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Service users get allocated a Care Coordinator / Lead Professional either on referral or when allocated to a clinician for assessment.
Allocation occurs after assessment where needs are identified that are to be met by secondary mental health / learning disability services of a Trust and the clinician who is most appropriate to be Care Coordinator / Lead Professional will be agreed (where there is joint work this could be a SW colleague from the local authority).
Care plans can't be written in simple / plain language
The care plan is the service user’s care plan, regardless if they are supported by a Care Coordinator or Lead Professional. As such they should be developed in a collaborative way and written in terms that are meaningful / accessible for the service user to understand (and it makes it easier for other clinicians too if it’s in plain language). For some service users this may mean that their copy uses pictures / symbols or is translated into their first language.
Care plans can only be printed on white paper.
If printing the care plan on different coloured paper e.g. in part to identify a crisis/risk management plan more easily, or entirely is helpful to the service user there is no reason why this can’t be done.
Keeping children safe assessment has to be completed for all service users.
The keeping children safe assessment is completed only as part of an assessment of risk for service users who express delusional beliefs involving children or might harm a child. A consultant psychiatrist (or associate specialist) should be directly involved in formulating risk assessment (s) and management plans (s) for service users who express delusional beliefs involving children or might harm a child as part of a suicide plan (including multi-agency planning via the safeguarding process where applicable).
Care plans can’t be shared with family / friends (Carers)
With the consent of the service user then Care plans can be shared with any family / friends (Carers) that the service user wants. Where the service user has not given consent to share information with their carer / family members who live with and or support them and there are significant issues of risk there may be justification to share proportionate and necessary information about risk management without consent. A lawful disclosure will be justified in circumstances where the appropriate healthcare professional/clinical team are satisfied that, the disclosure of confidential health information is necessary to prevent serious harm or abuse to the service user or another. In such circumstances the disclosure must be limited to that which is necessary and proportionate to the aim in mind.
WRAP plans can’t be used in Care Co-ordination as part of Care planning.
- All WRAP plans will be unique to the individual but with the service user’s agreement incorporating WRAP within care co-ordination has a significant impact in ensuring that care plans are truly collaborative in all aspects.
- Wellness tools / Daily maintenance parts of the WRAP plan can be incorporated into care planning with the outcomes desired being the care plan goals.
- A WRAP plan could either in total or in part contribute to the development of a service users relapse / crisis / contingency plan. Triggers / Early warning signs of distress parts of the WRAP plan can be incorporated into the Relapse / Risk management plan.
To meet policy and performance requirements a service user’s Care Co-ordination care plan (service users with enhanced needs / on CPA) has to be reviewed every 6 months.
- The frequency of a care plan being reviewed should be led by the needs of the service user. A service user or carer can ask for a review earlier than one that may be planned if they feel it’s needed as can any other member of their care team.
- Whilst national guidance and organisations’ policies will set out a minimum timeframe in which a care plan should be reviewed this should not then become the timeframe that is applied to all.
A consultant has to be present at a Care Co-ordination review.
If a consultant is involved with a service user then they should always be involved in the Care Co-ordination review. Ideally they should be present at the review, but this may not always be possible or indeed the service user may not want them to be present. For whatever reason if the consultant is not attending the review they should contribute to the review through discussion with the Care Co-coordinator / Lead Professional to provide their view of progress and future interventions. Whenever possible this should be supported by the completion of any relevant of the Care Co-ordination review record.
A service user cannot be discharged from mental health services unless there is only low assessed risk.
The collaborative decision to discharge a patient from any service is one that is informed by risk assessment but there is no requirement for a particular rating of risk to be achieved – every service user’s circumstances are different. The risk assessment and any associated risk rating must reflect the assessed level of risk at discharge, and for some service users because risks are chronic in nature the level of risk at discharge may still be a significant issue. If there is risk at discharge then there needs to be an appropriate management plan in place. A WRAP plan can be a really positive way of supporting this process.