undersigned, agree to implement the terms and conditions of this Protocol.
Organisation
Chief
Executive/Officer
Signature
15
Date
Contact
Telephone
E-mail
Appendix 1
Relevant Legislation
Data Protection Act 1998
The Data Protection Act 1998 governs the protection and use of personal
information, that is data that relates to a living individual who can be identified.
The Act does not apply to personal information about people who have died.
Any organisation processing, obtaining, holding, using, disclosing and
disposing of data is a ‘Data Controller’ responsible for abiding by the eight
data protection principles and notifying the Information Commissioner of that
processing.
The Act gives seven rights to individuals about their own personal data:





Right of subject access.
Right to prevent processing likely to cause damage or distress.
Right to prevent processing for the purposes of direct marketing.
Rights in relation to automated decision taking.
Right to take action for compensation if the individual suffers damage or
damage and distress, as a result of any breach of the Act.
 Right to take action to rectify, block, erase, or destroy inaccurate data.
 Right to request the Information Commissioner for an assessment to be
made as to whether any provisions of the Act have been contravened.
16
The Eight Key Principles of the Act
The Data Protection Act 1998
1
Personal data shall be processed fairly and lawfully and
shall not be processed unless at least one of the
conditions in Schedule 2 is met and for ‘sensitive
personal data’ at least one of the conditions in Schedule
3 is also met.
2
Personal data shall be obtained for specified and lawful
purposes and shall not be further processed in any
manner incompatible with that purpose/ purposes.
3
Personal data shall be adequate, relevant and not
excessive in relation to the purpose/ purposes for which
they are processed.
4
Personal data shall be accurate and, where necessary
kept up-to-date.
5
Personal data shall not be kept for longer than is
necessary for that purpose/ purposes.
6
Personal data shall be processed in accordance with the
rights of the data subject under this Act.
7
Appropriate technical and organisational measures shall
be taken against unauthorised or unlawful processing of
personal data and against accidental loss, destruction or
damage to personal data.
8
Personal data shall not be transferred to a country or
territory outside the European Economic Area, EEA,
without an adequate level of protection for the rights and
freedoms of the data subject in relation to the processing
of personal data.
17
Seventh Principle – Interpretation
The Act gives some further guidance on issues that should be considered in
deciding whether security measures are ‘appropriate’. These are:
 Taking into account the state of technological development at any time
and the costs of implementing any measures. The measures must
ensure a level of security appropriate to:
1 The harm that might arise from a breach of security; and
2 The type of data to be protected;
3 The Data Controller must take reasonable steps to ensure the
reliability of employees having access to the personal data.
Some of the security controls that the Data Controller is likely to need to
consider include:





Security management
Controlling access to information
Ensuring business continuity
Employee selection and training
Detecting and dealing with breaches of security
The Act has express obligations on Data Controllers when the processing of
personal data is done by a data processor on behalf of the Data Controller. To
comply with the seventh principle the Data Controller must:
 Choose a data processor providing sufficient guarantees in respect of
the technical and organisational security measures they take.
 Take reasonable steps to ensure compliance with those measures.
 Make sure that the processing by the data processor is done under a
contract, which is made or evidenced in writing, under which the data
processor is to act only on instructions from the Data Controller. The
contract must require the data processor to comply with obligations
equivalent to those imposed on the data controller by the seventh
principle.
Further evidence is in BS 7799 and ISO/IEC Standard 17799.
It is important to note that the seventh principle relates to the security of the
processing as a whole and the measures to be taken by data controllers to
provide security against any breaches of the Act rather than just breaches of
security.
18
Schedule 2 and Schedule 3 Conditions
In order to process personal data, one condition from Schedule 2 should be
met.
In order to process sensitive personal data, one condition from Schedule 2
and one condition from Schedule 3 should be met.
Schedule 2: Personal data
Schedule 3: Sensitive personal data
The data subject has given consent,
or the processing is necessary for:-
The data subject has given explicit consent,
or the processing is necessary for:-
• a contract
• a legal obligation
• protection of the vital interests
• public function
• in the public interest
• a statutory obligation
• legitimate interests of the data
controller
• employment-related purposes
• the purpose of, or in connection with, legal
proceedings
• protect the vital interests of the individual
when consent cannot be obtained
• made public by the data subject
• a substantial public interest
• preventing or detecting an unlawful act
• the legitimate interests of a non-profit data
controller making organisation
• medical purposes by a health professional
19
The Human Rights Act 1998
The Human Rights Act 1998 incorporates into our domestic law certain
articles of the European Convention on Human Rights. The Act requires all
domestic law to be read compatibly with the Convention Articles.
It also places a legal obligation on all public organisations to act in a manner
compatible with the Convention. If a public organisation fails to do this, then it
may be the subject of legal action under Section 7. This is an obligation not to
violate convention rights, but a positive obligation to uphold these rights.
Sharing of information between agencies has the potential to infringe a
number of convention rights. In particular, Article 3 – Freedom from torture or
inhuman or degrading treatment, Article 8 – Right to respect private and family
life and Article 1 of Protocol 1 – Protection of Property.
The qualification of Article 8 is ‘there shall be no interference by a public
organisation with this right unless it is in the interests of national security,
public safety, the economic well being of the country, the prevention of
disorder and crime, the protection of health and morals, or the protection of
the rights and freedoms of others’.
In addition, all convention rights must be secured without discrimination on a
wide variety of grounds under Article 14.
The convention does allow interference with the convention rights by public
organisations, under certain broadly defined circumstances known as
legitimate aims. However, mere reliance on a legal power may not alone
provide sufficient justification and they must consider:
 Is there a legal basis for the action being taken?
 Does it pursue a legitimate aim as outlined in the particular Convention
Article?
 Is the action taken proportionate and the least intrusive method of
achieving that aim?
Article 8.1 provides that ‘everyone has the right to respect for his private and
family life, his home and his correspondence.’
Article 8.2 provides ‘there shall be no interference by a public authority with
the exercise of this right except in accordance with the law and is necessary in
a democratic society in the interest of national security, public safety or the
economic well-being of the country for the prevention of crime and disorder,
for the protection of health and morals or for the protection of the rights and
freedoms of others’.
20
Other Legislation
Other Acts apply to further specify these exceptions. For example:
 Prevention of Terrorism Act 2002
 Health and Social Care Act 2000
 Regulation of Investigatory Power Act RIPA 2000
Further information about these or any other relevant legislation is on the
HMSO website: www.hmso.gov.uk
The Freedom of Information Act
The Freedom of Information Act 2000 applies to all public organisations and
came into force in 2003.
The Act creates new rights of access to information, rights of access to
personal information will remain under the Data protection Act, and revises
and strengthens the Public Records Act 1958 and 1967 be re-enforcing
records management standards of practice.
The Lord Chancellor has issued a code of practice on the management of
records under Freedom of Information. The principle is that ‘any freedom of
information legislation is only as good as the quality of the records to which it
provides access. Such rights are of little use if reliable records are not created
in the first place.’ Further information guidance is available at
www.informationcommissioner.gov.uk.
The Common Law of Confidence
The Common Law Duty of Confidence requires that information that has been
provided in confidence may only be used for purposes of which the subject
has been informed and given consent unless a specific statutory requirement
exists.
The duty is not absolute but may only be overridden if the holder of the
information can justify disclosure as being in the public interest, for example,
to protect others from harm.
21
Appendix 2
Glossary
Accessible Record
Unstructured personal information, usually in manual form relating to health,
education, social work and housing.
Agent
Acts on behalf of the data subject.
Anonymous Data
If the Data Controller has information that allows data subjects to be identified,
the Information Commissioner would rule it is not anonymous data. This is
regardless of whether or not they intend to identify individuals. The Data
Controller must be able to justify why and how the data is no longer personal.
CCTV
Close Circuit Television.
Consent
The Information Commissioner’s legal guidance to the Data Protection Act
1998 is to refer to the Directive, which defines consent as ‘any freely given
specific and informed indication of his wishes by which the data subject
signifies his agreement to personal data relating to him being processed’.
(3.1.5).
Data is information: being processed by means of equipment operating automatically; or
 recorded with the intention it will be processed by such equipment; or
 recorded as part of a relevant filing system; or
 the three items listed forming part of an accessible record but not part of
it.
Data Controller
A person or a legitimate organisation such as a business or public authority
who jointly or alone determines the purposes for which personal data is
processed.
Data flows
The movement of information internally and externally, both within and
between organisations.
Data processing
Any operation performed on data. The main examples are collecting,
retaining, deleting, using and disclosing data.
22
Data processor
Operates on behalf of the Data Controller. Not the organisations employees.
Data set
A defined group of information.
Data subject
An individual who is the subject of personal information.
Disclosure
Passing information from the Data Controller to another organisation or an
individual.
Duty of confidence
Everyone has a duty under common law to safeguard personal information.
EEA
This consists of the fifteen EU members together with Iceland, Liechtenstein
and Norway.
Fair processing
To inform the data subject how the data is to be processed before processing
starts.
Health professional
In the Data Protection Act 1998, ‘health professional’ means any of the
following who is registered as: a medical practitioner, dentist, optician, pharmaceutical chemist, nurse,
midwife or health visitor and osteopaths.
 Any person who is registered as a member of a profession to which the
Professions Supplementary to Medicine Act 1960bcurrently extends.
Clinical psychologists, child psychotherapists and speech therapists,
music therapists employed by a health service body, and scientists
employed by an organisation as head of department.
Health record
Any information relating to health, produced by a health professional.
Information Sharing Agreement
The local information sharing agreement in Appendix 3.
Personal data
Data relating to a living individual who can be identified from those data,
including opinion and expression of intention.
23
Purpose
The use of reason for which information is stored or processed.
Recipient
Anyone who receives personal information except statutory bodies for the
purpose of specific inquiries.
Relevant filing system (two level of structure):
 Filing system structured by some criteria.
 Each file structured so that particular information is readily accessible.
Sensitive personal data
Data concerning racial origin, politics, trade union activity, health, sexuality,
offending.
Serious crime
There is no absolute definition of ‘serious crime’, but Section 116 of the Police
and Criminal Evidence Act 1984 identifies some ‘serious arrestable offences’.
These include:












Treason
Murder
Manslaughter
Rape
Kidnapping
Certain sexual offences
Causing an explosion
Certain firearms offences
Taking of hostages
Hijacking
Causing death by reckless driving
Offences under Prevention of Terrorism legislation, disclosures are now
covered by the Prevention of Terrorism Act 1989.
Subject access
The individual’s right to obtain a copy of information held about themselves.
Third Party
Any person who is not the data subject, the data controller, or the data
processor. This includes health, housing, education, carers, voluntary sector
workers as well as members of the public.
24
Appendix 3
Doncaster Crisis Accommodation & Outreach Service Information
Sharing Agreement
Partners
1.1
Rethink and Doncaster Access Team
1.2
It will be the responsibility of these signatories to make sure that they:






have realistic expectations from the outset;
maintain ethical standards;
have a process by which the flow of information can be controlled;
provide appropriate training;
have adequate arrangements to test compliance with the agreement;
meet Data Protection and other relevant legislative requirements.
Purpose of this information sharing agreement
2.1
The purpose of this Information Sharing Agreement is to co-ordinate the
continued care between the partner organisations for people accessing
the Doncaster Crisis Accommodation Service and the Crisis Outreach
Service.
The type and extent of information to be shared
3.1
The information shared should be the minimum amount necessary.
The information exchanged routinely under this agreement is client
name, address and date of birth and a current assessment of risk and
mental health needs (using the Maracis screening assessment tool)
3.2
Anonymised Information
Whenever possible data should be anonymised. If large volumes of
data are provided for research and/or planning by partner organisations,
as a matter of courtesy the outcome of that research/ planning should
be provided to the organisation(s) supplying the data.
3.3
How the information may be used:
 Information provided under this agreement will not be used for
monitoring or reporting purposes.
 All information provided under this agreement will be used to coordinate and deliver support services to people for the duration of
25
their stay in the crisis accommodation and their engagement with
the Outreach Service. Information will be stored securely, with
access by authorised personnel only.
 Information provided under this agreement will not be shared with
any other agency.
Data Quality
4.1
Data quality issues will be addressed by managers of the partner
organisations, with advice sought from the Data Controller where
necessary.
4.2
Information discovered to be inaccurate, out-of-date or inadequate for
the purpose should be notified to the Data Controller who will be
responsible for correcting the data and notifying all other recipients of
the information who must ensure the correction is made.
Data retention, review and disposal
5.1
Data should be provided before admission to Doncaster Crisis
Accommodation Service can be facilitated.
5.2
Electronic and paper records will be stored and disposed of in line with
the Data Protection Act 1998 and Rethink’s Information Storage and
Disposal Policy.
Appropriate security
6.1
The partners to this agreement acknowledge the security requirements
of the Data Protection Act 1998 applicable to the processing of the
information subject to this agreement.
6.2
Each partner will make sure they take appropriate technical and
organisational measures against unauthorised or unlawful processing of
personal data against accidental loss or destruction of, or damage to,
personal data.
6.3
In particular, each partner must make sure they have procedures in
place to do everything reasonable to:
 Make accidental compromise or damage unlikely during storage,
handling, use, processing, transmission or transport.
 Deter deliberate compromise or opportunist attack.
 Dispose of or destroy the data in a way that makes reconstruction
unlikely.
 Promote discretion to avoid unauthorised access.
26
6.4
Access to information subject to this agreement will only be granted to
those professionals who ‘need to know’ to effectively carry out their
duties.
Additional arrangements
7.1
To determine what security measures are appropriate in any given
case, partners must consider the type of data and the harm that would
arise from a breach of security. Information obtained in confidence may
be regarded as requiring a higher level of security. In particular, they
must consider:
 Where the information is stored.
 The security measures programmed into the relevant equipment.
 The reliability of employees having access to the information.
Complaints and breaches
8.1
All complaints or breaches relative to this agreement will be notified to
the designated Data Protection Manager of the relevant organisation in
accordance with their respective policy and procedures.
8.2
Partner organisations should consider how they:




Tackle any breach of agreement.
Handle internal discipline.
Monitor security incidents.
Deal with malfunctions.
Indemnity
9.1
The partner or third party processor will accept total liability for the
breach if legal proceedings are service in relation to the breach.
Subject access requests
10.1 Access requests will be processed by the relevant partner in line with
their organisations Data Protection Policy.
Third party consent will be obtained in line with partner organisation’s Data
Protection Policies.
General operational guidance
27
11.1 Resource implications
Partner organisations must consider the staff time and resource
implications that are involved for the Data Controller extracting the data.
If a request is made and then the data is no longer required there
should be a process for withdrawing the request.
11.2 Appropriate signatories
 A named individual will lead on the Information Sharing
Agreement.
 Training in the Information Sharing Agreement will be the
responsibility of both partner organisations
11.3 Review the Information Sharing Agreement
 This Information Sharing Agreement be reviewed annually (next
review due May 2013).
11.4 Compliance with the agreement
Compliance with the Information Sharing Agreement will be monitored
through partnership meetings.
Closure/ termination of agreement
12.1 Any partner organisation can suspend the Information Sharing
Agreement for 30 days, if they feel that security has been seriously
breached.
12.2 They must notify termination and/or completion that must be given in
writing with at least 30 days’ notice.
28
Crisis Service Local Procedure
Page 1 of 2
Date: June 2012
Accepting Referrals
Purpose
The purpose of this document is to details the procedure for staff working at Doncaster Crisis
Accommodation Service when accepting referrals.
Scope
This document applies to all staff working in the Doncaster Crisis Service when accepting a
referral from the Access Team.
Procedure
Referrals to the Crisis Accommodation must be made by the Access Team who gate keep
the service.
When making a referral, the Access Team will contact Rethink Mental Illness staff to provide
a verbal overview by phone of the person’s circumstances and risk profile. This must then be
followed up with referral paperwork being faxed through / delivered to the service a minimum
of one hour before admission is due to take place.
Referral paperwork must include an up to date screening assessment (Maracis) and a
Rethink Mental Illness referral form. Where in use, a Sainsburys Risk Assessment or
Clustering Tool should also be provided to support the information provided in the screening
assessment.
Referral information must detail any known triggers, points of reference or specific risks that
apply to the service environment, staff or other users of the service that Rethink Mental
Illness need to be aware of. Information should be provided regarding what action should be
taken should these become apparent during the person’s stay. Rethink Mental Illness staff
are responsible for ensuring that the Access Team are informed immediately and a plan for
ongoing support is agreed and documented.
Where risks are identified, staff must ascertain whether these are manageable within the
service. Where additional information is required in order to make an informed decision
regarding the appropriateness of admission, this must be sought from the referrer.
Where there are concerns that the risks may be not be managed safely within the crisis
accommodation setting, or where additional information is not accessible, the referral must
be discussed with the Service Lead. Where this is out of hours, the local on-call must be
contacted for further advice.
Where the Service Lead requires guidance, they must liaise with the Services Manager to
ensure the service can safely facilitate the admission. Where this is out of hours, Service
Leads operating the local on-call should liaise with the Services Manager wherever possible.
Alternatively, advice can be sought from the Duty Manager.
Page 2 of 2
Date: June 2012
Where further advice and support is required, it is the responsibility of the Services Manager
to discuss the referral and associated risks with the Area Manager. Out of hours, the referral
should be discussed with the Duty Manager.
Where it is agreed that an admission cannot be safely managed at the service, this must be
communicated to the referrer explaining the reasons for decline of service. Where a service
is declines, the Decline of Service Log should be completed, detailing the reasons why the
admission could not be facilitated.
Where admission is agreed, Rethink Mental Illness staff must ensure that they obtain the
following information from the referrer prior to the admission:
1. Key risks the service will need to manage
2. The arrangements for the service users’ medication
3. What input the referrer / referring team will provide during the person’s stay (i.e. daily
visits or details of their first planned visit / review)
4. Details of carers, dependent children and/or significant others
5. When the person is due to arrive
Related Rethink Mental Illness documents
Risk Assessment Procedure
Local Procedure for Contacting On Call
Information Sharing Protocol
LOP Communication with Stakeholders
Review
This guidance will be reviewed in one year.
Authorised By
Area Manager
Page 1 of 2
Date: June 2012
Accepting Referrals
Purpose
The purpose of this document is to details the procedure for staff working at Rotherham
Crisis Accommodation Service when accepting referrals.
Scope
This document applies to all staff working in the Rotherham Crisis Service when accepting a
referral from the Access Team.
Procedure
Referrals to the Crisis Accommodation must be made by the Access Team who gate keep
the service. Referrals being made by community treatment teams must be gate kept by the
Access Team.
When making a referral, the Access Team or Treatment Team (when making a referral
during office hours) will contact Rethink Mental Illness staff to provide a verbal overview by
phone of the person’s circumstances and risk profile. This must then be followed up with
referral paperwork being faxed through / delivered to the service a minimum of one hour
before admission is due to take place.
Referral paperwork must include an up to date screening assessment (Maracis) and a
Rethink Mental Illness referral form. Where in use, a Sainsburys Risk Assessment should
also be provided to support the information provided in the screening assessment.
Referral information must detail any known triggers, points of reference or specific risks that
apply to the service environment, staff or other users of the service that Rethink Mental
Illness need to be aware of. Information should be provided regarding what action should be
taken should these become apparent during the person’s stay. Rethink Mental Illness staff
are responsible for ensuring that the Access Team or Care Co-ordinator are informed
immediately and a plan for ongoing support is agreed and documented.
Where risks are identified, staff must ascertain whether these are manageable within the
service. Where additional information is required in order to make an informed decision
regarding the appropriateness of admission, this must be sought from the referrer.
Where there are concerns that the risks may be not be managed safely within the crisis
accommodation setting, or where additional information is not accessible, the referral must
be discussed with the Service Lead. Where this is out of hours, the local on-call must be
contacted for further advice.
Where the Service Lead requires guidance, they must liaise with the Services Manager to
ensure the service can safely facilitate the admission. Where this is out of hours, Service
Leads operating the local on-call should liaise with the Services Manager wherever possible.
Alternatively, advice can be sought from the Duty Manager.
Page 2 of 2
Date: June 2012
Where further advice and support is required, it is the responsibility of the Services Manager
to discuss the referral and associated risks with the Area Manager. Out of hours, the referral
should be discussed with the Duty Manager.
Where it is agreed that an admission cannot be safely managed at the service, this must be
communicated to the referrer explaining the reasons for decline of service. Where a service
is declines, the Decline of Service Log should be completed, detailing the reasons why the
admission could not be facilitated.
Where admission is agreed, Rethink Mental Illness staff must ensure that they obtain the
following information from the referrer prior to the admission:
1. Key risks the service will need to manage
2. The arrangements for the service users’ medication
3. What input the referrer / referring team will provide during the person’s stay (i.e. daily
visits or details of their first planned visit / review)
4. Details of carers, dependent children and/or significant others
5. When the person is due to arrive
Related Rethink Mental Illness documents
Risk Assessment Procedure
Local Procedure for Contacting On Call
Information Sharing Protocol
LOP Communication with Stakeholders
Review
This guidance will be reviewed in one year.
Authorised By
Area Manager
APPENDIX K
KEY
HOME TREATMENT PATHWAY
Sub-process details of which can be found in
separate appendix
CONSULTANT
FIRST 72 HOURS [EXTENDED ASSESSMENT]
ACCESS TEAM
CONSULTANT
leads
Multidisciplinary
review of care plan
MEDIC
Consultant
available?
Telephone
Known to
service?
NO
Extended
assessment?
·· CPA
CPAreview
review
·· Care
Careplan
plan
·· Notes
Notes
·· Letters
Letters
Informs
extended
assessment
Undertakes medical
assessment
(but liaises with
consultant at earliest
opportunity)
NO
Informs
extended
assessment
YES
Medical
assessment?
NO
YES
LEAD PROFESSIONAL/CLINICIAN [QUALIFIED]
EVERY 7 DAYS [HOME TREATMENT]
Undertakes medical
assessment
YES
Carry out extended
assessment
Home
Treatment?
·· CPA
CPAStatus
Status
·· Care
Careplan
plan
·· Notes
Notes
·· Letters
Letters
Home
Treatment?
YES
Develop new care
plan (incorporating
relevant NICE
guidelines) for
addressing service
user’s identified
needs
CPA status
confirmed/allocated
NO
Return to
treatment
team?
NO
Discharge/
signpost?
In Home
Treatment ≥ 3
weeks
NO
NO
Admission to
ward?
NO
Return to
Treatment
Team?
NO
YES
Discharge/
signpost?
NO
YES
In Home
Treatment for 3
Months?
YES
Agree additional
components to be added
to care plan
Consultant leads
MDT Review to
see if Home
Treatment
remains most
appropriate
service
Implement and evaluate
additional care
components to be
delivered by team
YES
YES
YES
Admit to Ward
(see sub process)
Transfer
(see sub process)
Exception
report & MDT
Review
NO
YES
YES
YES
Admit to Ward
(see sub process)
Transfer
(see sub process)
Discharge/signpost
(see sub process)
[See appendix ]
Remains
Appropriate?
Update or
continue with
current care plan
ADMINISTRATIVE
FUNCTION
Admission to
ward?
NO
YES
NO
Care plan in
place?
Review care plan with Care
Team
Specific end point for Access Team
involvement
Decision point
Discharge/signpost
(see sub process)
Update
Updatecare
carenetwork
network
(by
(byletter)
letter)
YES
APPENDIX L
APPENDIX M
ROLE AND RESPONSIBILITIES OF THE KEY WORKER
The Key Worker will:

Inform the service user of the pathway into Home Treatment service

Inform the service user/carer(s)/family about:
o
o
o
o
o

the role of the Home Treatment team
the purpose of the Home Treatment team
the care that they are to receive
their role and,
their rights
As part of the service user’s journey through the Home Treatment pathway provide
information regarding:
o expected care
o liaison
o support

Check and confirm that a comprehensive Mental Health and Social Care and Risk
assessment are completed

Check and confirm identified care needs are addressed by way of a personalised care
and risk management plan, developed in liaison with the service user/carer(s)/family
and multidisciplinary team

Check and confirm that care plans are signed by the service user

Check and confirm that Mental Health and Social Care assessments, Risk
assessments, and care plans are provided to staff named in the service user’s care
network

Check and confirm that the service user/carer(s)/family are provided with education
and information around diagnosis and prescribed medication

Act as the ‘lead professional’ when dealing with interagency collaboration

Check and confirm that the service user’s mental health history is collated to include
medicines reconciliation

Check and confirm weekly reviews take place and any changes identified are
communicated with the service user/carer(s)/family), identified care network,
including the relevant primary care team in order to provide continuity of care and a
‘seamless service’

Check and confirm safeguarding issues are addressed, implementing ‘Safeguarding
Policy’ where required

Visit service user a minimum of 2 times per week

Check and confirm invitations are made to Care Coordinator and/or Lead
professional and/or Team Manager of the treatment teams to attend

