Operational Policy For Specialist Child & Family Clinics Child & Adolescent Mental Health Services

Transcription

1 Operational Policy For Specialist Child & Family Clinics Child & Adolescent Mental Health Services Authorising Officer Keith Moullin, Head of Service Delivery Version: 1 Ratified By: DSG Policy Group Date Ratified: 25 th July 2011 Name of originator/author: Janet Arris CAMHS Community Manager Name of responsible committee/lead Janis Pridgeon, Service Manager individual: Date issued: 28 th July 2011 Review date: 28 th July 2013 Type: Operational policy Summary: Operational guidance and procedures for the CAMHS Specialist Child & Family Clinics Target audience: Staff team and users of CAMHS services Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities. Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership NHS Foundation Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all. Page 1 of 22 February 2011

2 Version Control Version date author status comment V1 Feb 2011 Janet Ratified July 2011 Arris All superseded documents are archived on the Trust main server. Comments on this document were requested from: Divisional Managers CAMHS Clinicians CAMHS Commissioner Joint Head of Service User Representatives Comments and feedback received from: Divisional Managers Team Managers Clinical Staff Contents Page 2 of 22 February 2011

3 Section Title Page 1. Policy Context and Purpose Policy Context Local Strategic Context Purpose & Aims 4 2. Service Scope Service user Group Covered Eligibility Criteria Children Looked After Within The Specialist Child & Family Clinic Exclusion Criteria 6 3. Service Delivery Location of services Days/hours of operation Staffing Referral process Difficulties that can be referred Response Times Care Pathways Choice & Partnership Approach (CAPA) Risk Assessment Management Consent to Share information Safeguarding Care Coordination Outcome Measures Discharge Process Transition to Adult Services Induction, Training & Supervision Comments Complaints and Compliments Confidentiality Access to Records Care notes Records Management Health & Safety Communication Equality & Diversity Policy Statement re access to health care for people with a learning disability Capacity to Consent Freedom of Information Quality Audit & Practice Governance References Review 17 Appendices A EIA 18 Page 3 of 22 February 2011

4 1 POLICY CONTEXT AND PURPOSE 1.1 Policy Context Child and Adolescent Mental Health Services (CAMHS) describe the broad range of services, which support the emotional wellbeing, and mental health of children and young people. In the last 10 years a raft of policy heralding the way for the development of a comprehensive Child and Adolescent Mental Health Service (CAMHS) has emerged. Key strategic direction has been found in Change for Children - Every Child Matters, Department for Children, Schools and Families (DCSF), 2004; The National Service Framework for Children, Young Peoples and Maternity Services, Department of Health, 2004; The Children s Plan-Building Brighter Futures, DCSF, 2007; Children and Young People in Mind: the final report of the National CAMHS Review, DCSF, Local Strategic Context The Children and Young Peoples Plan (CYPP) sets out the multi agency vision for services for children and young peoples in Hertfordshire across two main themes: Safeguarding children and young people Narrowing the gap between vulnerable children and all children Within Narrowing the gap between vulnerable children and all children is priority outcome 4, which sets out the key objectives to ensure children and young peoples emotional wellbeing, and mental health is well supported. In addition the Hertfordshire Emotional Wellbeing and Mental Health Strategy (2009/12 sets out the vision to ensure that a broad range of services are available to support children and young people. The strategy has 4 main strategic objectives: PROMOTION AND PREVENTION: Promote emotional wellbeing and positive mental health through effective engagement of the wider community; to raise awareness; tackle stigma; advocate early help seeking; and involve children, young people and their families and carers in the development and review of services. EARLY IDENTIFICATION AND INTERVENTION: Work in partnership to deliver a range of integrated, preventative, and early intervening services that are flexible and accessible in supporting and meeting the needs of all children and young people. TARGETED PROVISION: Take a coordinated approach to the delivery of targeted provision for children and young people from vulnerable groups. SPECIALIST SERVICES: Work better together to ensure that children and young people with complex mental health needs have timely access to the level of support and expertise they need. The Specialist Child and Family CAMHS clinics are fundamental in ensuring children and young peoples mental health is well supported. Under pinning this are the following principles: Services provide evidence-based intervention whilst focusing on the needs and preferences of the child, young person and their family or carers. Children and young people are safe from abuse and neglect. Page 4 of 22 February 2011

