Care programme approach (CPA) policy

1 Introduction

The care programme approach (CPA) is an overarching system for coordinating the care of people with mental disorders. It requires close engagement with patients and their carers and includes arrangements for assessing, planning, delivering and reviewing care.

Central to CPA is the CPA care plan which aims to ensure a transparent, accountable and coordinated approach to meeting wide ranging physical, psychological, emotional and social needs which are associated with a person’s mental disorder.

The CPA also requires the clear identification of a named individual, the care co-ordinator, who has responsibility for coordinating the preparation, implementation and evaluation of the CPA care plan. The CPA should be used in secondary and tertiary mental healthcare to assess, plan, review and coordinate the range of treatment, care and support needs of those people in contact with secondary mental health services who have complex needs. CPA should include active involvement of and engagement with the patient at the heart of the process and focus on reducing distress and promoting social inclusion and recovery.

The key principles of the CPA are applicable to all patients, even those who require only a uni-disciplinary intervention. All people receiving services have the right to a thorough assessment of their needs, the development of a care plan and a review of that care with the professionals involved in their care. This is good professional practice.

1.1 Policy context

CPA was introduced in 1991 to establish a multi-agency approach to health and social care, setting out arrangements for the care of people with mental health problems in the community. CPA aims to facilitate closer and integrated working, enabling a coordinated approach to care delivery and the recovery process.

The four main elements of the CPA process are:

systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services
the formulation of a care plan, which identifies the health and social care needs, and support required from a variety of providers
the appointment of a care co-ordinator to keep in close touch with the patient and to monitor and co-ordinate care
regular review and, where necessary, agreed changes to the care plan

In October 1999 the Department of Health (DH) published ‘Effective care coordination in mental health services, modernising the care programme approach’ and broadened the application of the CPA to all adults of working age who are under the care of the secondary mental health services (health and social care), regardless of setting. It stated that CPA is care management for those of working age in contact with specialist mental health and social care services. All agencies are expected to integrate their approach across health and social care for people with mental health problems.

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance (DH, March 2008) was the outcome of a national review which had the intention of ensuring the national policy is more consistently and clearly applied and that unnecessary bureaucracy is removed. The revised (2008) national CPA policy stipulated that where it is silent on a particular issue then the previous (1999) policy should be referred to.

The essence of effective care co-ordination is sound professional judgement and practice. The implementation of any care co-ordination process can be no substitute for this but is intended to support good professional practice.

This policy should be read in conjunction with other relevant national and local policies and guidance, please see section 9.

2 Purpose

This policy sets out how clinical assessment, care planning, review, transfer and discharge processes should be carried out according to best practice, within (but not limited to) the context of the CPA.

3 Scope

This policy is applicable to all adult mental health services (including older adults) and learning disability services, including Amber Lodge within the trust, and to all staff working in those services.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

It is the duty of the board of directors to oversee that all individuals receiving treatment, care and support from secondary mental health services in the trust receive high quality care based on an individual assessment of the range of their needs and choices. The board of directors delegates authority to the chief executive.

4.2 Chief executive

The chief executive has overall responsibility for the implementation of this policy, and in turn this responsibility is delegated to the directors and senior managers.

4.3 Locality managers, service managers, modern matrons and team managers

Managers and modern matrons are responsible for:

overseeing the implementation of this policy within their areas of responsibility
raising awareness of this policy and its contents with any staff they manage
bringing any issues which may affect the implementation of this policy to the attention of the relevant assistant director
reporting any concerns that clinical staff may bring to their attention which relate to operation of this policy
exploring unmet needs as brought to their attention by care coordinators, assessing the case and specifying the action or process to be followed by the service in an attempt to meet the needs of the patient
monitoring the implementation of this policy
making any necessary arrangements for their staff to attend any training in relation to this policy
ensuring regular audit is undertaken and the results acted upon
providing regular supervision

4.4 Care coordinators

Care coordinators are responsible for:

implementing this policy and standards effectively
fulfilling the duties of the care coordinator role as outlined in this and other related policies (please see section 9, links to any associated documents) to the required professional standards of their particular discipline
bringing any issues which may affect implementation to the attention of their line manager
identifying any unmet needs as part of the process of completing the assessment and accounting for this within the care plan
informing the relevant manager when an identified action or intervention cannot be delivered, for example because of resource or availability problems
identifying learning and any training needs that will be addressed between staff member and line manager through local induction, supervision and personal development review
undertaking regular supervision