Check and confirm a formal handover is carried out before discharge form Home
Treatment Service
Changes to the nominated Key Worker
In exceptional circumstances, the service user’s ‘Key Worker’ may change as they travel
through the Home Treatment pathway. This may include:
 When current key worker has an excessive caseload, and either by mutual
agreement or direction of team manager, and the respective case will be allocated to
another member of staff
 Instances when the clinical outcome is likely to be improved by reallocation, e.g.,
where gender issues are relevant, specific clinical skills, etc.)
 Sickness or redeployment
Should this occur then the current Key Worker or Access Team manager will:

Discuss and agree with the service user/carer(s)/family the reasons for the need to
change the Key Worker, and who the new Key Worker will be

Document and inform the service user’s care network of the change in Key Worker
and who the new Key Worker will be
Competencies for the key worker role
The Key Worker will be able to:

Initiate a multidisciplinary (MDT) meeting and/or case reviews with professionals
involved in service user’s care network

Update and feedback to the multidisciplinary team

Act as the service user’s advocate

Know which documentation to provide the service user based on which stage of the
pathway they are on

Demonstrate their understanding, and use, of therapeutic self-disclosure when
required

Manage professional and interagency boundaries (e.g., information governance)

Maintain contemporaneous and clinically factual documentation, particularly
detailing any changes affecting the service user/carer(s)/family

Demonstrate knowledge in core areas of mental health care, including:

Follow identified policies, procedures, guidelines and standard of practice,

Initiate changes, where appropriate, to improve delivery of care to service
users/carer(s)/family

Describe and provide information on local and national resources (e.g., local national
support groups) in relation to their service user’s needs
APPENDIX N
CARE PLAN
Name:
Care Coordinator/Lead Professional:
Care Plan Start Date:
SUMMARY OF PROBLEM/NEED:
GOAL:
(What do we want to achieve):
ACTIONS:
SIGNATURES:
How will we know that we have
achieved it?
INVOLVEMENT:
TIMEFRAME:
(Who will do what?)
(When will we aim to have this
done by?)
APPENDIX O
A1
[TODAY]
Our Ref:
NHS No:
A1/[PATIENT NUMBER]/[ADMIN ID]
[PATIENT NHS NUMBER]
[CONSULTANT NAME]
[CONSULTANT SECRETARY’S NAME]
CONFIDENTIAL
[REFERRER NAME]
[REFERRER ADDRESS]
[TO POSTCODE]
Dear [REFERRER NAME]
REFERRAL TO [LOCALITY NAME] ACCESS TEAM
[PATIENT NAME], [PATIENT ADDRESS] [DOB], [PATIENT’S NHS No:]
Thank you for your referral for the above service user.
As part of our routine record check we have identified that this service user currently receives a
service from our [TREATMENT TEAM NAME] team, based at [TREATMENT TEAM BASE].
We have passed on the referral information to [TREATMENT TEAM MANAGER’S NAME] the
manager of that team who will ensure that the issues raised are addressed with the appropriate
worker and acted upon.
They can be contacted directly on [TREATMENT TEAM PHONE NUMBER].
Yours sincerely
[ACCESS TEAM MANAGERS NAME]
Team Manager
cc:
GP (If not original referrer)
A2
{TODAY}
Our Ref:
NHS No:
[CONSULTANT NAME]
CONFIDENTIAL
[REFERRER NAME]
[REFERRER ADDRESS]
[TO POSTCODE]
[PATIENT NAME], [DOB], [PATIENT’S NHS No:]
Thank you for your referral for the above service user. Following our initial triage assessment of
[PATIENT NAME] we have reached the conclusion that our available services will not be of
benefit to them.

[INSERT ASSESSMENT INFORMATION TO SUPPORT THE DECISION]

[INSERT RECOMMENDATIONS AND/OR ANY ACTIONS WE INTEND TO TAKE]
If you would like to discuss this further please call us on [ACCESS TEAM TELEPHONE
NUMBER]. If circumstances change or you obtain more information which may be relevant we
would welcome a re-referral to the service.
Yours sincerely
[ACCESS TEAM MANAGER’S NAME]
Team Manager
cc:
A3
Our Ref:
NHS No:
A3/[MARACIS NUMBER/ADMIN INITIALS]
CONFIDENTIAL
[PATIENT NAME]
[PATIENT ADDRESS]
PATIENT POSTCODE]
Dear [PATIENT NAME]
Following our telephone conversation, I am writing to confirm that we agreed the following
appointment:Date:
APPOINTMENT DAY AND DATE
Time:
HH:MM AM/PM
Location: AGREED LOCATION NAME AND ADDRESS
With:
CLINICIAN(S) NAME AND PROFESSION
The purpose of this appointment is for an initial assessment, which will give you the opportunity
to discuss your current difficulties with [CLINICIAN’S NAME]. The appointment may take up to
one hour and involves us gathering information about you, your history, your relationships and
your current situation in order to assess the type of help you may need.
As part of this assessment we will also look at your current medication history so we ask that
you have a list of any current medications you are taking and details of the dosage prescribed at
present.
If you have any queries or are unable to attend this appointment for any reason, please contact
us on [ACCESS TEAM TELEPHONE NUMBER] and we can arrange a more convenient time or
date for you.
In order to minimise missed appointments, two days before your appointment we will contact
and check if you are able to attend.
We look forward to meeting you.
Yours sincerely
Access Team
cc:
GP
Referrer (if not GP)
A4
FAX
{TODAY}
Our Ref:
NHS No:
[CONSULTANT NAME]
CONFIDENTIAL
[REFERRER NAME]
[REFERRER ADDRESS]
[TO POSTCODE]
Thank you for your referral of the above person.
I write to inform you that they did not attend their appointment today with our service, and had
not previously notified our service of their inability to attend.
We will offer a further appointment
Yours sincerely
[ACCESS TEAM MANAGER’S NAME]
Team Manager
cc:
A5
{TODAY}
Our Ref:
NHS No:
CONFIDENTIAL
[PATIENT NAME]
[PATIENT ADDRESS]
[PATIENT POSTCODE]
Dear [PATIENT NAME]
We have been unsuccessful in our attempts to make contact with you, but would like to meet
with you to discuss your mental health needs. We would like to offer you the following
appointment:Date:
APPOINTMENT DAY AND DATE
Time:
HH:MM AM/PM
Location: AGREED LOCATION NAME AND ADDRESS
With:
CLINICIAN(S) NAME AND PROFESSION
The purpose of this appointment is for an initial assessment, which will give you the opportunity
to discuss your current difficulties with [CLINICIAN’S NAME]. The appointment may take up to
one hour and involves us gathering information about you, your history, your relationships and
your current situation in order to assess the type of help you may need.
As part of this assessment we will also look at your current medication history so we ask that
you bring along a list of any current medications you are taking and details of the dosage
prescribed at present.
If you have any queries or are unable to attend this appointment for any reason, please contact
us on [INSERT ACCESS TEAM TELEPHONE NUMBER] and we can arrange a more
convenient time or date for you.
In order to minimise missed appointments, two days before your appointment we will contact
and check if you are able to attend.
We look forward to meeting you.
Yours sincerely
Access Team
cc:
GP
A6
{TODAY}
Our Ref:
NHS No:
CONFIDENTIAL
[PATIENT NAME]
[PATIENT ADDRESS]
[PATIENT POSTCODE]
Dear [PATIENT NAME]
DISCHARGE FROM [LOCALITY NAME] ACCESS TEAM
Following on from our last letter, we have contacted your [INSERT NAME OF REFERRER] &
[INSERT GP NAME, IF NOT ORIGINAL REFERRER]. We have agreed that:


There will be no further contact from our service at this time. If at a later date your
circumstances change, please do not hesitate to go back to your GP who can re refer.
[other options]
If you have any queries please do not hesitate to contact us.
Yours sincerely
[INSERT ACCESS TEAM MANAGER’S NAME]
Team Manager
cc:
Referrer
GP (if not original referrer)
A7
{TODAY}
Our Ref:
NHS No:
[CONSULTANT NAME]
CONFIDENTIAL
[REFERRER NAME]
[REFERRER ADDRESS]
[TO POSTCODE]
OUTCOME OF ASSESSMENT BY [LOCALITY NAME] ACCESS TEAM
The above named person was seen by [CLINICIAN’S NAME], [CLINICIAN’S TITLE] from the
Access Team on [INSERT DATE] at [HH:MM]. This took place at [INSERT VENUE].
Please find below a brief outcome of this assessment:


If you require any further information, please don't hesitate to contact us [INSERT ACCESS
NUMBER].
Yours sincerely
[CLINICIAN’S NAME]
[CLINICIAN’S TITLE]
Access Team
cc:
A8
Our Ref:
NHS No:
CONFIDENTIAL
[PATIENT NAME]
[PATIENT ADDRESS]
[PATIENT POSTCODE]
Dear [PATIENT NAME]
YOUR PLAN OF CARE
Following your assessment with [CLINICIAN’S NAME], [CLINICIAN’S TITLE] [Access Team]
on [INSERT DATE] at [HH:MM]. We agreed on the following plan of care to meet the needs
identified in your assessment.

[INSERT AGREED ACTIONS]

[ANY ADDITIONAL INFORMATION]

[N. B. - IF WE ARE TRANSFERRING TO A TREATMENT TEAM - PLEASE INSERT TEAM
MANAGER’S NAME AND TEAM CONTACT DETAILS & ENCLOSE RESPECTIVE
TREATMENT TEAM’S LEAFLET IF AVAILABLE]
If you have any queries on the plan of care, please contact us on [ACCESS TEAM
TELEPHONE NUMBER] and we will seek to clarify this with you.
Yours sincerely
Access Team
cc:
GP
APPENDIX P
About your appointment with
the Access Team
What is the Access Team?
The agreed plan could suggest groups or activities which may be helpful.
We are a team of Mental Health Professionals who assess the needs of people who have
contacted us about their mental health or who have been referred by other people usually their GP or other health professional.
We might suggest you see a mental health worker in your GP practice, or try different
medication, which your GP can prescribe.
The team is made up of specialist doctors, nurses, occupational therapist(s), social
workers and support workers(s). We are based at (Locality Name) in (Locality Name),
and see people across (Locality Name) borough.
Why have I been sent this appointment?
Usually we receive a referral from another health or social care worker, like a doctor,
community nurse or care manager. This (will be or should be) discussed with you when
you see them. Sometimes we are asked to see people because other people are
concerned for them. If you're not sure, please ask at the appointment.
What if I can’t come to the appointment?
We try and see everyone within 14 days of them being referred to us. You can help us
do this by letting us know as soon as possible if the appointment offered is not
convenient. Just call us on (Team Telephone Number) and we will arrange another time
for you.
Can someone come with me?
Yes! We know you may find seeing a mental health worker for the first time a bit
worrying, so if you want some support from family, a friend or carer please feel free to
involve them. If you have a carer, their needs can be assessed separately at a later point.
If we agree that you need additional support or treatment we will arrange for you to be
seen in a specialist team.
Is the assessment information confidential?
All staff are bound by national laws, local policies and their professional codes of
conduct on information sharing. Sometimes we may be obliged to share information if
there are any risks to you or other people. Your assessor will discuss this with you at the
start of your appointment.
What should I do if I am not happy about something?
Please contact the team manager:Name: (Team Manager’s name)
Address: (Team address)
Telephone Number: (Team telephone number)
If you remain unhappy with any aspect of our service, please contact the Patient Advice
and Liaison Service (PALS).
PALS contact details are put on the back of the leaflet.
If you need urgent assistance?
What will happen at my appointment?
The worker will talk with you about your current symptoms, how long they have lasted
and any other problems with your physical or mental health. They will ask about you
and your background. The purpose of the assessment is to help you to regain well-being
and maintain it, and how we may be able to support this. The appointment will last
between 60-90 minutes and will usually be with one or more members of the team.
What will happen after my appointment?
The worker or workers you see will develop a plan of care with you. This may include
further assessment or arranging an appointment with a Psychiatrist.
The Access Team includes crisis resolution and home treatment workers. If your concerns
are of an urgent nature, please call 01709302670, which is available 24 hours a day.
We look forward to meeting you at your assessment appointment
Contact Us
Opening Times:
Address: Team Address
Routine Enquires: 9am—5pm
Monday to Friday
Telephone: Team Telephone Number
Fax Number: Team Fax Number
Emergency 24 Hour Service
Your Plan of Care
Your plan of care
We have agreed that you may need to get extra help from:
Following your assessment by the Access Team staff your immediate plan of
care is outlined below. If you are to be taken on to the Home Treatment service
caseload a written care plan will be also be provided in due course.
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………….
We have agreed with you that your problems are:
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………..
We have agreed to provide the following help for you:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Please note – a list of organisations and agencies which may be able to support
you is enclosed on the back page of this leaflet.
The Access Team includes crisis resolution workers. If your concerns are of an
urgent nature, please call (Team Telephone Number, which is available 24
hours a day.
Contact Us
Opening Times:
Monday to Friday
About the Home Treatment
Service
What is Home Treatment?
Your Care Plan
The home treatment service provided by the access team provides short-term
help for people who are having a mental health crisis. This is as an alternative to
treatment in hospital. We will discuss your problems with you and if
appropriate, offer you a short term period of home treatment.
Your Key Worker will work with your to develop a written care plan that will
include the support you need from the team and/or other agencies.
Our staff mostly see people in their own homes, but if you wish you can ask to
be seen somewhere else, perhaps at a family member's home. We may offer
you a short stay in one of our crisis beds, which can provide 24 hour support
during the early days of a crisis.
As we are a busy team, please allow one hour either side of appointment times
in case staff are unavoidably delayed.
What should I do if I am not happy about something?
Please contact the team manager:Name: (Team Manager’s name)
If required, a doctor will usually see you within 48 hours of the start of any
home treatment. This is to discuss your medical needs, and to see if any
medication could be helpful for you.
Most people will be seen at their home once a day in the early stages of
treatment. As things start to improve for you we will see you less often.
Your Key Worker
In order to effectively coordinate the delivery of your care you will be provided
with a named ‘Key Worker’, who is a member of the Home Treatment service.
Their role is to work closely with you, your family and/or your carer(s). They will
liaise with other staff in the home treatment team, or other agencies that may
become involved in your care to ensure that all parts of your agreed care plan
are completed.
Wherever possible most of your home treatment visits will be made by your
named ‘Key Worker’, however there will be other staff within the team that
may also visit you on behalf of the key worker, these include our nursing staff,
social workers, or support workers.
The team works a shift pattern, so it is likely you will see a number of team
members, but we try to minimise this as much as possible.
Address: (Team address)
Telephone Number: (Team telephone number)
If you remain unhappy with any aspect of our service, please contact the Patient
Advice and Liaison Service (PALS).
PALS contact details are put on the back of the leaflet.
The Access Team includes crisis resolution and home treatment workers. If
your concerns are of an urgent nature, please call (Team Telephone Number,
which is available 24 hours a day.
Contact Us
Opening Times:
Monday to Friday
YOUR KEY WORKER IS:…………………………………………………………………………………..
Your plan of care
We have agreed that you may need to get extra help from:
Following your assessment by the Access Team staff your immediate plan of
care is outlined below. If you are to be taken on to the Home Treatment service
caseload a written care plan will be also be provided in due course.
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………..
We have agreed with you that your problems are:
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
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We have agreed to provide the following help for you:
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……………………………………………………………………………………………………………………………
Please note – a list of organisations and agencies which may be able to support
you is enclosed on the back page of this leaflet.
APPENDIX Q
Qualitative Care Planning Audit
Introduction
Aim
To monitor compliance with…… and to support a culture of continuous quality improvement within Community Adult Mental Health
practice. Through implementation of this procedure, qualitative and quantitative aspects of recording will be routinely examined to ensure
the best possible outcomes for service users.
Procedure

