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Assessment and care of children and young people with mental health needs who are placed in an acute general hospital ward policy

Contents

  1. Introduction
  2. Purpose
  3. Scope
  4. Responsibilities, accountabilities and duties
  5. Procedure or implementation
  6. Monitoring arrangement
  7. Training implications
  8. Equality impact assessment screening
  9. Links to any other associated documents
  10. References
  11. Appendices

1 Introduction

Children and young people with acute mental health needs may need admission to hospital for assessment and treatment. Acute general hospital wards (typically a paediatric ward) are often the first location for admission. Clinical staff from children and adolescent mental health services (CAMHS) have a pivotal role in working with the acute general hospital ward Multidisciplinary team (MDT) to assess, plan and co-ordinate care for these children and young people.

Out of Hours for those aged 16 and 17 years the adult crisis team may be involved in the assessment.

2 Purpose

The purpose of this policy is to clearly set out best practice guidance and CAMHS requirements for the assessment and care of children and young people who are admitted to an acute general hospital ward with mental health needs.

When any child or young person has been admitted to an acute general hospital ward with associated emotional and mental health issues, be that planned or unplanned, they, their parent or carer or legal guardian and the admitting ward staff should have clarity regarding the roles and responsibilities of CAMHS and the nature and frequency of contact that can be expected.

This policy aims to support staff to:

  • maintain the safety and well-being of the child or young person through a timely assessment, risk assessment and care and crisis plan
  • provide ongoing assessment, care and support to the child, young person or family and the acute hospital ward during prolonged admission
  • provide a consistent approach and have clarity regarding their roles and responsibilities for the care of children and young people admitted to an acute general hospital ward with mental health needs

2.1 Definitions and explanation of terms used

Definitions
Term Definition
FACE risk assessment ‘FACE’ is an abbreviation of the name of the company that produce several toolkits to assess risk and needs in health and social care. Functional analysis of care environments (FACE)
BMI Body mass index
SOP Standard operating procedure

3 Scope

This policy applies to those patients or service users who have not yet reached their 18th birthday and are therefore defined as children and young people and covers:

  • those children and young people who have been referred to trust services but whose needs and level of risk have yet to be assessed
  • those children and young people who have been accepted by CAMHS and whose level of risk has been assessed and or has changed

This policy applies to all clinical staff in CAMHS, who as part of their work will assess children and young people (as defined in the scope) who have been admitted to an acute general hospital ward with associated mental health concerns.

Whilst it is recognised that this Policy will predominantly apply to CAMHS, staff from adult services may also be involved in the assessment of children and young people and therefore should be aware of the content.

4 Responsibilities, accountabilities and duties

CAMHS staff should ensure they maintain their professional knowledge and competence by accessing available training and seeking advice and guidance through clinical and managerial supervision and using the resources available on the trust intranet.

4.1 Care group directors

Care group directors are responsible for:

  • the implementation of the policy across the specified care groups
  • the ongoing review of the policy to keep it up to date with current best practice
  • promoting collaborative working between services, in order that the needs of the patient remain at the centre of the process
  • providing reports to the operational management group (OMG) on any issues associated with the implementation of the policy
  • provide reports to the mental health legislation operational group of any young people admitted or detained under the Mental Health Act (MHA) (1983)
  • facilitating effective joint working with internal and external partners and stakeholders

4.2 Team managers

Team managers are responsible for:

  • making their staff aware of the contents of this policy
  • monitoring the compliance of their staff with the contents of this policy
  • facilitating Multidisciplinary team (MDT) discussion to assist decision-making and communication of concern or actions
  • reporting any breaches in relation to this policy

4.3 The Crisis team

The Crisis team is responsible for:

  • supporting staff with the implementation of this policy
  • reporting any breaches in relation to this policy
  • escalating any clinical issues that impact on the delivery of this policy
  • facilitating Multidisciplinary team (MDT) discussion and, or individual supervision to assist decision-making and communication of concern or actions
  • liaising with general hospital colleagues in relation to this policy

4.4 All clinical staff

Clinical staff are responsible for:

  • following the appropriate steps in this policy and informing the team manager where necessary of any issues that impact on the delivery of care as defined within this policy
  • reporting any breaches in relation to this policy

5 Procedure or implementation

5.1 Best practice guidance self harm

There is a national recommendation that children up to 16 years of age who have self-harmed should normally be admitted overnight to a paediatric ward and assessed fully the following day before discharge or further treatment and care is initiated. (NICE 2011) Self harm in over 8s: long-term management (opens in new window).

