CPA Scoping Project: Mapping of Existing Competencies, Skills, Values

CARE PROGRAMME APPROACH

Care Co-ordination

Core Functions and Competencies

PSE CONSULTING LIMITED PeopleSkillsEducation

Prepared by Karen Hardacre, Director

Contents

INTRODUCTION………………………………………………………………………………………..3 METHOD…………………………………………………………………………………………………….3 WHAT IS THE CARE PROGRAMME APPROACH?...... 4 CARE COORDINATOR ROLE………………………………………………………………………5 CORE FUNCTIONS…………………………………………………………………………………….7 FUNCTIONAL MAP…………………………………………………………………………………….8 USING NATIONAL OCCUPATIONAL STANDARDS (NOS)…………………….….9 USING THE FUNCTIONAL MAP……………………………………………………………….10 FUNCTIONAL MAP – FUNCTIONAL STATEMENTS………………………………….13 (TABLES 1-6)………………………………………………………………………………………….15 APPENDIX 1 …………………………………………………………………………………………..22 APPENDIX 2 …………………………………………………………………………………………..23

Introduction

This paper has been commissioned by the Department of Health, Care Programme Approach Review Group.

The paper presents:

 a functional map for the care co-ordination task; and,

 National Occupational Standards (NOS) which underpin these functions.

The functional map and associated NOS may be used to inform the implementation of Care Programme Approach (CPA) policy, including:

 the development of local protocols and procedures to support the implementation of CPA;

 role review and (re)design;

 the development of job descriptions, and recruitment processes;

 performance assessment, supervision and appraisal;

 skills review, to identify and inform continuing professional development needs and planning;

 training and education commissioning and delivery;

 curricula development;

 performance management; and

 service commissioning.

Method

Three key tasks were carried out to produce the functional map and associated competences. They were,

 a desktop review of literature and key policies and National Occupational Standard suites (Appendix 1);

 identification of the core functions of the care co-ordination role, and associated functional statements; and

 mapping competences against key functions, using the Skills for Health Competence Clusters tool.1

1 www.skillsforhealth.org.uk/competenceapplicationtools 3

What is the Care Programme Approach?

The CPA is a person centred approach used to inform partnership working in mental health. This partnership should always, as a minimum, include the service user, any carers and the CPA co-ordinator. It should also include working relationships with health and/or social care professionals and other relevant organisations.

The CPA is the principal vehicle of care assessment and planning for a defined group of individuals receiving mental health care. The CPA is aimed at ensuring this group of people have access to support and services (across the provider spectrum) to meet their diverse needs, strengths, preferences and choices.

This whole systems approach to care planning and delivery promotes care activity across the individual’s life domains (including housing, employment, leisure, education and other needs).

The CPA is an inclusive and dynamic process based on effective communication, appropriate information sharing and negotiation between partners. This negotiation is to draw on available resources to deliver an agreed plan of care.

All advice, care and treatment delivered in health and social care involves the making of an agreed plan. The CPA is a formalisation of existing care planning activity for those with complicated care planning needs and, when successfully delivered, will provide engagement and involvement from all participants in the partnership.

Reviewing the Care Programme Approach (2006) Department of Health, Care Services Improvement Partnership

Care Co-ordinator Role

Definition

The Care Co-ordinator takes a proactive and co-ordinated approach in identifying the most complex and vulnerable people with mental health problems, and then co-ordinating and managing their care in partnership with the individual and their carers.2

Values and principles

The Care Co-ordinator should be demonstrating, and actively ensuring that the service’s values and principles are adhered to, both with and through how s/he works, the relationships s/he develops and sustains, and the outcomes sought with and on behalf of people who use services and people who support them. These values and principles are set out in the Ten Essential Shared Capabilities:

 Working in partnership

 Respecting diversity

 Practising ethically

 Challenging inequality

 Promoting recovery

 Identifying people’s needs and strengths

 Providing service user centred care

 Making a difference

 Promoting safety and positive risk taking

 Personal development and learning.3

These values and principles are embedded in the National Occupational Standards associated with the key functions of the Care Co-ordinator.

Principles of practice

The Care Co-ordinator,

 works in partnership with people who have complex mental health and social care needs, and those supporting them;

 strives to empower people using services to have choices and make decisions to determine their wellbeing and recovery;

2 Case Management Competences Framework (2005). Department of Health

3 Ten Essential Shared Capabilities (2005). Department of Health, National Institute for Mental Health in England 5

 integrates and co-ordinates a person’s journey through all parts of the health and social care system;

 enables each person to have a personalised care plan based on his/her needs, preferences and choices;

 ensures that the person receives the least restrictive care in the setting most appropriate for that person;

 supports the person to attain wellbeing and recovery;

 ensures that the needs of carers/families are addressed;

 brokers partnerships with health and social care agencies and networks which can respond to, and help to meet the needs of the person who is experiencing mental health problems.

Care co-ordination is predicated on the principle that people, however vulnerable, should share in decision-making; that they are knowledgeable about themselves and the effect their conditions may have on their lives; and that they should be empowered and enabled to inform their own recovery.

Core Functions

To perform in the care co-ordination role, and to work within these principles, the Care Co-ordinator’s core functions are to carry out:

1. Comprehensive needs assessment

2. Risk assessment and management

3. Crisis planning and management

4. Assessing and responding to carers’ needs

5. Care planning and review

6. Transfer of care or discharge.

The core functions have been drawn from Care Programme Approach policy: they set out the key tasks required within care co-ordination.