5 Services recognise and respond to the diversity of the communities they serve including race, culture, religion, gender, family and social values. Children, young people and their families or carers are listened to and actively encouraged to participate in the planning and development of services. Services are designed around the needs of children, young people, and their carers so that they may find provision to be appropriate and acceptable to their needs. All organisations and services value, empower and support their staff within a learning culture which constantly strives for ongoing performance improvement, ensuring staff have the appropriate skills and competencies to respond to and support children and young peoples emotional wellbeing and mental health Services are age appropriate; flexible; accessible and conveniently located for all children and young people 1.3 Purpose & Aims of the Service There are 8 Multi Professional Specialist Child & Family Outpatient Clinics across Hertfordshire providing assessment and treatment to children and young people with complex mental health needs and their families 2. SERVICE SCOPE 2.1 Service User Group Covered The Specialist Child and Family CAMHS Clinics are a service for children, young people and their families or carers between the age of 0 and 18 years who are registered with a Hertfordshire GP and have severe, complex and/or persistent difficulties which present as emotional or behavioural symptoms. 2.2 Eligibility Criteria The service accepts referrals for children and young people up to their 18 th birthday. The child or young person has severe, complex and/or persistent difficulties which often present as emotional or behavioural symptoms An appropriate community (universal or targeted) intervention has not resolved the current difficulties Or the difficulties are of such a severity and are causing impairment to such a degree that a referral straight to specialist CAMHS is indicated e.g. Psychosis, risk of suicide or severe self harm, severe depressive episode, eating disorders Referrals from the lead professional of integrated practice/caf process should indicate Targeted service has been tried with limited impact and Specialist CAMHS is being indentified as the appropriate agency to refer to at the Team around the Child meeting. Except in exceptional circumstances, the child or young person must have at least been seen and assessed by the referrer prior to referring on to specialist CAMHS. The young person or family consent to the referral 2.3 Children Looked After Within Specialist Child & Family Clinics Page 5 of 22 February 2011

6 The CLA service within Specialist CAMHS is a dedicated multi disciplinary team which offers flexible targeted interventions with a lower eligibility threshold than other parts of the service. All referrals start with a consultation with the network around the child. Offering a multidisciplinary approach to children looked after ensures that a thorough assessments of need is undertaken and the appropriate therapeutic intervention can be offered. In addition to direct work the children looked after team offer consultations to children s homes, foster carers groups, professional networks and area CLA teams. The work carried out with children looked after is not time limited and depends on the child s identified needs rather than a specific number of sessions. 2.4 Exclusion Criteria Children and young people whose problems are primarily school/college-based Children and young people where the behaviour, although challenging is age appropriate Usual child response to life events e.g. bereavement, parental divorce/separation Legal issues relating to parental separation/disputes Family mediation Child neglect/abuse as the primary issue Primary diagnostic assessments for Autistic Spectrum Disorders 3 SERVICE DELIVERY 3.1 Location of Services Stevenage Child & Family Clinic Southgate Health Centre Stevenage Welwyn Hatfield Child & Family Centre 22 Parkway Welwyn Garden City Bishops Stortford Health Centre Market Square Bishop Stortford Hoddesdon Child & Family Clinic Hoddesdon Health Clinic Hemel Hempstead Child & Family Clinic Marlowes Health Centre Watford Child & Family Clinic Peace Children s Centre Borehamwood & Potters Bar Child & Family Clinic Elstree Way Clinic St Albans Child & Family Clinic St Peters House St Albans 3.2 Staffing Page 6 of 22 February 2011

7 Within each multidisciplinary Specialist CAMHS Clinic there are a range of professionals including Psychiatrists Psychologists Social Workers Child Psychotherapists Systemic Psychotherapists Nurses 3.3 Days/Hours of Operation Specialist CAMHS Clinics operate a Monday Friday 9AM to 5PM service 3.4 Referral Process Referrals should be made using the Specialist CAMHS Clinic referral form. Direct referrals are accepted from: GP s within Hertfordshire PCT School Health Nurses Health Visitors Social Workers if CSF key worker Paediatrician and other NHS consultants Specialist CAMHS workers from out of area CAMHS workers in YOT and BST Educational Psychologist Speech and Language Therapists Lead Professional for TAC Child & Adolescent Challenging Needs Psychological Service 3.5 Difficulties that can be referred Specialist CAMHS accepts referrals for assessment and treatment of severe, complex and/or persistent psychological and emotional difficulties Difficulties may include Psychosis Moderate to severe depressive symptoms Attention Deficit Hyperactivity Disorders & ADD symptoms Pervasive Developmental Disorders such as Autistic Spectrum Disorders with mental health issues (not for primary diagnosis) Severe Tourette s syndrome and complex tic disorder with co-morbid symptoms e.g. obsessive compulsive symptoms, depression Self-harm and suicide attempts Eating disorders Moderate to severe obsessive compulsive symptoms Moderate to severe phobias and anxiety disorders Mental health difficulties associated with physical health problems and somatoform disorders Mental health difficulties associated with learning disabilities Severe conduct disorders associated with mental health difficulties Complex elective mutism Severe and persistent emotional difficulties related to complex physical conditions that have failed to respond to universal or targeted interventions Page 7 of 22 February 2011