The role of the care coordinator (as set out in the Rethink care programme approach factsheet) is to:

fully assess the patient’s needs
write a care plan in collaboration with the patient, which shows how the NHS and other organisations will meet their needs
regularly review the plan with the patient to check the patient’s progress

This will include:

actively engaging and building a therapeutic relationship with the patient, and family or carers as appropriate
providing education and information, including information about treatment options, to support patients to make informed choices
working with the patient to promote recovery and reduce crises and inpatient admissions
liaising with other services involved in the patient’s care, including primary care services; gathering all relevant patient information and sharing information as appropriate, in accordance with the Information governance policy and management framework (includes data protection policy content) and the information governance handbook
resolving and, or escalating disputes related to patient care
meeting all statutory responsibilities under the Mental Health Act (including section 117 aftercare)
meeting all statutory responsibilities under the Mental Capacity Act
maintaining all clinical records to a high standard
to be open and clear about confidentiality and information sharing, the need to share information where there is a safeguarding concern and to advise the patient when there is a need to share information with relevant safeguarding partners, such as children’s social services. However, where there is an immediate risk to a child or vulnerable adult, consent is not required. Refer to the seven golden rules of information sharing, advice for safeguarding practitioners (opens in new window)

4.5 All other clinical staff

All other clinical staff are responsible for:

implementing this policy effectively
bringing any issues which may affect implementation to the attention of their line manager.

5 Procedure or implementation

5.1 CPA eligibility

CPA eligibility is not the same as eligibility for secondary mental health services or social care. The CPA should be used for individuals with a serious mental health problem including personality disorder, and are high risk of suffering deterioration in their mental condition and who need:

multi-agency support
active engagement
intense intervention
support with dual diagnoses

This will include (but is not limited to):

patients admitted to an inpatient unit
most people who are entitled to after-care under section 117 of the act
patients subjected to guardianship orders
patients subject to community treatment order (CTO)
some patients with parenting responsibilities
vulnerable adults (as defined in the safeguarding adults policy)
patients with co-morbid substance misuse
patients with multi-agency involvement
patients with significant risk history including risk to self and, or others
patients who have significant caring responsibilities
patients in unsettled accommodation

Decisions and reasons not to include individuals from the groups identified above should be clearly documented in care records. Once a decision as regards CPA eligibility has been made, the patient’s CPA status (that is, CPA or non CPA) should be recorded in the CPA node on the electronic patient record, and this should be kept updated at all times. Staff can refer to the CPA SystmOne guide (staff access only) (opens in new window) for further guidance.

5.2 Patients not subject to CPA

Patients not subject to CPA should be allocated a lead professional.

The lead professional has responsibility for:

overseeing the package of care provided by secondary mental health services and ensuring that the ongoing process of assessment, care planning and review is done in collaboration with the patient and carer (where appropriate)
identifying carers involved and ensure they are aware of their own right to an assessment of need
liaising as necessary with others involved in the patients care
ensuring that all transfers of care, both internal and external are agreed and overseen, and that all relevant information is shared in an appropriate and timely manner

5.3 The care coordinator

The care coordinator role is one of the key elements of the CPA and may be carried out by any registered health or social care professional. He or she must be able to support patients with multiple needs to access the services they require and have the professional skills and authority to manage the coordination of the care package.

5.3.1 Allocating a care coordinator

The needs and wishes of the patient regarding who should be care coordinator and the skills needed for the role should be taken into account when allocating the care coordinator. Allocation should reflect any issues around gender, culture or religious needs. If there are any specific issues affecting the choice of care coordinator, these should be documented in the patient record.

In community services the care coordinator should, wherever possible, be identified prior to the first CPA meeting. Where this hasn’t been done, allocation of a care coordinator should be an item on the meeting agenda. Ultimate responsibility for allocation rests with the team manager, and the team manager will be the care coordinator by default until another staff member is allocated this role.

Once agreed, the clinical record should identify the care coordinator.

5.3.2 Change of care coordinator

During periods of staff absences, there may be a need for other members of the care team to cover for the care coordinator, to note this is not a formal transfer of care coordinator responsibilities. This should be clearly communicated within the team and in the patient’s healthcare records.

There may be a requirement for a change of care coordinator during an episode of care, either due to patient choice or other circumstances, this is a planned event. A formal handover of care which is to be documented in the patient record, will take place between the existing and the new care coordinator, with the involvement of the patient, and the carer where appropriate. Should a new care coordinator not be identified the role of care coordinator will default to the team manager until a new care coordinator can be allocated.

In all circumstances, the team manager is responsible for ensuring that the patient’s care coordination needs are met at all times.