National Occupational Standards (NOS) have been mapped to each of these core functions (Diagram 1, below). The references on the right of this diagram refer NOS taken from the following suites:

 Health and Social Care (HSC)

 Mental Health (MH)

 Case Management (CM).

These NOS suites can be found on www.skillsforhealth.org.uk/competences.

A summary of each NOS is set out by core function, in Appendix 2, for reference. The full NOS can also be selected and viewed on www.skillsforheatlh.org.uk/competences.

For illustrative purposes, the full NOS MH14 - Identify potential mental health needs and related issues, is presented in Appendix 3. This illustrates the components of NOS.

Diagram 1: Care Co-ordination Functions (CPA 1-6) & Associated NOS

CPA 1 - Comprehensive Needs Assessment HSC417; MH14; MH18; MH25

CPA 2 - Risk Assessment & Management HSC 450; MH16; MH17

CPA 3 Crisis Planning & Management MH13; MH21

CPA 4 - Assessing & HSC387; MH6; MH7; MH9 responding to Carer’s Needs

CPA 5 - Care Planning MH19; MH23; MH24 & Review

CPA 6 - Transfer of Care or Discharge CM13; MH83

KEY – NOS REFERENCES : MH – Mental Health NOS HSC - Health & Social Care NOS CM - Case Management NOS

To view the full NOS, go to www.skillsforhealth.org.uk/competences

Using competences

Competences are descriptors of the performance criteria, knowledge and understanding that are required to undertake work activity. They describe what people need to do, and to know, to carry out the activity – regardless of who performs it.

Competences are classified as National Workforce Standards (NWCs) or National Occupational Standards (NOS). The only difference is that NOS are additionally approved for use in qualifications.

NOS associated with care co-ordination

Eighteen NOS have been identified which reflect the task of care co- ordination, and the role of the Care Co-ordinator. These are set out in Table A below. Summaries of the NOS are presented in Appendix 2.4

Whereas eighteen NOS have been identified, one should not assume that the full set of NOS should be assimilated by, or reflected in the role profile of a practitioner who is acting as a Care Co-ordinator.

NOS have been mapped against each core function; in many instances there is an overlap between these NOS because the respective NOS reflect different contexts and roles within which practitioners may be working in health and social care.

4 A NOS covering ‘supporting people to develop, implement and sustain an individual budget as part of a care plan’ is under development. For further information contact [email protected].

Table A

Comprehensive needs assessment 1. Assess individuals’ mental health and related needs (HSC417) 2. Identify potential mental health needs and related issues (MH14) 3. Identify the physical health needs of individuals with mental health needs (MH18) 4. Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care for individuals (MH25)

Risk assessment and management 5. Develop risk management plans to support individual’s independence and daily living within their home (HSC450) 6. Assess individuals’ needs and circumstances and evaluate the risk of abuse, failure to protect and harm to self and others (MH16) 7. Assess the need for intervention and present assessments of individuals’ needs and related risks (MH17)

Crisis planning and management 8. Work with families, carers and individuals during times of crisis.(MH13) 9. Respond to crisis situations (MH21)

Assessing and responding to carers’ needs 10. Work in collaboration with carers in the caring role. (HSC387) 11. Assess the needs of carers and families of individuals with mental health needs (MH6) 12. Develop, implement and review programmes of support for carers and families (MH7) 13. Empower families, carers and others to support individuals with mental health needs (MH9)

Care planning and review 14. Co-ordinate, monitor and review service responses to meet individuals’ needs and circumstances (MH19) 15. Plan and review the effectiveness of therapeutic interventions with individuals with mental health needs (MH23) 16. Implement, monitor and evaluate therapeutic interventions within an overall care programme (MH24)

Transfer of care and discharge 17. Plan and implement transfer of care and discharge with individuals who have a long term condition and their carers.(CM13) 18. Work with others to facilitate the transfer of individuals between agencies or services.(MH83)

Practitioners and their managers should refer to, and adopt those NOS that most closely reflect their role and the context in which they work. The NOS should be used as a resource to use to inform performance; more than one NOS, and parts of different NOS may be used in this way.

The Care Co-ordinator would be expected to demonstrate that s/he is competent to deliver a range of functions, specific to his/her role. The scope of a practitioner’s role and level of responsibility will be defined in the practitioner’s job description.

NOS describe the performance standards required to fulfil a range of functions; as such, the practitioner, line manager and/or human resources officer may refer to a selection of NOS to inform role development, job descriptions, and performance assessment.

Practitioners will call on, or use other skills or competences in their role, in addition to those associated with the care co-ordination function. For example, practitioners will use a range of shared (or foundation) competences, such as communicating effectively, and promoting a culture that values and respects the diversity of individuals. They may also be required to use other competences specific to their role, such as the delivery of specialist assessments, psychological therapies, or medication management. This should be determined by local service delivery workforce planning requirements.

Diagram 2, below, illustrates the differentiation between foundation, core, and role-specific competences within a role.

Diagram 2

Role-specific competences

Core competences

Foundation competences

NHS Knowledge and Skills Framework

Within the NHS, the scope of a practitioner’s role and level of responsibility would be appraised through the NHS Knowledge and Skills Framework (KSF).

Skills for Health works in partnership with the Agenda for Change Knowledge and Skills Framework (KSF) Group to ensure that National Occupational Standards fit well with the NHS KSF dimensions and levels. Every competence has been mapped to the indicated point on the KSF. This principle applies to the competences identified in the Functional Map (below).

Functional Map

Each core function has associated tasks, or functional statements. These are set out in Tables 1-6 (pp 13 ff). This can be described as a functional map for care co-ordination.

