WELCOME TO NOTTINGHAMSHIRE HEALTHCARE NHS TRUST AND SOCIAL SERVICES CPA TRAINING

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WELCOME TO NOTTINGHAMSHIRE HEALTHCARE NHS TRUST
AND SOCIAL SERVICES CPA TRAINING
Jaswinder Basi South Notts Emma McWilliams
Support Officer Mark Varney North Notts Sam
Yates CPA Secretary
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Any special requirements i.e. dietary, domestics,
physical Please inform facilitator All
documentation issued are amended regularly
available on intranet or CPA Office
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WHERE DID CPA COME FROM

• CLOSURE OF INSTITUTIONS
• FAILURES IN THE SERVICE i.e. J ZITO
• GOVERNMENT GUIDANCE
• NHS COMMUNITY CARE ACT 1990
• EFFECTIVE CARE CO-ORDINATION 1999
• DISABILITY, RACE AND RECOGNITION ACT
• CARERS (RECOGNITION AND SERVICE) ACT 1995
• CARERS AND DISABILITY CHILDRENS ACT 2000

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WHAT IS CPA MEANT TO HELP YOU DO ?
STOP THE MENTALLY ILL-

• KILLING
• KILLING THEMSELVES
• BEING ABUSED
• ABUSING OTHERS

AND INCREASE THE SOCIAL FUNCTIONING OF THE
MENTALLY ILL
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HOW DOES CPA HELP YOU STOP PEOPLE KILLING
THEMSELVES OR OTHERS ?

• Systematic assessment of Health and Social
  needs
• Identifies Care Co-ordinator
• Ensures regular reviews of care
• Ensure good quality information and
  communication systems
• Learn from mistakes /complaints / audits and
  enquiries

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EQUALS GP, RMO, CARER, FAMILY, NURSE, ART
THERAPIST, CARE CO-ORDINATOR, SOCIAL WORKER
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EQUALS GP, RMO, CARER, FAMILY, NURSE, ART
THERAPIST, CARE CO-ORDINATOR, SOCIAL WORKER
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GROUP EXERCISE COMMUNICATION BETWEEN
PROFESSIONALS AND THE SERVICE USER /CARER

• WHO?
• HOW?
• WHAT CAN GO WRONG IN
• Ward Round
• Community Review
• On ward (i.e. general day to day communication)
• Contacting Service Users and Carers
• Transfers
• WHAT HAPPENS WHEN THINGS GO WRONG?
• ACCESS TO INTERPRETERS/ TRANSLATION?

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EVEN WHEN THINGS GO RIGHT, THINGS STILL GO
WRONG
SO WHY DO WE BOTHER ? ?

• TO SHOW WE DID
• TO COVER OUR BACKS
• BECAUSE ITS OUR JOB
• TO LEARN, TO STOP IT HAPPENING AGAIN

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AN EXAMPLE OF THIS IS- Christopher Clunis was
born in 1963. Both his parents came from Jamaica.
He began to show odd behaviour in 1986 and went
to stay with his father in Jamaica. He was
subsequently admitted to Bellevue Hospital,
Kingston, Jamaica where he was diagnosed as
having paranoid schizophrenia. He returned to
London the following year and was admitted to
various psychiatric hospitals on a number of
occasions in the following years. On 20th August
1992, Christopher Clunis was detained under s.3,
Mental Health Act 1983 and transferred the
following day from Kneesworth House to Guys
Hospital. He was discharged on 24th September
1992 to accommodation in Haringey.
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1st Trust
2nd Trust
4th Trust
3rd Trust
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• On 17th December 1992, Christopher Clunis
  stabbed Jonathan Zito, a complete stranger, to
  death in an unprovoked attack at Finsbury Park
  Tube Station.
• On the day of the murder an Approved Social
  Worker visited Christopher Clunis' address
  unaccompanied, leaving a note asking him to call
  and see her. He was by then in custody.
• He pleaded guilty to manslaughter at the Old
  Bailey on 28th June 1993 and sent to Rampton
  Hospital under ss.37/41, Mental Health Act 1983
• Report of the Inquiry into the Care and Treatment
  of Christopher ClunisJean Ritchie QC, Dr Donald
  Dick and Richard Lingham
• http//www.zitotrust.co.uk

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LEVELS OF CPA

• What can you remember?
• Nationwide?
• Locally?
• Effective Care Co-ordination 1999
• Standardise levels across country
• Two Levels ONLY
• Standard
• Enhanced

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Why do we need Levels of CPA?

