Code of Practice to Parts 2 and 3 of the
Mental Health (Wales) Measure 2010
Print ISBN 978 0 7504 7203 0
Digital ISBN 978 0 7504 7205 7
© Crown copyright 2012
WG14643
Printed on recycled paper
Contents
Foreword by the Minister for 2
Health and Social Services
Introduction 4
Chapter 1: Guiding Principles 6
Chapter 2: Assessment within 10
Secondary Mental HealthServices
Secondary Mental Health Services 10
Purpose of assessment 11
Holistic assessment of need 12
Assessment of risk 13
Chapter 3: Care Coordinators 14
Role of the care coordinator 14
Appointment 15
Eligibility to act as a care coordinator 18
Duties and functions of the 20
care coordinator
Supporting care coordinators 21
Chapter 4: Care and 22
Treatment Planning
Involvement, engagement and consultation 22
Outcome planning 28
Matters to be considered in the care 29
and treatment plan
Timeliness of care and treatment plans 35
Copies of the care and treatment plan 36
Chapter 5: Coordination of the 38
Provision of Services
Duty to provide services 38
Coordination of the provision of services 39
Coordination for Discharge from hospital 40
Prison release 41
Chapter 6: Monitoring and Review 42
The importance of monitoring and review 42
Triggers to prompt review 43
Preparation for Reviews 44
Relationship to Section 117 aftercare 45
under the Mental Health Act 1983
Chapter 7: Discharge from 46
Secondary Mental Health Services
Meaning of discharge 46
Provision of information on discharge 47
Chapter 8: Assessments of 49
Former Users of Secondary
Mental Health Services
Purpose of Assessment under Part 3 49
of the Measure
Arrangements for the assessment 49
of former users of secondary mental
health services
Duty to carry out an assessment 51
Entitlement to assessment 51
Actions following assessment under Part 3 54
Appendix A: Glossary of key terms 56
Appendix B: Schedule 2 of the 60
Mental Health (Care Coordination
and Care and Treatment Planning)
(Wales)Regulations2011
Code of Practice
2
Chapter 1
Foreword by the Minister for
Health and Social Services
The introduction of the rst Wales-specic mental health legislation – the Mental Health (Wales)
Measure 2010 – provides a landmark in improving mental health care here in Wales. The Measure
isnot concerned with compulsion, but rather serves to improve access to and the delivery
of mental health care in primary and secondary care settings and to extend the availability
ofindependent advocacy.
This Code of Practice has been designed to give clear guidance to mental health service providers
in Wales in meeting their obligations under Part 2 of the Measure (Coordination of and Care Planning
for Secondary Mental Health Service Users) and Part 3 (Assessments of Former Users ofSecondary
Mental Health Services).
Whilst this Code of Practice relates specically to Parts 2 and 3 of the Measure, it should be read
with the entire Measure in mind.
Part 2 of the Measure requires that all people receiving secondary care mental health services in
Wales receive a care and treatment plan. A care coordinator is required to produce the plan with
the engagement of the service user and mental health service providers. The duty to produce
outcome-focused care and treatment plans will lead to more effective and efcient service delivery,
with an emphasis on the recovery of the service user. The requirement for a holistic approach
to care planning spanning a range of medical, psychological, social and spiritual needs will lead to
service delivery that is more comprehensive and more enabling.
Part 3 of the Measure introduces a safeguard for people who have formerly used specialist services
and have been discharged. It achieves this by placing a duty on Local Health Boards and local
authorities to assess whether former users of specialist care services once again need such services.
It therefore removes the requirement for referral via the G.P. and allows people to refer themselves
to specialist care if they believe that their mental health is deteriorating. This safeguard will remove
delays in accessing specialist care and ensure a more timely response to relapse.
The Measure is designed to support service providers to improve the quality and responsiveness
of mental health services in Wales and to ensure that service users have a greater say in how their
needs should be met.
Foreword
3
Code of Practice
Foreword
The Welsh Government has worked with stakeholders and consulted widely in drawing up this
Code of Practice, and I am grateful to all individuals and organisations who have contributed to
thisprocess.
I am certain that this Code will be an extremely useful resource to practitioners in meeting their
statutory duties under the Measure as well as being a useful guide to service users and those who
support them.
Lesley Grifths
Minister for Health and Social Services
Code of Practice
4
Introduction
Introduction
i. This Code has been prepared and is issued under section 44 of the Mental Health (Wales)
Measure 2010 (“the Measure”) by the Welsh Ministers after consulting such persons as
appeared to them to be appropriate, and having been laid before the National Assembly
forWales. The Code will come into force on 6 June 2012.
Purpose and status of the Code of Practice
ii. The Code is provided as guidance to local authorities, Local Health Boards (“LHBs”), andcare
coordinators and any other persons in relation to their functions under Parts 2 and 3 of the
Measure. These Parts make provision in relation to care and treatment planning and care
coordination for users of secondary mental health services, and in relation to the provision
ofassessments for former users of secondary mental health services.
iii. This Code also gives guidance to LHBs, Local Authorities, their staff, and care coordinators,
inconnection with the operation of these Parts of the Measure and the subordinate
legislation which has been made in connection with it.
iv. Local authorities, Local Health Boards and care coordinators are required to have regard
to this Code in carrying out their relevant functions under the Measure. Departuresfrom
the Code could give rise to legal challenge and a court, in reviewing any departure from
the Code, will scrutinise the reasons for the departure to ensure there is sufciently
convincing justication in the circumstances. It is good practice to ensure any such reasons
areappropriately evidenced.
v. In addition to the provision of guidance to the agencies or bodies with statutory duties under
the Measure, the Code also serves to inform relevant patients, their families, carers and
advocates of the duties as they apply to people who fall within the scope of the Measure.
vi. The Code is available in both English and Welsh.
General Note
vii. It is recognised that there are existing legislative provisions for planning and providing services
to individuals. When considering care and treatment planning under the Measure local
authorities and LHBs should have regard to other statutes relating to the wellbeing of children
and adults (for example social services) that require arrangements for care and support plans
and the review of such plans. Where there is an overlap with the care and treatment plan it
would be desirable that provision is considered for the coordinated integration and discharge
of the various plans. In relation to children or adults with parental responsibilities agencies and
professionals across all sectors should also consider the arrangements for the Safeguarding
of Children and Young People under the Children Act 2004 when carrying out Care and
Treatment Planning under the Measure.
5
Code of Practice
Introduction
Presentation
viii. Throughout the Code, the Mental Health (Wales) Measure 2010 is referred to as
‘theMeasure’. Where there are references to other statutes, the relevant Act or Measure
isclearly indicated.
ix. The Code also takes account of the Mental Health (Care Coordination and Care and Treatment
Planning) (Wales) Regulations 2011 relating to Part 2 of the Measure, the Mental Health
(Assessment of Former Users of Secondary Mental Health Services (Wales) Regulations 2011
relating to Part 3 of the Measure, and the proposed Mental Health (Secondary Mental
Health Services) (Wales) Order 2012 relating to Parts 1,2 and 3 of the Measure. These
are referred to in this Code as ‘the Part 2 Regulations’ or “the Part 3 Regulations” or “the
Order”
1
accordingly. Where there are references to other subordinate legislation, the relevant
Regulations, Rules, Directions or Orders are clearly indicated.
x. The Measure and the subordinate legislation set out the legal framework, and the
CodeofPractice provides the principles and guidance on how the legislation should
beapplied in practice. The Code shows, where relevant, the connections between the
Measure and other legislation, such as the Mental Health Act 1983.
xi. This Code provides context and positive practice guidance to care coordinators in
undertaking their functions under the Measure and associated Regulations. It identies
anumber of important care and treatment planning issues for relevant patients and their
carers. The Code seeks to guide care coordinators toward delivery of comprehensive and
outcome focused care and treatment planning.
Terms used in this Code
xii. The term ‘service user’ is often used for people accessing services for care and treatment
of their mental ill-health. Some people prefer the terms ‘survivor’, ‘client’, ‘consumer’ and
‘recipient’. This Code uses the term ‘relevant patient’ as dened in Part 2 of the Measure.
xiii. This Code uses the terms ‘child’ and ‘children’ for people aged less than 18 years,
whileacknowledging that ‘young person’ or ‘adolescent’ might sometimes be more appropriate.
xiv. The Welsh-language version of this Code uses the terms ‘cydgysylltydd gofal’ and
‘cydgysylltwyr gofal’ for ‘care coordinator’ and ‘care coordinators’ because these are the
terms used in the Measure. However, it is acknowledged that the terms ‘cydlynydd gofal’ and
‘cydlynwyr gofal’ are also used by those working in the eld.
xv. There are references throughout this Code to the Mental Health Act 1983 and the Mental
Capacity Act 2005. The Code assumes that its readers are familiar with the main provisions
of those Acts as they relate to the assessment, care and treatment of people with mental
disorders. Guidance on both Acts is given in their own respective Codes of Practice.
xvi. A list of key words and phrases used in this Code is given in Appendix A.
1
The Mental Health (Secondary Mental Health Services) (Wales) Order 2012 was consulted upon in 2011 and is due to be laid
inSpring 2011. It will come into force if approved by resolution of the National Assembly for Wales.
Code of Practice
6
Chapter 1
Chapter 1
Guiding Principles
1.1 This chapter provides a set of guiding principles which should be considered when exercising
functions under Parts 2 or 3 of the Measure. All of the chapters of this Code of Practice
should be read in light of these principles.
Relevant patients and their carers should be involved in the planning,
developmentand delivery of care and treatment to the fullest extent possible
1.2 Relevant patients should, be involved in planning their care and treatment, where practicable.
This means that mental health professionals should engage with relevant patients to identify
and plan the delivery of a range of services to meet their needs. Engagement should include
the co-production of a care and treatment plan between the relevant patient, their mental
health service providers and their care coordinator, as well as the setting of goals to achieve
the agreed outcomes within the plan. It should also include the monitoring of the delivery
of services included within the care and treatment plan, and amendment of plans, where
necessary through the review process. Engagement, ideally, should apply also to the families
and/or other signicant people in the lives of the relevant patient, subject to their ongoing
agreement and consent.
1.3 The principles identied in this Code also apply when relevant patients either choose not
to take an active role in the planning process or are unable to do so. The ongoing and
purposeful seeking of engagement (where none has previously been forthcoming) should
be undertaken routinely. Seeking smaller, more manageable engagement steps, with the aim
of increasing condence and promoting a sense of recovery is a major feature of positive
carecoordination.
1.4 The particular issues of engagement for relevant patients belonging to vulnerable groups
such as children, those with a co-occurring mental health problem and a learning disability,
those with a co-occurring mental health and substance misuse problems and older people
should be a focus of care coordinator activity. Children should be given the opportunity
to fully engage in the process even when consent may be required from their carers.
The involvement of carers is essential when the child is not competent to give consent.
The tailoring of care coordination to meet the specic needs of such groups requires
a coordinator’s careful attention, including the consideration of language needs and the
possibleinvolvement of carers or family members.
1.5 It is good practice within care and treatment planning to explore what a relevant patient
might wish to happen in relation to their health and social care at some point in the future,
for example planning for a time when admission to hospital may occur, planning for a time
when mental capacity may be lost or setting out what treatments a person would prefer.
7
Code of Practice
Chapter 1
Theuse of mechanisms such as advanced decisions to refuse treatment and the making of
Lasting Powers of Attorney for health and welfare decisions under the Mental Capacity Act
can be extremely useful in planning future care.
Equality, dignity and diversity
1.6 The requirements for care and treatment planning under Part 2 of the Measure apply
irrespective of age.
1.7 In producing a care and treatment plan, due regard shall be given to a relevant patient’s
specic needs. Needs arising from a relevant patient’s race, gender, religion, sexuality, age or
disability should be specically considered. Relevant patients should not be disadvantaged
intheir involvement or experience of care and treatment planning as a consequence of
thesefacets.
1.8 Local authorities and LHBs, as mental health service providers, along with 3
rd
sector
organisations, should pay particular attention to working together to address and avoid
inequalities in the operation of the Measure and ensure that relevant patients are treated
fairly, with dignity and respect.
Clear communication in terms of language and culture is essential to ensure
relevant patients and carers are truly involved, and receive the best possible care
and treatment. In Wales, this also means all possible steps should be taken to ensure
that bilingual (Welsh and English) services are available
1.9 Effective engagement is based upon good communication. Poor communication can lead
to misunderstanding, mistrust, misdiagnosis and subsequently inappropriate assessments,
interventions and care. It can also potentially lead to poorer outcomes for relevant patients
and their carers. Mental health practitioners, including care coordinators, should ensure
therefore that effective communication takes place between themselves, relevant patients
and any one else involved in the care or support of relevant patients. They shall ensure that
everything possible is done to overcome any barriers that may exist to communication in
an appropriate manner. This should include consideration of meeting communication needs
through interpreters or assistive technology such as British Sign Language, Sign Supported
English, Braille or induction loop systems. Consideration should be given to developmental
levels for children and literacy levels for all.
1.10 The Welsh Language (Wales) Measure 2011 places duties on public bodies to provide
services, which it is expected will be provided in accordance with the duties placed on
such bodies by their respective Welsh Language Schemes.
2
It is expected that mental
health services in Wales are to be underpinned by the principle that the Welsh and English
languages shall be treated on an equitable basis. The Welsh Government is positive about
the Welshlanguage and the benets of bilingualism, and recognises that bilingual services
are essential to providing quality care, effective assessment, treatment and care planning.
Allefforts should be made to match bilingual relevant patients with bilingual practitioners.
2
It should be noted that the Welsh Language Board is going to be abolished; from 1 April 2012 the Welsh Language Commissioner
will start work and will be responsible for preparing standards that will replace Welsh language schemes. However the
Welshlanguage schemes will still be operational until the standards have been agreed and implemented, and will be monitored
bythe Commissioner when the Commissioner’s Ofce is established.
Code of Practice
8
Chapter 1
1.11 Relevant patients should, where possible, be given the option of assessment, treatment
and provision of information in Welsh. Within the remit of their Welsh language schemes,
allpossible steps should be taken to ensure that services are available for Welsh speakers in
the language that best meets their individual needs, and that services are suitably developed
and supported to be delivered through the medium of English and Welsh. LHBs and local
authorities should promote the bilingual services that are already available and increase
capacity for providing bilingual services where there is a shortfall of Welsh speaking staff.
Theonus is on LHBs and local authorities to provide the appropriate service, rather than
fora relevant patient to have to ask for it.
Care and treatment should be comprehensive, holistic and person-focussed
1.12 In order to ensure that care and treatment is most effective in maximising recovery, the
assessment, planning and delivery of that care is to be holistic. This means addressing a broad
range of medical, psychological, social, physical, linguistic, cultural and spiritual needs which in
the case of children are developmentally appropriate. In formulating the care and treatment
plan, care coordinators need to focus on the needs of the relevant patient, rather than the
services that currently exist and could therefore be provided. In addition to services available
in specialist mental health services, consideration should also be given to broader services
such as education, training, employment, faith groups and leisure services that may assist in
arelevant patient’s recovery.
1.13 Recovery in this context means regaining mental health to the maximum extent possible
and achieving the best possible quality of life, lived as independently as possible. In children
this also includes achieving the relevant patient’s optimum physical, psychological and
socialdevelopment.
1.14 People with mental health problems, and their carers, should live as fullled a life as possible,
with additional support delivered in a timely manner through evidence based interventions to
help them achieve this goal where possible. Care and treatment plans for all relevant patients
within secondary mental health services should focus upon the minimisation of the impact
of their mental health problems, on living as fullled a life as possible and the maximisation
of their independence, community integration, mental and physical health and wellbeing.