Self-harm in over 8s: short-term management and prevention of recurrence clinical guideline (CG16) Published 28 July 2004 (opens in new window).

In accordance with national guidance for self-harm under ‘Special issues for children and young people (under 16 years)’ a paediatrician should normally have overall responsibility for the treatment and care of children who are admitted and have self-harmed. The admitting team should obtain consent, to undertake the mental health assessment of the child or young person, from the patient if they are Gillick competent or from someone with parental responsibility if they are not.

Young people aged 16 and 17 years are not identified separately in national guidance (as above NICE guidance) and therefore referral, treatment and discharge following self-harm should be based on the overall assessment of needs and risk.

National guidance states:

  • that the decision to discharge a person without follow-up following an act of self harm should be based upon the combined assessment of needs and risk. The assessment should be written in the case notes and passed onto their general practitioner (GP) and to any relevant mental health services
  • that a decision to discharge a person without follow-up following an act of self-harm should not be based solely upon the presence of low risk of repetition of self-harm or attempted suicide and the absence of a mental illness, because many such people may have a range of other social and personal problems that may later increase risk. These problems may be amenable to therapeutic and social interventions
  • that temporary admission, which may need to be overnight, should be considered following an act of self-harm, especially for people who are very distressed, for people in whom psychosocial assessment proves too difficult as a result of drug and alcohol intoxication, and for people who may be returning to an unsafe or potentially harmful environment. Reassessment should be undertaken the following day or at the earliest opportunity thereafter

See NICE guidance CG16: Self-harm, the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Sections: 1.9.1.3 and 1.9.1.5 and 1.9.1.6 for under 16 years and 1.8.1.3, 1.8.1.4 and 1.8.1.5. It is stated that these will be merged into one document, however this has not happened to date.

5.2 Response by local CAMHS services within working hours

Normal working hours are defined as Monday to Friday 9am to 5pm hours see appendix A.

Out of hours are defined as after 5pm hours and weekends or public bank holidays

5.2.1 CAMHS response to referrals made by admitting children and young people to wards in acute hospital settings

All children and young people placed on a paediatric or acute general hospital ward who require a mental health assessment will be seen within 24 hours of receipt of referral, or when medically fit.

Referrals will be assessed as urgent if a young person has been placed on a paediatric or acute hospital ward as a result of:

  • active self-harming and requires treatment
  • is actively suicidal (has a plan and intent)
  • has significant, rapid weight loss with a BMI of 14 or less, where the weight loss has been ruled out as being caused by a physical health cause
  • is exhibiting active psychotic symptoms or unusual thought processes which are causing them to act in a manner which poses a risk to themselves or others

There are local working instructions with local acute hospitals to be adhered to within working hours. These are held in local services

5.3 Referrals

Referrals are expected to be received from the relevant ward at the earliest opportunity to enable the CAMHS to plan. Referrals can be made by phone as detailed below pending the progression of secure email.

Eating Disorders team SPA (trust wide):

5.3.1 Receipt of referrals

All referrals received by CAMHS are directed to the single point of access (SPA) or duty worker for triage in accordance with the locality operating procedure for the SPA or duty worker in hours (Section 5.3.3 and 5.3.5 below) and in accordance with the children and young people’s mental health service (CAMHS) out of hours service SOP (section 5.3.4 and 5.5.2 below).

5.3.2 Monitoring of referrals

The team manager or Crisis team of the local CAMHS team will be responsible for collating referral data and information regarding all admissions to the acute hospital within their locality.

5.3.3 Triage

Triaging is a clinical function which aims to assess and categorise the urgency of the referred mental health related problem. This role is performed by the CAMHS SPA or duty worker on a daily basis between the hours of 9am and 5pm. A robust system is in place for the effective triage of all referrals received within 24 hours.