• Identify enduring Mental Health needs.
• Access to certain teams restricted to Enhanced
  CPA.
• Monitored on percentage of Enhanced CPA by
  Healthcare Commission.
• Future payment by results implications.
• Sainsburys Centre Guidance on good practice.
• Encourages a discussion of risk assessment from
  different perspectives within care.
• Encourages a discussion regarding disengagement
  and non-compliance.

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WHAT IS A STANDARD CPA SERVICE USER?

• They require the support or intervention of
  one agency or discipline or they require only
  low key support from more than one agency or
  discipline.
• They are more able to self-manage their mental
  health problems.
• They have an active informal support network.
• They pose little danger to themselves or
  others.
• They are more likely to maintain appropriate
  contact with services.

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WHAT IS AN ENHANCED SERVICE USER ?

• They have multiple care needs, including
  housing, employment etc, requiring inter-agency
  co-ordination.
• They are only willing to co-operate with one
  professional or agency but they have multiple
  care needs.
• They may be in contact with a number of
  agencies (including Criminal Justice System).
• They are likely to require more frequent and
  intensive interventions, perhaps with medication
  management.
• They are more likely to have mental health
  problems co- existing with other problems such as
  substance misuse.
• They are more likely to be at risk of harming
  themselves or others.
• They are more likely to disengage with services.

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ENHANCED
CLINICAL DECISION LAND
STANDARD
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HoNOS HEALTH OF THE NATION OUTCOME SCALES
TO MONITOR COMPLIANCE WITH GOVERNMENT TARGET
OF. IMPROVING THE FUNCTIONING OF THE LONG TERM
MENTALLY ILL HoNOS 65, HoNOS LD, HoNOS MDO WHY
DO ? - HEALTHCARE COMMISSION REPORTING, CLINICAL
OUTCOME INDICATOR, CLINICAL GOVERNANCE CIRCLE.
CAN USE OTHER MEASUREMENT TOOLS i.e. CORE NHS
HEALTH INFORMATICS RANKINGS
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• WHEN DO I SCORE HoNOS ?
• ADMISSION
• DISCHARGE
• REVIEW

WHO SCORES HoNOS ?

• QUALIFIED MENTAL HEALTH WORKER
• EXPERIENCED MENTAL HEALTH WORKER
• TRAINED IN USING HoNOS

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WHAT HoNOS IS NOT-

• IT IS NOT AN INTERVIEW
• IT IS CLINICAL JUDGEMENT - NOT Service
  UserS VIEW POINT
• LIFE HISTORY / TWO WEEK RULE
• ALWAYS RIGHT

ONLY SCORE A SYMPTOM/EVENT ONCE
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GROUP WORK - COMPLETE VIGNETTE 3 AS A
GROUP COMPLETE VIGNETTE 4 ON YOUR OWN
NOTE DONT BE AFRAID TO MARK LOW OR GIVE 0 AS A
SCORE NEVER SCORE 9 OR WATCH AND SCORE DVD
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What is Culture?

• What is our culture?
• Stereotypes
• Service user/ carer
• Consequence of judgement
• How do we challenge or support?
• Cultures within Cultures
• Differences across patch
• Mental Health Culture/ Career

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CULTURE AND DIVERSITY ISSUES

• ARE THERE NEEDS REGARDING
• CULTURE
• SEXUALITY
• ETHNICITY
• RELIGION
• GENDER
• AGE
• FOR ADVICE CONTACT CPA OFFICE OR DAVE HENRY/
  SOCIAL SERVICES

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CULTURE AND DIVERSITY ISSUES

• Interpreters?
• May be able to speak English may not be able to
  read English.
• Care plans etc translated?
• Does the individual need a specialist worker?