Careand treatment planning should therefore be based upon a recovery approach.
1.15 This requires a positive, strengths-based approach taking incremental steps to achieve long
term goals. It should be recognised that for some relevant patients these may only be small
steps, and that for some, especially those with degenerative disorders, the focus may centre
on maximising a relevant patient’s functioning within a process of gradual decline.
Care and treatment planning should be proportionate to need and risk
1.16 The development of an effective care and treatment plan is essential to meet the
requirements of the Measure and the Part 2 Regulations. At the same time these plans for
meeting the needs of relevant patients ought to be proportionate to need and risk, as they
are tools to assist in the delivery of effective care and for the review and achievement of
outcomes. In some cases this may require a detailed plan reecting the complexity of the
9
Code of Practice
Chapter 1
relevant patient’s need. However for many relevant patients the plan of care may be relatively
un-complicated. It is important, in order to ensure that the delivery of treatment and care
is maximised, that the care and treatment planning process minimises bureaucracy whilst
ensuring good quality planning, monitoring review and recording.
Care and treatment should be integrated and coordinated
1.17 LHBs and local authorities must work together in a coordinated and integrated way to
provide effective services for relevant patients. They should also work with any voluntary
organisations that provide services to relevant patients, to ensure the services provided
bythe statutory organisations are coordinated with those of the 3
rd
Sector.
1.18 Due regard should be given not only to services available in statutory and third sector
specialist mental health services but also to other statutory and non-statutory services
available in other sectors, for example employment support services, schools and colleges,
justice agencies, faith groups. Ideally, other services such as substance misuse services and
Integrated Family Support Services should work collaboratively with specialist mental health
services to ensure the most efcient use of resources and the most effective outcome for
relevant patients and their families.
A note on Recovery
1.19 There is no single denition of the concept of ‘recovery’ for people with mental health
problems, but the guiding principle is the belief that it is possible for each individual to
achievegoals that enable them to live a fullling life, despite serious mental illness.
1.20 Furthermore recovery can be looked at in terms of hope – the belief that it is possible for
someone to regain in time a meaningful life, despite serious mental illness. The process of
achieving this is unique to each individual. Some, for instance, may seek to challenge and
overcome the problems that have affected their lives and regain their previous way of life;
some may seek to change in a way that accommodates their difculties within a new or
different lifestyle. Some may change or develop their hopes and aims in time, in the nature
ofa journey. Recovery is often referred to as a process, outlook, vision, conceptual framework
or a set of guiding principles and care coordinators should facilitate every individual to
explore and to set their own aims in what recovery means to them.
1.21 Recovery does not always, therefore, refer to the process of complete recovery or cure.
It can be applied regardless of a person’s age but care is required in the use of the term
when addressing people with a dementia. It may be possible to review each individual’s
circumstances to establish if any changes may lead to ‘recovering’ some abilities. For this
group, recovery can be looked at as a person centred or reablement approach focusing
onmaximising the individual’s abilities and strengths at every stage despite a gradual process
ofdecline, in order that they enjoy the best possible quality of life.
Code of Practice
10
Chapter 2
Chapter 2
Assessment within Secondary Mental
HealthServices
2.1 This chapter gives guidance on the purpose and focus of assessment within secondary mental
health services as part of the process for developing outcomes to be achieved that will be
recorded in the care and treatment plans.
Secondary Mental Health Services
2.2 The requirements for care and treatment planning under Part 2 of the Measure apply when
aperson is a relevant patient. A relevant patient is an individual:–
• forwhomamentalhealthserviceproviderisresponsibleforprovidingasecondary
mental health service; or,
• underguardianshipofalocalauthorityinWales;or,
• forwhomamentalhealthservicesproviderhasdecidedthattheywouldprovide
secondary mental health services, if that individual cooperated with the provision of
suchservices.
2.3 A secondary mental health service is dened in Section 49(1) of the Measure as:–
(a) a service in the form of treatment for an individual’s mental disorder which is provided
under Part 1 of the National Health Service (Wales) Act 2006;
(b) a service provided under section 117 of the Mental Health Act 1983;
(c) a community care service the main purpose of which is to meet a need related to an
adult’s mental health;
(d) a service provided for a child under Part III of the Children Act 1989 the main purpose
ofwhich is to meet a need related to that child’s mental health.
Section 49(2) goes on to provide that a service is not to be taken as being provided under
Part 1 of the NHS (Wales) Act 2006 if that service is provided under:–
(a) section 41 of that Act;
(b) a general medical services contract entered into by a Local Health Board under
section42 of that Act;
(c) arrangements for the provision of primary medical services entered into by
aLocalHealthBoard under section 50 of that Act;
(d) Schedule 1 to that Act.
2.4 The main effect of section 49(2) is to exclude services provided under a General Medical
Services contract from being considered as a secondary mental health service for the
purposes of the Measure.
11
Code of Practice
Chapter 2
2.5 The proposed Mental Health (Secondary Mental Health Services) (Wales) Order 2012
once laid and if approved by the National Assembly for Wales, will modify the denition of
‘secondary mental health services’ in section 49 of the Measure so that any services which
are provided as local primary mental health support services within an LHB region under
Part 1 of the Measure are excluded from the denition, and therefore the care coordination
and care and treatment planning and assessment of former service users provisions of Parts 2
and 3 of the Measure.
2.6 The requirements of Parts 2 and 3 of the Measure are not dependent upon the way in which
services are congured or delivered, but rather are determined on the basis of whether
the service which is being provided (or would be provided if the person co-operated
appropriately) is intended to address an individual’s mental health problem. For example,
if a person has a co-occurring mental health problem and a learning disability, and receives
interventions or treatments from the learning disability service to address their mental
health as well as their learning disability, then they will come within the scope of Part 2 of
the Measure. They do not need to be receiving such interventions or treatment from a
separate mental health team for the duties of Part 2 and 3 to apply. Similarly, if an individual is
receiving interventions or treatments in relation to a mental health problem from a substance
misuse team, alongside any other services that are being provided to address that individual’s
substance misuse problems, that individual will also be within the scope of Parts 2 and 3 of
the Measure
Purpose of assessment
2.7 Part 2 of the Measure does not prescribe a particular assessment process, nor place duties
on mental health service providers to undertake assessments. Indeed the duties under Part 2
only have effect once an individual is a ‘relevant patient’.
2.8 A relevant patient is dened in the Measure as an individual for whom a mental health
service provider is responsible for providing a secondary mental health service. This is
irrespective of whether the individual is cooperating with the provision of such services.
2.9 In addition, a person who is under the guardianship of a local authority in Wales (within the
meaning of the Mental Health Act 1983) is a relevant patient for the purposes of Part 2.
2.10 For relevant patients, the assessment process for agreeing the outcomes to be achieved will
identify needs and risks (including vulnerability), alongside their personal strengths. Such an
approach maximises the opportunity for recovery and independence. Recognising, reinforcing
and promoting strengths at an individual, family and social level should be a key aspect of the
assessment process.
2.11 The aim is for the assessment process to establish information from which care and
treatment planning and future work, can take place.
Code of Practice
12
Chapter 2
Holistic assessment of need
2.12 Where an individual is a ‘relevant patient’ within the meaning of Part 2, their assessment will
identify, describe and evaluate their presenting needs and strengths and how they constrain
or support their capacity to live a full and independent life. This is integral to setting outcomes
and formulating the care and treatment plan.
2.13 Assessment as part of the process for producing a care and treatment plan should take into
account the relevant patient’s level of understanding, communication needs and capacity to
consent to and engage in, the process. In the case of assessments undertaken with children
the developmental maturity of the child, their family context and legal status should also be
taken into account. It is necessary that professionals engaged in the assessment process are
competent to evaluate these factors.
2.14 In order to agree the outcomes that are to be recorded in the care plan, a full assessment will
need to consider all the following aspects of a relevant patient’s life as set out in section 18 of
the Measure:–
a) nance and money;
b) accommodation;
c) personal care and physical well-being;
d) education and training;
e) work and occupation;
f) parenting or caring relationships;
g) social, cultural or spiritual;
h) medical and other forms of treatment including psychological interventions.
This is not an exhaustive list and there may also be areas in addition to the above which
emerge through the assessment process and need consideration such as communication
orsensory needs.
2.15 In order to establish whether a relevant patient has needs, strengths or risks in these areas,
each should be considered during the initial, and all subsequent, assessments.
2.16 The assessment process should also ensure that the relevant patient is encouraged and
facilitated to make clear their views and their ambitions for the future. It is crucial for the
joint production of a care and treatment plan that, where possible the assessment process
engages the relevant patient collaboratively, although it is recognised that this might not be
possible in all cases. Where a relevant patient lacks the capacity, or refuses to cooperate in
the assessment process, this should not prevent efforts continuing to engage or involve the
relevant patient as much as possible. Where practicable and appropriate the views of any
carers or signicant others should also be sought and recorded.
2.17 In relation to the assessment of children and young people (within the context of Part 2 of
the Measure), practitioners undertaking assessments should consider the child in the context
of their developmental level and seek to view problems and issues in the ways in which
13
Code of Practice
Chapter 2
children experience them. In addition, they should ideally empower good parenting, include a
focus on prevention and health promotion and aim to develop relationships that aid children
in tackling their problems. Consideration needs to be given to establishing:–
a) who has parental responsibility for the child and the needs of the carers to enable them
to provide care;
b) the ability of the child to make their own decisions in terms of emotional maturity,
intellectual capacity, mental state and their competence;
c) The involvement and role of other statutory services in the support of the child such
aseducation or local authority children’s social services.
Assessment of risk
2.18 Assessment of risk forms a part of the necessary rst step to setting outcomes and
formulating the care and treatment plan, as provided by section 18 of the Measure. It should
be part of best practice in all holistic assessments and in all cases the assessment process
ought to seek to identify any risks the relevant patient may be exposed to and any risks
they may present to themselves or others. The care and treatment plan should contain
steps to mitigate these risks, and so contribute to the setting of outcomes on the relevant
patient’splan.
2.19 Whilst the Measure does not prescribe a particular risk assessment process or tool LHBs and
Local Authorities should ensure that in all cases risk assessments should seek to identify and
minimise the potential for:–
a) social vulnerabilities (including vulnerability to harm from others, e.g. Vulnerable Adult,
Child Safeguarding issues);
b) harm to self (including deliberate self harm);
c) suicide;
d) harm to others (including violence);
e) self neglect;
f) neglect or abuse of children;
g) neglect or abuse of adults for whom they provide care;
h) adverse risks associated with the abuse of alcohol or substance abuse;
i) risk of becoming institutionalised.
2.20 In practice terms, assessment of risk is an aid rather than a substitute for decision making
about what outcomes need to be achieved, and assessments should be considered, along
with the entirety of the assessment information, to be translated into a formulation of any
risks, and subsequent management of those risks. All care and treatment planning processes
should take into account risk management arrangements.
2.21 The assessment of risk and the planning for risk management is an essential part of the
review of care and treatment plans (see Chapter 6 below).
Code of Practice
14
Chapter 3
Chapter 3
Care Coordinators
3.1 The care coordinator is central to the relevant patient’s journey through secondary
mental health services; the Measure requires a care coordinator to be appointed as soon
as reasonably practicable for each person upon becoming a relevant patient. This chapter
outlines the role of the care coordinator, and also details their duties and functions under
theMeasure and the Part 2 Regulations.
3.2 This chapter also provides guidance on the appointment of care coordinators, and
organisational responsibilities in supporting the care coordinator.
Role of the care coordinator
3.3 The role of the care coordinator is a distinct one within the care and treatment planning
process, which may overlap with some areas of professional practice but also has its own
distinct responsibilities. There may be many people involved in a relevant patient’s care in
secondary mental health services but there will be only one care coordinator acting for
arelevant patient at any one time.
3.4 The care coordinator is responsible for the following:–
• workingcollaborativelywiththerelevantpatientandtherelevantpatient’smentalhealth
service providers with a view to agreeing the outcomes which the provision of mental
health services are designed to achieve;
• ensuringthatacareandtreatmentplanisdevelopedandwritten;
• ensuringcareandtreatmentplansarereviewedandrevised;
• providingadvicetoserviceprovidersontheeffectivecoordinationofthecarewhich
isdelivered;
• keepingintouchwiththerelevantpatient.Thecarecoordinatormayalsochoosetokeep
in touch with family and carers where appropriate or necessary.
3.5 Care coordinators are the principle source of information for the relevant patient and are
responsible for seeking their active involvement and engagement in the care planning process.
They also have a signicant role in managing relationships with a wider range of partners in
the care and treatment process. The care coordinator may also deliver certain components
ofthe care and treatment plan themselves.
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Appointment
Duty to appoint a care coordinator
3.6 Section 14 of the Measure places a duty upon the ‘relevant mental health service provider’
(see paragraph 3.10 below) to appoint a care coordinator for the individual receiving
secondary mental health services as soon as reasonably practicable after the individual
becomes a relevant patient (or after an existing care coordinator permanently ceases to
be appointed). In practice this means that the appointment must take place as soon as
practicable after the individual has been accepted into secondary mental health services,
or their existing care coordinator ceases to be appointed, or they have become subject
to guardianship. It is not appropriate, or safe, for relevant patients to be without a care
coordinator once they have been accepted into services. For this reason it is recommended
that a care coordinator is appointed for a relevant patient when the individual is accepted
into services, or very soon afterwards, and this should in all but exceptional circumstances
bewithin 14 days.
3.7 A person can only be appointed as a care coordinator if they meet the eligibility requirements
set out in the Regulations made under Part 2 of the Measure (see paragraph3.24 below).
3.8 The relevant mental health service provider may appoint a care coordinator from amongst
the staff of another organisation, provided that the consent of the other organisation is
obtained. For example, an LHB may think it best to appoint an eligible person from an
independent hospital to be the care coordinator where the relevant patient is in that
independent hospital. Other examples could include a local authority appointing an eligible
health professional, with the agreement of the employing LHB, or vice versa. A care
coordinator acts on behalf of the mental health service provider which appointed them.
3.9 Organisations who work together in multiagency teams to deliver secondary mental health
services may consider the development of joint protocols relating to the appointment of care
coordinators as a means of setting out an agreed process for meeting their statutory duties
inappointing care coordinators.
Relevant mental health service provider
3.10 Care and treatment provision within secondary mental health services is often undertaken
by a range of different professionals and via a number of agencies, reecting the complex
and sometimes enduring needs that users of those services may have. This complexity of
provision is recognised in the Measure and associated Part 2 Regulations, which establishes
amechanism for identifying the provider with a duty to appoint a care coordinator. This is set
out in the table below:–
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3.11 Although the duty to appoint a care coordinator sits with the relevant mental health service
provider, an LHB or local authority may delegate the function (but not the responsibility)
ofappointment to another LHB or local authority.
3.12 LHBs and local authorities should identify the ofcers within their organisations who may
perform the function of appointment on their behalf, and include this in their Schemes of
Delegation. The Schemes should also make clear the circumstances when an LHB or local
authority may delegate their function of appointment to another LHB or local authority, as
the case may be.
Temporary appointments of a care coordinator
3.13 There may be occasions when the care coordinator is, temporarily, unable to act as such.
Forexample, they are unwell and are away from work for a period of time. In such cases the
relevant mental health service provider may appoint a temporary care coordinator and that
temporary care coordinator must perform all of the functions of the usual care coordinator.