CAMHS will support the acute general hospital by offering advice and or assessment to support decision-making regarding the safe discharge of children and young people.

5.3.4 Triage out of hours

CAMHS provide an out of hours service as detailed in section 5.5.2

5.3.5 Intoxication by drugs and or alcohol

Alcohol and drug intoxication may influence a person’s mental state presentation and may imitate or mask symptoms of an underlying mental disorder.

The presence of alcohol and, or drug intoxication does not preclude early assessment, although it may indicate the need for further assessment when the person is no longer intoxicated or under the influence of drugs.

Consideration whether the child or young person has the capacity to consent to an assessment, due to being under the influence of alcohol or drugs at the point of request, needs to be taken account of. Equally the level of disturbance to the child or young person’s presentation and associated risk should be a critical consideration.

The Mental Health Act: Code of Practice 2015 (14.56) makes reference to the role of the approved mental health professional (AMHP) and states: “Where patients are subject to the short-term effects of alcohol or drugs (whether prescribed or self-administered) which makes interviewing them difficult, the AMHP should either wait until the effects have abated before interviewing the patient or arrange to return later. If it is not realistic to wait because of the patient’s disturbed behaviour and the urgency, the assessment will have to be based on whatever information the AMHP can obtain from reliable sources. This should be made clear in the AMHP‘s record of the assessment.”

5.4 Consent and parental responsibility

Parental responsibility means the rights and responsibilities that parents have in law for their child, including the right to consent to medical treatment for them, up to the age of 16 in England.

The valid consent of a child or young person will be sufficient authority to carry out a mental health assessment, additional consent by a person with parental responsibility will not be required.

5.4.1 Valid consent

A child under 16 must have competence and a young person aged 16 and over must have the mental capacity to make the particular decision. They must have sufficient relevant information to make that decision and not be subject to any undue influence when doing so.

Unlike adults, the refusal by a competent child or young person with capacity may or can in certain circumstances, be overridden by someone with parental responsibility or an order of the court.

It is good practice to involve the child or young person’s parents and others involved in their care in the decision-making process, if the child or young person consents to information about their care and treatment being shared.

5.4.2 Children under 16

Children under 16 should be assessed to establish whether they have competence to make a particular decision at the time it needs to be made.

The test for children under 16 is determined by considering whether they are “Gillick competent” (appendix B Gillick competence).

5.4.3 Consent to the care regime during admission

The decision whether the child or young person consents to their care regime, or if it amounts to a deprivation of liberty, must be kept under regular review.

A significant factor to be considered is the scope of parental responsibility and the level of supervision, for example, what is usual for a young child would not usually be an acceptable restriction for a 17-year-old. This is particularly significant where for example the risk assessment and care plan indicate that close observation or supervision is required (for example, to manage risk to self and others).

5.4.4 Deprivation of liberty

In determining whether a person with parental responsibility can consent to the arrangements which would, without their consent, amount to a deprivation of liberty, CAMHS should advise the admitting ward MDT they will need to consider and apply developments in case law following “Cheshire West”, and may need to seek safeguarding or legal advice in respect of individual cases to ensure the care of the child is delivered within the appropriate legal framework (staff can refer to the trust deprivation of liberty policy).

CAMHS staff should seek advice and guidance as required though clinical and managerial supervision, the trust Safeguarding team, the trust’s Mental Capacity Act lead (where appropriate) and via the CAMHS On call manager out of hours.

Approved mental health professionals will also have access to legal advice via the local authority.

5.5 Assessment prerequisites

The admitting ward staff are required to:

  • confirm who has parental responsibility
  • assess the competence or capacity of the child or young person to consent to and participate in a mental health assessment
  • obtain consent for referral or discuss with CAMHS those rare cases where consent cannot be secured to ensure the child or young person is assessed within the appropriate legal framework
  • agree a suitable time for assessment and make all attempts to have a person with parental responsibility present for any child or young person being assessed if appropriate
  • ensure a member of the ward team is available to provide a handover of reliable clinical information to inform the assessment
  • confirm that the child or young person is ‘medically fit’ for assessment having excluded toxicity or organic pathology as a cause of the presenting problem

For the purpose of this policy, ‘Medically fit’ is described as having completed all tests and treatment pertinent to the physical presenting problem and being suitably alert to participate in the assessment as in 5.3.5 and 5.7.