This audit proforma is to be used during clinical supervision sessions.

All staff should complete this form at least once during each quarter.

A copy of the audit should be forwarded to Gus McKnight for auditing purposes.

All actions should be completed within the agreed timescale and monitored for completion by the Team Leader/Manager. A
separate form (Appendix) can be used for this purpose.
Audit of MDT Full Needs Assessment
Date of Audit:
Staff Name:
Maracis Number:
Was the assessment an: please circle
Area: Rotherham
Doncaster
North Lincs
Emergency
Urgent
Question
Y
Please tick
N
NA
Routine
Comments
Have any abbreviations been used within the assessment?
Have clinical terms been used?
If yes, have the clinic terms been described in detail?
Have all sections of the Assessment been completed?
Question
Does the outcome show that the
key contributory factors from the
relevant ‘headings’ have been
identified?
Does the outcome show
formulation of the service user’s
current problems?
Does the outcome identify actions
to be taken?
Meeting
Requirements
OUTCOME OF ASSESSMENT
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Does the outcome prioritise these
actions?
Action:
Action:
Is someone named to undertake /
complete the specific actions?
Action:
Action:
Are there timescales identified for
implementing each action?
Action:
Action:
Comments
Question
Meeting
Requirements
Have any previous mental health/
illness experience been clearly
identified as relevant to their
current mental health problems?
If not, has this been ruled out?