Given the importance of the care coordinator, it is not appropriate for a relevant patient
Circumstances
Relevant mental health
serviceprovider
The relevant patient receives secondary mental health
services from only a Local Health Board
The Local Health Board
The relevant patient receives secondary mental health
services from only a Local Authority
The Local Authority
The relevant patient is under guardianship (within the
meaning of the 1983 Act)
The Local Authority
The relevant patient is under 18 and is looked after
byalocal authority
3
The Local Authority
The relevant patient is under 18 and is a ‘relevantchild’
4
The Local Authority
The relevant patient is under 18 and qualies for
adviceandassistance under certain provisions of the
Children Act 1989
5
The Local Authority
The relevant patient is under 18 and is admitted to a school
in accordance with a statement of special education needs
6
that names the school
The Local Authority
The relevant patient receives secondary mental health
services provided by the Welsh Ministers
7
The Welsh Ministers
All other cases, including where the relevant patient receives
services from both a LHB and aLocalAuthority
The Local Health Board
3
within the meaning of section 22(1) of the Children Act 1989
4
within the meaning of section 23A of the Children Act 1989
5
i.e. qualies under section 24(1A) or 24(1B) of the Children Act 1989
6
made under section 324 of the Education Act 1996
7
The Welsh Ministers have general and specic powers under the National Health Service (Wales) Act 2006 to provide services.
Section 13(2) of the Mental Health (Wales) Measure 2010 makes clear that where an LHB is providing a service under a function
in relation to which directions have made the function exercisable by the LHB, the service is to be treated as being provided by the
LHB and not the Welsh Ministers
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to be left in limbo with no one overseeing the coordination of care and treatment and
mental health service providers should pay close attention to this when deciding whether
atemporary appointment is necessary.
3.14 A person should only be appointed as a temporary care coordinator if they meet the
eligibility requirements established in the Part 2 Regulations for care coordinators (see
paragraph 3.24 below).
3.15 Temporary appointments cease when the relevant mental health service provider considers
that the usual care coordinator has regained the ability to undertake their functions. There is
no need for a fresh appointment of the usual care coordinator to be made, as their previous
appointment will simply recommence.
3.16 Whenever a temporary appointment is made, it is good practice for the relevant patient and,
where appropriate, their carer to be informed of the temporary arrangements. It is unlikely
that there will be a need to make revisions to care and treatment plans, or undertake reviews
of such plans where the only change is the appointment of a temporary care coordinator.
Changes in the appointment of the care coordinator
3.17 Over time the care coordinator for a relevant patient may need to change, perhaps to reect
their changing needs. Where this happens the duty on the relevant mental health service
provider for appointing a care coordinator continues.
3.18 It is recognised that care coordinators are likely to develop close therapeutic relationships
with relevant patients, and as such, any change in appointment may well be a disruptive
event for the relevant patient concerned. In line with the guiding principles set out above,
thereasons for any change should be discussed with both the relevant patient and the
widercare team. If possible, the relevant patient should be involved in discussions about
potential replacements.
3.19 It is not necessary for there automatically to be a change in the appointment of care
coordinator because a relevant patient has been admitted to hospital, although it may be
the case that having a care coordinator based within a hospital setting may be the most
appropriate choice for meeting the relevant patient’s needs.
3.20 When there is a planned change in care coordinator, there should be a clear handover
of information (for example, case summary, need and risk assessments, and the care and
treatment plan itself). It is important that, where possible, the relevant patient is involved in
decisions about changes in responsibility for their care coordination, although it is recognised
that this is not always possible.
3.21 Where a relevant patient requests a change of care coordinator this should be considered
bythe relevant mental health service provider and where possible accommodated.
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Termination of appointment of the care coordinator
3.22 A relevant mental health service provider may terminate the appointment of an individual
appointed as a care coordinator at any time. However, where they remain a relevant patient
(within the meaning of Part 2 of the Measure), the relevant mental health service provider
must ensure that a new care coordinator is appointed as soon as is reasonably practicable,
and this should in all but exceptional circumstances be within 14 days.
3.23 A person’s appointment as a care coordinator does not necessarily come to an end as a
result of a change in a relevant patient’s relevant mental health service provider.
Eligibility to act as a care coordinator
3.24 In every case the relevant mental health service provider may only appoint a care coordinator
who is eligible to be appointed; eligibility criteria are set out in the Part 2 Regulations.
Underthese Regulations, a person is only eligible to be appointed if that person:–
a) meets one or more of the professional requirements (see paragraph 3.26 below); and,
b) demonstrates to the satisfaction of the appointing organisation that he or she has
appropriate experience, skills or training, or appropriate combination of experience,
skillsand training to undertake the functions of a care coordinator.
3.25 The appointing organisation should be satised that the care coordinator is skilled to their
satisfaction in communicating and negotiating care and treatment plans with relevant patients,
carers, multi-disciplinary and multi-agency care providers. The appointing organisation should
be satised that they have made every effort to ensure they have sufcient care coordinators
who can work with relevant patients in Welsh. It is not assumed that experience, in terms
of years served as a mental health practitioner is an adequate benchmark of skills for this
complex and challenging role. As a minimum, it is expected that the care coordinator should
be skilled in active involvement of relevant patients, carers and other workers in the care
planning process.
3.26 The professional requirements are that the potential care coordinator is:–
a) a qualied social worker (registered with either the Care Council for Wales or the
General Social Care Council);
b) a rst or second level mental health or learning disabilities nurse (registered in
Sub-part1or Sub-part 2 of the Register maintained under article 5 of the
Nursing and Midwifery Order 2001
8
);
c) an occupational therapist (registered in Part 6 of the Register maintained under
article5of the Health Professions Order 2001
9
);
d) a practitioner psychologist (registered in Part 14 of the Register maintained under
article5 of the Health Professions Order 2001);
e) a registered medical practitioner;
8
S.I. 200/253
9
S.I. 2002/254
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f) a dietician (registered in Part 4 of the Register maintained under article 5 of the
HealthProfessions Order 2001);
g) a physiotherapist (registered in Part 9 of the Register maintained under article 5 of the
Health Professions Order 2001); or,
h) a speech and language therapist (registered in under Part 12 of the Register maintained
under article 5 of the Health Professions Order 2001).
3.27 When considering whether a person has the appropriate experience, skills or training
(orcombination of experience, skills and training), the relevant mental health service
providerought to consider:–
a) the experience, skills and training of the person and how these compare to the needs
ofthe relevant patient;
b) the potential level of input into care that the person will provide, and their relationship
with the relevant patient;
c) the language and communication needs of the relevant patient, and the experience,
skills or training of the person to meet these. This includes the ability to work bilingually
or in Welsh with relevant patients who are bilingual, and the ability to assess patients
(particularly children) appropriately considering their developmental needs.
3.28 It is also good practice for consideration to be given to:
a) the preference and choice of the relevant patient as to who their care coordinator
maybe;
b) the current caseload of the person being considered for appointment, including other
duties they may be required to perform (for example, working on an Approved Mental
Health Professional (AMHP) duty rota); and,
c) any issues that might give rise to a conict of interest which may inuence a care
coordinator’s judgement or practice.
3.29 The care coordinator need not be the person who has the most involvement with the
relevant patient, although in practice this is often the case. Whilst direct therapeutic
involvement may be provided by a number of practitioners, good practice would be to
ensure that the person with the most appropriate skills and experience is appointed as the
care coordinator.
3.30 It can also be the case that there is a single practitioner providing services to meet the
identied needs of the relevant patient.
3.31 It is important that care coordinators have the necessary authority to undertake their functions.
Service providers who appoint care coordinators should ensure that such individuals have the
necessary authority to perform their functions under the Measure and to:–
a) coordinate service provision on behalf of the service providers, including accessing
resources;
b) monitor service provision;
c) call and hold reviews;
d) access other members of the relevant patient’s care team where applicable.
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Chapter 3
Duties and functions of the care coordinator
3.32 At the most fundamental level the care coordinator must work with the relevant patient,
andmental health service providers, with a view to:–
a) agreeing the outcomes which the provision of mental health services for the relevant
patient are designed to achieve; and,
b) agreeing a care and treatment plan for achieving those outcomes, and putting that plan
into writing (in the format required by the Part 2 Regulations ).
3.33 The care coordinator must also work with the relevant patient and the service providers
in connection with the review and revision of the care and treatment plan. In certain
circumstances the care coordinator has discretion over whether or not the plan should
bereviewed or revised (See paragraph 6.7).
3.34 In preparing the care and treatment plan, the care coordinator is also required to take all
practicable steps to consult certain other persons, including carers and in relation to children,
people with parental responsibility. Once the plan is complete, the care coordinator must,
ifappropriate, provide copies of that plan to the relevant patient and to certain other
persons. Further guidance on this is given in Chapter 4 below.
3.35 Mental health service providers are under a duty to take all reasonable steps to coordinate
the provision of mental health services to a relevant patient. The aim of such coordination
is to improve the effectiveness of those services. Mental health service providers may seek
the views of the care coordinator as to how the provider can meet this duty, and the care
coordinator may, at any time, give advice to service providers on this. Such advice can be
inthe form of reporting where needs cannot be met, or are not fully being met, through
theservices that are available (see Chapter 5).
3.36 In undertaking their functions, and meeting their duties, care coordinators in partnership
withrelevant patients will need to:–
a) ensure that comprehensive need and risk assessments have been undertaken for all
relevant patients for whom they have responsibilities as part of the process for agreeing
the outcomes which the provision of mental health services are designed to achieve
under section 18 of the Measure. This can include arranging specialist assessments where
required, and keeping these assessments under review to ensure they remain up to date
and accurate;
b) maintain regular contact with the relevant patient and any signicant others in the life of
the relevant patient (parents, partners, carers, etc), so that changes in their health and
social circumstances are known, and appropriate action is taken where required;
c) remain actively involved in the care and treatment of the relevant patient throughout
thetime that they remain in receipt of secondary mental health services, including during
admission or discharge from hospital;
d) record and seek resolution of any disagreements which may arise during the care and
treatment planning process;
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e) keep the relevant patient’s care and treatment plan under review, based on ongoing
assessment, including whether actions recorded in care and treatment plans are
completed within the agreed timescale(s), and revise the plan as necessary;
f) develop and maintain relationships with carers and family which are supportive
oftheirrole, and which values their contribution, treating them as equal partners
inthecare relationship;
g) ensure the appropriate sharing of information;
h) maintain contemporaneous, accurate and lawful records in a manner proportionate
toacase’s level of complexity;
i) support the delivery of care and treatment in a way which is consistent with a
recovery ethos, seeing the relevant patient’s perspective and maximising strengths
andindependence;
j) maintain relationships with the relevant patient, and any agencies which are delivering care
or treatment when transferring the relevant patient from one service or place to another.
Supporting care coordinators
3.37 Service providers should ensure that there are clear arrangements in place to manage service
demand and delivery. These arrangements should support the appointment, and effective
caseload management, of care coordinators. Similarly, care coordinators will need to give
consideration to such matters when planning the delivery of care and treatment, and the
potential identication of unmet needs due to the availability of practitioners and services.
3.38 Employing organisations should ensure that care coordinators have access to clinical and also
caseload supervision as part of their role as care coordinators. Supervision can be dened
as a regular and protected time where a practitioner can reect, learn, explain and rene
their understanding of mental health practice. Additionally it provides opportunities for care
coordinators to monitor the relationships required to coordinate and oversee complex
care packages and seek resolutions to ongoing challenges. The provision of peer or mentor
support can also have a positive role in supporting care coordinators.
3.39 Care coordinators should also be supported by effective training to undertake their functions.
As well as training and education in relation to the practical aspects of holistic assessment,
addressing communication needs, planning, and liaising, this should include understanding the
importance of maximising opportunities for recovery and achieving a better quality of life for
the relevant patient.
3.40 Training may include a mixture of process training (for example, ensuring documentation
andrecord keeping is consistent with organisational and legislative requirements) and
values-based practice resources which promote engagement methods and support the
recovery ethos of Parts 2 and 3 of the Measure.
3.41 Responding to the needs of relevant patients is central to mental health practice and
consequently it is advisable that training opportunities for care coordinators and other
members of the care and treatment planning team have the active involvement of relevant
patients as co-trainers/facilitators.
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Chapter 4
Chapter 4
Care and Treatment Planning
4.1 Part 2 of the Measure, and the associated Part 2 Regulations, place duties on mental health
service providers and care coordinators regarding the preparation, content, consultation and
review of care and treatment plans. These plans must be provided for all relevant patients.
4.2 The Part 2 Regulations also prescribe the content and the form of the care and treatment
plan which all care coordinators are required to use. Schedule 2 of the Mental Health
(CareCoordination and Care and Treatment Planning) (Wales) Regulations 2011 sets out
theform and is included at Appendix B.
Involvement, engagement and consultation
4.3 The Measure requires the care coordinator to collaborate with the relevant patient and
the relevant patient’s mental health service providers to agree outcomes, and prepare the
care and treatment plan. Appropriate engagement is important if a relevant patient’s rights
are tobe respected and they are to participate in the co-production of their care and
treatment plan. Encouragement for involvement in care and treatment planning should be
clear and unambiguous. Technical language and jargon should be avoided in the planning
process and encouragement for involvement and engagement should be in the relevant
patient’s preferredlanguage. The plan may be completed in the Welsh or the English language,
orpartly in Welshand partly in English.
4.4 The relevant patient’s ability to understand issues, and any communication difculties they
may have, should be considered, and where required, access to interpreters and/or persons
with specialist skills in communication should be considered. This is particularly important
where a relevant patient has a Learning Disability as it is quite common for such a relevant
patient to understand more or less than appears to be the case from their verbal skills.
4.5 For children, it will normally be necessary to ensure the involvement, engagement and
consultation of appropriate family members. Consequently, the care coordination skills and
actions noted above may need to be applied within this broader group setting. It is of critical
importance that technical language is avoided and that the language and methods used
when discussing care and treatment is understood by all. This may mean thinking and acting
creatively in relation to how care and treatment plans are constructed and communicated
with children and their families/carers (while still ensuring that the form and content of plans
required by the Part 2 Regulations are followed). For example, a care coordinator must
complete a care and treatment plan in the required format, but may also communicate the
contents of that plan in a way which enables and ensures understanding on the part of the
child and their family.
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Code of Practice
Chapter 4
4.6 In some cases the relevant patient may wish to nominate a representative to be engaged in
the planning process on their behalf. In some cases the care coordinator may need to take
action to ensure that there is appropriate support for a relevant patient in developing the
care and treatment plan, for example suggesting that an advocate could provide help and
support to the relevant patient. Every opportunity should be taken to overcome barriers to
involvement and engagement. If a relevant patient does not wish to be involved at a particular
point in time, this should not be seen as a denitive or permanent statement; involvement
and engagement in care and treatment planning may uctuate and so the relevant patient’s
preferred level of inclusion should be subject to regular and ongoing review.
4.7 Where a relevant patient is an inpatient in hospital, or subject to relevant provisions of the
Mental Health Act 1983 as amended by the Measure, they are eligible to receive help and
support from an Independent Mental Health Advocate (IMHA). The IMHA may provide help
and support in relation to care and treatment generally or more specically – for example
helping (by way of representation or otherwise) those relevant patients who wish to be
involved in decisions made about their care and treatment. Where an IMHA is involved,
the care coordinator and members of the care and treatment team should respect the
independence of the IMHA and seek to work openly and collaboratively to achieve the best
treatment plan and actions for the relevant patient. One of the ways this can be achieved
is engagement in care and treatment planning meetings. Under the 1983 Act an IMHA may
have access to the health and social care records of the relevant patient, subject to certain
conditions. Further information on the role, duties and powers of the IMHA is available in the
Mental Health Act 1983 Code of Practice for Wales and the Welsh Government’s Delivering the
Independent Mental Health Advocacy Service in Wales: guidance for independent mental health
advocacy providers and Local Health Board advocacy service planners.
