Mission Statement of the Service
“Working together to live well in the community.”
The overall aims of the service are:
- Reduce risk through effective discharge and collaborative risk assessments
- Develop and maintain positive relationships with our patients, carers and all services.
- Promote/support/encourage/assist recovery, AND deliver strength-focussed care
- To maximise individual patients’ potential, recovery and wellbeing in a collaborative relationship, this is holistic, supportive, empowering and ultimately seeks to improve their mental health.
- Focus outwards to the community and support outside of the clinical team
- Co-produce services - Use and value the Lived experiences of our peer recovery workers, patients and their friends, family and carers.
- Follow the principles of least restrictive practise
- The Care Programme Approach (CPA) is there to support your recovery from mental illness.
- CPA is a framework used to assess your needs and make sure that you have support for your needs.
- Community Mental Health Teams, Assertive Outreach Teams and Early Intervention Teams are likely to use CPA.
- Your mental health services will have policies about who is able to get help under CPA.
- Under CPA you will get a care coordinator who monitors your care and support.
- Your care coordinator will review your plan regularly to see if your needs have changed.
Rethink care programme approach factsheet: Care Programme Approach (CPA) - Rethink Mental Illness
Working with men and women over 18 with a diagnosed psychotic mental health disorder and personality disorders, whom have been an inpatient in secure mental health services within the West Midlands/or who are being repatriated from secure services out of the West Midlands area.
The inclusion/exclusion will be based on clinical need/risk including a psychological formulation. The list below is indicative only, decisions will be made based on individual needs/safety and support available. The main risk factors are:
- A clinical risk history of extremely poor engagement with secondary services leading to offences being committed.
- Those whose relapses are sudden causing the risk of a serious offence being committed.
- Those who have committed a serious index offence of murder/ manslaughter, severe violence, arson or sexual offending, with a mental health diagnosis and are subject to section 37/41.
- Those who struggle with transitions and are frequently in crisis, there needs to be evidence that this has increased the risk of offending behaviour.
- Those with co-morbidities, such as substance misuse, which increase the risk of offending behaviour alongside their mental health condition.
- Senior clinicians within the team can be contacted prior to a referral being made if clarification regarding eligibility is required by the referrer.
- Enquiries and requests for advice will be accepted from any agency working with this patient group; however requests for this team to take on case management will only be considered if the requests originate from the Responsible Clinician. It is expected that all referrals should be made with the Responsible Clinicians’ knowledge and agreement.
To ensure the maintenance of good communication systems within and between agencies and services involved in patient care.
The wider roles and responsibilities within the team are as follows:
- Collaborative working with other teams/ may include:
- Joint assessment with staff from other teams
- Consultation/advice to other teams
- Joint working with local housing providers
- Joint working with charitable organisations/voluntary agencies
- Strategic development and maintenance of interagency liaison, including:
- Membership of MAPPA – Head of Forensic Social Work
- Accommodation Working Group
- Wolverhampton Liaison Scheme
- Reachout meetings
- Project Work as appropriate
- Contributing in general terms to the services provided by Midland Partnership NHS Foundation Trust including the provision of:
- Collaborating in service developments which may have a joint impact on generic and Forensic services
The role of Peer Recovery Worker (PRW) has been developed specifically for people who have lived experience of having received care via secure services/adult mental health. Through sharing wisdom from their own experiences, Peer Recovery Workers will inspire hope and belief that recovery is possible in others.
The role will provide formalised peer support and practical assistance to service users in order for them to regain control over their lives and their own unique recovery process. Within a relationship of mutuality and information sharing, they will promote choice, self-determination and opportunities for the fulfilment of personally valued roles and connection to local communities.
The PRW will act as a recovery champion and an ambassador of recovery for the Trust with external agencies and partner organisations. There is also an expectation that PRWs will be involved in the on-going development of peer roles in the Trust including the Peer Training Programme and evaluation.
All patients will be central to and encouraged to be actively involved in the development of their care plan and treatment.
As far as is possible we will tailor the service offered, with respect to the patient’s wishes and choices.
FIRST will respect, encourage and value the right for patients to have a carer/advocate present at any meeting or discussion in relation to decisions or choices about their care.
All carers will be advised of their right to have an assessment of their own individual needs.
A range of information will be available to all patients and carers. This will include a guide to the service which will be developed as part of on-going improvements towards patients understanding of the service.
FIRST will give a commitment to take into account user and carer feedback and where possible utilise these views to affect change.
Referrals to the team must be made via FIRST referral form and include the following information:
- Purpose and expectations of the referral (i.e. consultancy, joint working or full CPA transfer).
- Details of the specific ongoing support required and current risks.
- A full psychiatric history (including social history, medication history, previous offending even if this did not result in charges and forensic history).
- Patients views relating to referral and future pathway.
- Current Care plan.
- Current Risk Assessment – FACE, HCR20, Relapse Signature and CRISIS Plan
All referrals will be discussed at the Team clinical meeting and a decision will be made regarding suitability. Requests for further information will then be made if required. Actions regarding the referral will be discussed at the meeting and a decision made as to the most appropriate team member is to carry out agreed work.
Update to the referrer
An update will be given to the referrer no more than 7 working days post this initial visit describing work to date and expected work/assessments to be completed.
Wherever possible, the outcome of the assessment will be presented at the next team meeting and discussed with all members of the team. This will be placed onto RiO once completed and sent to the referrer.
Written acknowledgement of the referral and an outcome of the team discussion will be sent to the referrer within one week, up to a maximum of 10 working days allowing for bank holidays. If accepted, the team will allocate a lead person to undertake liaison work/care coordination and the patient will be seen within 15 working days.
Where immediate/urgent action is indicated, the team will liaise with the referring team/agency and advice of the appropriate course of action verbally, following this up in writing (e-mail /RIO) by the next working day. FIRST will support the referrer practically until a full and comprehensive referral has been completed and accepted.