5.5.1 Assessment pathway: Attending the ward following admission in working hours

It is the responsibility of the Crisis team to conduct a mental health and risk assessment on the paediatric or acute hospital ward in their locality irrespective of the child’s usual place of residence.

In the event that the child or young person has an allocated care coordinator or CAMHS lead professional, and they are available to undertake an assessment they may accept responsibility to do this themselves within the agreed timescales.

Assessment should be undertaken by a single clinician except in exceptional circumstances where there is a complex presentation.

The CAMHS clinician that conducts the assessment will:

  • complete a FACE risk assessment (as a minimum) for all children or young people seen. The purpose of the assessment is:
    • to determine whether the young person is mentally fit for discharge to an agreed community setting and will no longer pose an unacceptable level of risk to themselves or others
    • to establish a risk management plan for young people deemed fit for discharge
    • to establish if parents or carers are able to implement the support and risk management plan
    • to determine the risk management plan for a young person not deemed fit for discharge
    • to ensure the risk assessment and risk management plan is clearly communicated and recorded in the young person’s file on the ward and also the CAMHS electronic patient record
  • adopt a collaborative approach to care and risk planning ensuring the child or young person, parent or carer and or legal guardian are involved and agree to the plan in consultation with the admitting ward where continued admission is agreed
  • inform the admitting ward’s Multidisciplinary team or manager where the child or young person, parent or carer are not in agreement with the care plan or risk management proposed
  • record a clear plan of care in the child or young person’s file on the admitting ward at the point of assessment and ensure this is shared with the child or young person, parent or carer and or legal guardian (appendix C)
  • record the full assessment and outcome in the child or young person’s file on the admitting ward and also onto the CAMHS electronic patient record or SystmOne)
  • issue the child or young person and their family, with a summary of their care plan and contact numbers if concerns
  • contribute to multidisciplinary or multi agency decision-making and discharge planning for the child or young person
    • where this is at the point of initial assessment this is typically undertaken by the assessing clinician as the CAMHS representative (with support from CAMHS team manager or pathway lead or consultant psychiatrist as required). Where admission has been prolonged (for example, over 72 hours) or the presentation is more complex ( for example, safeguarding concerns, elevated risk factors) CAMHS will ensure the most appropriate CAMHS representatives attend any discharge planning meetings convened by the acute general hospital, see 5.6.1 and 5.6 2
  • add a face to face contact to their staff calendar
  • take on the role of care coordinator (for those cases with no current allocated care coordinator or CAMHS lead professional) and ensure that they are allocated on the care network (SystmOne). Care coordinators are allocated as part of CPA and lead professionals usually non-CPA framework
  • care programme approach (CPA) policy
  • complete a first contact ‘current view’ form
  • communicate the outcome of the assessment within 5 working days in writing to the child or young person’s GP as a minimum. Copies of this letter should be sent to the child or young person and their legal guardian in accordance with the healthcare record keeping policy
  • where there are identified safeguarding concerns and, or the child or young person has an allocated social worker, the details of the assessment or outcome and risk management plan should be shared with the allocated social worker in accordance with trust and local safeguarding children board policies

5.5.2 Attending the ward following admission out of hours (in accordance with the CAMHS out of hours SOP)

Staff are expected to undertake assessments in line with section 5.5.1 (a to h and l) however there are process differences as below:

  • referring agencies will contact Tickhill road hospital switchboard (03000 213000) in the first instance, who will then contact the on call clinician. CAMHS clinicians will contact the referrer and triage the referral by phone to determine suitability and necessity to attend the ward to undertake an assessment (there will be no Home visits outside of core working hours due to safe alone working, as detailed in the OOH SOP)
  • CAMHS clinicians will assess all young people up to the age of 16 years. For young people between the ages of 16 years and 18 years the Locality Access and Liaison teams may conduct assessments without CAMHS clinicians, unless there are complex presentations. Where a young person aged 16 or 17 years has been admitted to a general hospital ward and an assessment is deemed necessary a joint assessment will be completed by the CAMHS on call clinician and the access and liaison team worker. Refer to the above SOP for full details of the assessment arrangements
  • the CAMHS on call record should be completed for all out of hours contacts, including those where the child or young person has not been assessed
  • a FACE risk assessment and assessment document should be completed for all children and young people who have been assessed. This should be uploaded to SystmOne or emailed to the Locality team
  • the locality CAMHS team must be informed of any assessment the following morning via a task on SystmOne
  • correspondence to the child or young person, parent or carer and or legal guardian and GP will be followed up by the locality team within 1 working week. This will not be the responsibility of the assessing out of hours clinician
  • following an out of hour’s assessment, the clinician is responsible for handing over the information to the relevant team the next day or as soon as practicably possible. Information about children or young people who are already known to service should be passed to the lead clinician, or if they are not available, the clinical lead or team manager for the relevant team
  • for those children or young people who are “looked after” ensure that there is liaison with the relevant local authority throughout the assessment and decision-making process
  • the following handover process should be adhered to for those children and young people who are presenting to service for the first time or are not currently in receipt of a service:

Children and young people currently in receipt of services should be directed to the lead professional or care coordinator. In the absence of the lead professional or care coordinator, the team manager or Crisis team should be informed.

Where psychiatric medical assessment is required, this must be clear within the handover of the case and further information may be required from the appropriate psychiatrist.

5.6 Decision and outcome pathway, discharge of the child or young person into the community

  • Where possible the clinician or care coordinator (where known to the service) will be required to review the child or young person again within 7 working days following discharge, as per NICE guidelines (NICE 2004). This may be sooner dependent upon presenting need and risk factors and may require a joint assessment with a Medical team member. Follow-up contact may be in person or by phone or alternative method as agreed with the young person or family
  • Where the clinician or care coordinator (where known to the service) is not available to undertake the 7-day review, it is the responsibility of the assessing worker to ensure that the child or young person and parent, carer or legal guardian are clear as to who will undertake this assessment. This may be a member of the Crisis team. Information should be provided to the child or young person and parent, carer or legal guardian as to when and how to contact the service in the interim (crisis card). This should be recorded clearly in the electronic patient record
  • Where the 7-day follow-up appointment indicates ongoing care is required the child or young person and their parent or carer or legal guardian must be clear about who is their allocated care coordinator. The care coordinator must be named and allocated by the CAMHS within 10 working days of referral by the admitting ward

5.6.1 Decision and outcome pathway, where the child or young person is not fit for discharge and remains on the ward

There are occasions where a child or young person may have a brief admission and in more rare circumstances have a prolonged stay in an acute general hospital but also have ongoing mental health needs. This may be due to coexisting or complex physical health needs and or delay in sourcing a suitable place for transfer or discharge. It is essential that the child or young person’s mental health and wellbeing is promoted and recovery maximised though ongoing assessment and treatment by the local CAMHS during this time.

If on assessment the child or young person is not fit for discharge and remains on the ward, the following minimum standards will apply:

  • daily phone contact with the ward by the care coordinator or Crisis team as per the local arrangement is expected. Details of the discussion and any decisions taken must be recorded in the CAMHS electronic patient record
  • for young person on ward with eating disorder, the plan of contact will be agreed between the ward and the eating disorders team
  • daily discussion of cases that are not discharged from the wards will take place with the CAMHS medical staff, as necessary
  • face to face appointments must take place at no longer than 72 hourly intervals (Monday to Friday) unless agreed otherwise. Where visits are not required at this frequency this must be agreed in liaison with the ward manager or MDT and the reasons documented in the clinical record
  • CAMHS staff will ensure that the ward is provided with a written initial care plan at the point of assessment to include (see appendix D):
    • an outline of the identified problem and core principles of care
    • any observation required, for what purpose and describe how this should be undertaken ( for example, frequency, proximity, role of parents, carers or legal guardian)
    • frequency of visits planned by CAMHS workers
    • overview of risk factors or triggers to risk and management plan including safeguarding concerns
    • information where the child or young person or parent, carer or legal guardian do not consent to the care regime
  • this care plan should be reviewed within a maximum of 7 working days and amended or updated as necessary. It should be agreed with the child or young person, parent, carer or legal guardian (and ward staff for all children and young people who remain as an inpatient)
  • a written copy of the full CAMHS FACE risk assessment should be shared with the ward within 3 working days for all children and young people who remain as an inpatient
  • CAMHS staff will be required to provide support to the paediatric nursing and medical staff. They should be clear about the risks and communicate this effectively to the paediatric staff highlighting what they should do if the risk changes, both in and out of hours
  • CAMHS staff will be required to progress any referral to tier 4 inpatient services in a timely manner, update the admitting ward with regard to progress and escalate concerns to NHS England regarding delays
  • CAMHS or admitting ward staff should contact the relevant trust’s safeguarding team for advice or support where there is a safeguarding concern. Any safeguarding referrals must be completed at the point of assessment by CAMHS or admitting ward in accordance with trust or local safeguarding children board policies. This will include escalation of concerns where discharge is delayed pending review by another agency for example, local authority children services or tier 4 providers.

5.7 Assessment under the Mental Health Act

There are situations where a child or young person may require, either immediately (urgently) or as part of an assessment (routinely), a Mental Health Act assessment to be carried out. Approved mental health professionals that are employed within the Adult Access teams will follow the trust agreed pathway for dealing with Mental Health Act assessments including those for children and young people.

Mental Health Act Assessments are divided into ‘unplanned’ or ‘planned’. Unplanned Mental Health Act assessments, where a response is expected that day include the following:

  • section 136
  • section 135
  • section 2
  • section 3
  • section 4

It is less likely that adult mental health practitioners from the adult access team will be included in planned Mental Health Act assessments for children and young people as these should be provided by CAMHS community and tier 4 staff however these would include the following:

  • section 5(2)
  • section 2 to 3
  • cases known to the treatment teams such as early intervention in psychosis (including section(s) 2 and 3, section 135)
  • community treatment orders
  • guardianship (under the MHA, a guardianship order does not authorise any deprivation of the person’s liberty which is different to the MHA sections which are legal sections for detention

The Mental Health Act: Code of Practice 2015 (14.56) makes reference to the role of the approved mental health professional (AMHP) and states:

“Where patients are subject to the short-term effects of alcohol or drugs (whether prescribed or self-administered) which make interviewing them difficult, the AMHP should either wait until the effects have abated before intervening the patient or arrange to return later. If it is not realistic to wait because of the patient’s disturbed behaviour and the urgency, the assessment will have to be based on whatever information the AMHP can obtain from reliable sources. This should be made clear in the AMHP‘s record of the assessment.”

5.8 Escalation of concerns or conflict resolution

Any member of staff who has concerns regarding the application of this policy or encounters conflict which they are unable to resolve with regard to the care and treatment of a child or young person within the scope of this policy should:

  • praise initial problems with the locality team manager or Crisis team or on call manager out of hours
  • if at this point it cannot be resolved, then the manager or clinical lead will pass the information on to the service manager of CAMHS

If problems still persist and a resolution has not been sought then this will be escalated to the Children’s care group director.

6 Training implications

There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents:

All CAMHS clinical staff and any other individual or group with a responsibility for implementing the contents of this policy. Each CAMHS Locality team will make the team aware of any new or updated policy via team meetings and ensure this is covered in local induction for new starters.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through: trust wide email.

7 Monitoring arrangement

7.1 Compliance with the standards within this policy

  • How: Monitoring of all admissions of under 18-year-olds to a general health ward, review of any complaints, concerns escalated or action plans that relate to the admission of children and young people to paediatric ward.
  • Who by: Team managers or Crisis team.
  • Reported to:
    • children’s mental health legislation monitoring group
    • escalate to mental health legislation operational group
    • feeds up to the mental health legislation committee for assurance at the trust board
    • children’s care group governance group
  • Frequency: 6 months.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure for that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the mental capacity Act 2005.