8 Once a referral has been accepted by Specialist CAMHS Clinics the Choice and Partnership Approach is used. An assessment including risk assessment of the child or young person is carried out. Formulation and or diagnosis are shared with the child/young person and family/carers. The child /young person is then offered a choice of therapies/treatment and this is the basis for their care plan. The child/young person will be given a copy of their care plan. A range of interventions are offered in line with NICE Guidance and evidence based practice these include Professional Consultations and liaison (face to face and telephone) o Advice on appropriateness of referrals, advice about ongoing work in the community as well as request for CAMHS clinicians it attend Team Around the Child Meetings o Discussion about a child, which may clarify whether a formal referral is appropriate route or signposting to alternative provision. Identification of likely best interventions based on evidence and/or best practice bearing in mind the context in which the problems present. This may include sign posting to alternative provision Direct Intervention A range of face to face therapies including o Family Therapy o Psychotherapy o Psychosocial interventions o Cognitive Behavioural Therapy 3.6 Response Times The Specialist Child & Family CAMHS Clinics are currently working within the 18 week pathway once a referral has been accepted. Referrals are screened and prioritised on a daily basis. Emergencies referrals will be arranged to be seen within 24 hours to assess risk. All other referrals will be discussed at a weekly team screening meeting, urgent referrals will be offered the next available Choice appointment or unfilled Partnership appointment. 3.7 Care Pathways Choice & Partnership Approach (CAPA) The aim of CAPA is to provide services to young people that are user friendly, designed around their needs, accessible, safe and effective. CAPA relies upon the principles of Choice & Partnership children/young people and their families are invited to an initial choice appointment where the aim is to identify what help is wanted and reaching a shared understanding of the difficulties. From here a range of alternative interventions can be offered including other services, self help strategies and/or appropriate specialist CAMHS interventions. If the child & family chose to be seen for further appointments within the service then they are invited to book partnership appointments. The aim is for the family to work in partnership with the CAMHS professional on jointly agreed goals 3.8 Clinical Risk Assessment/Management Page 8 of 22 February 2011

9 Clinical Risk Assessment and Management is defined by the Trust as a continuous and dynamic process for judging risk and subsequently making appropriate plans considering the risks identified. Modern risk assessment should be structured, evidence based and as consistent as possible across settings and across service providers (Best Practice in Managing Risk, Department of Health, March 2009) Essentially clinical risk assessment and management is fundamental so that: Risks to the wellbeing of children, young people, their families staff and others are assessed and identified Indicators of possible adverse outcomes e.g. non-compliance with treatment or nonattendance at appointments are addressed Risks to children, young people, their families, staff and others are regularly reviewed Risks to children, young people, their families, staff and others are communicated appropriately Shortfalls in services are identified and addressed And ultimately Children, young people, their families, staff and others are safeguarded. The standard risk assessment tool will be used by the person conducting the initial clinical interview. The enhanced/comprehensive risk assessment will be completed where significant risk is indicated. A risk assessment is an ongoing process and any change to risk will be documented by the care coordinator. As a minimum all risk assessments will be reviewed annually. Identified risks will be shared with all HPFT staff working with the child, young person and their family. A copy of the risk assessment will be placed on the care records. It is a clinical decision who out side the organisation the risk assessment is shared with, this will be done in line with the guidance on consent to share information. 3.9 Consent to Share Information Consent to Share Information should be discussed at the Choice Appointment and consent to share information form completed. This should also be recorded on Care notes The requirement for the individual's consent to disclosure will not apply if the duty of care to the individual or the public interest makes disclosure essential for example: Notifiable infectious diseases Poisoning and serious accidents/incidents in the work place The information is required by statute or court order The information is required by the Coroner Page 9 of 22 February 2011