Working with the relevant patient
4.8 The Measure places a duty upon the care coordinator to collaborate with the relevant
patient, and that relevant patient’s mental health service providers, with a view to:–
a) agreeing the outcomes which the provision of mental health services are designed
toachieve;
b) agreeing the care and treatment plan; and,
c) reviewing and, if necessary, revising the plan.
4.9 Being aware of the potential barriers to involvement is key. In writing a care plan with a
relevant patient it is important to make the process as easy to understand as possible,
byexplaining what is happening and putting the relevant patient at ease. Where discussions
take place can affect how much a relevant patient participates and how comfortable they
feel, so care coordinators should give consideration to this and adopt a exible approach
tothe choice of venues. It may also be the case that more than one discussion or meeting
isnecessary to write the care plan.
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24
Chapter 4
4.10 Working with the relevant patient in their preferred language is central to overcoming
barriers to involvement. In addition, care coordinators should use plain language in writing
care plans and should attempt to write outcomes in the relevant patient’s own words.
Indoing this consideration needs to be given to, amongst other things, any sensory
impairment, cognitive impairments or the developmental maturity of the relevant patient.
4.11 There will be circumstances where either a relevant patient does not wish to take an active
part in care and treatment planning or where they do not agree with either the full plan or
parts of the plan. Effective coordination is built on a belief in partnership and collaborative
working arrangements. A desire to disengage should be viewed as a temporary situation and
ongoing efforts on the part of the care coordinator should be made to engage the relevant
patient. Where a relevant patient does not agree with the plan, or parts of it, the care
coordinator should make ongoing efforts to negotiate a plan, based on assessment, on which
all care and treatment participants are in agreement. In the rare circumstances where there
is no engagement despite the efforts of the care coordinator, the care and treatment plan
may have to be formulated based upon the information available through assessment and
information from others such as family or carers.
4.12 For children, the focus should be on the collaborative nature of the relationship between the
relevant patient and the care coordinator. In most cases this will need to be mirrored in the
relationship between the care coordinator and the child’s carers/parents. Care and attention
should be paid to ensuring, by all practical means, that the child and usually their family have
been fully engaged in the care and treatment planning process. This will help ensure that
the child’s needs have been fully identied across the spectrum of social, psychological and
physical developmental areas. Gaining and maintaining this engagement with the child and
usually their family is an ongoing activity for the care coordinator.
4.13 If a relevant patient lacks the capacity to make decisions about their care and the outcomes
to be achieved in the care and treatment plan then they should still be at the centre of
the care planning process, with their capacity to be involved maximised. Decisions made
inthe care planning process should be made under the framework of the Mental Capacity
Act2005, with assessments of capacity documented and the determination of best
interestsevidenced.
4.14 When working with relevant patients who have a Learning Disability it is important to
be familiar with, and take into consideration, their personal strengths and support needs.
Anawareness of cognitive competencies, including concentration, memory and the processing
of information must be augmented by knowledge of any difculties in relation to social
interaction. This could include communication difculties and the potential that the relevant
patient may have for acquiescence and suggestibility. It is also important to be aware of the
way environmental variables such as time and location may affect the relevant patient and
toconsider the implications of sensory impairments.
4.15 The views of the relevant patient on the content of the care and treatment plan can be
recorded on the care plan itself, including views on the mental health services to be provided
and any future arrangements that ought to be considered. If no views are expressed by the
relevant patient, or no views can be ascertained, then this should be recorded.
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Code of Practice
Chapter 4
4.16 The Part 2 Regulations require that a record is made on the care and treatment plan as to
whether the plan has been agreed with the relevant patient. If the relevant patient has not
agreed the care and treatment plan, or is in disagreement with the plan, then the reasons for
this should be recorded. It is good practice for the reasons to be recorded on the care plan
itself and a suitable place is suggested as being the part where a relevant patient can record
their views on the care and treatment plan, the mental health services to be provided and
any future arrangements that ought to be considered.
Consultation with others
4.17 Part 2 of the Measure requires the care coordinator to work with the relevant patient
and the mental health service providers with a view to agreeing outcomes, and preparing,
reviewing or revising care and treatment plans.
4.18 In addition, the Part 2 Regulations also require the care coordinator to take all practicable
steps to consult the following persons, where they are identied in relation to the
relevantpatient:–
a) all persons with parental responsibility for the relevant patient;
b) all the relevant patient’s carers and adult placement carers;
c) the relevant patient’s responsible clinician;
d) the relevant patient’s guardian (within the meaning of the Mental Health Act 1983);
e) a donee or deputy the relevant patient, where the matters to be considered in the
consultation fall within the scope of their decision making powers;
f) an independent mental capacity advocate who has been appointed for the
relevantpatient;
g) the managing authority and supervisory body, where the relevant patient is subject
to urgent or standard authorisations under the Deprivation of Liberty Safeguards of
the Mental Capacity Act 2005, together with any ‘relevant persons representative’,
underthoseprovisions.
A full explanation of all of these terms (and persons listed) is given in the glossary of terms
atAppendix A.
4.19 The care coordinator may also consult any other person who they wish to consult, in order
to facilitate the carrying out of their functions as a care coordinator.
4.20 Before consulting any of these persons the care coordinator must take account of the views
of the relevant patient about whether these persons or individuals ought to be consulted.
The relevant patient should be given support and information to help them understand the
nature, risks, implications and purpose of consulting with others. The care coordinator may
consult persons against the wishes of the relevant patient, provided that they have given
due consideration to the views of the relevant patient. This may include any feelings or fears
associated with consultation. Good practice would suggest that such decisions to consult
despite the views of the relevant patient, and evidence of due consideration being given,
areclearly recorded.
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26
Chapter 4
4.21 The care coordinator may also consult any other person who the relevant patient wishes
tobe consulted.
4.22 It is essential that the care coordinator, and where appropriate the relevant patient,
communicate regularly and in a timely manner with any consultees. The avoidance of technical
language and jargon also applies to communication with the wider care team and other
consultees. The care coordinator should ensure that there is a clear understanding of each
individual’s and agency’s contribution to the plan, and where the accountability for delivery
of services sits. The care coordinator’s function is to oversee this involvement. Whereagreed
actions are not being delivered this is the responsibility of the mental health service provider
concerned, but it would be good practice for the care coordinator to seek to nd a
resolution, as this may require a review or revision of the care and treatment plan.
Engagement with the care team
4.23 Within the care and treatment planning process, the importance of team work, regular
communication and review of outcomes should form part of care plan discussion and review.
This is particularly important where there may be conicts about any proposed treatments
or interventions. Negotiation between the relevant patient and practitioners involved in
the care plan is a necessary process in developing a coherent and systematic approach
tooutcome planning in care and treatment.
4.24 Information sharing between professionals is often an essential part of coordinated care and
treatment plans, particularly where a number of professionals and organisations are involved,
or signicant risks are identied. It is the responsibility of the care coordinator to discuss and
seek the agreement of the relevant patient to relevant information being shared. The rationale
for information sharing should be clearly presented and the maintenance of condentiality
within the immediate care and treatment planning team assured. Organisations should adhere
to their existing information sharing protocols.
4.25 Those involved in making decisions regarding the provision of services need to be
empowered to make commitments on behalf of their agency. If approval for plans needs to
be obtained from more senior ofcials (for example, for funding) it is important that, where
possible, this should not delay implementing the care and treatment plan. Where discharge
from hospital is concerned, this is particularly important.
4.26 For relevant patients placed in services away from their place of usual residence, services
from the relevant patient’s ‘home’ area should continue to be engaged. The relevant patient’s
‘home’ area should remain involved through attendance at care planning meetings, and regular
involvement in other discussions.
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Engagement with family, friends and carers supporting the relevantpatient
4.27 Carers and parents can be important members of the care delivery team, even in
certain circumstances when their involvement is not requested by the relevant patient.
TheRegulations require care coordinators to take all practicable steps to consult with
parentsand any carer(s) who may have a caring relationship with the relevant patient during
the preparation or review of the care plan. Before any such consultation takes place, the care
coordinator is required to take account of the views of the relevant patient as to whether the
parent or carer should be consulted with. However, where the relevant patient has indicated
that they do not wish the parent or carer to be consulted, the care co-ordinator may still
consult against the relevant patient’s wishes so long as they have given due consideration
tothe views of the relevant patient (see paragraph 4.20).
4.28 The relevant patient may wish to nominate family, friends and/or carers to support the
delivery of the care and treatment plan; these supporters can play a major role in providing
practical assistance in the delivery of the care and treatment plan.
4.29 The Part 2 Regulations also require care coordinators to provide the relevant patient’s parents
or carers with a copy of the care and treatment plan when it has been produced, andany
revised versions of the plan which are produced following review – unless that parent or carer
has indicated that they do not wish to receive a copy. Again, the care coordinator must take
into account the views of the relevant patient before providing a copy of the plan to a parent
or carer, but may still provide a copy of the plan against the relevant patient’s wishes so long as
they have given due consideration to the relevant patient’s views. The care co-ordinator may
also decide to withhold a copy of the plan, or provide a copy of part of a plan, to a parent or
carer, if they believe it is in the relevant patient’s interests to do so. It may be that where partial
disclosure is considered that this includes details about what should happen if the relevant
patient is becoming more unwell, and emergency contact details.
4.30 The key role that carers play in supporting relevant patients is acknowledged and where it is
decided that consultation, or sharing copies of the care plan with parents or carers should not
take place, it is good practice to record the reasons for this decision. Such decisions should
be kept under ongoing review. It may also be appropriate that where this is the case an
explanation is offered to parents or carers as to why consultation has not been undertaken
or copies of the plan provided, where doing so would not be detrimental to the interests
ofthe relevant patient.
4.31 For children, unless the care coordinator believes it to be in the child’s interests to withhold
a plan or part of a plan (e.g. to do so would increase risk to a child), care plans should
be shared with all those with parental responsibility for the child. Sharing copies with
other bodies with statutory responsibilities such as local education authorities should also
beconsidered.
4.32 The Carer’s Strategies (Wales) Measure 2010 requires LHBs and local authorities to have in
place local strategies to ensure that carers are identied (including young carers who may be
caring for a parent or other relative) and provided with information and support which will
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assist them in their caring role – including their entitlement to an independent assessment of
their needs as a carer. Care coordinators and service planners should be aware of their own
service’s carers’ strategy requirements and ensure that these are adhered to when carers are
involved in the care and treatment planning process.
Outcome planning
4.33 The care coordinator must work with the relevant patient and providers of services to agree
the outcomes that the provision of mental health services for the relevant patient should be
designed to achieve.
4.34 The care and treatment plan should list these outcomes, record the services and/or actions
that are to be provided to achieve each outcome, including when they will be provided
and state who is responsible for providing the service. The care and treatment plan should
reect the ndings of any assessment of need and risk that has been undertaken. The care
coordinator should ensure that a comprehensive assessment has been conducted, in order
toensure that the agreed outcomes and the care and treatment plan appropriately reect
the needs of the individual relevant patient.
4.35 The process of agreeing outcomes requires involvement and engagement with the relevant
patient, mental health service providers, and other appropriate consultees. Seeking agreement
for those actions or services designed to deliver outcomes may require differences of opinion
on care and treatment options to be openly discussed, and any conicts resolved.
4.36 The care and treatment plan should include a clear description of the outcomes agreed
with the relevant patient (where possible), and the relevant patient’s mental health service
providers. Outcomes to be achieved will be drawn from one or more of the following areas
as set out in section 18 of the Measure:–
a) nance and money;
b) accommodation;
c) personal care and physical wellbeing;
d) education and training;
e) work and occupation;
f) parenting or caring relationships;
g) social, cultural or spiritual;
h) medical and other forms of treatment including psychological interventions.
4.37 Whilst there is no requirement for a care and treatment plan to record outcomes against
each of these potential areas for intervention, it is likely that, outcomes would arise in more
than one of these areas. It is also the case that care coordinators are not limited to recording
outcomes only in relation to these 8 areas. Outcomes in additional areas may be recorded
where identied, such as sensory or communication needs. It is also possible to record
outcomes where the relevant patient is taking responsibility for the action.
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4.38 For children, best practice would be for outcomes across these domains also to consider
attainment of achievable physical, psychological & social developmental goals and
interventions that support family and/or carers in enabling the child to achieve the desired
outcomes. The outcomes should be expressed in language that is understandable to the
relevant patient and family.
4.39 Whilst outcomes can be based on the wishes, feelings and experiences of the relevant
patient, they should be recorded in a way which is objective and quantiable. In all cases
outcome planning should be based on the principles derived from recovery-orientated
mental health practice, where the relevant patient is supported to take as much responsibility
for developing the care and treatment plan as they are able. A whole-person approach should
be used (seeing the person from a wider health and social perspective) where each partner
in the care and treatment plan – including the relevant patient themselves – is making a
commitment to achieving the stated outcomes.
4.40 In writing an outcomes-based care and treatment plan, a clear statement of the issues to
be addressed will rst be required. Following this, the care coordinator and care team,
alongwith the relevant patient, will work to identify, agree and describe the desired outcomes,
eitherlong term or short term, which if attained would demonstrate that the issues identied
had been resolved or are progressing towards resolution. To achieve a full and meaningful
outcomes-based care and treatment plan the care coordinator, care team andrelevant
patient will need to work together to identify and agree the realistic, observableand
achievable milestones to be reached in order to realise each outcome. This can promote
thepositive approach of building upon achievements.
4.41 Ongoing monitoring and review should be undertaken of whether the outcomes or
milestones recorded in the care and treatment plan are being achieved. Timescales for
reviews should be linked to the expected achievement of outcomes or milestones.
Thisapproach is consistent with good practice in care and treatment planning, and
assuchremains the responsibility of the care coordinator.
Matters to be considered in the care and treatment plan
Finance and Money
4.42 The assessment process should consider the nancial aspects of the relevant patient’s life,
and agree any related outcomes which ought to be achieved and recorded on the relevant
patient’s care and treatment plan. This will enable consideration of any support that may be
required to help the relevant patient access benets, respond to any nancial anxieties or
address any identied vulnerabilities of nancial abuse.
4.43 Mental health problems may cause a relevant patient to neglect personal nances.
Alternatively, for someone living with a diagnosis such as dementia, they may worry about
how they and their family will cope as their illness progresses. The assessment process should
therefore consider a range of issues relating to nance and money, including:–
a) if the relevant patient’s ability to work is affected and whether there may be a sudden or,
possibly, dramatic reduction in their income as a result;
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b) the impact of time away from home (for example, admission to hospital) on the relevant
patient’s ability to keep abreast of nancial commitments;
c) whether a relevant patient’s capacity to make nancial decisions is affected,
perhapsleading them to act recklessly or unwisely;
d) loss of motivation or the ability to concentrate and thus keep control of nances;
e) vulnerability to nancial exploitation or abuse.
4.44 Outcomes in this area may also be related to the impact of nancial problems on a relevant
patient’s mental health (for example, stress and worry associated with trying to maintain
control of nances could lead to feelings of inadequacy and despair, and a lack of security,
or pessimism about the future). Such issues can also have an impact on family and carers,
whichwill need to be considered and which may include a relevant patient’s ability to parent
or meet other caring responsibilities arising from nancial pressure.
4.45 Consideration should be given as to whether there needs to be longer term planning where
the relevant patient’s capacity may uctuate or be lost. Assessment of nance must identify
whether or not a donee or deputy for the relevant patient is in place, and whether the scope
of their powers includes nancial matters.