5.3.3 In-patient admission

All people being admitted to adult acute inpatient units (see 5.1) will meet the criteria for CPA, and the patient’s CPA status should be recorded to reflect this on admission in the electronic patient record, on the CPA node on SystmOne.

Following admission to hospital a CPA review should be convened at the earliest opportunity.

Where an individual is admitted to hospital and a community based care coordinator is already allocated their worker will retain the role. It is the responsibility of the named nurse (in-patients) to initiate contact with the care coordinator, to jointly review the existing care plan. Good communication between inpatients and community services should be maintained throughout the admission.

Where an individual is not currently known to the trust mental health services (or known and not currently subject to CPA) is admitted to an inpatient ward then the named nurse will assume care co-ordinator responsibilities. The patients CPA status must be reviewed prior to discharge to determine if the patient continues to meet the criteria of CPA. The CPA status must be amended accordingly to reflect the decision.

If it is agreed that the individual requires ongoing care under CPA from a community team, then care co-ordination will transfer at the earliest opportunity. If at the point of discharge a care coordinator has not been identified by the community team, the team manager will assume care coordination role. In all circumstances, the receiving community team should be involved in the discharge planning.

5.3.4 72-hour follow-up

Patients who will be subjected to CPA at the point of discharge (from a mental health ward) must receive a 72-hour follow-up. Patients allocated to a CMHT:

the care coordinator or their respective team will assume responsibility of the 72-hour follow-up.

Patients not allocated to a CMHT:

the discharging ward should make arrangements with the local Crisis or Home Treatment team and, or CMHT to undertake the 72-hour follow-up on their behalf.

Regardless of CPA status, all patients are followed up within 72-hours of discharge from mental health in-patient care.

Should there be any issues in carrying out the 72-hour follow-up, it is the responsibility of staff to escalate these concerns in a timely manner.

Service managers and modern matrons must work collaboratively to resolve disputes in agreeing a solution that enables a 72-hour follow-up to be undertaken in a timely way in the best interests of the patient.

5.4 Assessment

Everyone referred to secondary mental health services should have an assessment of their mental health needs. Patients and their carers (if appropriate) should be involved fully in the assessment.

Patients with communication difficulties, including those whose first language is not English, should have communication support arranged in accordance with the interpreters policy (provision, access and use of, for patients, service users and carers).

Staff should also familiarise themselves with the NHS England Accessible Information Standard. Accessible Information aims to ensure that people with a disability, impairment or sensory loss get information about their health and care which they can read and understand (for example in easy read, braille or via email) and communication support if they need it (for example British Sign Language (BSL) interpretation).

The assessment process should include full assessment of any risk to the patient or others, and this should be documented in the appropriate section of the electronic patient record (see the clinical risk assessment and management policy).

There are a range of issues and needs a multi-disciplinary health and social care assessment (and care plan) may cover depending on need. These include:

psychiatric, psychological and social functioning, including impact of medication
risk to the individual and others, including contingency and crisis planning
needs arising from co-morbidity (including substance misuse):
- for patients with complex, severe, and enduring mental health illness and a co morbid substance misuse it would be appropriate for mental health services to lead in their care, with supplementary specialist support offered by substance misuse services
personal circumstances including family and carers as well as considering the impact of a patient’s mental distress on others (including the children) within the home
including sharing of information with other professionals who are involved with the family
housing needs
financial circumstances and capability
employment, education and training needs
physical health needs
equality and diversity issues
social inclusion, social contact and independence including a comprehensive social care assessment
spiritual needs

The assessment should also consider any safeguarding issues (see the safeguarding adults policy and safeguarding children policy).

The assessment and planning process should aim to meet the patient’s needs and choices and not just focus on what professionals and services can offer. It should address a person’s aspirations and strengths as well as their needs and difficulties.

The outcome of the initial assessment should be communicated to the individual (in a way that they will understand) and the referrer promptly.

5.4.1 Parenting responsibilities

For a family with children and young people under 18, an episode of mental ill-health can represent a significant crisis, not just in terms of a parent’s individual mental health but in family life overall. Assessment, including risk assessment, should assess the potential or actual impact of mental health on parenting, the parent and child relationship, the child and the impact of parenting on the adult’s mental health and what appropriate support might look like and how it can be accessed (Care Programme Approach Briefing: Parents with mental health problems and their children April 2008). This must be documented on the FACE risk assessment and the mental health inpatient assessment launch pad.

Seek safeguarding supervision as there may be a need to refer a child or children to children’s services due to the impact of a patient’s mental distress on the child or children.

