Freedom of Information request 469-2023

One Stop Team
Assertive Outreach Services
Community Learning Disability Service
Later Life Service
Complex Psychological Interventions CPI Pathway Appendix 1. Recovery Service
Care Home Support Team Operational Policy
Version: 4.0
Consultation: Delivery Committee Sept 2015
Ratified by: Gloucestershire Locality Board Date ratified: Sept 2015
Name of originator/author: Trish Butler/ Jan Furniaux/Debbie Furniss
Date issued: Sept 2015
Review date: June 2021
Scope: Staff working in the One Stop Teams
Replaces Any previous Operational Policy for Recovery Teams/ Community Learning Disability Teams/Community Mental Health Teams
This policy / procedure /guidance has been equality impact assessed using the Trust’s agreed process, and the assessment has not identified any significant adverse impact on people with one or more protected characteristic. Version 4.0
This policy / procedure /guidance has been quality impact assessed using the Trust’s agreed process. Version 4.0
1. Introduction
This document has been developed to describe the operational procedures for the One Stop Teams OSTs.. The One Stop Team concept was proposed by Gloucestershire Health and Care NHS Foundation Trusts clinical and service leaders in “Fair Horizons; an integrated mental care service model, fit for the 21st century” Fear et al 2009.. It was developed in response to legislative and policy drivers to increase the equity of access to mainstream services and achieve equity of health outcomes as detailed in Health Care for All 2008. No Health without Mental Health 2010. and the Equality Act 2010. & Health & Social Care Act 2012.. The policy also reflects service specifications, which outline requirements for each component service.
This operational policy is designed to be read in conjunction with:
• the Intermediate Care Service Operational policy • Contact Centre Operational Policy
• Service Specifications for each clinical service 2. Purpose
2.1 Purpose One Stop Teams provide mental health care for people with episodes of serious or acute mental ill health. It is for people of all ages and IQs. It also provides integrated social care currently for 18 – 65 year olds. and specialist care for people with a learning disability. Social Care for Learning Disability and Older Age is accessed via Gloucestershire County Council.
The services are community based and have a focus on: • the promotion of recovery and mental well being
• the minimisation of the impact of learning disability
• social care packages for 18 – 65 year olds
• personalised care planning 2.2 Scope
This policy applies to all staff employed within the One Stop Team Services and should be referred to for agencies accessing the service. In all cases the aim will be to provide a high quality service, in line with best practice and national guidance, to service users experiencing mental health difficulties and/or a learning disability.
2.3 Context
Gloucestershire Health and Care NHS Foundation Trusts can integrated model of mental health care provision. The service will aim to provide full equity of access with no discrimination on the grounds of age, sexual orientation, religion, ethnicity, physical or learning disability.
The service will work in conjunction with the Contact Centre and other tertiary services to support seamless pathways of care both within Gloucestershire Health and Care NHS Foundation Trusts and with external agencies and partners.
2.4 Aims & Objectives
The main aim of the service is to offer a needs led assessment service, which will utilise Health of the Nation Outcome Scales HoNOS., Mental Health MH. Care Clusters and Learning Disability LD. specific clusters where available. to allocate to the appropriate care package
The following are the underpinning principles of the service:
• To promote positive mental health and/or learning disability care for all
• To offer equitable access to mental health and/or learning disability care that is non-discriminatory and person centred • To support equality and diversity for the communities we serve
• To see each service user as a whole person with a range of health, psychological, educational, social spiritual and occupational needs
• To intervene early when people become unwell
• To meet multiple needs of service users/carers including education, recreation, occupation, vocation, employment and where appropriate accommodation
• To closely monitor outcomes to ensure we are providing high quality care and meeting contractual commitments
• To provide reasonable adjustment to ensure equitable service provision • To embrace the values of:
o health promotion
o positive risk taking o easy access
o tackling stigma associated with mental health and/or learning disabilities
o focusing on recovery
o focusing on social inclusion
• Based on the principle ‘no decision about me without me’ to help service users & carers develop self-management skills utilising individualised budgets, relapse prevention, end of life planning and advance directives. • To provide positive patient and carer experience that is open and honest with participation and involvement from carers and users of the service.
• To develop a culture of innovation and service improvement in the workforce. 2.5 Duties
Responsibility for the development, maintenance, review and ratification of this document lies with the Director of Service Delivery DSD.. The DSD has Board level responsibility for the development of this document and may delegate this responsibility to a subordinate. The DSD and Trust Governance Committee will be notified when this policy has been approved by Gloucestershire Locality Board made aware of any amendments.