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Social Inclusion

• Need to increase access of mentally ill to jobs
  and learning opportunities.
• Need to engage the mentally ill as part of their
  local community.
• Often said Although obviously a money saving
  angle is ethically based.
• Can Service Users access colleges/ job centres/
  training/ local council representatives?

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LUNCH
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SUPERVISED DISCHARGE AND THE SERVICE USER
The Service User must be consulted at all
stages The Service User and their nearest
relative have the right of appeal to the
MHRT Supervised Discharge automatically
terminates if Service User re-admitted under
section 3 The RMO must inform the Service User
orally and in writing what aftercare provision
they are expected to follow
Administration Monitored and Records kept by
Support Services
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WHO SHOULD BE THE CARE CO-ORDINATOR ?

• Best placed to oversee Care planning and
  resource allocation
• Have the authority to co-ordinate the delivery
  of care
• Can relate to cultural and ethnic backgrounds
• Competence in delivering mental health care
• Knowledge of Service user and families / carers
• Knowledge of Community Services
• Good Co-Ordination skills
• Access to resources

Reference NSF Framework Community Care Act 1990
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ROLE OF THE CARE CO-ORDINATOR

• BE CLEAR ABOUT THE ROLE OF OTHERS.
• COMMUNICATE CONCERNS AND RISK FACTORS.
• BE CLEAR ABOUT WHERE ROLE STARTS AND ENDS.
• BE AWARE OF RELATIONSHIP WITH SERVICE
  USER AND POSSIBILITY OF HANDING OVER.

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ROLE OF THE CARE CO-ORDINATOR

• ENSURE CRISIS AND CONTINGENCY PLAN
  FORMULATED FROM SERVICE USER AND ORGANISATIONAL
  PERSPECTIVE.
• CONSIDER THE NEED FOR ADVOCACY.
• IDENTIFY ANY UNMET NEEDS.
• REMAIN IN CONTACT IF SERVICE USER ENTERS
  PRISON SYSTEM.
• ARRANGE DEPUTY IF ABSENT.
• PROVE INVOLVEMENT OF SERVICE USER/CARER IN
  ONGOING PROCESS.
• ENSURE CARER ASSESSMENT COMPLETED WHERE
  REQUIRED

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ROLE OF THE CARE CO-ORDINATOR

• ENSURE USER AND CARER ARE AWARE OF COMPLAINTS
  PROCEDURE.
• ENSURE SERVICE USER REGISTRATION WITH GP.
• CHILD RISK ASSESSMENT AND GATHER RELEVANT
  INFORMATION.
• COMPLETE CLINICAL OUTCOME INDICATORS.
• ENSURE SERVICE USER CARER IS AWARE OF CPA
  PROCESS.
• ENSURE ACCURATE INFORMATION WITHIN
  INFORMATION AND COMMUNICATION SYSTEMS.
• CPA Handbook CPAA 2004

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RISK !
THERE ALWAYS HAS AND ALWAYS WILL BE RISK
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RISK IN NOTTS HEALTHCARE

• OVERALL TRUST RISK STRATEGY.
• LOCAL IMPLEMENTATION AND TOOLS.
• NOTTS CITY AND NORTH NOTTS TOOL VERY SIMILAR.
• NORTH NOTTS RISK PROCEDURE TO BE REVIEWED
  2005.
• TRUST STRATEGIES REGARDING SUICIDE
  PREVENTION/RISK TRAINING.