Please consider the safeguarding children policy where appropriate.

Use the Think Child, Think Parent, Think Family Model when working with a patient.

The SENSE Think family acronym spells out how we should use professional curiosity when we have contact with our patients and their families:

S, I will be sure I am considering the needs of the whole family and to be responsive to these needs
E, I will consider all the factors of everyone in the home and frequent visitors. Consider complex safeguarding factors such as poverty or financial hardship, the adult’s own adverse childhood experiences or traumas (ACS’s), criminality within the home, drug or alcohol use or misuse within the home, parental mental distress, parental conflict or domestic abuse within the home, all of which impact on the child or children and their development
N, I will think about the needs of the family as well as other professionals that may be involved with the family to safeguard and work together
S, share information, this can save lives, I will make sure information is shared appropriately (The seven golden rule of information sharing, advice for safeguarding practitioners (opens in new window)) to enable others to understand my worries
E, I will escalate my concerns to others if I feel that I am not being listened to or heard by others

5.4.2 Physical health

The links between mental ill health and physical ill health are well documented. Research has shown that people with mental illness have increased rates of morbidity and premature mortality. Smoking, certain medications, poor diet and a lack of exercise can cause or compound physical health risks.

Under the CPA, physical health needs should always be considered as part of a holistic care plan and addressed as a high priority. The care plan should look at the effect that mental health and associated treatments can have on physical health and the effect that physical conditions can have on mental health. The electronic patient record hosts a variety of templates to help assess and monitor the effects of certain medications and a physical health check template for patients meeting the definition of severe mental illness (see the physical health policy).

5.4.3 Carers

Care coordinators should take into account of the needs of carers of patients (including children who provide care) and must comply with the children and families act 2014 within the children act 1989, The Carers and Disabled Children’s Act 2000, the NHS Plan and the standards in caring about carers.

Where carers are identified they should be informed of their right to a carer’s assessment. The carer’s assessment may be carried out by the service or the local authority depending on local commissioning arrangements (NICE NG53 transition between inpatient mental health settings published 2016, updated in 2020, 2021) (NG27 transition between inpatients hospital settings and community or care homes settings for adults with social care needs published 2015).

There are areas within the trust that engage with carers through the triangle of care.

Carers should:

be identified on the patient record
understand the patient’s care plan (subject to patient consent and taking risk issues into consideration where the carer may be identified as at risk)
know how to contact the care coordinator if they need to
be offered an assessment of their caring, physical and mental health needs, repeated on at least annually (where this is indicated in local commissioning arrangements)
be offered separate carer support if appropriate where this is indicated in local commissioning arrangements
be offered information about or signposting to carer support services
have their own written support plan developed in partnership with them, a copy of this should be offered to them where this is indicated in local commissioning arrangements
have their communication needs to be considered where appropriate in line with the interpreters policy (provision, access and use of, for patients, service users and carers) and the NHS England Accessible Information Standard.

5.4.4 Medication

The assessment should include a thorough assessment of medication needs, which must be clearly documented in the electronic patient record. It is essential that everyone involved in the care of the patient understands who prescribes the medication, where it is obtained from, the instructions for its administration, and what other medications are being prescribed for physical health problems.

Specialist mental health pharmacists should, where possible, be involved in care planning for patients with complex medication needs.

For guidance relating to medication reconciliation staff should refer to the safe and secure handling of medicines manual and NICE Guidance NG5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.

5.5 Care planning

Central to CPA is the CPA care plan this is formulated following a full needs assessment and a risk assessment being carried out. Care plans should focus on patients’ strengths and aspirations as well as their needs and choices and promote social inclusion and recovery. Care plans should recognise the diverse needs of patients, reflecting their cultural and ethnic background as well as their gender and sexuality, and need to take into consideration the following:

a treatment plan which details medical, nursing, psychological and other therapeutic support for the purpose of meeting individual needs promoting recovery and, or preventing deterioration
details regarding any prescribed medications
details of any actions to address physical health problems or reduce the likelihood of health inequalities
details of how the person will be supported to achieve their personal goals
support provided in relation to social needs such as housing, occupation and finances
support provided to carers
the patient’s own caring responsibilities
actions to be taken in the event of a deterioration of a person’s presentation
guidance on actions to be taken in the event of a crisis.

The care coordinator (or named nurse on inpatients) is responsible for coordinating the care plan and recording it in the electronic patient record. Other members of the care team have a responsibility to communicate and liaise with the care coordinator or named nurse regarding the delivery of the agreed care plan, including any difficulties with or changes to the agreed plan.