10 There is a serious risk of harm to the individual There is a serious public health risk or a serious risk of harm to others The information is required for the prevention, detection or prosecution of serious crime within the Crime and Disorder Act 1998 A child protection investigation is being carried out or the child is on the child protection register, and disclosure is necessary to assess the risk to the child or to promote the effective protection of the child The child is looked after, and the sharing of information with carers is necessary to ensure the best possible care for the child Where Child Protection is an issue, the overriding principle is to ensure the safety of the child Safeguarding Where there is reason to believe that a child under the age of 18 years or an unborn baby has suffered, is suffering or is likely to suffer significant harm a referral should be made to Hertfordshire Children Schools and Families. Professionals should seek to discuss concerns with the parent / carer and where possible seek their agreement to making a referral. This should only be done where such discussion and agreement seeking will not place a child at increased risk of significant harm. Referrals should also be made to Children s Social Care where it is thought the family may benefit from family support services. In this situation agreement of the parent / carer is always required. If staff are unsure about making a referral then consultation should take place with the Lead Nurse or Lead Doctor for safeguarding children Referrals to Hertfordshire CSF should always be made in writing. The named nurse for safeguarding children must receive a copy of the referral. Professional referrals cannot be made anonymously. All cases of suspected or actual abuse must be taken seriously and acted on from what initially appears minor to serious incidents. Professionals must ensure they record their concerns and actions taken onto care notes, including entering an alert on care notes about any child protection matters. Concerns regarding subsequent action taken by other agencies must be escalated by the professional to their line manager and discussed with the lead nurse safeguarding children who will advice on appropriate action Care Coordination Once Partnership has been agreed the child and family will be allocated an identifiable care coordinator 3.12 Outcome Measures Page 10 of 22 February 2011

11 CAMHS Outcome Research Consortium (CORC) CORC is an agreed set of measures to routinely evaluate outcome from at least three key perspectives (the child, the parent/carer and the practitioner). The current core measures are Strengths & difficulties questionnaire (SDQ) for the child & parent perspective Commission for Health Improvement (CHI) Experience of service questionnaire (ESQ) for the parent & child to feedback on the Service Children s Global Assessment Scale (CGAS) Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) for the practitioners perspective These measures are taken at two points: Time 1 SDQ CGAS or HoNOSCA Goals completed by parents and child before they are first seen or during the first meeting completed by practitioner after the first meeting completed by practitioner following discussions with the child and family (usually within first 3 meetings) Time 2 SDQ CGAS or HoNOSCA Goals CHI-ESQ completed by parents and child at 6 months after first meeting (no less than 4 months or more than 8 months) completed by practitioner at 6 months after first meeting or at end of contact if this is sooner completed by practitioner at 6 months after first meeting or at end of contact if this is sooner completed by parents and child at 6 months after first meeting or at end of contact if this is sooner The data gathered from the measures is then stored locally in a database and then sent to the CORC technical team for analysis (when enough data has been collected). Currently there are psychology assistance working within Specialist CAMHS in Hertfordshire who are able to interpret and present local data. In addition to local interpretation the data can be presented in two main ways in the form of automatically generated reports from the YouthinMind database, on a case by case basis, and in the form of the main CORC report prepared by the central team and made available to each member on receipt of their data. Page 11 of 22 February 2011

12 3.13 Discharge Process All discharges/transfers will be documented in the electronic patient records and the following information will be recorded in a discharge summary and sent to the referrer and GP: The reason for discharge/transfer The child/young persons condition at discharge/transfer A written final evaluation summary of the service user s progress towards identified treatment/care goals Any recommendations to maintain progress 3.14 Transition to Adult Services Where a young person who currently receives a service from CAMHS, is assessed as requiring HPFT mental health services beyond their 18 th birthday, a proposed transfer will be discussed by the CAMHS care coordinator with the service user, and their family/carers, The service user and their family/carers will continue to be involved at each stage of the transfer process and receive the appropriate information regarding the new service/s, contact numbers etc. A formal written referral will be made to the relevant local Adult Mental Health Service by the CAMHS care coordinator. This referral will be made approximately 7 months before the young persons 18 th birthday. A planning meeting will take place at least 6 months before the young persons 18 th birthday with ongoing communication to ensure a smooth transition to adult services. A final Care-co-ordination/ transfer meeting will take place where the CAMHS service officially hands-over the care of the young person to adult mental health services, and discharges them from CAMHS (including any Responsible Clinician responsibility). The date of this meeting should be set at the planning meeting. Following the final transfer meeting, a CAMHS discharge letter will be sent to the service user s GP. All other services providing ongoing services to the young person will be made aware that the handover has taken place Induction Training & Supervision All newly appointed staff undergoes an induction programme in line with HPFT policy Staff development and training is a high priority for HPFT and each member of staff has an annual appraisal and a personal development plan identifying training needs Clinical and managerial supervision is available to all members of staff 3.16 Comments, Complaints and Compliments All comments, complaints and compliments will be dealt with in accordance with the jointly agreed Hertfordshire Partnership NHS Trust and Child Care Services Policy. Any comment, complaint or compliment should be made directly to the Complaints Manager. A leaflet outlining the procedures is available in the unit Confidentiality Staff will aim to preserve the confidentiality of information acquired from young people and protect the privacy of individuals about whom such information is collected or held Page 12 of 22 February 2011