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RISK MANAGEMENT PLAN

• FACTORS TO INCLUDE-
• PAST HISTORY
• NATURE OF CURRENT RISK
• RISK MANAGEMENT PLAN

• INDIVIDUAL RESPONSIBILITIES

• RELAPSE SIGNATURE

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• SERVICE USERS VIEW OF RISK
• PROFESSIONALS VIEW OF RISK
• CARERS VIEW OF RISK
• WHEN TO REVIEW
• SHOULD BE AN MDT DECISION

WHAT SPECIFIC INTERVENTIONS IN 1ST THREE MONTHS
AFTER DISCHARGE AND SERVICE USER AT RISK MUST BE
SEEN WITHIN SEVEN DAYS OF DISCHARGE FIRST 48
HOURS IS THE HIGHEST RISK TIME
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HIGH RISK
MEDIUM RISK
LOW RISK
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Risk cannot be eliminated It can be rigorously
assessed and managed but outcomes cannot be
guaranteed. It is possible that harm will
occur.
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In making risk decisions the objective is not to
eliminate risk but to reach a balanced decision,
based on all available evidence, which maximises
the likelihood of a beneficial outcome for the
service user and effected persons
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• The range of risks that will need to be
  considered will include
• Risk of self neglect
• Risk of deliberate self harm
• Risk of abuse or violence from others
• Risk of harm or violence to children
• Risk of harm or violence to other adults
• Risk of harm from Carers
• Risk of domestic violence

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Levels of risk are not static however, they
change as an individuals attitude, behaviour and
circumstances change. Assessment of risk should
therefore be repeated when there is a significant
change in a persons circumstances and prior to
any formal review.
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• Risk assessment is an evidential process and the
• information on which decisions are made should
  be
• specific and include
• The past history of the person, particularly
  focusing
• on previous harm to self or others
• Information from the service user/significant
  other
• Information from individuals and other agencies
  who
• have previous knowledge of the person
• Observation of the behaviour and mental state of
  the person
• Discrepancies between what is reported and what
  is
• observed

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It is also important to fully record
circumstances in which it is decided that no
action should be taken.
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Staff should be aware that in cases where there
is disagreement or dissatisfaction with
outcomes, it is the case record which will
provide the evidence upon which judgements about
the reasonableness of interventions (or
non-interventions) will be made.
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Group Exercise Vignettes

• In groups read through vignette (1 8).
• Discuss and record on flip chart
• Issues of risk and care.
• Care Plan
• Level of CPA
• Who should be Care Co-ordinator?
• Use your imagination
• Do NOT use any cases you know
• Page 27 30 effective care co-ordination

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Nottinghamshire HM Coroner
Coroners Office 50, Carrington St, Nottingham,
Nottinghamshire NG1 7FG Tel [phone]  
Deaths, Births and Marriages The Register
Office50 Shakespeare StreetNottinghamNG1
4FPTelephone 0115 9475665e-mail
office.register_at_nottinghamcity.gov.uk
Dr Nigel Chapman
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Referral to the Coroner

• A death should be referred to the coroner if
• The cause of death is unknown
• The deceased was not seen by the certifying
  doctor either after death or within 14 days of
  death
• The death was violent, unnatural or suspicious
• The death may be due to an accident (whenever it
  occurred)
• The death may be due to self-neglect or neglect
  by others
• The death may be due to an industrial disease or
  related to the deceased employment
• The death may be due to an abortion
• The death occurred during an operation or before
  recovery from the effects of an anaesthetic
• The death may be due to suicide
• The death occurred during or shortly after
  detention in police or prison custody

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Role of the Coroner

• Coroner's Act 1988 defines when an inquest should
  be held
• Inquests are held in public and may involve a
  jury
• Purpose of the inquest is to determine
• Who is the deceased
• How, when and where he died
• Details of the cause of death
• The coroner is not concerned with civil or
  criminal liability
• Coroner may record the cause of death as
• Natural causes
• Accident / misadventure
• Industrial disease
• Sentence of death
• Dependence on drugs or non-dependent abuse of
  drugs
• Lawful killing
• Open verdict
• Want of attention at birth
• Unlawful killing
• Suicide
• Still birth