The care plan should be developed by the care coordinator (or, in inpatient settings, by the named nurse in collaboration with the care coordinator) with the patient, carers and other professionals where relevant. Where the patient lacks the capacity to engage in the care planning process and does not have an advance directive and, or advance statement in place, a best interest decision should be made to involve, where appropriate, carers and other professionals at the earliest possible opportunity.

The care plan is likely to involve consideration of:

continuing mental healthcare
the psychological needs of the patient and, where appropriate, of their carers physical healthcare
daytime activities or employment
appropriate accommodation
identified risks and safety issues
any specific needs arising from, for example, co-existing physical disability, sensory impairment, learning disability or autistic spectrum disorder
any specific needs arising from drug, alcohol or substance misuse (if relevant)
any parenting or caring needs
social, cultural or spiritual needs
counselling and personal support
assistance in welfare rights and managing finances
involvement of authorities and agencies in a different area, if the patient is not going to live locally
involvement of other agencies, for example the probation service or voluntary organisations (if relevant)
for a restricted patient, the conditions which the Secretary of State for Justice or the first-tier Tribunal has, or is likely to, impose on their conditional discharge
contingency plans (should the patient’s mental health deteriorate) and crisis contact details

It is important that patients are involved, agree, sign and have a copy of the care plan.

It is acknowledged that on occasions there may be disagreements between the patient and the care team about the care planned. In these circumstances, it is important to record the reasons for disagreement and continue ongoing discussions to resolve such disagreements.

Care plans completed for discharge from in-patient care must include the plans for follow-up within 72-hours of discharge (measured as 3 times 24 hours from the time and date of discharge). Discharge care plans should be reviewed within one month of discharge by the care co-ordinator.

All care plans must include explicit crisis and contingency plans. A good crisis and contingency plan will include all necessary information to manage the situation, to prevent harm and distress caused by the escalation of problems. It will describe a staged approach to crisis and contingency management and include:

signs that things are going wrong (relapse indicators and triggers)
patients own resources, strengths and coping strategies for preventing any difficult situations or distressing experiences from escalating (for example, self-management skills and close support networks)
where the situation worsens, details of other networks and resources including the person’s community care team including contact numbers
if early de-escalation work is not successful, details of how to manage an emergency with the use of resources outside the person’s usual care team, such as the crisis team, or possibly police, ambulance or hospital services including contact numbers

In the event of a crisis, if the patient contacts the community care team it is their responsibility to assess the situation and respond appropriately within their normal hours of working.

Care plans must include contact numbers for services both within and out of hours. Individual communication needs and the accessible information standard should be taken into consideration as regards how the care plan is presented.

Once the care plan is completed, the patient should be offered a copy and this should be recorded in the electronic patient record (including if the patient declines), ensuring that the patient fully understands the content of the plan.

5.5.1 Inpatient leave

For those patients detained under the mental health act the responsible clinician must have authorised the period of leave. In circumstances when a patient goes on leave from in-patient care, whether that is short term or long term extended leave, an appropriate care plan for the leave period must be in place, including crisis and contingency planning.

Regular contact should be maintained with patients on leave. This responsibility rests with the inpatient team, however it may be delegated to the community team, in discussion and agreement by them. Consideration should be given to informing the GP of the leave, where this is for an extended period.

Where it is not possible to contact patients on leave the responsible clinician or approved clinician and care team must consider what action to take based on their knowledge of the patient, any risks and in line with the patients missing or absent without leave (AWOL) policy including completing appendix one of the policy.

The responsible clinician or approved clinician should be notified immediately of any significant deterioration or breakdown of the leave care plan.

5.5.2 Advance statements and advance decisions to refuse treatment

An advance statement is an expression of wishes by a patient setting out how they would prefer to be cared for or treated if they lose the capacity to make decisions for themselves. Such expressions of wishes or preferences must be taken into account when considering an incapacitated patient’s best interests but are not legally binding.

Please see the advance statements and advance decisions to refuse treatment policy for further details and guidance.

5.5.3 Self-directed care, direct payments and personal budgets

Requirements for the assessment for community care services under The Care Act 2014 do not sit separately from CPA. The local authority’s responsibilities under the requirements of this act are met through the defined processes. CPA aims to promote effective liaison and communication between agencies, thereby managing assessed risk, and meeting the individual needs of people with mental health problems so that they are better able to function in society.

The patient will have as much influence as possible in determining how they will be supported. Where they need help to manage this arrangement, this will be provided as an essential part of their support plan.