The functional statements have been derived from the NOS which have been mapped against each core function. The functional statements describe in more detail the components of each core function.

Why use a Functional Map?

The Functional Map and Functional Statements may be used by service planners and service managers to:

 define the role and function of mental health and social care workers who are performing the role of a Care Co-ordinator;

 review and redesign roles and responsibilities within services;

 consider and review the distribution of a practitioner’s workload and caseload, in the light of care co-ordination responsibilities;

 agree local protocols for the delegation of specific tasks associated with care co-ordination, where the Care Co-ordinator remains both responsible and accountable for the appropriate and effective delivery of the care co-ordination function. For example, a support worker may support a person to follow his/her recovery plan, and the Care Co-ordinator will monitor and review progress with both the person , the support worker, and others involved in that person’s care as appropriate;

 to inform supervision and appraisal; for example by referring to the performance standards set out in the associated National Occupational Standards, the principles of practice; and the values and principles embedded therein (i.e. as described in the Ten Essential Shared Capabilities);

 to inform training and development; for example, by providing learning objectives to be achieved via work based learning, mentoring, and coaching;

 within the care plan review process, to be used as a point of reference or ‘check list’ both by the Care Co-ordinator, the person using services, and those supporting him/her;

 to inform service governance processes; for example,

- to define criteria for audit, evaluation, and review, - to inform caseload management and supervision, - to design approaches for service user focused monitoring;

 to develop information for people who use services, and people who support them. 13

The core functions for the Care Co-ordinator role, and the associated functional statements are set out in Tables 1-6, below. The NOS which have been mapped against each core function are presented in the respective tables.

Appendix 2 provides a summary of each NOS, by core function, for reference. The full NOS can be viewed on the Skills for Health website at www.skillsforheatlh.org.uk/competences

Functional Map Functional Statements (Tables 1-6)

Table 1 FUNCTION CPA 1 - COMPREHENSIVE NEEDS ASSESSMENT

Functional statements associated National CPA 1.1 Occupational Clarify your role within the assessment process. Standards

CPA 1.2 HSC417 Involve the person and others involved in that person’s care (NHS KSF HWB4 - 4) in the assessment process. MH14 CPA 1.3 (NHS KSF HWB2 – 2) Arrange advocacy for people who are unable to represent their own interests, and those who seek advocacy. MH18 (NHS KSF HWB2 – 2) CPA 1.4 MH25 Carry out an assessment of physical, emotional, (NHS KSF HWB2 – 3) psychological, and social care needs

CPA 1.5 Assess any immediate risk to the person or to others.

CPA 1.6 Consult with, and refer to specialist advice and assessment if appropriate.

CPA 1.7 With the person and others involved in that person’s care, identify and agree actions and interventions.

CPA 1.8 Review assessment process and next steps with participants.

CPA 1.9 Record and provide information in line with legal and organisational requirements

KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; NHS KSF = NHS Knowledge & Skills Framework)

Table 2 FUNCTION CPA 2 - RISK ASSESSMENT AND MANAGEMENT

Functional statements associated National In consultation with the person using services, and others Occupational involved in his/her care, Standards

CPA 2.1 HSC450 Support and enable people to participate in the assessment, (NHS KSF HWB2 – 3) actions, processes, procedures and practices for dealing with the risk of danger, harm and abuse. MH16 (NHS KSF HWB2 – 4) CPA 2.3 Assess and record the potential impact of harm, failure to MH17 protect and harm to self and others according to degree, (NHS KSF HWB2 – 4) likelihood and effect on people.

CPA 2.4 Prioritise identified needs and level of risk.

CPA 2.5 Arrange specialist assessments where required.

CPA 2.6 Consider the strengths and weaknesses of options to manage risk.

CPA 2.7 Consider issues and risk management options and communicate to those who need to receive them.

CPA 2.8 Negotiate agreement on the information which will need to be shared, and with whom, in accordance with agency and legislative requirements.

CPA 2.9 Acknowledge and record any disagreement concerning the source and level of risk.

CPA 2.10 Negotiate and agree a plan to manage risk. Identify and record instances where preferred options for action are not consistent with organisational priorities.

CPA 2.11 Share the risk management plan with the person, and others involved in his/her care, as appropriate.

CPA 2.12 Take action to protect people considered to be in immediate danger.

CPA 2.13 Agree your role and responsibilities and those of others in reviewing the risk management plan, and the effectiveness

of actions to deal with the risk of danger, harm and abuse.

CPA 2.14 Record and provide information in line with legal and organisational requirements

KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; NHS KSF = NHS Knowledge & Skills Framework)

Table 3 FUNCTION CPA 3 - CRISIS PLANNING AND MANAGEMENT

Functional statements associated National CPA 3.1 Occupational Assess the risk of crisis situations occurring with people, Standards and others involved in their care. MH13 (NHS KSF HWB3 – 3) CPA 3.2 Negotiate agreement to the risk management strategies MH21 with people, their carers/families, service providers, other (NHS KSF HWB3 – 3) agencies and practitioners.

CPA 3.3 Negotiate agreement on the information which will need to be shared, and with whom, in accordance with agency and legislative requirements.

CPA 3.4 Ensure that the agreed actions are implemented as promptly as possible in accordance with the assessed urgency of the need.

CPA 3.5 Review the outcomes of actions taken to address immediate needs.

CPA 3.6 Ensure that the results of the review are communicated clearly to all those who need to receive them.