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NATIONAL CONFIDENTIAL INQUIRY INTO SUICIDE AND
HOMICIDE BY PEOPLE WITH MENTAL ILLNESS
INFORMATION FROM CORONER VERDICT - SUICIDE/OPEN
RMO/MANAGER COMPLETES QUESTIONNAIRE
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SUMMARY OF 2001 REPORT

• A ¼ OF ALL SUICIDES HAD
• BEEN IN CONTACT WITH
• MENTAL HEALTH SERVICES
• IN THE YEAR BEFORE DEATH

25 1500 DEATHS PER YEAR
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COMMONEST METHODS MEN HANGING WOMEN OVERDOSE
AT FINAL CONTACT WITH SERVICES SUICIDE ESTIMATED
TO BE LOW OR ABSENT IN 85 OF CASES
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IN - Service User SUICIDES
MOST COMMONLY FROM CURTAIN RAIL USING BELT AS
LIGATURE.
A ¼ OF Service User SUICIDES IN FIRST WEEK OF
ADMISSION
20 OF SUICIDES WERE UNDER CLOSE OBSERVATIONS
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SUICIDE STATS

• 4 OF SUCIDES WERE LONE CARERS OF CHILDREN.
• YOUNG SUICIDES ASSOCIATED WITH PSYCHOSIS,
  PERSONALITY DISORDER, DRUG/ALCOHOL MISUSE,
  VIOLENCE.
• 47 OF SUICIDES IN CONTACT WITH SERVICES ON
  ENHANCED CPA.
• 25 OF SUICIDES IN CONTACT WITH SERVICES WERE
  NON COMPLIANT/MISSED FINAL APPOINTMENT.

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SUICIDE STATS

• 3 OF SUICIDES WERE HOMELESS.
• 71 OF HOMELESS SUICIDES OCCURRED WITHIN THREE
  MONTHS OF DISCHARGE.
• 6 OF SUICIDES IN ENGLAND AND WALES WERE FROM
  OF AN ETHNIC MINORITY.
• MOST PEOPLE WITH SCHIZOPHRENIA WHO COMMITTED
  SUICIDE WERE UNEMPLOYED AND UNMARRIED.
• 1/3 OF IN-SERVICE USER SUICIDES IN ENGLAND
  AND WALES WERE ON AGREED LEAVE.

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HOMICIDE FINDINGS

• 15 OF HOMICIDES WERE SAID TO HAVE SYMPTOMS
  OF MENTAL ILLNESS AT TIME OF OFFENCE.
• MENTALLY ILL PERPETRATORS WERE LESS LIKELY TO
  KILL A STRANGER.
• FEW HOMICIDES WERE REGARDED AS PREVENTABLE.
• THREE PEOPLE PER YEAR WERE FOUND UNFIT TO
  PLEAD AND TWO PER YEAR WERE NOT GUILTY BY
  REASON OF INSANTIY (2001)

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SAFER SERVICE

• STAFF TRAINING IN THE MANAGEMENT OF RISK
  BOTH SUICIDE AND VIOLENCE EVERY THREE YEARS.
• ALL SERVICE USER WITH SEVERE MENTAL ILLNESS
  AND A HISTORY OF SELF-HARM OR VIOLENCE TO
  RECEIVE THE MOST INTENSIVE LEVEL OF CARE.
• INDIVIDUAL CARE PLANS TO SPECIFY ACTION TO BE
  TAKEN IF SERVICE USER IS NON-COMPLIANT OR FAILS
  TO ATTEND.
• PROMPT ACCESS TO SERVICES FOR PEOPLE IN CRISIS
  AND FOR THEIR FAMILIES.
• ASSERTIVE OUTREACH TEAMS TO PREVENT LOSS OF
  CONTACT WITH VULNERABLE AND HIGH-RISK SERVICE
  USER.