13 Carers and relatives frequently request information. This will be given to them when appropriate and with the agreement of the service user. If there is a significant risk to the service user or others then information will be shared with carers on a need to know basis and the service user will be informed of this necessity Subject to the requirements of the law, staff will take care to prevent the identity of any young person being revealed without the expressed permission of the individual. Staff operate a system of shared confidentiality this means information about individuals will be shared by members of the multi-disciplinary team for the purposes of allocation, advice and supervision. Further guidance can be found in the HPFT Policy on the Management of Care Records and the protocol Inter-Agency Exchange of Information Access to Records Members of staff have a statutory duty (Data Protection Act 1998) to inform the young people that information is being held by the Trust on Care Notes, the electronic patient record, which records details of their health and social care assessment, treatment and progress, and that these records are identifiable. The young people must also be informed of the right to request access to their records. This information should be given verbally and by offering the young person the relevant information leaflet. The mental health professional should inform the individual that all information is confidential but may be shared on a need to know basis. Formal applications for access to records have to be in writing. An Access to Your Health Records" leaflet can be obtained from a member of staff or from the Records Officer, Albany Lodge, Church Crescent, St Albans, AL3 5JB and can be sent direct to the Unit Manager. This requirement does not override the promotion of good practice where health and social care staff share information and records with service users during the course of the treatment/care episode 3.19 Care Notes Care Notes, is the HPFT Electronic Patient Record used throughout the Trust Staff are required to have training on the use of the system and to ensure all records are completed on Care Notes as agreed 3.20 Records Management All NHS employees (including seconded staff) are responsible for all records that they create or use in the course of their duties. This responsibility is defined both in law and in other professional guidelines covering the handling of records. For example, the Public Records Act 1958, the Data Protection Act 1998 and the Freedom of Information Act The Trust's Records Management Policies give full details of those responsibilities and the standards we need to meet 3.21 Health and Safety On the unit the health and safety of staff, young people and visitors is of high importance. Any kind of violence verbal or physical to staff, young persons or visitors will not be tolerated. This may well be reported to the police and a criminal prosecution may follow. Page 13 of 22 February 2011

14 It is the general duty of every member of staff to take reasonable care of their own health and safety, and that of others. This includes the use of necessary safety devices and protective clothing, and to co-operate with managers in meeting responsibilities under Health and Safety legislation. Staff should report all concerns of a health and safety nature to the unit manager (or delegated representative) for appropriate action 3.22 Communication For people with physical, cognitive or sensory disabilities and people who do not speak or read English, information should be provided in a way that is suited to the individual s requirements and enables them to participate as partners in decisions about their health or social care If the individual (or in the case of a child their parents) relatives or carers, do not have sufficient understanding of English and the member of staff does not speak their language, an interpreter should be available to assist when giving information. The telephone interpreting service Language Line is available to all Trust staff for short conversations or face-to-face interpreters including a sign language interpreter, can be arranged. The HPFT Policy On 'Communicating With Individuals From Diverse Communities' provides guidance and the procedure for accessing the interpreting service It is not good practice to use families, especially children aged 16 and under, to act as interpreters for healthcare information 3.23 Equality and Diversity All staff must be aware of issues relating to equality and diversity for service users, carers and staff including: Understanding how to ask questions about culture, religion and ethnic background. Arranging interpreters where necessary. Offering adaptations for people with disabilities e.g. Hearing Loop, Downstairs meeting rooms etc. Opportunity to discuss relationships and issues relating to sexuality. Ensuring that older people do not suffer disadvantage and are supported appropriately within services. Ensuring that people with learning disabilities do not suffer disadvantage and are supported appropriately within services. The needs of both men and women are represented equally including the needs of transgendered service users. Staff have a responsibility to challenge any discrimination they may witness and report back in accordance with risk management and complaints and incidents processes. All staff have the right to be treated with dignity and respect. Any situations of harassment, bullying or other abuse must be dealt with in accordance with the Trust harassment & bullying policy and other associated guidelines. All staff are also entitled to access the Employee Assistance Programme which includes the counselling service, if needed. Staff must also be aware of issues relating Human Rights including how they apply to staff and service users. Information on this is available within the Trust Single Equality Scheme. Page 14 of 22 February 2011