All staff who have contact with service users and other care agencies are responsible for using the policy correctly to ensure patient safety.
2.6 Ownership & Consultation
The Locality Director, Community Service Managers CSMs. and Team Managers are responsible for the OST services and for this document.
2.7 Ratification Details
This Policy has been ratified by the by Gloucestershire Locality Board.
2.8 Release Details
This policy will be available on the trust intranet page in the policy section under ‘Operational Policies – Gloucestershire Localities’. Notification of its review and updating will be published in Gloucestershire Health and Care NHS Foundation Trusts intranet ‘What’s New’ section. 2.9 Review Arrangements
This document will be reviewed annually to ensure that it is contemporaneous to modern mental health practice and research.
2.10 Training
The service will induct all new staff to their role within the OST. This will compliment corporate and local induction. All staff will be offered an induction period to develop a working knowledge of the elements of the service. This will be recorded in accordance with Trust Policy. Staff will attend statutory and mandatory training related to their role as per Trust policy.
The service will ensure that every staff member involved with the provision of services:
• Receives an appraisal and on-going education and training in accordance with the standards of their relevant professional body
• Receives Continuing Professional Development CPD. appropriate to their role
• Have access to protected learning time. • Training in Assessment & Care Management CPA., RiO, Risk Assessment & Management, Care Clusters and Care Packages.
3.0 Demographics and target population.
The One Stop Teams serve a geographically defined population based in West, North and South Gloucestershire. 4.0 Activity Assumptions
Care will be delivered in line with the Trust Assessment & Care Management CPA. Policy and Risk Management Policy. The clinical system for supporting the delivery of clinical services is RIO. The OST provides care packages as described in the Gloucestershire Health and Care NHS Foundation Trust’s Adult Mental Health Care Packages Manual Version 1.0. April 2014.. Cluster diagram-see overpage
5.0 Performance Measures
The Gloucestershire Contract outlines the main measures for services and are detailed in the service specifications for each clinical service.
The Locality Delivery Committee oversees performance measures
The Governance Committee has a specific focus on audit and assurance
Terms of reference are available for both of these committees.
5.1 Activity Performance Indicators
Activity indicators are described in the Service Specifications associate with the One Stop Teams for Recovery, Assertive Outreach, Later Life and Dementia, Community Learning Disability, Complex Psychological Interventions. The Service Specifications form part of the contract we have with Gloucestershire Clinical Commissioning Group to provide services for those with Mental Health and Learning Disability needs.
A dashboard of indicators is used and overseen by the Locality Delivery Committee and Forums. This can be located on SharePoint or for those with access more discrete information on Performance Point. Performance issues are managed by exception and supported by Recovery Plans 5.2 Quality Requirements
An annual audit cycle is determined in discussion with the locality services and will include some team audits. The audit programme is available from the Quality Department.
5.3 Minimum Data Set Requirements
Information is collected for a minimum mental health data set MHMDS. The collection for the MHMDS will start in the Contact Centre where as much of the data set as possible will be collected. Where appropriate, the minimum data set will be sent with the service user’s first appointment letter and they will be asked to bring it to their first appointment.
6.0 Service Delivery
6.1 General Description
The service is delivered by multi professional teams consisting of staff experienced and trained in working with adults with mental health and learning disability issues across traditional age and IQ boundaries. One Stop Teams operate in each of the three localities:
West OST: Gloucester and the Forest of Dean
North OST: Cheltenham, Tewkesbury and North Cotswolds
South OST: Stroud, Cirencester and South Cotswolds
The One Stop Teams are managed by designated Band 7 Team Managers in each locality.
Service Delivery is via clinics and home visits with reasonable adjustment to support the assessment & treatment needs of the population served.
6.2 Clinical Services
The One Stop Team provides three main clinical functions:
• Assessment Appointments • Treatment Appointments
• Advice, support and education
Note: As part of undertaking the OST clinical functions consideration should be given to whether the service user meets a protected characteristic under the Equality Act 2010 and as such require reasonable adjustment to facilitate ‘good’ assessment and interventions. This may include, but is not exhaustive:
• Age; access to all services, noting the challenge to facilitate social care for over 65 year old
• Sex; request for same sex practitioner
• Disability; Sensory Deficits; hearing, sight, mobility or living with long term condition
• Ethnicity; Language, need for an interpreter, culture differences
• Gender; transgendered, identity issues
• Religion; awareness of the interrelationship of medicalised and euro centric practices with culture and religious practice
• Orientation; gay or bisexual, identity issues
• Socioeconomic; refugees, uncertain legal status, transport to and from appointments
6.3 OST Referral Process.
6.3.1 The External Referral Process
• Routine and urgent external referrals received from the list in section 6.3.2. will be processed by the Contact Centre see the Contact Centre Operational Policy.