CPA 3.7 Record and provide information in line with legal and organisational requirements

KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; NHS KSF = NHS Knowledge & Skills Framework)

Table 4 FUNCTION CPA 4 - ASSESSING & RESPONDING TO CARERS’ NEEDS

Functional statements associated National CPA 4.1 Occupational Develop relationships with carers that recognises their role Standards and expertise and enables them to communicate their needs and preferences. HSC387 (NHS KSF HWB4 – 3) CPA 4.2 Provide information about the carers' rights to have their MH6 needs assessed and the procedures for this. (NHS KSF HWB2 – 3)

CPA 4.3 MH7 Assess carers’ needs in line with legislation and (NHS KSF HWB2 – 3) organisational policy. MH9 (NHS KSF HWB4 – 3) CPA 4.4 Provide accessible information about resources, services, facilities and support groups that are available and appropriate to the carers.

CPA 4.5 Identify what support will be needed by carers to enable them to meet their own needs and preferences.

CPA 4.6 Identify any risks to carers and individuals and how these should be managed.

CPA 4.7 Identify how carers’ access to resources, services, facilities and support groups will be reviewed, when this will happen, and who will be involved.

CPA 4.8 Take appropriate action to challenge discriminatory information and practice.

CPA 4.9 Record and report on actions, processes and outcomes in line with organisational policy.

KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; NHS KSF = NHS Knowledge & Skills Framework)

Table 5 FUNCTION CPA 5 - CARE PLANNING AND REVIEW

Functional statements associated National CPA 5.1 Occupational Encourage people and others involved in their care to take Standards a full and active part in the care planning and review process, consistent with the person's wishes. MH19 (NHS KSF HWB2 – 3) CPA 5.2 Clarify how information will be shared. MH23 (NHS KSF HWB7 – 2) CPA 5.3 Encourage and support people and others involved in their MH24 care to consider what recovery means to them, and what (NHS KSF HWB7 – 2) will enable them to recover.

CPA 5.4 Identify and take account of the views of other service providers, agencies and practitioners who are in a position to contribute to the person’s care planning.

CPA 5.5 Help people who are unable to exercise their rights to make decisions for themselves.

CPA 5.6 With the person and others involved in his/her care, discuss options and agree a care /recovery plan.

CPA 5.7 Agree the role of the person and others involved in his/her care in achieving the aims and goals of the plan.

CPA 5.8 Establish with the person and others involved in his/her care how the aims and goals of the person’s care/recovery plan will be reviewed, and the timescale for review.

CPA 5.9 Monitor progress to ensure that the person is able to access the facilities, resources, and interventions agreed within the care/recovery plan. Take action where this is not achieved.

CPA 5.10 With the person and others involved in his/her care, review the care/recovery plan.

CPA 5.11 Record and share as agreed the planning and review process.

KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; NHS KSF = NHS Knowledge & Skills Framework)

Table 6 FUNCTION CPA 6. TRANSFER OR DISCHARGE

Functional statements associated National CPA 6.1 Occupational Discuss with the person, and others involved in his/her Standards care, as appropriate, the options for transfer of care or discharge. Agree the goals for transfer of care or CM13 discharge. (NHS KSF HWB2 – 3)

CPA 6.2 MH83 Agree a transfer/discharge plan, including the support (NHS KSF HWB4 – 3) needs of the person upon transfer/discharge.

CPA 6.3 Agree with the person, and others involved in his/her care the transfer/discharge arrangements. Implement the transfer of care or discharge.

CPA 6.4 Monitor and review the effectiveness of the transfer/discharge arrangements.

CPA 6.5 Record and share transfer/discharge records in line with legal and organisational requirements.

(KEY: HSC = Health & Social Care NOS; MH = Mental Health NOS; CM = Case Management NOS; NHS KSF = NHS Knowledge & Skills Framework)

Appendix 1

Key sources

1. DH 2004 The ten essential shared capabilities: A framework for the whole of the mental health workforce. NIMHE

2. Skills for Health 2007 National occupational standards for health. Available at http://www.skillsforhealth.org.uk/page/competences

3. Skills for Care 2007 National occupational standards for care. Available at http://www.topssengland.net/view.asp?id=57

4. Skills for Justice 2007 National occupational standards for justice. Available at http://www.skillsforjustice.com/template01.asp?pageid=37

5. DH 2007 Best practice in managing risk. NIMHE. CSIP. London

Appendix 2

CPA 1 – COMPREHENSIVE NEEDS ASSESSMENT

NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

HSC417: Assess individuals mental health and related needs

This workforce competence is about the assessment of individuals' mental health and related needs. This involves evaluating referrals for their appropriateness to the practitioner and the services offered by the organisation or team. The evaluation will include determining the urgency of the individual's needs and the overall caseload of the practitioner, and making the necessary arrangements for the assessment to take place. Once the decision has been made to see the individual, then the nature and purpose of the assessment is agreed with the individual and significant others and an understanding of their needs obtained from them. This is followed by undertaking the assessment to determine the nature and extent of the individual's needs and subsequently, agreeing courses of action with them.

This competence is based on the premise that, for effective assessment to take place, you need to have an adequate understanding of the individual's personal, cultural and social situation and the holistic nature of health and social well-being. You must be able to communicate effectively with individuals and significant others and balance the information they provide about their own needs with the other information gained during the assessment. As the assessment process often acts as a gateway to services, there is also a particular need to monitor the pattern of referrals and evaluate the extent to which services are meeting the needs of the broad community they serve. You are expected to be proactive and alert your employing organisation and, if necessary your professional body, when inappropriate patterns of referral or service delivery arise. While this is effectively a quality assurance issue and dealt with accordingly within other management standards, it needs to be borne in mind in this context and followed through with a reflective attitude.