Accommodation
4.46 The relationship between accommodation and mental health can be complex and
multifaceted. Poor housing or homelessness can contribute to mental ill health, or make an
episode of mental ill health more difcult to manage. Mental ill health can make it more
difcult for people to nd and maintain good-quality accommodation and on some occasions
the Mental Health Act 1983 may be called upon to require a person to reside at a particular
place. The assessment process will need to identify whether the relevant patient’s current
accommodation has an impact upon their mental health, and agree any related outcomes
which ought to be achieved and recorded on the relevant patient’s care and treatment plan.
4.47 An assessment needs to consider whether the relevant patient’s accommodation is warm,
weatherproof, equipped with modern facilities and in a good state of repair, and is safe and
secure. The security of a relevant patient’s home in their absence is of particular relevance
when admission to hospital is being considered. The immediate environment of the
accommodation should also be taken into account, including whether there is access to clean,
safe, green spaces, access to public services and opportunities for social contact.
4.48 Taking into account other needs of the individual relevant patient, agreeing outcomes may
relate to the suitability of the accommodation in relation to any physical requirements,
including mobility or poor sight, and whether assistance is needed in such areas.
Additionallythe assessment should consider any history of rental or mortgage arrears,
as this can be an indicator of help required with ‘money management’ and can adversely
affect future accommodation needs. Accruing rent arrears or other debt can also be an
indication of relapse of a mental illness. The accruing of rent arrears and the risk of eviction
could therefore be seen as a potential relapse indicator and also an area where contingency
planning may be required.
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4.49 For relevant patients in hospital, accommodation should be viewed on two levels –
rstlytheir accommodation needs in hospital regarding the suitability of the ward
environment, together with a consideration of their accommodation needs when they are
to be discharged from hospital. In relation to children, section 131A of the 1983 Act places
aduty on hospital managers to ensure that a child that is admitted to hospital for treatment
of their mental health is accommodated suitably for their age, subject to their needs.
4.50 It may also be that an Independent Mental Capacity Advocate is appointed for a relevant
patient under the duties of the Mental Capacity Act 2005 where decisions about long
term accommodation are to be made and the relevant patient lacks capacity to agree to
placements and has no-one other than professionals or paid carers involved in their care.
4.51 Addressing needs and setting outcomes which may be met by the availability of appropriate
accommodation upon discharge is a critical part of discharge planning. This should be
undertaken as early as possible following an admission to hospital.
4.52 In more general terms, agreeing the outcomes for a child will need to establish the safety
and suitability of their current accommodation. If the parents of the child are separated,
consideration should be given as to whether there is a residency order, and if so, the
requirements of that order.
Personal care and physical wellbeing
4.53 A relevant patient’s personal care needs and physical wellbeing ought to be identied
regardless of their age, with any outcomes which ought to be achieved recorded on the
relevant patient’s care and treatment plan. Such consideration will include the relevant
patient’s ability to address their own personal care and wellbeing (such as washing, dressing
or cooking) or the support that is provided to meet these basic needs. It may be that the
provision of equipment, or aids is required to improve independence in personal care, or it
may be a matter of education to acquire skills or encouragement to use existing skills.
4.54 Consideration should be given to the impact of other physical and well being issues such as
disability, mobility, or pain management, together with lifestyle choices on the relevant patient’s
mental health. In doing this consideration should be given to whether the relevant patient has
a GP and other relevant health professionals such as a dentist or optometrist, for example,
and if so, is maintaining appropriate contact with them.
4.55 Following assessment, outcomes may be agreed regarding physical health screening or
support to access health promotion or screening for long-term health conditions such as
diabetes, respiratory diseases or cancers. Physical health assessments may be undertaken by
the relevant patient’s GP or by an appropriately qualied member of the secondary mental
health service.
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Education and training
4.56 Education and training for relevant patients of all ages, not just those in or aspiring to full
or part-time education, and agreeing and recording any related outcomes which ought to
be achieved on the relevant patient’s care and treatment plan is important. Education and
training may be particularly relevant to the relevant patient’s recovery journey and personal
goals, whether or not it results in a formal qualication. For some, participation in education
or training may provide necessary life skills or social skills.
4.57 Agreeing outcomes for the care and treatment plan may involve recognising that the
relevant patient is receiving education and training but requires support to continue with this,
whetherin specialist services or within mainstream learning environments.
4.58 Access to education and training for children should not be denied because they are receiving
care and treatment. It is important that the educational needs of a child are considered,
andsuitable arrangements for these to be met are identied when agreeing outcomes.
Themeans to ensure attainment of functional literacy and numeracy should be considered
and future career plans identied as a means to clarify appropriate educational goals.
4.59 It is important that the learning needs of older people are not overlooked. Developing new
skills, or pursuing activities which build upon existing skills, is important. This is particularly the
case where relevant patients need to adjust to life events in later life such as retirement or
bereavement. Pursuing interests including education, training or hobbies can be enormously
benecial in promoting self esteem, condence and social connectedness – all crucially
important to good mental health.
4.60 Outcomes may relate to the education and training that a relevant patient requires,
or may benet from in managing their own mental health, or in developing coping and
preventionskills.
Work and occupation
4.61 Work is generally good for our physical and mental health. Therefore, needs and wishes
in relation to full or part-time employment should be carefully considered when agreeing
outcomes for a relevant patient’s care and treatment plan. This may well include work-related
activities such as volunteering.
4.62 For a relevant patient who is not working, exploring outcomes around the support that may
be required in identifying new job opportunities, vocational skills, contacting employment
agencies, or accessing specialist mental health employment services can be benecial.
Theprospect of paid employment for those who have been out of the job market for some
time can be stressful, and may for some people negatively impact on their mental health.
Care coordinators and other members of the mental health team may need to review
theadditional support a relevant patient may require in overcoming this potential barrier.
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4.63 For children who may be approaching, or have attained, working age, consideration should
be given to goals for employment and occupation in the treatment plan and the steps for
supporting the achievement of such goals as soon as possible, particularly for those in the
nal 2 years of their statutory education.
4.64 For relevant patients who have retired from paid employment and who do not wish to seek
fresh employment, consideration should be given to other meaningful activity and occupation,
for example volunteering.
4.65 For all people the active use of leisure time, whether in combination with occupational time
or not, can be important in contributing to recovery, self management and improvements
inquality of life. In children this may include opportunity for play.
4.66 In all cases, outcomes which ought to be achieved need to be agreed and recorded on the
relevant patient’s care and treatment plan.
Parenting or caring relationships
4.67 Agreeing any outcomes relating to a relevant patient’s parenting or caring relationships or
responsibilities is important. Determining what, if any, support is required to maintain any such
parenting or caring relationships should inform outcomes and consideration should be given
to the effect that these relationships may have on the relevant patient’s health.
4.68 It is important that any risks (including neglect or acts of omission) towards children or
vulnerable persons are identied and acted upon appropriately and in accordance with
safeguarding children or vulnerable adults procedures.
4.69 If there is a parental or caring relationship which the relevant patient is maintaining and
managing well this can be acknowledged positively, along with the fact that support may
notbe required at this time.
4.70 Where the assessment identies that the relevant patient has a carer, the care coordinator
should take steps to ensure that the carer is directed to sources of information and support
– including the right to a carer’s needs assessment – in line with the service provider’s
Carer’sStrategy
10
and a separate carer’s assessment is undertaken if appropriate.
4.71 A child who is a relevant patient may also have parenting or caring responsibilities and it
is imperative that in agreeing outcomes any such responsibilities are identied. The care
and treatment plan should recognise any such role, and outcomes may relate to the ability
that the child has to care for others and the effects on the child’s mental health of such
responsibilities or failure to meet these responsibilities adequately.
10
The Carer’s Strategy Wales Measure 2010 requires Local Authorities and Local Health Boards to put in place Carer’s Strategies
which ensure that carers are identied and referred on to appropriate sources of support. Guidance on developing these
strategies will be published by the Welsh Government in 2012.
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Social, cultural or spiritual
4.72 A relevant patient’s needs in relation to enjoying a full social life, good personal relationships
with family and friends, and full engagement with community and leisure facilities are the same
as for any other person in the community. Networks of support are signicant protective
factors in helping individuals to maintain or improve good mental health.
4.73 Agreeing social, cultural; and spiritual outcomes should consider the social wellbeing of
the relevant patient, including leisure activities and aspects of social inclusion or exclusion,
together with the impact that this has on the relevant patient’s mental health. It is important
to consider strengths and abilities when setting outcomes and interventions as it can be the
case that doing more of what a person is good at, using their strengths, is an effective way of
bringing about change and promoting recovery.
4.74 The process for agreeing outcomes needs to recognise and give full regard to the cultural
identity of the relevant patient. This may include recognition of the relevant patient’s own
perception of their cultural status and background. Services should seek to ensure that there
is provision to meet the cultural needs of the relevant patient as appropriate. It should be
noted that, as with any other community, cultural and linguistic needs are intertwined with
each other within the Welsh speaking community, and therefore language needs should be
considered as part of cultural needs.
4.75 Spirituality can play an important role in helping people live with, or recover from, mental
health problems. Spirituality is often seen as a broader concept than simply religion.
Outcomes can relate to those aspects of life which give a relevant patient meaning, hope,
value and purpose and can help to inform the care and treatment planning process overall.
Medical and other forms of treatment, including psychological interventions
4.76 Identifying whether the relevant patient has previously received treatment or interventions
for their mental health, and whether this was successful, is a necessary step in agreeing
outcomes for the care and treatment plan.
4.77 The agreement of outcomes will also need to involve consideration of which treatments
or interventions may be required now, how these will be accessed, and the agencies or
organisations that will provide the services. The process will also need to ensure that any
information regarding the benets and drawbacks of treatment options is provided and
discussed with the relevant patient.
4.78 Interventions can be aimed at reducing specic symptoms but can also be concerned with
reducing the negative effects of symptoms and coping more effectively with them.
4.79 For children, as well as eliminating or minimising symptoms and improving coping skills,
consideration should be given to developing resilience factors within the child and family
toreduce the likelihood of future mental health problems or reduce their impact.
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4.80 For many relevant patients, treatment for mental disorder will include medication. The care
coordinator should ensure that the assessment identies potential and actual side effects
and contra-indications of prescribed medication. Additionally the care coordinator should
liaise with the relevant patient to monitor medication effectiveness, satisfaction, and to seek
ongoing consent with the treatment programme. Where a relevant patient does not have the
capacity to consent to the treatment programme decisions should be undertaken in line with
the requirements of the Mental Capacity Act 2005.
What should happen if a relevant patient is becoming more unwell
4.81 The Part 2 Regulations set out a standard format for care and treatment plans which includes
sections to record the thoughts feelings or behaviours that may indicate when a relevant
patient is becoming more unwell and may require extra help or support (sometimes referred
to as ‘relapse signatures’) and also the actions that ought to be taken should this happen
(sometimes referred to as a ‘crisis plan’).
4.82 The purpose of recording these is to try and prevent circumstances escalating into a crisis
by detailing the arrangements or strategies that may have worked well in the past for the
relevant patient.
4.83 The actions that ought to be taken may include identifying who the relevant patient is
most responsive to or expressing wishes about care or treatment in certain circumstances,
including details of the relevant people or services to contact. In some circumstances relevant
patients may have set out advanced decisions detailing treatments that they would wish
to refuse should they lose the capacity to decide for themselves in accordance with the
MentalCapacity Act 2005.
4.84 The contact details of services, including telephone numbers and the times when the services
are available, should be included in the care and treatment plan as a means to ensure that
relevant patients know where they can go for assistance or advice whenever they may
needto.
4.85 Identifying factors that are signicant to a person being able to remain as independent as
possible is important, such as the support provided by a family member. Contingencies can
then be discussed and agreed in advance of such support unexpectedly being unavailable.
Timeliness of care and treatment plans
4.86 In the rst instance, the duty of the care coordinator to prepare and put into writing a
care and treatment plan for a relevant patient arises when they are appointed. Care and
treatment plans should therefore be provided as soon as is reasonably practicable after
the individual has become a relevant patient and the care coordinator has been appointed.
Carecoordinators will need to balance the importance of settling the plan so that outcomes
and services are agreed and so that the provision of services is not delayed, with ensuring
that the plan is comprehensive, and that due consultation in its preparation has taken place.
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4.87 Whilst the Part 2 Regulations do not specify a time limit for the production of a Care and
Treatment Plan it is recommended that in most cases it should be produced within 6 weeks
of the appointment of a care coordinator and distributed within 2 weeks of its completion.
Itis also suggested that mental health service providers consider local reporting on where
this is not achieved in order to monitor performance.
4.88 Whenever a care and treatment plan has been revised, the revised care and treatment
plan should be copied to the relevant patient, and others in accordance with the Part 2
Regulations, as soon as practicable after completion (see paragraphs 4.90 – 4.97 below).
Aswith the initial production of care and treatment plans, there is no specic statutory
timescale for sharing revised care and treatment plans. However, as the sharing of information
and an understanding of what all agencies are delivering is central to coordination of care, it is
recommended that the revised care and treatment plan be distributed within 2 weeks of the
review taking place.
4.89 It may be that at a local level, mental health service providers wish to set more specic
and stringent targets in relation to the production of care and treatment plans, based upon
local circumstances. In any case, to monitor these statutory duties and for ensuring that the
requirements of the Measure and Regulations are met in a timely manner, it is recommended
that, LHBs and local authorities set out jointly agreed standards for completion and provision
of care and treatment plans, and audit performance against these to assure themselves that
timely and accurate information is provided to relevant patients, and to those involved in the
provision of the relevant patient’s care and treatment.
Copies of the care and treatment plan
4.90 So that the relevant patient and those involved in their care and treatment are aware of
the outcomes which the provision of mental health services are designed to achieve, and of
the plan for the achieving those outcomes, it is essential that the relevant patient’s care and
treatment plan is made available.
4.91 For this reason, the Part 2 Regulations require that the care coordinator takes all practicable
steps to ensure that where the following persons may be identied in relation to a relevant
patient, they are provided with a copy of the care and treatment plan:–
a) the relevant patient, unless they do not wish to receive a copy, or the provision of a copy
(or part of it) is likely to cause serious harm to the physical or mental health or condition
of the relevant patient;
b) all persons with parental responsibility for the relevant patient, unless they do not wish
toreceive a copy;
c) all carers of the relevant patient (including adult placement carers), unless they do not
wish to receive a copy;
d) the relevant patient’s general practitioner;
e) the mental health service provider(s) and voluntary organisations who provide mental
health services to the relevant patient;
f) the relevant patient’s responsible clinician;
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g) the relevant patient’s guardian and responsible local social services authority (within the
meaning of the Mental Health Act 1983);
h) a donee or deputy the relevant patient, where the matters included in the plan fall within
the scope of their decision making powers;
i) an independent mental capacity advocate who has been appointed for the
relevantpatient;
j) the managing authority and supervisory body where the relevant patient is subject
to urgent or standard authorisations under the Deprivation of Liberty Safeguards of
the Mental Capacity Act 2005, together with any ‘relevant persons representative’,
underthoseprovisions.
4.92 A full explanation of all of these terms (and persons listed) is given in the glossary of terms
atAppendix A.
4.93 The care coordinator may also provide a copy of the plan to any other person in order to
facilitate the achievement of the outcomes which the provision of services are designed to
achieve. For children within the youth justice services this may include Probation Ofcers or
Youth Offending Team Workers who have supervision responsibilities. For children who have
a statement of special educational needs this may include the local education department.
4.94 Before providing copies of the plan to any of these persons the care coordinator must take
account of the views of the relevant patient about whether or not copies should be provided.
The relevant patient should be given support and information to help them understand
the value and purpose of sharing information in this way. The care coordinator may provide
copies of plans against the wishes of a relevant patient provided they have given due
consideration to the wishes of the relevant patient. It is recommended that such decisions,
and evidence of due consideration being given, are clearly recorded.