10 References

11 Appendices

11.1 Appendix A Locality pathways in working hours

11.1.1 Doncaster in hours overarching pathway

Acute hospital manages any acute medical or physical problems and excludes toxicity or organic pathology as cause.

Admitting ward refer to CAMHS service.

  • In hours: 9am to 5pm, Monday to Friday
  • Phone: 03000 211219

Staff can also discuss with member of the Crisis team who provides support to the paediatric unit or acute hospital wards during the hours of 9am to 5pm, Monday to Friday.

CAMHS respond within 24 hours to admitting ward unless mutually agreed otherwise (for example, not medically fit).

CAMHS team advise on appropriate admission or discharge and support.

11.1.2 North Lincolnshire in hours overarching pathway

Acute hospital manages any acute medical or physical problems and excludes toxicity or organic pathology as cause.

Admitting ward refer to CAMHS service.

CAMHS urgent criteria is a met and response time of within 24 hours to admitting ward unless mutually agreed otherwise (for example, not medically fit).

CAMHS team advise on appropriate admission or discharge and support.

11.1.3 Rotherham in hours overarching pathway

Acute hospital manages any acute medical or physical problems and excludes toxicity or organic pathology as cause.

Admitting ward refer to CAMHS service.

Staff can also discuss with member of the Crisis team who provides support to the paediatric unit or acute hospital wards during the hours of 9am to 5pm, Monday to Friday.

CAMHS urgent criteria is met and response within 24 hours to admitting ward unless mutually agreed otherwise (for example, not medically fit).

CAMHS team advise on appropriate admission or discharge and support.

11.1.4 Children eating disorders in hours overarching pathway

Acute hospital manages any acute medical or physical problems and excludes toxicity or organic pathology as cause

Admitting Ward refer to children’s eating disorders service (CEDs)

Staff can also discuss with the Crisis team who provides support to the paediatric unit or acute hospital wards during the hours of 9am to 5pm, Monday to Friday.

CEDs urgent criteria is met and response within 24 hours to admitting ward unless mutually agreed otherwise (for example, not medically fit for assessment)

CEDs team advise on appropriate admission or discharge and support.

11.2 Appendix B Gillick competency

11.2.1 Mental Health Act: Code of practice 2015 (19.34 to 19.37)

11.2.1.1 Establishing Gillick competence?
  • 19.34, Children under 16 should be assessed to establish whether they have competence to make a particular decision at the time it needs to be made. This is because in the case of Gillick, the court held that children who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the competence to consent to that intervention. This is sometimes described as being “Gillick competent”. A child may be Gillick competent to consent to admission to hospital, medical treatment, research or any other activity that requires their consent.
  • 19.35, The concept of Gillick competence is said to reflect the child’s increasing development to maturity. The understanding required for different interventions will vary considerably. A child may have the competence to consent to some interventions but not others. The child’s competence to consent should be assessed carefully in relation to each decision that needs to be made.
  • 19.36, When considering whether a child has the competence to decide about the proposed intervention, practitioners may find it helpful to consider the following questions:
    • does the child understand the information that is relevant to the decision that needs to be made?
    • can the child hold the information in their mind long enough so that they can use it to make the decision?
    • is the child able to weigh up that information and use it to arrive at a decision?
    • is the child able to communicate their decision (by talking, using sign language or any other means)?
  • 19.37, A child may lack the competence to make the decision in question either because they have not as yet developed the necessary intelligence and understanding to make that particular decision; or for another reason, such as because their mental disorder adversely affects their ability to make the decision. In either case, the child will be considered to lack Gillick competence.

11.3 Appendix C Mental Capacity Act 2005

The Mental Capacity Act (MCA) in general, applies to individuals aged 16 years and over and empowers individuals to make their own decisions where possible and protects the rights of those who lack capacity. Where an individual lacks capacity to make a specific decision at a particular time, the MCA provides a legal framework for others to act and make that decision on their behalf, in their best interests, including where the decision is about care and treatment.

11.3.1 Principles of the MCA

11.3.1.1 Principle one

A person must be assumed to have capacity unless it is established that they lack capacity

11.3.1.2 Principle two

A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success.