Users of this competence will need to ensure that practice reflects up to date information and policies.

MH14: Identify potential mental health needs and related issues

This workforce competence covers the initial identification of mental health needs. Partners, families and/or friends of the individual should be included in the discussion of the individual's needs only where s/he has agreed for this to happen, except when working with children and young people, when discussion and agreement about referral to mental health and/or other services must include the parent or legal guardian.

emergency departments, social services, criminal justice and other areas where people with mental health needs are likely to present themselves.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence leads onto workforce competence MH15 which covers making referrals and to workforce competence HSC417 which covers the assessment of individuals' mental health and related needs as a result of the referrals made in the course of this workforce competence. The specific instance of recognising indications of substance abuse is covered in detail in workforce competence DANOS AA1 for those practitioners and agencies who specialise in that area of health and social care.

MH18: Identify the physical health needs of individuals with mental health needs

This workforce competence covers identifying an individual's physical health needs and their capability, or that of their carer, to address these needs within the limitations and risks of the individual's mental health needs.

This workforce competence applies to anyone responsible for identifying the physical health needs of individuals with mental health needs and determining appropriate courses of action to promote their physical health.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence has links to other workforce competences concerned with the assessment of individuals, including MH14 which addresses screening, MH15 which covers referral, and HSC417 which covers formal assessment as a result of referral. Since mental health and mental health needs frequently interlink with physical health needs, this workforce competence forms one part of the overall process of assessment.

MH25: Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care for individuals

This workforce competence covers working as a member of an inter- disciplinary team through contributing to the assessment of service users' needs, contributing to the planning of individualised programmes of care, and contributing to evaluation and review. The assessment methods and approaches and the nature of interventions will be those which are agreed on a case-by-case basis with other members of the inter-disciplinary

team.

The term ‘inter-disciplinary team' has been used to mean teams formed of practitioners drawn from different professions (or different disciplines within a profession) who are working together as a co-ordinated team to achieve agreed objectives with service users.

As you will be one of the main points of contact with individuals and will be undertaking specific individualised programmes of care, probably on a person-focused basis, there is a strong focus in this workforce competence on promoting individual's rights. Due to the nature of the interventions, there will also be a number of issues related to confidentiality and consideration of who has access to certain information.

When working with children and young people, you will need to take account of their age and stage of development as well as the context of the family or substitute care and ensure that planning, implementation and evaluation of therapeutic activities is carried out in active collaboration with their parents/guardians.

This workforce competence applies to people who work as a member of an inter-disciplinary team to plan, and review individualised programmes of care for people with mental health needs.

The focus of the work is likely to be related to the services offered by an integrated service (such as a rehabilitation workforce competence, community mental health team or in day care) or the service offered by a functional team (such as assertive outreach, crisis intervention). It is particularly relevant to mental health practitioners working within schools. It is likely that the practitioner will specialise in working with one particular service user group or in one setting.

Users of this competence will need to ensure that practice reflects up to date information and policies.

CPA 2 – RISK ASSESSMENT AND MANAGEMENT NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

HSC450: Develop risk management plans to support individual's independence and daily living within their home

This workforce competence covers developing risk management plans to support individuals' independence and daily living within their home. This involves preparing to and carrying out risk assessments, and developing, agreeing and regularly reviewing risk management plans for individuals.

Users of this competence will need to ensure that practice reflects up to date information and policies.

MH16: Assess individuals’ needs and circumstances and evaluate the risk of abuse, failure to protect and harm to self and others

This workforce competence covers identifying the needs and circumstances of the individual in relation to the possibility of harm being suffered or caused.

This workforce competence is one in which multi-disciplinary and inter- agency working may be a feature, particularly with regard to the exchange of information to support identification of needs and assessments and in communicating the results of assessments.

This workforce competence applies to qualified staff who work with individuals to assess how they function in everyday life and any related risks to the individual or others which would call for interventions.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence has links to other workforce competences concerned with the assessment of individuals, including MH14 which addresses screening, MH15 which addresses referral assessments and HSC417 which covers formal assessment as a result of referral.

In relation to assessment of the risks to others, the workforce competence also has links to workforce competences HSC335 and HSC325 concerning the protection of individuals and children from abuse.

The workforce competence specifically links to workforce competence MH49 on assisting people who are a risk to themselves and others to develop control. Additionally, since assessment is a process which may lead on to any one of a number of interventions to support recovery, the workforce competence has forward links to many other workforce competences within the suite of national occupational standards for mental health e.g. workforce competence MH9 Empower families, carers and

others to support individuals with mental health needs.

MH17: Assess the need for intervention and present assessments of individuals’ needs and related risks

This workforce competence covers assessing the need for intervention to manage risk to the individual or others and presenting assessment of individuals' needs and related risks. Interventions can take a variety of forms with therapeutic outcomes leading to recovery.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence follows on from workforce competence MH16 which is about assessing individuals' needs and circumstances and evaluating the risk of abuse, failure to protect and harm to self and others in accordance with relevant legislation. It also has links to other workforce competences concerned with the assessment of individuals, including MH14 which addresses screening, MH15 which covers referral assessments and HSC417 which covers formal assessment as a result of referral.

In relation to assessment of the risks to others, the workforce competence also has links to workforce competences HSC335 and HSC325 concerning the protection of individuals and children from abuse.