5.6 CPA review

CPA reviews monitor and evaluate the effectiveness of the care plan and focus on how the needs of the patient can continue to be met. The CPA review also provides opportunity to deliver statutory responsibilities such as 117 aftercare, in relation to mental health legislation. This should take place at least annually.

Please note that the patient, carer or member of the care team can request a review of the care plan at any time. If the team decide that a review is not necessary the reasons for this must be recorded and explained to the patient or carer.

Circumstances where an urgent review should be considered:

the patient wishes to withdraw from a significant component of their care plan
the patient discharges themselves from hospital against medical advice, or threatens to do so
there are specific circumstances where informal carers or relatives should be told if they are likely to be exposed to violent behaviour or harm (with or without consent to protect an individual at risk of harm) this should be documented in the electronic record: the risk; the information; the assessment and the decision.
there is a major change in the patient’s mental health, personal or social circumstances including admission to hospital.

It is essential that CPA meetings are distinct and timetabled by the care coordinator and care team around the needs of the patients and their carers, with advocacy support where identified.

For patients with children or regular access to children where there is an allocated children’s worker, the worker should be routinely invited to attend CPA meetings.

When deciding which review option is appropriate, staff should consider factors such as risk behaviour, the complexity of the care plan and the wishes of the patient. The following review options could be considered:

a meeting between the care coordinator and patient to review the key elements of the care plan (within a routine planned contact)
a meeting between the care coordinator and patient, with others contributing by phone or in writing
a full multi-disciplinary team (MDT) review involving all appropriate professionals
MDT in which patient and carer(s) participate

A CPA review provides the opportunity to:

evaluate the care plan (progress, successes and setbacks)
explore alternative ways of supporting people to meet their goals
gather and share information
re-assess needs and risks
review patient consent to share information with carers
review the use or potential use of Direct Payments or Personal Budgets
review or explore the use of Advance Statements and Advance Decisions
revise and agree the care plan
review CPA eligibility and the need for continued support under CPA
review use of mental health legislation

It is good practice to hold a CPA meeting prior to a managers’ hearing or first tier tribunal or CTO hearing to inform and plan for any changes in circumstances.

A CPA review should also be held prior to a patient being discharge from hospital. This provides the opportunity to review the CPA status and make appropriate plans for discharge.

5.6.1 Planning a CPA meeting

There are many factors which need to be considered when deciding where and when to hold a CPA review meeting and it is important to adopt a flexible approach. The following should be considered in planning a CPA meeting:

where appropriate meetings should be planned and organised as far in advance as possible
the care coordinator should involve the patient and carer (where appropriate) in any discussions and decisions about who will be invited to the meeting. The patient should know or be aware of who will be attending.
the patient should always be encouraged to attend and participate, with advocacy support where necessary, and the meeting arrangements should facilitate this
in line with the accessible information standard arrangements should be made for interpretation services where needed. Please see the interpreters policy (provision, access and use of, for patients, service users and carers)

5.6.2 Who should be involved?

In order to ensure that the care plan reflects the needs of each patient, it is important to consider who needs to be involved, in addition to the patients themselves. Subject to the patient’s views, this may include:

the patient’s nearest relative (if there is one) or other carers
anyone with authority under the Mental Capacity Act 2005 (MCA) to act on the patient’s behalf, for example, lasting power of attorney or deputy appointed by the court
an independent mental capacity advocate (IMCA) if the patient has one
an independent mental health advocate (IMHA), if the patient has one
any other advocate who may be involved or supporting the person
any other representative nominated by the patient (partners, family members or friends where appropriate)
the patient’s responsible clinician
health and social care professionals involved in caring for the patient
the patient’s GP and primary care team (if there is one)
a representative of any relevant voluntary organisations
a representative of housing authorities if accommodation is an issue
an employment expert if employment is an issue
in the case of a restricted patient, multi-agency public protection arrangements (MAPPA) co-ordinator
in the case of a transferred prisoner, the probation service
the clinical commissioning group’s appointed clinical representative (if appropriate)
a person to whom the local authority is considering making direct payments for the patient people not directly involved in the patient’s care (for example students) should only be allowed to attend with the patient’s consent

5.6.3 Conducting CPA review meetings

The care coordinator should normally chair CPA meetings; however consideration may be given to the patient being supported to chair their own meeting. If the care coordinator is unable to chair, a chairperson should be identified at the beginning of the meeting.

The chairperson has a key role to play in supporting everyone’s views being heard, that decisions are reached, and that the meeting starts and finishes on time. Patients and carers should be encouraged to be first to express their opinions and views about the care they are receiving.