Has mental health history been
ordered (e.g. chronologically,
problem, risk etc)
Have any patterns of previous
history and current mental
health problems been explicitly
identified?
Question
Has a FACE risk assessment been
completed?
Have all sections of the risk
assessment checklist been
completed?
Where a risk has been identified as
‘yes’ or ‘not known’ has the
relevant narrative box been
completed?
Has the risk assessment been
summarised on the CPA
assessment?
Meeting
Requirements
MENTAL HEALTH HISTORY
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
RISK
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Comments
Comments
Question
Meeting
Requirements
Have any physical health problems
been clearly identified as relevant
to their current mental health
problems?
If physical health problems have been identified:
Has the impact on current mental
health problems been identified?
Has the service user been asked to
identify which physical health
problems are of concern to them?
Question
Meeting
Requirements
Has substance misuse been
identified as relevant to the service
users current mental health
problems?
If substance misuse has been identified:
 Have frequency and amounts
of each substance been
recorded?
 Has the impact of identified
substance misuse on current
mental health been recorded?
 Has the service user been
asked if this is a concern to
them?
 Has dual diagnosis been
considered for presentation?
 Has a rationale been given for
inclusion or discounting dual
diagnosis?
PHYSICAL
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
SUBSTANCE MISUSE
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Comments
Comments
Question
Meeting
Requirements
Have current and/or previous
forensic history been recorded?
Has the impact of previous forensic
history on current mental health
been recorded?
Question
Has current housing been clearly
identified?
Meeting
Requirements
FORENSIC
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Action:
Action:
HOUSING / ENVIRONMENT
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Has the current environment been
clearly described?
Action:
Action:
Have issues been recorded as
relevant to their current mental
health problems?
If not, have these been ruled out?
Action:
Action:
Action:
Action:
Has the impact of these issues
been identified?
Action:
Action:
Comments
Comments
Question
Meeting
Requirements
Has the service user’s level of
personal care been clearly
identified?
Has the service user’s domestic
routine been clearly described?
PERSONAL CARE / DOMESTIC ROUTINE
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Action:
Action:
Have any personal care / domestic
routine issues been clearly
identified as relevant to their
current mental health problems?
Action:
Action:
Action:
Action:
Has the impact of personal care /
domestic routine on the service
user’s mental health problems
been identified?
Action:
Action:
Question
Has the service users benefits
and/or financial status been
recorded?
Have any issues relevant to the
service user’s mental health
problems been identified?
Has the impact of the identified
issues been recorded?
Meeting
Requirements
WELFARE BENEFITS / FINANCE
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Comments
Comments
Question
Has the service user’s current
employment / occupation /
education status been recorded?
Have any issues been identified as
relevant to the service user’s
current mental health?
If not, have these been ruled out?
EMPLOYMENT / OCCUPATION / EDUCATION
Meeting
Partially Meeting
Not Meeting
Requirements
Requirements
Requirements
Action:
Action:
If any issues have been identified,
has the impact on the service
user’s mental health been
identified?
Has the service user been asked to
identify any vocational needs they
would like to pursue?
Question
Has the service user’s family
network been recorded?
Meeting
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
FAMILY / SUPPORT NETWORKS
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Has the quality of each relationship
been recorded?
Action:
Action:
Has the service users other support
network been identified?
Has the quality of each relationship
been identified?
Has the impact of the
family/support networks on the
service user’s current mental health
been recorded?
Action:
Action:
Action:
Action:
Action:
Action:
Comments
Comments
Question
Meeting
Requirements
Has the service users caring
responsibility been identified or
ruled out?
If caring responsibility has been
identified, has the impact of this on
their current mental health
problems been recorded?
CARING RESPONSIBILITY
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Action:
Action:
PSYCHOLOGY
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Action:
Action:
CULTURE / ETHNICITY
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Have any issues been identified
regarding culture / ethnicity?
Action:
Action:
Has the impact on the service
user’s mental health of any
identified issues been recorded?
Action:
Action:
Question
Meeting
Requirements
Has the service user identified
specific cognitive skills, abilities or
competencies that they use to help
reduce the impact of their current
mental health issues?
Has each specific cognitive skill,
ability or competency been
elaborated on in how it helps
reduce the impact on their current
mental health?
Question
Has the service user’s
culture/ethnicity been recorded?
Meeting
Requirements
Comments
Comments
Comments
GENDER / SEXUALITY
Partially Meeting
Requirements
Action:
Not Meeting
Requirements
Action:
Have any issues been identified
regarding gender / sexuality?
Action:
Action:
Has the impact on the service
user’s mental health of any
identified issues been recorded?
Action:
Action:
Question
Meeting
Requirements
Has the service users gender /
sexuality been recorded?
Question
Have any coping strategies been
identified and recorded?
Meeting
Requirements
STRENGTHS / COPING STRATEGIES
Partially Meeting
Not Meeting
Requirements
Requirements
Action:
Action:
Is it recorded which problems are
being dealt with, with these
strategies?
Action:
Action:
Has the impact of the coping
strategies in reducing mental health
problems been recorded?
Action:
Action:
Comments
Comments
Question
Meeting
Requirements
SAFEGUARDING
Partially Meeting
Requirements
Action:
Have safeguarding issues been
explicitly documented as ‘present’
or ‘not present’?
If safeguarding issues have been identified in the assessment
Action:
 Has the type/types of abuse
been clearly specified?
 Has there been sufficient detail
to explain the type of abuse
identified?
 Have actions and /or referral
onto other agencies been
identified?
 Have these actions and/or
referrals to other agencies been
described in detail?
 Has an individual been named
to carry out any further actions
and/or referrals to other
agencies?
 Has a specific timeframe been
stated for actions and/or referral
to be carried out?
Not Meeting
Requirements
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Action:
Comments
Audit of Care Plans
Date of Audit:
Staff Name:
Maracis Number:
Question
Area: Rotherham
Doncaster
North Lincs
Yes
No
NA
Summary of Problem Need
NR Action:
Comments
Is the problem/need specified in detail?
Is the problem/need described in
service user terms?
Question
Yes
No
GOALS
Action:
NA
NR
NA
EVALUATION
NR Action:
Comments
Is each identified goal specific?
Is each identified goal described in
service user terms?
Is each identified goal linked to an
identified problem/need?
Question
Is each recovery/stability indicator
specific?
described in service user terms?
linked to an identified problem/need
and goal?
Yes
No
Comments
Question
Yes
No
ACTIONS
Action:
NA
NR
NA
INVOLVEMENT
NR Action:
Comments
Is there a specific action (or set of
actions) for each goal?
Is the specific action (or set of actions)
described in service user terms?
Is the specific action (or set of actions)
linked to an identified problem/need
and goal?
Question
Yes
No
Comments
Is there person (or persons) named to
undertake a specific action to achieve
a specific goal?
Is there a detailed description of what
each named person (or persons) will
do to achieve each specific action
Is the specific action described in
service user terms?
Question
Yes
No
NA
NR
TIMEFRAME
Action:
Comments
Does each action have an identified
timeframe/review date?
Is each timeframe realistic?
Additional Criteria:


Has the service user been given a copy of the plan
Has the plan been signed by the service user / is there evidence that the service user has been involved in the care plan


Is there evidence of family / care involvement in the care plan
Is there evidence of a plan for discharge?
Audit of Clinical Notes
Date of Audit:
Staff Name:
Maracis Number:
Area: please circle
Question
Please tick
Y
N
NA
Doncaster
North Lincs
Comments
Have any abbreviations been used within the assessment?
Have clinical terms been used?
If yes, have the clinic terms been described in detail?
Question
Yes
No
RELATIONSHIP TO CARE PLAN
NA NR Action:
Yes
No
CONTACTING / INFORMING PEOPLE
NA NR Action:
Yes
No
NA
Comments
Comments
Does the clinical note relate to a
specific part of the care plan?
Does the clinical note evaluate
progress on achieving the specific part
of the care plan?
Question
Does the clinical note indicate if other
people are to be contacted and / or
informed?
If yes, does it
a) name who will contact the identified
people?
b) identify the timescale for when the
contact is to be made?
Question
Does the clinical note identify further
actions to be taken?
If yes, does it
a) name the person, who will carry out
the action?
b) identify the timescale for the action
to be taken?
c) state if the care plan is to be
updated (by whom and when)?
FURTHER ACTION
NR Action:
Comments
Rotherham

access team - RDaSH NHS Foundation Trust

Transcription

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