CPA 3 – CRISIS PLANNING AND MANAGEMENT NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

MH13: Work with families, carers and individuals during times of crisis

This workforce competence covers working with individuals and their carers and families in times of crisis to assess the urgency of requests for action, take and review the effectiveness of actions to meet needs and agree risk management strategies.

The term ‘carers and families' is used to mean any persons who have an active and on-going informal role in caring for the individual with mental health needs, including those with a familial relationship to the individual. Partners, where they exist, would be considered as family members. Individuals with mental health needs may be adults of working age, children or adolescents or older people.

This workforce competence applies to those who respond to and work with individuals with mental health needs and their carers and families during times of crisis.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence is one of several which address the needs of the families and carers of individuals with mental health needs. Other workforce competences include MH6 and MH7 which look at assessing family and carer needs and planning, implementing and reviewing support programmes which address those needs. Workforce competence MH9 is about enabling families, carers and others to support individuals with mental health needs and workforce competence MH11 which is concerned with families taking action to prevent crises arising. Finally, the workforce competence has links with workforce competence MH21 which relates to responding to crisis situations within the family or other care context.

MH21: Respond to crisis situations

This workforce competence covers responding to crisis situations by assessing the urgency for action, identifying the need for legal or procedural intervention, taking action to meet the immediate needs and reviewing the outcomes with others involved.

This workforce competence applies to practitioners who respond to crisis situations such as mental illness, family violence, family breakdown, attempted suicide, death. In the context of mental health, the crisis situations will involve individuals with mental health needs, e.g. risk of self-harm or harm to others, potential or actual abuse, death of a parent/carer.

Users of this competence will need to ensure that practice reflects up to 29

date information and policies.

Relationship to other workforce competences within the Mental Health framework

The focus of this workforce competence is on the interventions of social work and community mental health practitioners to crisis situations within the family or wider community and taking immediate actions to resolve the situation. Workforce competence MH13 is about mental health practitioners, from health or social care, working with families, carers and individuals with mental health needs during times of crisis. The workforce competence covers both addressing immediate needs and developing longer term risk management strategies with individuals, families and carers.

CPA 4 – ASSESSING AND RESPONDING TO CARERS’ NEEDS NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

HSC387: Work in collaboration with carers in the caring role

This workforce competence covers supporting carers in their caring role. This involves working with carers to identify their needs and preferences, carers to access resources, services, facilities and support groups and to review how well the services and facilities meet their needs.

Users of this competence will need to ensure that practice reflects up to date information and policies.

This competence replaced DANOS AB9 during rationalisation of the database.

MH6: Assess the needs of carers and families of individuals with mental health needs

This workforce competence is about establishing the strengths, vulnerabilities, needs and circumstances of carers and families and using this information to assess their support needs.

The term ‘carers and families' is used to mean any persons who have an active and on-going informal role in caring for the individual with mental health needs, including those with a familial relationship to the individual. Partners, where they exist, would be considered as family members. The individual with mental health needs may be an adult of working age, a child or adolescent or an older person.

This workforce competence applies to those who are responsible and accountable, within statutory or voluntary organisations, for identifying the support needs of carers and families of individuals with mental health needs. It would be particularly suitable for care co-ordinators.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence is about identifying the support needs of carers and families of individuals with mental health needs. Developing, implementing and reviewing programmes of support based on the identified needs are covered in workforce competence MH7.

MH7: Develop, implement and review programmes of support for carers and families

This workforce competence covers developing, implementing and reviewing programmes of support for carers and families of individuals.

The term ‘carers and families' is used to mean any persons who have an 31

active and on-going informal role in caring for the individual, including those with a familial relationship to the individual. Partners, where they exist, would be considered as family members. The individual may be an adult of working age, a child or adolescent or an older person.

This workforce competence applies to those who are responsible and accountable, within statutory or voluntary organisations, for developing, implementing and reviewing programmes of support for carers and families of individuals with mental health needs. It would be particularly suitable for care co-ordinators.

Users of this competence will need to ensure that practice reflects up to date information and policies.

MH9: Empower families, carers and others to support individuals with mental health needs

This workforce competence is about working with families, carers and others to encourage and enable them to support individuals with mental health needs through the provision of practical and emotional support and helping them to review and develop the support they provide and receive.

The term ‘carers and families' is used to mean any persons who have an active and on-going informal role in caring for the individual with mental health needs, including those with a familial relationship to the individual. Partners, where they exist, would be considered as family members. The individuals with mental health needs may be adults of working age, children or adolescents or older people.

Others who may be involved in supporting individuals with mental health needs includes friends and others within the individual's social network such as religious leaders.

This workforce competence applies to those who work with families, carers and others to enable them to support individuals with mental health needs.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

CPA 5 – CARE PLANNING AND REVIEW NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

MH19: Co-ordinate, monitor and review service responses to meet individuals’ needs and circumstances

This workforce competence covers implementing agreed responses to the needs and circumstances of individuals and involves co-ordinating, monitoring, adjusting and reviewing the provision of services to the individual

As a central focus of this workforce competence is the co-operation, monitoring and review of service responses to meet individuals' needs, you need to be very aware of your relative position of power to the individual and the rights of the individual in the process. You will need to understand the concepts of empowerment and participation and how these inform or influence the involvement of individuals and carers in the co-ordination of care, and how the concepts of efficiency, effectiveness, economy and equity inform and influence the co-ordination of services.