4.95 The care coordinator may also provide copies of the care and treatment plan to any other
person who the relevant patient wishes to receive a copy.
4.96 Copies of care and treatment plans should be provided to the persons mentioned in
paragraph 4.91 above as soon as practicable after it is recorded. In cases where it is not
possible for the relevant patient to be given a copy of their care and treatment plan
immediately after a planning or review meeting with their care coordinator, the relevant
patient should still be provided with a explanation of what services are being provided and
the arrangements for provision, together with an understanding of what needs are not being
met and why this is the case.
4.97 The Part 2 Regulations provide specic instructions about the delivery of copies of care and
treatment plans to the persons identied in paragraph 4.91 above. In order to meet the
requirements for providing copies, a care plan is considered to be provided when it has been:–
a) delivered to a person by hand or to their last known address;
b) sent by prepaid post to their last known address;
c) sent by facsimile to a number specied by a person; or,
d) delivered or sent by any other means agreed between the person for whom it is intended
and the care co-ordinator.
Code of Practice
38
Chapter 5
Chapter 5
Coordination of the Provision of Services
5.1 This chapter gives guidance to mental health service providers and care coordinators on how
they should undertake their duties to coordinate and provide mental health services under
Part 2 of the Measure.
Duty to provide services
5.2 Section 18(10) of the Measure requires that, so far as it is reasonably practicable to do so, a
mental health service provider must ensure that mental health services for a relevant patient
are provided in accordance with their current care and treatment plan. However, the care
coordinator does not have responsibility for ensuring that the services on a relevant patient’s
care and treatment plan are provided. The responsibility for the provision of services rests
with the organisations with statutory duties for meeting a relevant patient’s assessed needs
under their care and treatment plan.
5.3 The care coordinator instead has oversight of the delivery of the care and treatment
plan. This is achieved by monitoring the delivery of the care and treatment plan and the
achievement of the recorded outcomes through the delivery of appropriate mental
healthservices.
5.4 Where it is not possible to provide mental health services in accordance with the care
and treatment plan, the care coordinator should inform the relevant mental health service
provider. The service provider must have regard to any advice given by the care coordinator
and, together with other relevant agencies, should take the necessary steps to ensure that,
where practicable, the services specied in the care and treatment plan are provided. Ifafter
following such steps it is still not reasonably practicable to provide such mental health
services, the care and treatment plan ought to be reviewed in order to seek alternative
means of delivering the desired outcomes. The need for a review should be explained to
therelevant patient.
5.5 Unmet needs (including those that are being partially met) are needs that cannot be met
by an organisation’s available resources and having a record of these can provide crucial
information that could assist in improving the planning of mental health services. It is
recommended that a process is put in place whereby the care coordinator’s power to advise
mental health service providers is utilised to inform local strategic mental health joint planning
groups of unmet needs. This process may also include the inclusion of an annual report on
unmet needs identied by local mental health service providers.
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Code of Practice
Chapter 5
Coordination of the provision of services
5.6 Section 17 of the Measure places mental health service providers under a duty to take all
reasonable steps to ensure that the mental health services that it is required to provide
are delivered in a coordinated manner. The provider is also under a duty to coordinate
itsmentalhealth services with those provided by other mental health service providers,
ornot-for-prot, third sector providers who are providing services to a relevant patient.
5.7 The mental health services which must be coordinated include:–
a) secondary mental health services which include certain community care services, services
provided under section 117 of the Mental Health Act 1983, and certain services provided
to a child under Part III of the Children Act 1989;
b) any local primary mental health support services provided under Part 1 of the
Measure;and,
c) things done in the exercise of a local authority’s powers in relation to guardianship
underthe Mental Health Act 1983.
5.8 The care coordinator may (at any time) give advice to the service provider(s) on how
the duty to coordinate services can be achieved. Such advice could include identifying the
most effective means of delivering the various components contained within the care and
treatment plan.
5.9 Mental health service providers should aim to meet the needs of relevant patients and
provide them, where practicable, with choice. Care coordinators are expected to ensure
thatcare and treatment plans are holistic and draw on a breadth of service provision, not just
those services that are available or provided locally. Such services may be drawn from a broad
base of specialist mental health and mainstream services.
5.10 Where aspects of the care and treatment plan are being delivered by carers, mental health
professionals should ensure that, where possible, they work in partnership with those carers
to ensure that outcomes are being worked towards and, where possible, achieved.
5.11 Collaborative care is particularly important in cases of complex need. Co-occurring mental
health and substance misuse problems are frequently cited as a particularly common and
challenging cause of complexity. In such cases the service framework to meet the needs of
relevant patients with a co-occurring substance misuse and mental health problem should
befollowed to facilitate the delivery of effective care for the purposes envisaged by Part 2
ofthe Measure.
5.12 Specic arrangements will also need to be in place to support and manage relevant patients
of all ages with mental health needs complicated by a physical health problem, sensory
impairment or a physical or learning disability.
5.13 Relevant patients may need to access different levels of mental health services at various
stages in their care and treatment. For example, receiving support from Crisis Resolution
Home Treatment type services, or medical outpatient services, or fast stream inpatient
Code of Practice
40
Chapter 5
rehabilitation services. In addition, relevant patients may move from one geographical area to
another whilst still requiring secondary mental health services. Ensuring continuity in support
and care for relevant patients that may be moving between areas, or receiving support from
different agencies, including 3rd sector providers, is important and can be enhanced through
the co-ordination of care as required by section 17 of the Measure.
5.14 In order to achieve an effective transfer of care and thus ensure that services continue to be
coordinated in accordance with section 17 of the Measure, careful assessment by competent
clinicians should be conducted and used as the basis for planning decisions. They should also
be used to establish arrangements for effective case management.
5.15 It is expected that any such changes would usually require a review and possible revision
tothe care and treatment plan.
5.16 Mental health service providers should have robust procedures in place to support the timely
and effective transfer of care between services. Whilst a patient’s care and treatment plan
may need to be reviewed and revised in such circumstances, it is not acceptable for care to
be adversely affected because of administrative or organisational barriers. Every effort should
be made to avoid any negative impact on the care and treatment provided to the relevant
patient during any transfer of care from one team, organisation or agency to another.
5.17 A transfer of a relevant patient’s care will not necessarily mean a change of care coordinator
for the relevant patient, but where it does, the guidance on changing care coordinators
provided in Chapter 3 should be followed.
5.18 The care coordinator should ensure that, where possible, the implications on care and
treatment arising from a transfer between services are clearly understood by the relevant
patient, their carer(s) and family.
5.19 It is important that, where possible, the relevant patient is involved in making decisions about
the need for, and the process of, transferring between services, including the need to transfer
information between services, although it is recognised that this may not always be possible.
Coordination for Discharge from hospital
5.20 It is important that when a relevant patient no longer requires inpatient care, but still requires
secondary mental health services that the coordination of those services is considered.
Itisgood practice that discharge from hospital be planned as early as possible in the inpatient
episode and that reviews of care and treatment plans (see chapter 6) or development of a
rst care and treatment plan is undertaken as part of the process of achieving outcomes for
living as independently as possible outside of the inpatient setting. It is particularly important
that services which take time to secure, such as accommodation, are considered as early as
ispossible in the planning of discharge.
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Code of Practice
Chapter 5
5.21 The reports of the National Condential Inquiry into Suicide and Homicide by People with
Mental Illness highlight the importance of early follow up on discharge from inpatient care
11
and the recommendations from these reports should be followed. It is good practice that,
where appropriate, any relevant patient discharged from hospital, but who will continue
to receive secondary mental health services, is contacted within a week of discharge by
amentalhealth professional. This does not need to be the care coordinator.
5.22 Where an inpatient has discharged them self from hospital against medical advice,
effortsshould be made to contact them in the community as expeditiously as possible.
Prison release
5.23 Clearly dened working arrangements should be in place to support and manage relevant
patients who have a history of offending. This is particularly important at the point of
entry into, and release from, secure environments including mental health secure units,
custodyorprison.
5.24 As with hospital discharge, prison release needs to be carefully planned and coordinated.
Themental health prison in-reach service should ensure that local services are notied in
advance of release and at the point of release. This will ensure that where secondary mental
health services are required these are available upon release from prison and that the
services planned are recorded within the care and treatment plan.
11
Safety First – Five-Year Report of the National Condential Inquiry into Suicide and Homicide by People with Mental Illness. 2001
Avoidable Deaths – Five-Year Report of the National Condential Inquiry into Suicide and Homicide by People with
MentalIllness.2006
Code of Practice
42
Chapter 6
Chapter 6
Monitoring and Review
6.1 Part 2 of the Measure, and the associated Regulations, place duties on care coordinators to
review and revise care and treatment plans which have been developed to meet the needs
of relevant patients. The Part 2 Regulations set out when and how frequently a plan must be
reviewed, and if necessary revised, as well as who may request a review.
6.2 This chapter provides guidance on these requirements and how they may be met.
The importance of monitoring and review
6.3 The degree of need and risk evident in a relevant patient’s life, and therefore the outcomes
which the provision of mental health services are designed to achieve for that relevant
patient, will change over time depending upon their circumstances, including their current
mental health. Monitoring and responding to such changes is fundamental to the delivery
of effective care and treatment, and is also needed to ensure that reviews take place
when required. In order to ensure that care and treatment provision remains optimal to
the relevant patient’s recovery, regular monitoring of the plan and the delivery of services
isrequired.
6.4 The process of monitoring the implementation of the care and treatment plan should
therefore include:–
a) ongoing assessment of the relevant patient’s mental health related needs along with
thenature and degree of need and risk they are currently presenting;
b) ensuring the delivery of the care and treatment specied in the plan; and,
c) that the outcomes specied within the care and treatment plan continue to be suitable
and minimise any risks posed.
6.5 The usefulness of a care and treatment plan and how meaningful it is to a relevant patient
is likely to be affected by changes of circumstance in their life, whether positive or negative.
Changes of circumstance not only include issues such as securing or losing employment,
moving house, establishing a relationship, the loss of a carer but also issues such as poor
compliance with the care and treatment plan, relapse indicators becoming apparent,
improvements of mental health and social functioning, an increase in the level of risk,
orthepotential for an identied risk to be realised.
6.6 The review should consider any monitoring information which has been gathered since
the care and treatment plan was rst established, or since its revision at a previous review.
Whereamendment is required, consideration should be given to all aspects of care and
43
Code of Practice
Chapter 6
treatment and not simply a revision of those components that were included in the initial
plan. Any member of the care and treatment planning team can request that a review
takeplace.
6.7 Where such changes require only minor amendment of the care and treatment plan, the
care coordinator may use their discretion to revise the plan in consultation with the relevant
patient, without a formal review. Where amendments are more signicant, the change of
circumstances should trigger a formal review through which the care and treatment plan
should be amended.
6.8 The degree of impact on the care and treatment plan by a proposed amendment is a
judgement to be made by the care coordinator, however, attention must be paid to the
individual relevant patient affected by the care plan. A seemingly minor change to a care
plan may give rise to major implications for the relevant patient. Each change to a care and
treatment plan must be viewed on a case by case basis. Consequently, the care coordinator
must be satised on the degree of impact of care and treatment plan changes. Where minimal
impacts are perceived a full review may not be required. Minor amendments do not require
a re-distribution of the care and treatment plan, but it is good practice to send a revised copy
of the plan to those affected by the amendment. Further good practice would be indicated
by sharing minor changes with the team at a full review.
6.9 In addition to ongoing monitoring, the more formal review process which is required under
the Regulations is crucially important. It provides an opportunity to consider the effectiveness
of the care and treatment plan in meeting goals, assessing whether outcomes set have been
met, whether the care and treatment plan should be amended, whether or not the relevant
patient requires continued care and treatment within secondary mental health services and if
not whether the relevant patient should be discharged for management within primary care.
Triggers to prompt review
6.10 The care coordinator may review the care and treatment plan for a relevant patient at
anytime.
6.11 The Part 2 Regulations require that a review must be held, as a minimum, at least once in
any twelve month period. However, reviews should be needs-led, and should be held as
frequently as required. For example, when the care coordinator becomes aware of any
signicant changes to the relevant patient’s health or social needs or identied risks.
6.12 A review must be held if requested by a mental health service provider.
6.13 A review must also be held if requested by the relevant patient or a carer (including an
adult placement carer), unless the care coordinator considers that the request is frivolous or
vexatious, or there has been no change in circumstances which merit the holding of a review
since the last review. Guidance on what may be considered ‘frivolous or vexatious’ requests
is given in Chapter 8. Repeated requests in themselves should not be a reason to refuse
areview.
Code of Practice
44
Chapter 6
6.14 Where it is decided that a review is not to take place when requested by a relevant patient
or their carer, the reasons for this should be clearly recorded and an explanation provided
tothe person who made the request.
6.15 Reviews should be held as soon as reasonably practicable after any request is made, but it
is recommended that once requested a review should be arranged in the majority of cases
within 6 weeks of the request being received.
6.16 A formal and clear record should be made of each review, including any changes to the care
and treatment plan, together with any updates to assessments (including risk assessment).
Itis advised that, where practicable, an agreed care and treatment plan should be produced
within 2 weeks of the review.
6.17 A review may be undertaken in a meeting involving a number of members of the care team
and other interested persons. Equally such a review may only include the relevant patient and
care coordinator, if the care coordinator considers that there is no requirement to involve
other health and social care professionals. It is advised that the relevant patient should be
informed prior to the meeting that a review is taking place so that the process is open and
understood. This information sharing should be recorded.
Preparation for Reviews
6.18 Proper preparation and organisation pays dividends in helping to ensure that those involved
in the care and treatment plan can contribute to the review. It should also be noted that the
requirements for consultation in the preparation of a care and treatment plan as a result of
areview are the same as for the initial preparation of a care and treatment plan.
6.19 It can be benecial to meet with the relevant patient to discuss the review meeting, to
identify achievement of outcomes, and to obtain views on further outcomes or actions
before the actual meeting. This could be on the day of the review, a few days before the
review or may require discussions over a few meetings.
6.20 The needs of the relevant patient should be taken into account when considering how best
to prepare, with views sought on such things as who the relevant patient feels should be
at the review (including people to support them), where the review should take place and
howthe review should be conducted.
6.21 For reviews in relation to children, as well as the child, the views of family and others
with statutory responsibility, such as the school, or local authority social services, may
be required. Wherever possible duplication of plans and the planning process should be
avoidede.g.bycoordinating with existing educational or local authority review processes
andschedules
45
Code of Practice
Chapter 6
Relationship to Section 117 aftercare under the Mental Health Act 1983
6.22 Section 117 of the Mental Health Act 1983 requires Local Health Boards and Local Social
Services Authorities, in collaboration with 3rd sector agencies, to provide aftercare for
patients who are detained under sections 3, 37, 45A, 47 or 48 of the Act and then cease
to be detained and leave hospital. Statutory guidance relating to aftercare is provided in
Chapter31 of the Mental Health Act 1983 Code of Practice for Wales.
6.23 For those relevant patients to whom aftercare under section 117 applies, the care and
treatment plan under Part 2 of the Measure may be the means to record the aftercare
arrangements in terms of outcomes to be achieved and the services to be provided or
actions taken.
6.24 It is recommended that meeting the requirements to regularly review aftercare under section
117 and adhering to the statutory duties to review care plans are combined to reduce the
need for multiple meetings that could otherwise create duplication.
Code of Practice
46
Chapter 7
Chapter 7
Discharge from Secondary Mental
HealthServices
7.1 This Chapter gives guidance on the duties which are set out in the Measure and the Part 2
Regulations which may relate to discharge from secondary mental health services, and the
provision of certain information to relevant patients upon their discharge from services.