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SAFER SERVICE

• ATYPCIAL ANTI-PSYCHOTIC MEDICAITON TO BE
  AVAILABLE FOR ALL SERVICE USER WITH SEVERE
  MENTAL ILLNESS WHO ARE NON-COMPLIANT WITH
  TYPICAL DRUGS BECAUSE OF SIDE EFFECTS.
• STRATEGY FOR DUAL DIAGNOSIS COVERING TRAINING
  ON THE MANAGEMENT OF SUBSTANCE MISUSE, JOINT
  WORKING WITH SUBSTANCE MISUSE SERVCIES, AND
  STAFF WITH SPECIFIC RESPONISIBILITY TO DEVELOP
  THE LOCAL SERVICE.
• IN-SERVICE USER WARDS TO REMOVE OR COVER ALL
  LIKELY LIGATURE POINTS, INCLUDING ALL
  NON- COLLAPSIBLE CURTAIN RAILS.

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SAFER SERVICE

• FOLLOW UP WITHIN 7 DAYS OF DISCHARGE FROM
  HOSPITAL FOR EVERYONE WITH SEVERE MENTAL
  ILLNESS OR A HISTORY OF SELF-HARM IN THE
  PREVIOUS THREE MONTHS.
• SERVICE USERS WITH A HISTORY OF SELF-HARM IN
  THE PAST 3 MONTHS TO RECEIVE SUPPLIES OF
  MEDICATION COVERING NO MORE THAN 2 WEEKS.
• LOCAL ARRANGEMENTS FOR INFORMATION- SHARING
  WITH CRIMINAL JUSTICE AGENCIES.
• POLICY ENSURING POST-INCIDENT MULTI
  DICIPLINARY CASE REVIEW AND INFORMATION TO BE
  GIVEN TO FAMILIES OF INVOLVED SERVICE USERS.

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SUMMARY OF RISK ASSESSMENT

• RISK ALL AROUND - CANNOT AVOID
• GOOD PRACTICE FOR THE LIVING AND THE DEAD
• ALTERNATIVE WAYS OF LOOKING AT RISK
• ?
• USE RISK AS MAIN ASSESSMENT TOOL THEREFORE
  TURNING WHAT IS SEEN AS NEGATIVE INTO A POSITIVE

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WHAT CAN THE CPA SERVICE DO FOR ME?

• ASSIST WITH DOCUMENT DESIGN
• STAFF TRAINING IN SCRIPTING AND RISK AWARENESS
• FIND SERVICES IN OTHER AREAS
• ADVISE ON DIFFICULT CASES
• MINI AUDITS AT MANAGERS REQUEST
• CARE CO-ORDINATION DETAILS

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Screen shots by Emma eCPA DATABASE

• FROM SPRING 2004 TRUSTWIDE ELECTRONIC DATABASE
  OF ALL LETTERS, CARE PLANS, RISK ASSESSMENTS.
• WILL INCLUDE POLICIES, PROCEDURES AND
  DOCUMENTATION (BLANK) THAT CAN BE PRINTED OFF.
• ALL LETTERS/CARE PLANS TO GO TO CPA OFFICE
  MILLBROOK OR BASSETTLAW CPA ADMIN.
• DOCUMENTS SCANNED INTO SHARE POINT SYSTEM.

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eLearning

• 3 yearly update should be initially completed on
  Trust eLearning site.
• Useful for new staff/ admin/ students.
• Web links to relevant documents.
• Automatically informs workforce development of
  your update.
• Takes 2 2 ½ hours.
• Any problem accessing contact CPA Office.

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THANK YOU
THANK YOU FOR YOUR TIME AND ATTENTION ALL
COPIES OF DOCUMENTS SHOWN CAN BE FOUND IN THE
FOLDERS LOCATED ON THE DESK
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CPA OFFICES
MILLBROOK UNIT KINGS MILL SUTTON IN ASHFIELD TEL
NO 01623 784787
DUNCAN MACMILLAN HOUSE PORCHESTER
ROAD MAPPERLEY TEL NO 0115 9934580
HOURS- MONDAY TO FRIDAY 9.00 AM - 5.00 PM VOICE
MAIL AVAILABLE OUT OF HOURS