• The Contact Centre will work with the referrer and One Stop Team to book assessment slots in the relevant locality • The overview for assessment slots will be held by the OST team manager, and held as a RiO caseload. The OST team manager will then allocate to the relevant clinician responsible for the assessment.
6.3.2 Which services can refer to this service?
• General Practitioners GPs.
• Other Primary Care colleagues in consultation with the GP
• Service users who have an Advanced Care Plan drawn up in consultation with the GP
• Social Care Community & Adult Care Directorate.
• Acute and Community hospital practitioners in consultation with the GP or hospital liaison service
• Non statutory providers in consultation with agreement/approval of the GP
• Note: Carers may request a referral via the GP 6.3.3 Response Times Response times are highlighted within contractual requirements. • Routine appointments will be provided within 28 days of receipt of referral
• Urgent Recovery Referrals will be provided within 72 working hours
6.3.4 Gloucestershire Health and Care NHS Foundation Trusts Internal Referral Process
The OST can receive referrals from other clinical teams. Referrals from the following teams will be via the Contact Centre
• Intermediate Care Team • Criminal Justice Liaison Service
• Hospital Mental Health Liaison Services This may be supported by:
• A clinical discussion between the teams prior to referral • Joint appointments if appropriate. with staff from the referring service and OST 6.3.5 Urgent Referrals Between 0900hrs & 1700hrs urgent referrals will be actioned by Band 6 clinician and/or Consultant Psychiatrist within the Contact Centre as outlined in the Contact Centre Operational Policy. Urgent new referrals are defined as those where the service user is:
• a high risk of harm to self or others non-psychosis, psychosis and organic. • meeting the criteria for psychotic crisis or severe psychotic depression clusters 14 and 15.
• requiring assessment under the Mental Health Act
The Contact Centre will decide if the service user is to be seen by the Crisis Resolution & Home Treatment Team CRHTT. or the OST. Discussion and consultation with the respective team may be needed particularly if the person needs to be seen within 24 hours. After assessment by the CRHTT the service user may be referred for further assessment or for treatment appointment with the One Stop Team if clinically appropriate. Where the referral has a social care dimension, such as safeguarding, loss of home or destitution then the appropriate action should be taken in line with local protocols and procedures. 6.3.6 Urgent Response Times
Currently these are:
• Recovery: within 72 hours working hours Recovery service specification.
• Later Life: response within 6 hours local practice – not required by the service specification. Response may be face to face, telephone contact or liaison with referrer
• LD: according to need local practice – not required by the service specification. Response may be face to face, telephone contact or liaison with referrer
For some urgent referrals there may be a requirement to refer onto CHRTT or the Emergency Duty Team.
6.3.7 Management of Cancelled/ Missed Appointments
The OST service will work together to actively manage cancelled appointments. Where possible opportunities should be taken to fill assessment/treatment slots where patients have given sufficient notice of not being able to attend.
6.4 Initial Assessment
An initial specialist core assessment will be undertaken to ensure the referral is appropriate detailed within the Assessment & Care Management Policy..
If the assessment suggests that it is not an appropriate referral for Gloucestershire Health and Care NHS Foundation Trust or the One Stop Team, then the team will endeavour to ensure the referral is signposted to the most appropriate partner organisation or internal service for consideration. • Most new referrals will only require one assessment appointment to ascertain the person’s needs, however where more detailed information is required a further assessment appointment may be offered until the treatment package is clear. • If required the OST team will refer to other clinically appropriate services in Gloucestershire Health and Care NHS Foundation Trusts using the principles outlined in the Interface Policy. 6.4.1 Risk Assessment and Management
In line with the Risk Assessment & Management Policy all patients seen will have risk screening undertaken. When high risk is identified a formal risk assessment and management plan will be provided to support the service user. Risk assessments should be completed by the person that ‘knows the patient best’ in conjunction with the service user, their carers/family and professional carers. 6.4.1 Administration
Following assessment, a summary letter to the service user, carer where appropriate. and referrer will be sent and include:
• a summary of the discussion
• goals and actions agreed including what self-help the service user has agreed to undertake.