15 Disability access All services that are offered above ground floor level must have clear contingency plans for how they work with service users, carers and staff with disabilities, that prevent them accessing premises above the ground floor. A clear contingency protocol must be outlined in the service operational policy. Single sex accommodation must be available to service users admitted to mixed sex units Policy statement re access to healthcare for people with a learning disability All mental health services in HPFT are available to people with a learning disability. HPFT have a responsibility to ensure that all people with a learning disability access appropriate services and that they receive the best treatment available in line with good practice and legal frameworks. Therefore all services will ensure that Reasonable adjustments are made to ensure that each person has the same opportunity for health, whether they have a learning disability or not. (Disability Discrimination Act 2005) Assume that each person presented to the service has capacity. If assessment shows they don t, a decision must be made in their best interest. (Mental Capacity Act 2005) Everyone has a right to expect and receive appropriate healthcare. (Human Rights Act 1998) Adjustments will include spending time with the individual to gain an understanding of their preferences for treatment To ask them where they would prefer to be treated, To provide additional support to assist with communication, this support will be available via easy read material/and/or audio equipment. Templates for appointment letters and easy read information leaflets are available via the Performance page on the intranet. If an individual continues to have difficulty understanding their treatment it is the responsibility of the staff to refer them to a specialist learning disability service for additional support All people with a learning disability should have a Health Action Plan (Valuing People) and all HPFT staff will ask for permission to see these and contribute to the plan when appropriate To value and welcome the contribution of the relative/carer/advocate 3.25 Capacity to Consent Where the young person does not have the capacity to consent, (from April 2007) parts of the Mental Capacity Act will be in force so common law will not apply. They will need to refer to the Trust/ACS joint policy on the MCA to treatment, health professionals can and should provide treatment if it is considered to be clinically necessary and in the 'best interest' of the service user. Discussion should take place within the multidisciplinary team and where appropriate with relatives and carers. It may be necessary to obtain legal advice in some circumstances. Issues on capacity are fully covered in the Mental Capacity Act Freedom of Information The purpose of the Freedom of Information Act (FOI) is to allow greater access to non-clinical information held by public authorities and potentially the Public can Page 15 of 22 February 2011

16 scrutinize every document (that is not about an individual e.g. young person). The Act gives the Public the right to be told whether a piece of information exists and the right to receive it if requested The FOI Act DOES NOT supersedes the Data Protection Act 1998 and information about an individual (and described as personal data) would not be disclosed under the FOI Act Quality, Audit and Practice Governance Every effort will be made to provide services of high quality. Local Practice Governance Groups, involving all stake holders, meet bi-monthly to review, reflect, prioritise and learn the lessons identified from practice issues such as serious incidents, near misses, complaints and compliments 4.0 References Clinical risk assessment and management Lone Worker and Essential travellers policy Policy on Comments, complaints and compliments Policy on learning from adverse events policy Policy for the Management of Care Records Mental Health Act 1983 and the Code of Practice Policy on Transition from CAMHS to Adult Mental Health Services Hertfordshire Interagency response to allegations of Abuse Policy on Communicating with service users from diverse communities Policy on Access to Records Policy on prevention and Management of Violence Hertfordshire Safeguarding Children policy Supporting References Every Child Matters 2004 NSF for Children DoH 2004 The Childrens plan Building a Brighter future National CAMHS review 2008 (Children and Young people in mind) The Childrens Act 1989 Emotional & Wellbeing Strategy Review This policy will be reviewed after 1 year. Page 16 of 22 February 2011