Patients should be made aware that the multi-disciplinary team may discuss their care prior to the meeting, and appropriate information from these discussions should be shared with them.

The following processes should be followed for all CPA review meetings:

the care coordinator should, if possible, spend time with the patient both before and after the CPA meeting to ensure maximum involvement in the CPA process
all relevant documentation should be available
everyone present should introduce themselves in full and, if there might be uncertainty, explain their reasons for involvement in the meeting
issues for discussion should be identified at the start of the meeting
explanations should be offered to patients of any jargon or abbreviations used in the meeting
the care coordinator is responsible for records of the CPA review, and for arranging for the distribution of the revised care plan to all relevant people
a date for the next review should be agreed at the meeting and recorded in the CPA review documentation

5.6.4 Discharge from CPA

Each CPA review is an opportunity to consider whether the patient needs to remain on CPA. During the patient’s recovery the level or complexity of a patients needs may reduce and while the clinical process of care planning and review does not change, this may no longer need to be done within the CPA framework, refer to section 5.1 eligibility criteria.

Patients and carers should be reassured that discharge from the CPA will not affect their eligibility for health or social care services.

If the patient is discharged from CPA there should be a handover of all relevant information to an identified lead professional within the team if the patient is remaining in mental health services or to the patient’s GP if they are being discharged from the trust.

Patients appropriately subject to CPA on discharge from a secure hospital or prison should normally remain on CPA for a period of time in the community before being considered for discharge from CPA. The decision to discharge should be based on individual risk assessment and risk management and MDT discussion and decision, with consideration to any section 117 aftercare.

5.6.5 Disengagement

In the event that a patient on CPA disengages from services it may be appropriate to discharge them from both CPA and mental health services, however this should only be done after every effort has been made to reengage them and in line with the disengagement policy.

5.7 Transfers

Effective management of care transfers is a key part of the CPA process, however, it is not solely the responsibility of the care coordinator and is dependent on good communication between key individuals and agencies. Transfers may be between trust services, with out-of-area services or with prisons. Short term input by another trust team (for example intensive home treatment) is not a care transfer, and responsibility for care coordination and CPA remain with the originating team (NICE NG27). Discharges and transfers should be managed in accordance with the admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures and Discharge or transfer SOP’s appropriate to the service involved.

5.7.1 Internal transfer within service or specialisms

Whenever a change of care coordinator takes place there must be a formal handover of care.

5.7.2 Internal transfers outside service specialisms

Transfer from one service area or specialism to another (for example, from an adult mental health team or service or practitioner to an older people’s mental health team or service or practitioner) should be considered according to the clinical needs and wishes of the individual and their families or carers.

Considerations for transfer should include:

the nature of the illness and the consequent needs of the individual, for example, dementia
the development of physical difficulties, chronic illness and frailty, which require the expertise of another service or specialism (for example, older person’s service) regarding the treatment and management of a mental illness and associated care needs

To assist in decision-making, appropriate guidance should be used or followed, such as the criteria for old age psychiatry services in the UK published by the Royal College of Psychiatrist (Faculty of the Psychiatry of Old Age) 2015.

Any such transfer and subsequent transition process should be carried out as part of an individualised clinical review and be care planned accordingly. The person and, or relative or carer should be consulted about the plans and their wishes considered where appropriate. If the client does not have capacity to be involved in decision-making about the transfer, a best interest decision should be made and documented.

5.7.3 Transfer out of area

Some trust patients are admitted to provider units out of area. As the responsible mental health service, the trust must continue to provide a care coordinator, attend CPA reviews and be involved in discharge planning in line with this policy. Where a patient is not known to services and does not have an identified care coordinator the responsibility for this rests with the inpatient services. The patient flow team will maintain a general oversight and link up with the out of area ward with specific teams (for example, community team if a patient needs a community psychiatric nurse or care coordinator) or repatriate where necessary.

It should remain a priority where appropriate to bring such patients back into our services at the earliest opportunity. This should support effective discharge planning and after-care.

When a patient is to be transferred to another area it is important that their transfer is planned and organised to facilitate continuity of care with the receiving service. It is the duty of the trust care coordinator to make a referral to the appropriate mental health service, and provide a full suite of documentation. In complex cases a senior clinician should be involved. Where there is significant risk to the patient or others, this information should be shared directly in person or by phone, and the discussion should be documented in the electronic patient record.