Meaning of discharge
7.2 Discharge from secondary mental health services can be considered as an important
potential outcome for relevant patients within secondary mental health services as part of
the recovery process, and in order to maximise the opportunities for good mental health
and achieving a better quality of life for the individual. It is important, however, to understand
the implications of being discharged for both the relevant patient and mental health
serviceproviders.
7.3 The phrase ‘discharge from secondary mental health services’ is used to describe a situation
where, for whatever reason, the individual who was formerly a relevant patient is no longer
in receipt of any secondary mental health services provided by an LHB, a local authority,
or (exceptionally) the Welsh Ministers. The individual may well continue to be in receipt of
other services provided by these bodies, for example community care services from a local
authority, or mental health support from their GP.
7.4 Discharge from secondary mental services can be considered to be a signicant achievement
and outcome for the relevant patient. However there must also be recognition that some
relevant patients may nd the transition from high levels of support to reduced levels,
orevenno further support, difcult.
7.5 Although it may not always be possible, discharge from services should be based on
agreement that the planned outcomes for that relevant patient have been achieved.
Forchildren, who may have disengaged from the process discharge may be agreed with
thosewith parental responsibility.
7.6 Ongoing monitoring and review of the relevant patient’s care and treatment plan should
continue until it is determined when considering the outcomes to be achieved that the
relevant patient no longer requires the services provided by secondary mental health
services. It is normally the case that this will take place during the formal review of the care
and treatment plan where the views of all relevant members of the care team should form
apart of this decision making process alongside those of carers, immediate family members
and other signicant supporters in the relevant patient’s life.
47
Code of Practice
Chapter 7
7.7 For the relevant mental health service providers, discharge means that the duties placed on
them under Part 2 of the Measure for appointment of care coordinators and for care and
treatment planning cease. However, the responsibilities under Part 3 of the Measure relating
to assessment will come into effect should a request for a reassessment for secondary care
services be made directly to such providers in their role as local mental health partners under
Part 3 of the Measure.
7.8 The care and treatment team should not necessarily regard discharge as an end point in
meeting a relevant patient’s mental health needs. Discharge from secondary mental health
services may be a staging post in a longer course of recovery.
Provision of information on discharge
The duty to provide information
7.9 The Regulations made under Part 2 of the Measure place duties on LHBs and local
authorities to provide relevant patients who are being discharged from secondary mental
health services with certain information.
7.10 When a relevant patient is discharged from secondary mental health services the duty
to provide information falls upon the LHB or local authority undertaking the discharge.
However,this duty only arises where the relevant patient is being fully discharged from
all secondary mental health services. If, for example, the LHB discharges a relevant patient
from the secondary mental health services which it provides, but they remain in receipt of
asecondary mental health service provided by the local authority, the duty will fall upon the
local authority to provide the required information at such time as a full discharge from those
secondary mental health services nally takes place.
7.11 Where a decision is made to discharge a relevant patient from secondary mental health
services provided by an LHB and also from secondary mental health services provided by
alocal authority on the same day, and it cannot be ascertained which partner made the nal
discharge, local policies may be developed between the partners for an area that set out
which partner is to be viewed as making the later discharge for the purposes of provision
ofinformation to that relevant patient on discharge.
Information to be provided
7.12 When a relevant patient is discharged from secondary mental health services the LHB
orlocal authority is under a duty to provide certain written information to the relevant
patient, namely:–
a) the reason for the individual’s discharge from secondary mental health services; and,
b) the action which may be taken, and by whom, if the individual who has been discharged
considers that further support and advice in relation to his or her mental health is
required following discharge.
Code of Practice
48
Chapter 7
7.13 To enable this to take place appropriate planning with the relevant patient, their family/carers
and any ongoing support agency is likely to be necessary including the relevant patient’s
general practitioner. A lack of comprehensive transition arrangements around discharge is
known to elevate the risks of ongoing support breaking down. It is likely that in doing this the
care coordinator, acting on behalf of the local authority or Local Health Board, may lessen the
potential risks associated with a break in the continuity and consistency of care and support
following discharge.
7.14 When an adult is discharged from secondary mental health services, in addition to the
information above, they must also be informed in writing about their entitlement to
assessment under Part 3 of the Measure for 3 years from the date of their discharge
(seeChapter 8).
7.15 When a child (i.e. a relevant patient below the age of 18) is discharged from secondary
mental health services, but will become an adult (i.e. attain the age of 18) within 3 years
of the date of their discharge, then they must also be informed in writing about their
entitlement to assessment under Part 3 of the Measure when they reach the age of 18.
In providing this information, the child should also be informed of the duration of their
entitlement (i.e.theperiod of time between their 18th birthday and the end of the relevant
dischargeperiod).
7.16 In addition to the information required by the Measure and Regulations, the mental health
service provider may also choose to give additional information to a relevant patient (of any
age) on discharge. In practice this may well be carried out by the care co-ordinator. This could
include, for example, information on:–
a) medication and side effects;
b) who to speak to for advice on benets and entitlements;
c) other services available to provide ongoing support, such as voluntary support groups,
drop in centres, self help groups;
d) where to access housing advice;
e) the availability and access to health and leisure activities, such as gymnasia and
swimmingpools.
7.17 The information which is provided should be in a language and format which is appropriate
and easily understood. It is also advisable to check that the information has been understood.
The information may also be provided to the relevant patient’s carer, parent, partner or
similar, if it is believed that this would be appropriate and the relevant patient is in agreement.
7.18 It is also recommended that this information is provided to the relevant patient’s GP, with the
consent of the relevant patient, to promote continuity of care and understanding.
7.19 In practice, this information may be provided by the relevant patient’s care coordinator,
although the responsibility for the provision of such information rests with the mental health
service provider.
49Code of Practice
Chapter 8
Chapter 8
Assessments of Former Users of Secondary
Mental Health Services
8.1 Part 3 of the Measure is concerned with assessments of former users of secondary mental
health services. The aim of Part 3 is to enable individuals who have previously been in
receipt of secondary mental health services to refer themselves back to secondary services
for assessment directly. This allows assessments to take place without individuals necessarily
needing to rst go to their GP or elsewhere for a referral, therefore improving access.
8.2 This chapter provides guidance on how the arrangements under Part 3 of the Measure
should be managed and delivered.
Purpose of Assessment under Part 3 of the Measure
8.3 Whilst Part 2 of the Measure deals with care and treatment planning and care coordination
for individuals in secondary mental health services, Part 3 of the Measure provides eligible
individuals who have received secondary mental health services at some point in the past,
butwho have been discharged from those services, with an entitlement to request an
assessment should they feel that their mental health is deteriorating.
8.4 An assessment under Part 3 of the Measure is an analysis of an individual’s mental health
to identify the secondary mental health services (if any) which might improve or prevent
adeterioration in the mental health of the person being assessed. The assessment must also
identify whether there are any community care services (other than those which would be
considered secondary mental health services), or housing or well-being services which might
improve or prevent a deterioration of the individual’s mental health.
Arrangements for the assessment of former users of secondary mental
health services
8.5 Section 19 of the Measure, as applied by the Mental Health (Regional Provision) (Wales)
Regulations 2012
12
, requires local mental health partners to take all reasonable steps to agree
arrangements for responding to requests for assessments from former users of secondary
mental health services and the making of referrals following such assessments.
8.6 These arrangements must be recorded in writing. Once initial arrangements have been
agreed and put into writing, they can subsequently be altered, provided that the partners
agree and record the alterations in writing.
12
The Mental Health (Regional Provision) (Wales) Regulations 2012 are to be debated by the National Assembly for Wales
inMay2012. If approved, they will come into force in June 2012.
Code of Practice
50
Chapter 8
8.7 The agreed arrangements may allow for:–
a) one of the partners to provide all the assessments and make all the referrals that ow
from the assessments; or,
b) that different aspects of an assessment, and different referrals following assessment,
maybe undertaken by different partners.
8.8 This allows a level of exibility which enables partners to make arrangements which maximise
joint working, and reect the joined-up delivery of secondary mental health services.
8.9 It is important that the arrangements which are made ensure that the processes for former
users of secondary mental health services to request an assessment are simple and accessible,
and do not place disproportionate burdens on the individual seeking help and support from
the service.
8.10 The arrangements should also ensure that assessments are provided in a timely manner,
which should be consistent with response times for requests for assessments from GPs or
other referrers. Local mental health partners may include standards for response times for
assessment within their written arrangements. Where such response times are included it is
expected that these should, at a minimum, match the usual standards for community mental
health teams – namely that emergency referrals are to be seen within 4 hours of request,
urgent referrals within 48 hours of request, and all other referrals within 28 days of request.
8.11 Inclusion of ‘usual response times’ in written arrangements ought to enable practitioners
undertaking assessments under the arrangements to use their clinical judgement to
prioritise assessments according to perceived clinical need or risk, and respond to requests
in a way which ensures that individuals receive a timely and safe response to their request
forassessment.
8.12 Arrangements should also consider the responsibilities that mental health service providers
have for providing a written report following assessment. Such reports must set out
whether any services have been identied that may improve or prevent a deterioration
in the individual’s mental health, and should include information regarding the date of the
assessment and who undertook the assessment on behalf of the mental health partners.
Failure to agree arrangements
8.13 In exceptional circumstances, it may be the case that local mental health partners are
unable to reach agreement on the arrangements for undertaking assessments and making
referrals as outlined above. Where this is the case the LHB involved is required to inform the
WelshMinisters that agreement cannot be reached. Such notications should be sent in the
rst instance to:–
Head of Mental Health & Vulnerable Groups Division
Welsh Government
Cathays Park
Cardiff CF10 3NQ
51Code of Practice
Chapter 8
8.14 Upon notication, the Welsh Ministers may determine the arrangements for the area of
the local mental health partnership, and where they do so, the Welsh Ministers will record
these arrangements in writing. Where arrangements have been made in these circumstances,
the local mental health partners can subsequently amend the arrangements (provided the
partners are in agreement, and the alterations are recorded in writing).
8.15 During any period when agreed arrangements are not in place, it is the responsibility of the
LHB to carry out any assessments, and make any necessary referrals. The LHB should ensure
that former relevant patients of secondary mental health services requesting assessment are
able to access such assessments without any impediment, and that requests are responded to
in a timely manner in accordance with the standards for responding to referrals for secondary
mental health services from GPs and others.
Duty to carry out an assessment
8.16 The local mental health partners for a local authority area are under a duty to carry out
assessments in accordance with the arrangements agreed under Part 3 of the Measure
and make any referrals required as a consequence of those assessments in accordance
witharrangements agreed between the partners.
8.17 As stated at paragraph 8.15 above, where arrangements have not been agreed, theduty
to provide assessments lies with the LHB, until such time as the Welsh Ministers
determinearrangements.
Entitlement to assessment
8.18 A former user of secondary mental health services is able to seek a further assessment
oftheir mental health, with a view to determining whether secondary mental health
services or community care and housing or well-being services may be required to improve
or prevent a deterioration of their mental health. This entitlement arises if, at the time of
makingthe request the individual:–
• isaged18yearsorabove(i.e.anadult);
• isusuallyresidentinthelocalauthorityareawheretheyaremakingtherequest;
• has,atanytimeinthe3yearspriortomakingtherequest,beendischargedfrom
secondary mental health services or guardianship (within the meaning of the
MentalHealth Act 1983); and
• thelocalmentalhealthpartnerstowhomtherequestismadedonotconsiderthe
request to be frivolous or vexatious (see below).
8.19 Where an individual has not been known previously to the services provided by local
mental health partners for example having moved into an area, local mental health partners
should make all reasonable efforts to establish the details of previous care or support from
secondary mental health services. Where there is uncertainty as to whether an individual
is eligible, local mental health partners should undertake assessment based upon need and
urgency in the same way that they normally would.
Code of Practice
52
Chapter 8
8.20 The entitlement to make a request lies only with the individual who was previously a relevant
patient. No other person can make the request on behalf of the individual (e.g. a carer),
unless they are a donee or deputy under the Mental Capacity Act 2005. However, it is
acknowledged that the people closest to those with mental health problems often have an
important perspective on how that individual is doing. Just because the entitlement to request
an assessment lies with the individual who was the relevant patient, this does not prevent
carers, family members or anyone else from providing information to services about an
individual who they believe may be becoming unwell. Services should give due consideration
to concerns or requests made by carers or family members in deciding what action to take.
8.21 If an individual has made a previous request for assessment, and an assessment was
undertaken which concluded that no secondary mental health or community care services
were required, or the request was ruled to be frivolous or vexatious, this does not affect the
individual’s ability to request a further assessment within the 3 year qualifying period – indeed,
the number of requests which an individual may make is unlimited, as long as at the time of
making each request, the individual continues to meet the eligibility requirements.
8.22 A new period of entitlement to assessment will begin each time an individual is discharged
from secondary services.
8.23 Relevant patients who are below the age of 18 at the time of their discharge from secondary
mental health services, but will attain the age of 18 within 3 years of their discharge, willqualify
for assessment under Part 3 of the Measure from the point at which they reach their
18thbirthday. They will remain eligible until the remainder of the 3 year period has expired.
8.24 Further, the secondary mental health services which the individual received need not have
been provided by, or on behalf of, the LHB or local authority to whom the request for
assessment is made.
8.25 Guidance on what is meant by ‘discharge from secondary mental health services’ is given
inChapter 7.
‘Usually resident’
8.26 For the purposes of responding to requests for assessment under Part 3 of the Measure,
anindividual is considered to be usually resident in the local authority area where they
currently live.
8.27 There may be occasions when it is unclear where the individual is usually resident, and in such
circumstances a decision as to usual residence will be made in accordance with Regulation 5
of the Mental Health (Assessment of Former Users of Secondary Mental Health Services) (Wales)
Regulations 2011.
8.28 These Regulations set out that where there is any question or uncertainty regarding an
individual’s current address, or where the individual who has requested an assessment does
not have a current address, then it is the responsibility of the local authority to whom the
53Code of Practice
Chapter 8
individual has made the request to establish where that individual is usually resident. It is also
incumbent upon that local authority to make arrangements for that assessment to take place
whilst the usual residence of the individual is being determined. Requests for assessments
should not be delayed unnecessarily because an individual’s place of usual residence has not
yet been established, or is disputed.
8.29 Where an individual has received secondary mental health services in the past, but is now
detained in a state run prison in Wales, they will be considered as usually resident in the
localauthority area where the prison is located
13
An individual in a state run prison in Wales
is therefore eligible to seek an assessment under Part 3 of the Measure. Local mental health
partners for the local authority areas of Swansea, Cardiff and Monmouthshire, shouldensure
that their agreed arrangements accommodate requests from prisoners. For Parc, the
privately run prison, good practice would suggest that the local mental health partners
for the Bridgend local authority area, in which Parc is located, be responsible for providing
assessments under Part 3 of the Measure. (The Welsh Government’s draft Responsible Body
Guidance
14
acknowledges that, with the exception of primary care, the NHS in Wales is
responsible for the health and well-being of adults who are detained in Parc).
8.30 Further, where an individual who has received secondary mental health services whilst in
prison in Wales is subsequently released and takes up or returns to usual residence in Wales,
they will also be eligible to seek an assessment from secondary mental health services in the
local authority area in which they are usually resident at the time they make that request.
8.31 Where an individual received secondary mental health services in a prison outside of Wales,
their eligibility for further assessment will depend on whether those services are recognised
for the purposes of Part 3 as secondary mental health services.