17 APPENDIX A HERTFORDSHIRE PARTNERSHIP NHS FOUNDATION TRUST USING THE TOOLKIT - FORMS Equality Impact Assessment (EIA) Stage 1 The approach adopted by HPFT is one that will enable you to undertake the EIA systematically, within a short time period. It should not be a long complex process. NB please copy and paste the relevant forms into your policy or other paperwork as the final appendix. Data Checklist The first part of the Equality Impact Assessment is to complete the questions in the Data Checklist. The Data Checklist will enable you to bring into the equation any existing equality and diversity information and data related to the policy, procedure and/or service being assessed. The data checklist will help you identify information which can then be used to inform the EIA. All the questions are specific to equality. Name of Policy: Specialist Child & Family Clinics Child & Adolescent Mental Health Services Lead Officer: CAMHS Service Manager Yes/No Please give details 1 Have there been any complaints, about the policy, procedure or service? Yes Complaints in relation to eligibility and access to the Child and Family clinics 2) Have officers raised concerns, or issues about implementation of the policy, procedure or service? 3) Have previous consultation highlighted any concerns about the policy, procedure or service? 4) From implementation of the policy, service or function, do you have any concerns about the policy, procedure or service? 5) Does any accessible data, identify gaps for service users? No No No No 6) Are there any other issues No Page 17 of 22 February 2011

18 which you think could be relevant? Equality Impact Assessment (EIA) Stage 1 THE INITIAL SCREENING OR SCOPING STEP 1. Is this a new or existing policy? 2. Identify the aims of your policy, service, standards for practice PROCESS New: Existing: New To provide information in relation to the Child and Family clinics in relation to Eligibility Exclusion How to access the services Where they are located 3. Does the policy/service link to others? If yes please state. 4. Does the policy/service show that the 11 principles of mental health recovery have been taken into account? Yes: please explain below NSF for Children Safeguarding children Mental Health Act Yes: Real Choice and Respectful Partnership this is demonstrated through the Choice & Partnership Model of assessment and treatment and focuses children and young people setting their own achievable goals No: No: 5. Who is intended to benefit from the policy/service? CAMHS Commissioners GPs Paediatricians Children schools and families Any professionals who may make referrals to the Child and Family clinics 6. How is the policy/service to be put into practice? Who is responsible? The policy will be circulated to all referring agencies once it has been ratified Janet Arris CAMHS Community Manager Page 18 of 22 February 2011

19 7. How and where is information about the policy published? It will be on the Trust website for CAMHS as well as circulated to referrers 8. What regular consultation do you carry out with different groups re policy/service publicised? 9. Have you involved staff who have or will have direct experience of implementing the policy, procedure, service? If yes how? All draft documents are shared with potential referrers to the service All of the Child and Family clinics have been involved in the development of this policy./ 10. Are there concerns that the policy/service could have an adverse impact because of: Age, Disability, Gender, Ethnicity, Sexual Orientation, Religion and/or Belief 11. Do the differences amount to discrimination? 12. If yes could it still be justifiable e.g. on grounds of promoting equality of opportunity for one group? Yes: please explain the service is age specific Yes: Yes Yes: This is an age specific service that addresses the needs of children and young people with complex and or enduring mental health issues No: No: No: Page 19 of 22 February 2011

20 13. Do you think this policy/service specifically contributes to promoting equality and diversity? 14. What approaches will you take to get feedback on your assessment? Yes: No: 15. How will the assessment link to other mainstream service planning review process? 16. Should there be a Full Impact Assessment and if so what are the reasons? It will link to an overall service review currently being undertaken in CAMHS No as it is a confirmation of current practice that needed to be laced in a policy 17. If the assessment needs to progress to a Full EIA then you need to consider what further data, information or assistance do you need to carry out the full assessment GETTING FEEDBACK AND ADVICE Feedback should now be sought from representatives of the Equality Impact Assessment Scrutiny Group or other agreed forum. Details can be found in Appendix 4. What feedback did you receive in relation to the Stage 1 EIA? The policy was discussed at the EIA on 2 nd April and the following comments made: 1) s.3.23 Equality and Diversity should reflect standard Trust position text 2) 2)q.4 EIA must state how it meets 11 principles of recovery 3) Q.10 policy age specific, so negative impact should be reflected, Page 20 of 22 February 2011

21 although justified due to nature of the service. 12. Please list the actions that requires implementing to address any negative or adverse impact? Page 21 of 22 February 2011

22 Page 22 of 22 February 2011