• Any plans for further appointments • risk management plans if required
6.4.2 Clinical Responsibility & Care Planning Approach CPA.
• Prior to the assessment appointment: all new referrals will be allocated to the team managers caseload on RiO
• At Assessment the person is allocated to a lead professional
6.5 During Care
Care and treatment is managed in accordance with the Assessment & Care Management Policy.
6.5.1 Care Packages
The role of the OST is to provide a range of evidence based interventions. All work will be supported by evidence based care packages. The interventions will reflect the principle, aims and objectives outlined in section 2.4.
The aim is to support people with a plan of care that is personal, strengths based, about the person, easy to understand, measurable, has attention to physical as well as mental health/ learning disability care and is regularly reviewed in line with cluster review periods and Care Management arrangements.
The CPI brief overview and pathway are detailed in Appendix 1. 6.6 Links to other Agencies/Services
The team will work in partnership with other professional colleagues & agencies to deliver joint interventions. It’s the joint responsibility of all agencies to ensure good communication to ensure safe and efficient service delivery for the patient. The team will work collaboratively with the Intermediate Care Team and GPs and the local social services teams to support shared care arrangements and will negotiate discharge to primary care where possible. 6.6.1 Entry Level Services/ Primary Care Facing Services
Intermediate Care Team IAPT/Primary Mental Health.: there will be a close interface with the One Stop Team to ensure smooth transition between Primary and Secondary Care. Criminal Justice Liaison Services: the relationship between this team and the One Stop Team will be on a case by case basis as the need arises when service users in the criminal justice system require support.
Early Intervention in Psychosis Service: this team provides services for people aged 14-35 and work with those in cluster 10 for a maximum of three years before transfer to: • Back to primary care
• Intermediate Care
• One Stop Team for people in clusters 12 and 13
• Assertive Outreach team for people in clusters 16 and 17.
Mental Health Hospital Liaison: this team offers support to service users who present at the acute hospital with mental health needs. They liaise with current care coordinators in any of the One Stop Teams for services users that are in receipt of services or to organise onward referrals for new service users. Managing Memory Gloucestershire Health and Care NHS Foundation Trust : Managing Memory provides memory assessment and services for those with Dementia. There is a close working relationship with the One Stop Team to ensure smooth transition from clusters 18 and 19 to clusters 20 and 21.
6.6.2 Community Based Services
Day Services: Day Services are provided by The Independence Trust. The One Stop Team works closely with day services to ensure continuity of care. Children and Young People’s Services CYPS.: a transition policy has been developed with the Children and Young People’s Service to ensure effective transition within agreed time and quality standards as outlined in national best practice. NMHDU 2010. Social Care
Current service provision provides integrated social care for adults between 18-65 years of age. The social care pathway should be used to support self-directed care. The social care needs for and clients aged over 65 on their entry into service and for People with Learning Disabilities PwLD., will be met via referral to the Local authority Social Care Teams. 6.6.3 Countywide
Acute Adult Inpatients and Adult Rehabilitation and Recovery Inpatient: there is a close working relationship to facilitate admission to, and discharge from, inpatient settings. Acute inpatient admissions for functionally mentally unwell are managed via the Crisis Resolution and Home Treatment Team CRHTT..
Intensive Outreach Services: CRHT and 136: there is a close working relationship to support crisis management and provide alternative to inpatient admission. Intensive Health Outreach Team IHOT.: IHOT provides assessment and treatment for adults of all ages who have multiple disabilities. IHOT aims to provide expertise in reasonable adjustment and supportive interventions to support the delivery of equitable outcomes for care packages in the One Stop Team. LDISS-
Specialist substance misuse services are provided by Turning Point
6.10 Discharge From The Trust
All discharges will be communicated with the Service User with capacity., relevant carer and GP as a minimum. Discharges should be consistent with the Trust’s Assessment & Care Management Policy. 7.0 Service Times The OST service will operate between 9.00 to 5.00 pm Mon-Fri with service user/ carer led flexibility to ensure effective relationships with 24 hour teams e.g. CRHTT. Assertive Outreach will operate between 9.00 to 5.00 pm Mon-Fri, and a weekend service:
West Locality: 9.00 to 1.00 pm Saturday and Sunday
North Locality: 9.00 to 1.00 pm Saturday and Sunday
South Locality: 9.00 to 1.00 pm Saturday and Sunday
The above weekend working hours are currently being piloted with an expected date for ratification by Autumn 2015.