This workforce competence applies to practitioners in all types of service settings who are responsible for monitoring the effectiveness of service provision in relation to either their role as a service provider or in relation to agreed joint working with other workers and organisations. This will involve monitoring the effectiveness of individual care plans and service objectives. Methods of monitoring and evaluation are both formal and informal.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence is related to workforce competences DDANOS AA1 and HSC417 on assessing individuals' needs and circumstances and evaluating the risk of harm and failure to protect. Workforce competence DANOS CB3 precedes this workforce competence and focuses on procuring services for individuals.

MH23: Plan and review the effectiveness of therapeutic interventions with individuals with mental health needs

This workforce competence covers planning and reviewing therapeutic interventions with individuals with mental health needs as part of their overall care programme.

The workforce competence is based on the premise that for effective care planning and review to take place, you need to have sufficient understanding of the context of the individual and the holistic nature of health and social well being. You must be able to communicate effectively with individuals and significant others and integrate your work with that of other practitioners. Throughout the process, individuals and significant others are encouraged and supported to take an active part and this is 33

enhanced by using, as far as is possible, therapeutic interventions which are sustainable by the individual in their own context.

When working with children and young people, you will need to take account of their age and stage of development as well as the context of the family or substitute care and ensure that planning and review of therapeutic interventions are carried out in active collaboration with their parents/guardians. It will also be important to hear the child or young person's own views in planning, delivery and evaluation, not only those of the parents/guardians.

This workforce competence applies to those who work with people with mental health needs to provide therapeutic interventions within an overall care programme. It is applicable to qualified therapists responsible for providing any type of therapy that might be provided for individuals with mental health needs in any sort of care settings.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence is suited to qualified practitioners who are responsible for planning, implementing and evaluating a programme of therapeutic interventions within an overall care programme. Workforce competences MH25 and MH26 are for people who work as a member of an inter-disciplinary team to plan, implement and review individualised programmes for people with mental health needs. Workforce competence HSC211 is for those who prepare and provide development activities for individuals without direct supervision from a team leader or practitioner although they will be working under the overall supervision or direction of such a person and workforce competence HSC393 is for those who assist in preparing and implementing group activities in situations where the practitioner is acting with the agreement of the care team but without direct supervision.

MH24: Implement, monitor and evaluate therapeutic interventions within an overall care programme

This workforce competence covers implementing and reviewing therapeutic interventions and ending your involvement with individuals following therapeutic interventions with individuals with mental health needs as part of their overall care programme.

The workforce competence is based on the premise that for effective care implementation to take place, you need to have sufficient understanding of the context of the individual and the holistic nature of health and social well being. You must be able to communicate effectively with individuals and significant others and integrate your work with that of other practitioners. Throughout the process, individuals and significant others are encouraged and supported to take an active part and this is enhanced by using, as far as is possible, therapeutic interventions which are sustainable by the individual in their own context.

When working with children and young people, you will need to take 34

account of their age and stage of development as well as the context of the family or substitute care and ensure that implementation and evaluation of therapeutic interventions are carried out in active collaboration with their parents/guardians. It will also be important to hear the child or young person's own views in planning, delivery and evaluation, not only those of the parents/guardians.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence is suited to practitioners who are responsible for implementing and evaluating a programme of therapeutic interventions within an overall care programme. Workforce competences MH25 and MH26 is for people who work as a member of an inter-disciplinary team to plan, implement and review individualised programmes for people with mental health needs. Workforce competence HSC211 is for those who prepare and provide development activities for individuals without direct supervision from a team leader or practitioner although they will be working under the overall supervision or direction of such a person and workforce competence HSC393 is for those who assist in preparing and implementing group activities in situations where the practitioner is acting with the agreement of the care team but without direct supervision.

CPA 6 – TRANSFER OF CARE OR DISCHARGE NOS Summaries for full text go to www.skillsforhealth.org.uk/competences

CMI3: Plan and implement transfer of care and discharge with individuals who have a long term condition and their carers

This competence is about working with individuals who have a long term condition and their carers to plan and implement transfer of care and discharge. It covers planning how and when transfer and discharge will take place, ensuring all necessary arrangements are made, and implementing and monitoring the agreed discharge plan.

The competence is relevant to practitioners who co-ordinate transfer of care and discharge for individuals with a long term condition. Practitioners working in this area require specialist expertise concerning the continuing health and social care of individuals with a long term condition and with age related conditions, and the different care pathways for addressing their needs.

This competence is relevant to those who provide proactive and co- ordinated Case Management. Here, Case Management means identifying and risk stratifying vulnerable, high-risk people with complex multiple long term conditions. Case Management should take place within the philosophy of enabling and promoting self care, self management and independence.

Users of this competence will need to ensure that practice reflects up to date information and policies.

MH83: Work with others to facilitate the transfer of individuals between agencies or services

This workforce competence covers working with staff in other agencies and services to ensure individuals experience a seamless transition between agencies and services. In the context of this workforce competence the term ‘transfer' covers all types of referral and shared responsibility for individuals, including:

a) where individuals are transferred to another agency/service on a long- term or permanent basis

b) where individuals are transferred to another agency/service for specific short-term interventions

c) where the agencies/services concerned have shared responsibility for the care and treatment of individuals

d) where the ‘receiving' agency/service provides advice and guidance to the referring agency/service which remains responsible for the care and treatment of the individual.

This workforce competence applies to those who work with others to facilitate the transfer of individuals between agencies and services. This role may be carried out for an agency/service which refers to and/or 36

accepts referrals from other agencies/services. The job holder will be responsible for managing boundary issues between the agencies or services concerned and may or may not be directly involved in individual transfers.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

This workforce competence complements workforce competence HSC386 which covers assisting in the transfer of individuals between agencies and services.