11.3.1.3 Principle three

A person is not to be treated as unable to make a decision merely because they make an unwise decision.

11.3.1.4 Principle four

An act done, or decision made, on behalf of a person who lacks capacity, must be done, or made, in their best interests.

11.3.1.5 Principle five

Before the act is done, or the decision is made, regard must be had to whether the purpose of the act or the decision can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

It is important for professionals to be aware that individuals with a mental disorder do not necessarily lack capacity. The assumption should always be that a patient has capacity unless it is established otherwise in accordance with the MCA.

11.3.1.6 Patients lacking capacity

A person lacks capacity in relation to a matter if, at the material time, the person is unable to make a decision for themselves in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

The above definition contains both a “diagnostic test” and a “functional test”. The diagnostic test determines whether the individual has an impairment of or a disturbance in the functioning of the mind or brain. The impairment or disturbance can be temporary or permanent, but if it is temporary, the decision maker should justify why the decision cannot wait until the circumstances change.

The functional test determines whether the individual is unable to make the specific decision in question themselves because of the impairment or disturbance. Both tests must be satisfied for an individual to be deemed to lack capacity to make the specific decision in question at the material time.

A person is unable to make a decision for themselves if they are unable to do any one of the following:

  • understand information which is relevant to the decision to be made
  • retain that information in their mind
  • use or weigh that information as part of the decision-making process
  • communicate their decision (whether by talking, sign language or any other means)

As capacity relates to specific matters and can change over time, capacity should be reassessed as appropriate over time and in respect of specific treatment decisions. Decision makers should note that the MCA test of capacity should be used whenever assessing a patient’s capacity to consent.

11.3.1.7 Best interests

Is a core principle that underpins the act. In brief, it stresses that any act done or decision made on behalf of an individual who lacks capacity, must be done or made in their best interests. This principle covers all aspects of financial, personal welfare, health care decision-making and actions.

Everything that is done for or on behalf of a person who lacks capacity must be in that person’s best interests. The act provides a checklist of factors that decision makers must work through in deciding what is in a person’s best interests. A person can put his or her wishes and feelings into a written statement if they so wish, which must be considered by the decision maker. Also, carers and family members have a right to be consulted. In order to document and structure this process in a formal and clear way, RDaSH in collaboration with the Local Authority have developed a best interest checklist “Pro forma (Form MCA 2)” as a means of ensuring that all the statutory requirements are covered.

Staff should also refer to the trust’s Mental Capacity Act 2005 Policy.

11.3.1.8 Younger people

The Act applies to people of 16 or over who lack capacity to make their own decisions. Most of the provisions of the Act apply to young people of 16 and 17 years old. Decisions relating to treatment of young people of 16 and 17 who lack capacity must be made in their best interests in accordance with the principles of the act. The young person’s family and friends should be consulted where practicable and appropriate. However, a person needs to be 18 or over to make an advance decision.

The Children Act 1989 covers the care and welfare of children in most situations.

The Mental Capacity Act applies to children under 16 years in two ways:

  • the court of protection can make decisions about the property and affairs of a child where it is likely that the child will lack capacity to make those decisions when they reach 16 years old
  • the criminal offence of ill treatment or neglect applies to children who lack capacity
  • recording assessments of capacity and best interests decisions
  • decision makers should ensure that where a mental capacity assessment is undertaken, the evidence is recorded on the MCA1 questionnaire on SystmOne and where the young person lacks capacity the record of actions taken to make a best interest decision should be recorded on an MCA2 questionnaire

11.4 Appendix D Initial care plan and risk overview following assessment of a child or young person on an acute hospital ward

Document control

  • Version: 3.1.
  • Unique reference number: 365.
  • Approved by: Clinical policies review and approvals group.
  • Date approved: 14 March 2022.
  • Name of originator or author: Nurse consultant.
  • Name of responsible individual: CAMHS service manager.
  • Date issued: 23 March 2022.
  • Review date: March 2025.
  • Target audience: All clinical staff within children and adolescent mental health services (CAMHS) and as appropriate, staff from adult mental health services (Crisis or Access teams), approved mental health professionals (AMHP) from local authority.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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