9.0 Service User/ Carer Involvement
Delivery of this service is linked to a service experience programme to ensure that information is collected to demonstrate the effectiveness of the service in meetings its aims. 10. Staff Support
10.1 Clinical/Management Supervision
Gloucestershire Health and Care NHS Foundation Trust is committed to delivering its key policies that support staff within their day to day work. The Trust has a supervision policy and toolkit to ensure that forms of supervision are embedded into every day clinical practice. Each team is expected to have a management supervision tree explaining the supervision structure.
10.2 Training/Continuing Professional Development
• The One Stop Team has a training requirement for Care Management, RIO, Risk and Care Packages. This is at induction and as a periodic refresher
• Protected learning time and periodic away days will be supported to foster a culture of openness and opportunities for learning and innovation
• All staff are required to meet their mandatory and statutory training profiles. • Further CPD and learning will be considered as part of Appraisal Discussions
10.4 Team Meetings
The OST will hold a weekly team meeting. The team meeting will focus on the following areas of business using the shared structured agenda: • Sharing information
• Trust business
• Current performance by exception and recovery plans.
• Complex Cases
• Interface and Escalation issues
• Referrals to other teams and other statutory and non-statutory agencies
.
10.5 Day to Day Management
.
The team manager will ensure that there is daily coordination within each team to:
• Ensure the effective running of the team and manage any interface issues with both internal Gloucestershire Health and Care NHS Foundation Trust teams and external partner agencies
• Business continuity
• Management of buildings with support of admin managers through the Site Responsible Officers SRO..
• Health and Safety
10.6 Staff Appraisal Staff appraisal will be consistent with the ²gether NHS Foundation Trust’s policy and will conducted on an annual basis. 11.0 Staff Safety/Lone Working
All OST staff will undertake clinical work in line with the Trust Lone Working Policy and associated local arrangements. In particular:
• Whenever possible clinical appointments will take place in a clinic at a time when other staff are available and aware that the session is taking place. • The patient’s risk assessment, risk profile and associated management plan will be used to inform all decisions around face to face meeting arrangements.
• All appointments and visits should be pre booked in the RIO diary before they take place.
• All staff, both clinical and non-clinical, will be familiar with the local lone working arrangements in any building they use and of their associated roles and responsibilities. 12.0 Clinical Governance Issues
Clinical Governance is the framework through which we are accountable for improving the quality and safety of our services and safeguarding high standards of care. It is anticipated, therefore, that the content of this policy document reflects how the OST service in Gloucestershire will work in accordance with the ²gether NHS Foundation Trust commitment to working within the clinical governance framework. Governance issues relating to the application of this policy can be raised at the Locality Governance Committee.
13.0 Business Continuity
The Trust has a business continuity lead that will identify actions required in the event of an issue that affects the provision of the service.
Appendix 1
Psychological Interventions:
Clinicians from the Complex Psychological Interventions CPI. service are embedded within Recovery teams. They operate a stepped care model of direct clinical intervention for patients requiring specialist psychological input alongside multidisciplinary team needs. They take referrals from the Recovery team caseload referral pathway in Appendix ***.
They are responsible for providing psychological assessment and interventions as required at tier 4; these assessments should be provided within 4 weeks. CPI clinicians also provide team and individual supervision, consultancy, team training and development to enable psychological interventions to be provided to patients by Recovery team staff.
CPI: Referral Pathway RECOVERY TEAM
STEP 1 Care Coordinated by the Recovery Team
Assessment Joint Consultation/
Assessment Supervision
Psychological Brief Formulation Intervention
Could be Care Coordinated by STEP 2 Recovery or CPI *
Group Programme
C3
Open Art Thinking Minds Therapy Group Group Bipolar Group
Closed Art Therapy Emotional Skills Group Group STEP 3 Could be Care Coordinated by
Recovery or CPI*
Specialist 1:1 Therapy
*CPI can hold care coordination if clinically appropriate once therapeutic intervention has begun.
Appendix 2 GP REFERRAL TO ICT FOR ADHD ASSESSMENT
Diagnosis of ADHD
No Diagnosis of ADHD
The pathway is currently under review with Commissioners 28.09.2015.
Appendix 3 ADHD: Transition issue clarification pathway
The pathway is currently under review with Commissioners 28.09.2015.
Appendix 4 GP REFERRAL – FOR REVIEW OF ADHD/MEDICATION