Service Description
About the Brooker Centre
Lectures
SHO Competency
Crash Call Procedure
Liaison Psychiatry
Preventing Violence
Managing disturbed In-patients
Care Programme Approach
For patients who decline to co-operate with the agreed care programme, it is the
responsibility of the keyworker to make every effort to establish alternative ways of
presenting the Care Plan that is acceptable to the patient. The patient may opt only to
accept part of the programme offered and as far as possible, the programme should be
sufficiently flexible to accommodate this. It is the responsibility of the keyworker to
record that the patient has rejected the Care Plan as a whole or in part.
Carers should also be offered assistance on a regular basis and a reliable point of
contact.
For patients assessed as being at risk to self or others who refuse Care Programme
Approach, it is the responsibility of the keyworker to communicate this to other agencies.
It is considered good practice to the care team to plan and review care for those patients
who do not comply with their Care Programme Approach.
Leave
Patients going from hospital on leave shall continue to do so as part of their programme.
It is the responsibility of the named nurse to ensure that the patient and carer are given
the name and telephone number of a key person to contact in an emergency should the need
arise.
For longer periods of leave a care planning meeting should be held for those patients who
have been identified using the agreed criteria (see Form 1), and the relevant leave forms
must be completed on each occasion by the RMO/Ward Doctor stating reason for, dates and
duration of leave.
For patients subject to aftercare arrangements under section 117 of the Mental Health Act
1983, a Care Planning meeting should take place before any period of leave commences.
Reviews
The responsibility for identifying the frequency that care programmes will be reviewed
rests with the multi-disciplinary team and is
determined at the initial Care Planning Meeting and
henceforth at each review, and as such should be recorded on the Care Plan.
Patients must be asked whether they wish their carer/relative/friend to attend their
reviews or to have the Care Programme Approach information sent to them.
Care Plans must be reviewed regularly according to need, but initially it is likely the
reviews will be more frequent. The review date must be included in the plan. It is the
responsibility of the keyworker to inform the Care Programme Approach Co-ordinator of the
date of the next review.
The responsibility for subsequent reviews will be that of the keyworker. Patients must be
invited to attend their reviews together with their carers and any professional involved
in the delivery of their care. Where only one or two workers are involved, a specific
review needs to take place and be documented, with consideration given to the involvement
of other professionals and services, but a review meeting as such may not be necessary.
The keyworker should maintain liaison with the consultant or other relevant worker if a
patient is still attending out-patient appointments or the day unit, and any comments etc.
recorded in the review.
For patients on the Supervision register, consideration needs to be made as to whether
registration is still appropriate, or if inclusion is indicated for those patients who are
considered to be at significant risk.
Reviews will be documented on Form 7 and copy forwarded to the patient's general
practitioner and the Psychiatric Support Services Manager.
DISCHARGE FROM THE CARE PROGRAMME APPROACH/SECTION 117
The decision to discharge a patient from the Care Programme approach should be taken in
conjunction with other relevant workers and agreed at the point of review, or the need to
discharge may be apparent at any time in the Care Programme process.
Form 8 should always be completed to discharge someone from the Care Programme Approach.
Reasons for discharge should be recorded by the keyworker who will circulate copies to
those agencies involved including the patient's general practitioner. A copy must also be
sent to the Psychiatric Support Services Manager.
Typical reasons for discharge being:
Aftercare or community plan no longer required.
Patient refuses the Care Programme Approach
Patient moves out of the area
Death
CONSULTATION WITH PATIENTS AND RELATIVES/ CARERS
Patients, together with significant others, should be given the opportunity to attend care
Planning meetings and, as far as possible, be involved in the drawing up and
implementation of their Care Plan together with any other discharge arrangements.
Relatives/carers should be kept fully informed of the Care Plan.
It is implicit within this policy that full consultations should be sought and agreed with
patients on the content of the Care Plan and that his/her approval will be necessary to
disclose information for such plans. Where carers are involved, their contribution to the
Care Plan will be requested subject to the above in respect of the patient's consent.
INVOLVEMENT/NOTIFICTAION OF GENERAL PRACTITIONERS
General practitioners should be invited and actively encouraged to attend case conferences
and reviews regarding Care Management and Care Programme Approach.
With the patient's consent a copy of the Care Plan and subsequent review forms should
always be sent to the general practitioner. The keyworker/care manager will be responsible
for this.
IDENTIFICATION, ROLE AND RESPONSIBILITES OF THE KEYWORKER/CARE MANAGER
The keyworker/care manager will be present at the Care Planning meeting, having agreed to
take on this role.
The keyworker/care manager will be the principle worker most closely in touch with the
patient's circumstances. He/she may come from any discipline but should be sufficiently
experienced to command the confidence of colleagues from other disciplines.
The keyworker/care manager is responsible for :
Ensuring patient needs and details of the Care Plan are recorded.
Ensuring that care is delivered. This with the patient and advising professional
colleagues of changes in circumstances which might require review of modification of the
Care Plan.
Evaluating the care provided and reporting at review meetings.
Ensuring that proper arrangements are made for alternative point of contact and/ or carers
when the keyworker/care manager is unavailable.
Instigating action for regular reviews and to ensure that the relevant documentation is
completed and a copy forward to the general practitioner, the Psychiatric Support Services
Manager and any other professionals involved.
Instigating action for emergency reviews if the need arises.
It is the responsibility of all members of the multi-disciplinary team to inform the
keyworker/care manager of any changes to the Care Plan.
CHANGE OF KEYWORKER/CARE MANAGER
There will be occasions when it is appropriate to change the keyworker/care manager as the
patient's circumstances and needs change or if an individual worker leaves post.
Decisions to change the keyworker/care manager, or any professional's decision to withdraw
from a Care Plan, should be properly planned and can only be taken within a care
plan/review meeting. Any such decision, and reasons given, must be recorded on the review
form 7.
MONITORING/ADMINISTRATION OF THE POLICY
The Psychiatric support services Manager will be responsible for managing the Care
programme Approach with the General Manager/Senior Nurse.
The Director of Nursing will report on a regular basis to the Hospital Trust Board on the
management of issues related to Care Programme approach.
Throughout the process, all relevant forms must be forwarded to the Psychiatric Support
Services Manager who will be responsible for the administration system of the policy by
keeping record of patients on Care Planning Approach and notifying the Keyworker/care
manager of reviews and programme requirements.
Version 4.0
October 2000