Frivolous or vexatious requests
8.32 Most individuals seeking an assessment of their mental health needs under Part 3 of the
Measure will do so because their previous experience and knowledge of their own health
and needs leads them to believe that they may require the help and support of secondary
mental health services once more. It is recognised, however, that there is a risk that some
individuals may seek to exercise a right to assessment with requests that are manifestly
unreasonable and which, were they to be met, would impose substantial burdens on the
local mental health partners. For this reason, where a request is considered to be frivolous
or vexatious, the duties on the mental health partners to carry out assessments do not
arise. However, local mental health partners cannot conclude that a request is frivolous or
vexatious unless there are sound grounds for such a decision, and it is expected that the
individual should be notied of the grounds for any such decision.
8.33 The Measure does not dene what is meant by ‘frivolous’ or ‘vexatious’. Frivolous requests
would include those that were made without serious intention, for example, mentioned in
passing in a general conversation. Frivolous requests are requests that would not warrant
anyaction at all, or that any action required would be disproportionate.
13
See the Directions to Cardiff Local health Board, Swansea Local Health Board and Monmouthshire Local Health Board 2006
14
See the Welsh Government’s draft Responsible Body Guidance http://wales.gov.uk/docs/dhss/consultation/110808guidanceen.pdf
Code of Practice
54
Chapter 8
8.34 Vexatious is generally accepted to mean ‘causing annoyance or worry’, and therefore it may
be reasonable to consider a request for assessment to be vexatious if it is designed to subject
the LHB and/or the local authority to inconvenience, harassment or expense. However it
would not be sufcient for a request to be treated as vexatious simply because it causes
inconvenience or expense – the mental health partners should consider the effect of the
request as well. Even though it may not have been the explicit intention of the individual
requesting assessment to cause inconvenience or expense, if a reasonable person would
conclude that the main effect of the request would be disproportionate inconvenience
orexpense, then it will be appropriate to treat the request as being vexatious.
8.35 It is recommended that local mental health partners should include within their agreed
arrangements a process for determining if a request is frivolous or vexatious, and identifying
the delegated ofcers with responsibility for making such a determination.
8.36 At all times it must be remembered that an apparently frivolous or vexatious request may
well be an indication that an individual requesting assessment does in fact require secondary
mental health services to improve or prevent deterioration in their mental health. Mental
health service providers must carefully consider all such requests and ensure that any decision
not to assess which is taken on these grounds is demonstrably fair and well-evidenced, and
is recorded. A decision to not undertake an assessment under Part 3 should not prevent
information being provided to the individual requesting assessment if it is felt that there are
other services that are available and which might be in a position to provide assistance.
8.37 Where an individual is unhappy with a decision to not undertake an assessment under
Part3 then the normal procedures that organisations have for resolving disagreements,
orfordealing with complaints, should be utilised.
Actions following assessment under Part 3
Provision of a report
8.38 In all cases it is important that the assessed individual is aware of the ndings of their
assessment, and mental health service providers are required to provide a written report
following assessment which sets out whether any services have been identied that may
improve or prevent deterioration in the individual’s mental health.
8.39 Both the assessment and the written ndings of the assessment should be undertaken in
a timely manner, as soon as reasonably practicable after a request is made. The Regulations
made under Part 3 require that a copy of the report is provided to the individual who was
assessed no later than 10 working days after the conclusion of the assessment.
8.40 A report will be considered to have been provided when it has either been delivered by
hand to the individual or sent by prepaid post to the individual’s usual or last known address.
55Code of Practice
Chapter 8
Provision of services following assessment
8.41 Where a need for secondary mental health services or other community care services have
been identied as part of the assessment, which might improve or prevent deterioration in
an individual’s mental health and either the local authority or LHB would be responsible for
providing those services, they must consider whether or not the provision of such services
iscalled for.
Referrals relating to housing or well-being services
8.42 The assessment may identify that housing or well-being services are potentially required
which might improve or prevent deterioration in a person’s mental health. Where either
theLHB or local authority would not be responsible for providing such a service, a referral
to the relevant provider must be made by the assessing partner. However, as the provision of
some housing and well-being services are only considered if applied for by the individual who
considers they may require them, the individual should be invited to apply for such a service,
and supported in doing so where appropriate.
Code of Practice
56
Appendix A
Appendix A
Glossary of key terms
The following terms and abbreviations have been used in this Code of Practice.
Term Meaning
The 1983 Act Mental Health Act 1983
Adult placement
carer
adult placement carer means a person in whose home an adult is or
may be accommodated and provided with personal care under an adult
placement agreement entered into or proposed to be entered into by
the carer;
After-care Services provided following discharge from hospital; especially the duty
of health and social services to provide after-care under section 117 of
the Mental Health Act 1983 following the discharge of a patient from
detention or treatment under that Act
Attorney Someone appointed under the Mental Capacity Act 2005 who has the
legal right to make decisions within the scope of their authority on behalf
of the person who made the power of attorney. Also known as a ‘donee
of lasting power of attorney’
Care coordinator The person acting on behalf of the mental health service provider who
has responsibility for appointing them to act as the care coordinator.
The care coordinator works with the relevant patient and service
providers to agree outcomes which the provision of services are
designed to achieve, prepare a care and treatment plan for the individual,
and oversee and keep under review the delivery of the services and
outcomes recorded in those plans
Care and treatment
plan
A plan prepared for the purpose of achieving the outcomes which the
provision of mental health services for a relevant patient are designed
toachieve
Carer In relation to a relevant patient this means an individual who provides
or intends to provide a substantial amount of care on a regular basis for
that relevant patient, but does not include an individual who provides
(orintends to provide) that care by virtue of a contract of employment
or other contract with any person, or as a volunteer for a body.
In this code the term carer should also be taken to mean adult placement
carer (see above).
Carers Strategy The Carer’s Strategy (Wales) Measure 2010 requires Local Authorities
and Local Health Boards to put in place Carer’s Strategies which ensure
that carers are identied and referred on to appropriate sources of
support. Guidance on developing these strategies will be published by the
Welsh Government in 2012
Child (also children) A person under the age of 18
57
Code of Practice
Appendix A
Term Meaning
CAMHS Child and adolescent mental health services
Specialist mental health services for children and adolescents
Community care
services
Has the same meaning as in section 46 of the National Health Service
and Community Care Act 1990, namely services which a local authority
may provide or arrange to be provided under any of the following
provisions:–
a) Part III of the National Assistance Act 1948;
b) section 45 of the Health Services and Public Health Act 1968;
c) section 254 of, and 20 to, the National Health Service Act 2006,
and section 192 of, and schedule 15 to, the National Health
Service (Wales) Act 2006, and
d) section 117 of the Mental Health Act 1983;
Detention/detained Unless otherwise stated, being held compulsorily in hospital under the
Mental Health Act 1983 for a period of assessment or medical treatment
for mental disorder. Sometimes referred to as “sectioning” or “sectioned”
Deputy Someone appointed under the Mental Capacity Act 2005 by the
Courtof Protection with ongoing legal authority to make particular
decisions on behalf of a person who lacks capacity.
Donee See ‘attorney’
Guardian The person named as the guardian in a guardianship application or order
under the Mental Health Act 1983
Guardianship The arrangements including the appointment of a guardian under the
Mental Health Act 1983 to help and supervise patients in the community
for their own welfare or for the protection of other people.
GP A general practitioner (or ‘family doctor’)
IMCA Independent Mental Capacity Advocate
Someone who provides support and representation for a person who
lacks capacity to make specic decisions, where the person has
no-one else to support them. The IMCA service is established under
the MentalCapacity Act 2005. It is not the same as an ordinary
advocate, oran independent mental health advocate provided under
theindependent mental health advocacy (IMHA) service.
IMHA Independent Mental Health Advocate
An advocate independent of the team involved in the patient’s care,
available to offer support to patients under arrangements which are
specically required to be made under the Mental Health Act 1983.
TheIMHA is not the same as an ordinary advocate or an independent
mental capacity advocate (IMCA)
Note: Since January 2012 the IMHA scheme in Wales differs to that in
England, with more patients in Wales eligible to receive help and support
from an IMHA
Local authority A county council or a county borough council
Local Health Board
(LHB)
Type of NHS body responsible for providing NHS services in a local area
Code of Practice
58
Appendix A
Term Meaning
Local mental health
partners
The Local Mental Health Partners for a local authority area are:–
i) The Local Health Board for an area which includes the
localauthority area, and
ii) the local authority for that area
Local social services
authority (LSSA)
The local authority (or council) responsible for social services in a
particular area of the country
Managing authority The person or body with management responsibility for the hospital
orcare home in which a person is or may become, deprived of
their liberty under the Deprivation of Liberty Safeguards of the
MentalCapacity Act 2005
The Measure The Mental Health (Wales) Measure 2010, unless the context otherwise
requires
Parental responsibility This is dened by the Children Act 1989 as being all the rights, duties,
powers and responsibility which a parent of a child has in relation to the
child and his or her property up to the age of 18. It includes rights and
duties with regard to education, choice of religion, administration of a
child’s property and choice of residence.
Recovery There is no single denition of the concept of recovery for people
with mental health problems, but the guiding principle is the belief that
it is possible for someone to regain a meaningful life, despite serious
mental illness. Recovery is often referred to as a process, outlook, vision,
conceptual framework or a set of guiding principles.
Part 2 Regulations
(also referred to as
Regulations made
under part 2)
Mental Health (Care Coordination and Care and Treatment Planning)
(Wales) Regulations 2011 which are made under the Mental Health
(Wales) Measure 2010 setting out detailed requirements as to how
certain parts of the Measure will work in practice
Part 3 Regulations
(also referred to as
Regulations made
under part 3)
Mental Health (Assessment of Former Users of Secondary Mental
health Services) (Wales) Regulations 2011 which are made under the
MentalHealth (Wales) Measure 2010 setting out detailed requirements
as to how certain parts of the Measure will work in practice.
Relevant discharge
period
The period of time, following discharge from secondary mental health
services, within which the former relevant patient may request an
assessment by secondary mental health services if they believe that their
mental health is deteriorating to the point where such an assessment
is required. This period is set in regulations made under Part 3 of the
Measure at 3 years.
Relevant mental
health service
provider
The secondary mental health service provider who is identied under
section 15 of the Measure, or regulation 3 of the Regulations
Relevant patient Within the meaning of Part 2 of the Measure, an individual for whom a
mental health service provider is responsible for providing a secondary
mental health service; or one who is under guardianship of a local
authority in Wales; or one for whom a mental health services provider
has decided that they would provide secondary mental health services,
ifthat individual cooperated with the provision of such services.
59
Code of Practice
Appendix A
Term Meaning
Relevant person’s
representative
Under the Deprivation of Liberty Safeguards of the Mental Capacity Act
2005 this is a person who is appointed to maintain contact with a person
who is being deprived of their liberty and to represent and support them
in all matters relating to the safeguards.
Responsible clinician Within the meaning of the Mental Health Act 1983, the approved clinician
with overall responsibility for the patient’s case
Responsible local
social services
authority
This is the local authority for a person who is subject to Guardianship
under the Mental Health Act 1983 as set out in section 34(3) of that Act.
Section 117 See ‘after-care’
Supervised
community treatment
(SCT)
Arrangements under which patients can be discharged from detention
in hospital under the Mental Health Act 1983 but remain subject to
that Act in the community rather than in hospital. Patients on SCT are
expected to comply with conditions set out in the community treatment
order (CTO) and can be recalled to hospital if treatment in hospital is
necessaryagain
Supervisory body The Local Health Board, Primary Care Trust or Local Authority which has
issued a standard authorisation, or in the case of an urgent authorisation
to whom a request for a standard authorisation has been made,
withinthe meaning of the Deprivation of Liberty Safeguards of the
Mental Capacity Act 2005
Working day Any day except a Saturday, Sunday, Christmas Day, Good Friday or bank
holiday in England and Wales under the Banking and Financial Act 1971
Code of Practice
60
Appendix B
Appendix B
Schedule 2 of the Mental Health
(CareCoordination and Care and
TreatmentPlanning) (Wales)
Regulations 2011
Schedule 2 Care and Treatment Plan
Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg
ac yn rhannol yn y Saesneg
This plan may be completed in the Welsh or the English language, or partly in Welsh and partly
inEnglish
Mental Health (Wales) Measure 2010 Section 18 —
Care and Treatment Plan
This care and treatment plan has been prepared under section 18 of the Mental Health (Wales)
Measure 2010, and in accordance with the requirements of the Mental Health (Care Coordination
and Care and Treatment Planning) (Wales) Regulations 2011.
This is the care and treatment plan of [Name of relevant patient] who lives at [Full usual address
ofrelevant patient].
The care coordinator who has prepared this care and treatment plan is [Name of care coordinator]
who can be contacted at [Telephone number, postal address and, where appropriate, email address
of care coordinator]. The care coordinator has been appointed by, and is acting on behalf of,
[Nameof Local Health Board or Local Authority that appointed the care coordinator].
This plan was made on [Date the plan was made] and is to be reviewed no later than [Date by
which the plan must be reviewed]. However, [Name of relevant patient], his or her carer(s) or adult
placement carer(s) may request a review of this care plan at any time.
This part of the care and treatment plan records the outcomes which the provision of mental
health services are designed to achieve, details of those services that are to be provided, and the
actions that are to be taken with a view to achieving those outcomes.
61Code of Practice
Appendix B
[The planned outcome(s) included in the following part of the plan must relate to one or more of
the areas listed, and include an explanation of how each outcome relates to each area. Outcomes
also may be achieved in other areas, and are to take into account any risks identied in relation to
the relevant patient.
This part of the plan also sets out details of the services that are to be provided, or actions taken,
to achieve the planned outcomes, including when, and by whom those services are to be provided
or actions taken.
[Outcomes to be achieved must be agreed in relation to at least one of the following areas:
a) accommodation
b) education and training
c) nance and money
d) medical and other forms of treatment, including psychological interventions
e) parenting or caring relationships
f) personal care and physical well-being
g) social, cultural or spiritual
h) work and occupation.
Outcomes to be achieved may also be agreed in relation to other areas]
Outcome to be achieved
What services are to be provided, or actions taken
When
Who by
The following thoughts, feelings or behaviours may indicate that [Name of relevant patient]
isbecoming more unwell and may require extra help from the care team (these are sometimes
called relapse signatures):
If [Name of relevant patient] feels that his or her mental health is deteriorating to the point where
he or she requires extra help or support, the following actions ought to be taken (this is sometimes
known as a crisis plan and must include details of the services to be contacted):
Any language or communication requirements or wishes which [Name of relevant patient]
has(including in relation to the use of the Welsh language) ought to be recorded here:
The views of [Name of relevant patient] on this care and treatment plan, the mental health services
that are to be provided, and any future arrangements that ought to be considered, are:
[Record any views that the relevant patient wishes to be included (including past and present
wishes and feelings about the matters covered by the plan), and include any statements about
anyfuture arrangements which may apply. If the patient does not have any views or statements
onthese matters, or the patient’s views cannot be ascertained, this ought to be recorded also.]
Code of Practice
62
Appendix B
his care and treatment plan has
* been agreed with [Name of relevant patient] and is recorded in accordance with section
18(2) of the Mental Health (Wales) Measure 2010
* not been agreed with [Name of relevant patient] but the outcomes have been determined
by the mental health service provider(s), and are recorded in accordance with section 18(6)
of the Mental Health (Wales) Measure 2010
[* delete as applicable (one, but not more than one, statement must apply)]
So far as it is reasonably practicable to do so, the following mental health service provider(s)
must ensure that the mental health services set out in this care and treatment plan are provided:
[Enterthe name of the Local Health Board and/or the Local Authority who are responsible for
providing secondary mental health services to the relevant patient]
Signed [The relevant patient may sign the care and treatment plan, if they wish] Relevant patient
Signed [The care coordinator must sign this care and treatment plan] Care coordinator
Date [Enter the date the care and treatment plan is made]