This workforce competence also relates to workforce competences MH47, HSC382, HSC383, HSC412 which address issues relates to transfer of individuals from the individuals viewpoint. They are MH47 Enable individuals, their family and friends to explore and manage change, HSC382 Support individuals to prepare for, adapt to and manage change, HSC383 Prepare and support individuals to move and settle into new living environments, and HSC412 Ensure individuals and groups are supported appropriately when experiencing significant life events and transitions.

Appendix 3

MH14: Identify potential mental health needs and related issues

Status: National Occupational Standards (NOS) Suite: Mental Health

About this workforce competence This workforce competence covers the initial identification of mental health needs. Partners, families and/or friends of the individual should be included in the discussion of the individual's needs only where s/he has agreed for this to happen, except when working with children and young people, when discussion and agreement about referral to mental health and/or other services must include the parent or legal guardian.

This workforce competence applies to people who identify and act on indications of mental health needs as part of their wider job role. This includes those working in areas such as primary health care, accident and emergency departments, social services, criminal justice and other areas where people with mental health needs are likely to present themselves.

Users of this competence will need to ensure that practice reflects up to date information and policies.

Relationship to other workforce competences within the Mental Health framework

Links This workforce competence has indicative links with the following dimension and levels within the NHS Knowledge and Skills Framework (October 2004): Health and wellbeing HWB2: Assessment and care planning to meet people's health and wellbeing needs. Level 2: Contribute to assessing health and wellbeing needs and planning how to meet those needs.

Origin This workforce competence has been developed by Skills for Health.

Glossary This section provides explanations and definitions of the terms used in this workforce competence. In competences, it is quite common to find words or phrases used which you will be familiar with, but which, in the detail of the competence, may be used in a very particular way.

Criminal justice system - Interaction with the criminal justice system may be a factor to be taken into account in the context of legal and substance abuse related issues.

Scope This section provides guidance on possible areas to be covered in this competence. Action in relation to: 38

a) the service(s) to which you refer the individual b) the urgency with which you make the referral c) the information you provide to support the referral.

Indications of mental health needs may be: a) physical b) behavioural c) emotional d) psychological e) information provided by the individual f) information from other sources, e.g. parents, partners, family, friends, medical records.

Related issues include: a) physical b) social c) legal d) cultural e) substance misuse.

Risk includes: a) self harm or suicide b) harm to others c) abuse (e.g. physical, emotional, sexual, financial) d) mental health emergencies e) physical health emergencies.

Performance Criteria You need to: 1. regularly update your knowledge about the range of mental health needs and the possible indications of these 2. remain constantly alert to possible indications of mental health needs in those with whom you come into contact 3. explore situations sufficiently to allow you to make a reasonable judgment about whether individuals have mental health needs 4. identify and recognise the importance of the individual's ethnicity and socio- cultural context in relation to mental health needs 5. obtain specialist advice or assistance where you are unable to make a reasonable judgement about whether individuals have mental health needs 6. respond promptly to any indications of mental health needs in order to seize the opportunity for intervention 7. involve the individual in the assessment process as much as possible, ensuring and open and empowering approach 8. assess any immediate risk to the individual and to others which may result from mental health and/or related issues in accordance with legislation and organisational policy and procedures 9. take prompt action appropriate to your assessment of risk in line with legal and organisational requirements 10. record situations and actions taken in line with organisational requirements 11. provide information about situations and actions taken only to those entitled to have it in accordance with legal and organisational requirements.

Knowledge and understanding You need to apply: Information handling K1 A working knowledge of the importance of keeping full and accurate records, and how to do so K2 A working knowledge of the importance of providing full and accurate information, and how to do so

K3 A working knowledge of the agency's policy and procedures regarding confidentiality of information and the disclosure of information to third parties, and the specific circumstances under which disclosure may be made K4 A working knowledge of professional codes of practice with regard to information handling and disclosure K5 A working knowledge of how to present information to individuals in a clear and positive manner Monitoring and evaluation K6 A working knowledge of the importance of monitoring the situation regarding an individual's mental health and how to do so Risk assessment and management K7 A working knowledge of how to assess and manage the risk to individuals, to self and to others K8 A working knowledge of the importance of regularly reviewing risk assessments K9 A working knowledge of organisational requirements and policies relevant to risk assessments Mental health needs K10 A working knowledge of the range of different mental health needs and their effects K11 A working knowledge of the physical, behavioural, emotional and psychological indications of mental health needs K12 A working knowledge of how to evaluate information provided by the individual or from other sources for indications of mental health needs K13 A working knowledge of ways of keeping your knowledge about mental health and indications of mental health needs up to date K14 A working knowledge of how to gather the required information in order to make a reasoned judgment about mental health needs, including the use of appropriate objective measurements K15 A working knowledge of how to access specialist advice or assistance when required K16 A working knowledge of mental health and related services, and procedures for referring individuals to them K17 A working knowledge of the range of actions you can take when individuals may have mental health needs and/or related issues, and how to decide what action is appropriate Mental health and related services K18 A working knowledge of sources of information on mental health and related services K19 A working knowledge of the eligibility criteria for accessing services in your locality K20 A working knowledge of how to plan and facilitate referrals to mental health and/or related services K21 A working knowledge of how to assess the required degree of urgency when referring individuals to services K22 A working knowledge of the legal and organisational requirements and procedures for reporting and responding to actual or potential mental health needs.

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