The patient remains the responsibility of the original team until a handover of care has taken place. Agreements should be made about any period of joint working or follow-up by the referring team, where this is appropriate. If an out of area service refuses to accept a referral, this should be followed up by senior management as appropriate.

5.7.4 Transfer into area (excluding Amber Lodge, forensics who have their own referral process)

Referral from out of area services should be directed to the appropriate trust team. The team manager and consultant psychiatrist from the receiving team should discuss the referral at the earliest opportunity and if the transfer is accepted, a care coordinator should be allocated.

The new care coordinator should actively engage with the referring mental health service to facilitate a smooth transition of care, and work with the referring team and the patient to develop a new care plan. The patient should be kept informed of the transfer arrangements and given contact details of their new care team.

All referrals for the transfer of a restricted patient or from secure services are to be made to the appropriate trust team. The team manager and consultant psychiatrist from the receiving team should discuss the referral and in order to consider the appropriateness of the referral the consultant should have access to the following information:

diagnosis
brief past psychiatric history
risk assessment
reason for the restriction order being in place
current treatment
reason for request to transfer to less secure environment

5.7.5 Funding responsibilities

Where patients transfer between areas, health and social care funding responsibilities are as set out in the Who pays? Determining Responsibility for Payments to Providers August 2020 guidance, NHS contracting and incentive team: NHS England.

Staff should maintain contact with the responsible commissioner; in particular to inform them if one of their patients returns to hospital or if this is being planned. Staff should use the out of area placement questionnaire on SystmOne to maintain a record of their discussion with both providers and commissioners.

6 Training implications

There are no specific training needs in relation to this policy, however the following staff will need to be familiar with its contents: All service managers, modern matrons and team leaders, clinical staff (qualified and unqualified) who have direct involvement with patient care, and any other individual or group with a responsibility for implementing the contents of this policy. Staff will be made aware of this procedure and its contents in the following ways:

the review and re-issuing of the procedure is to be publicised in the trust weekly news bulletin
a copy of the procedure will be available on the trust web
the procedure will be covered at local induction within their relevant areas

7 Monitoring arrangements

7.1 Application of CPA policy or CPA process

How: Clinical audit.
Who by: Clinical Audit team directed by the care groups.
Reported to: Individual care group quality committees.
Frequency: As directed by the care groups.

7.2 72-hour Follow-up

How: Patient information system.
Who by: Performance team.
Reported to: To monitor through MHSDS for NHSE and NHSI.
Frequency: Monthly.

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

Staff to implement and adhere to the guidance stipulated in the policy for eliminating mixed sex accommodation and maintaining privacy, dignity and respect.

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 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).

9 Links to any other associated documents

The CPA policy should be read in conjunction with related policies which include:

10 References

Care Programme Approach Briefing: Parents with mental health problems and their children April 2008.
Criteria for old age psychiatry services in the UK published by the Royal College of Psychiatrist (Faculty of the Psychiatry of Old Age) 2015.
Department of Health (1999) Effective Care Coordination in Mental Health Services, Modernising the Care Programme Approach.
Department of Health (2007) Best Practice in Managing Risk. London: DH.
Department of Health (2008) Refocusing the Care Programme Approach, Policy and Positive Practice Guidance. London: DH.
Department of Health (2012) The NHS Constitution. London: DH HM Government or Department of Health (2011) No Health Without Mental Health. London: DH.
H M Government (2010) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. Nottingham: DCSF.
NICE CG136 service user experience in adult mental health published 2011, updated 2019.
NICE NG5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.
NICE NG27 transition between inpatients hospital settings and community or care homes settings for adults with social care needs published 2015.
NICE NG53 transition between inpatient mental health settings published 2016, updated in 2020, 2021).
Princes Royal Trust for Carers or National Mental Health Development Unit (2010) The Triangle of Care. Carers included: A guide to best practice in acute mental health care.
Rethink Care Programme Approach Factsheet.
Social Care Institute for Excellence or Department of Health (2008) Care Programme Approach (CPA) Briefing: Parents with mental health problems and their children.
Who Pays? Determining Responsibility for Payments to Providers August 2020 guidance, NHS contracting and incentive team: NHS England.

Document control

Version: 12.
Unique reference number: 360.
Approved by: Clinical policy review and approval group.
Date approved: 3 May 2022.
Name of originator or author: Deputy chief operating officer.
Name of responsible individual: Executive director of nursing and allied health professionals.
Date issued: 23 May 2022.
Review date: May 2025.
Target audience: Clinical staff, clinical managers, modern matrons, team leaders.

Page last reviewed: November 15, 2024
Next review due: November 15, 2025

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