Name: The Cambridge Centre for Paediatric Neuropsychological Rehabilitation (CCPNR) Lead contact: Diana McCollum

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1 EDS Outcome 1.3 (EDS Goal 1 Better health outcomes for all) Changes across services for individual patients are discussed with them, and transitions are made smoothly Name: The Cambridge Centre for Paediatric Neuropsychological Rehabilitation (CCPNR) Lead contact: Diana McCollum Children referred to the service may also benefit from the input of the Croft Child and Family Unit. One particular referral who required this input, also required provision of an interpreter so that the family therapy sessions were of benefit to the child s mother who could only speak Slovak. Additionally, transport was also a significant issue for this family; therefore provisions were made to enable the entire family to attend the family therapy sessions. Good collaboration and transition between CCPNR and the Croft Unit, together with thorough explanation of the programme of intervention to the family, has ensured that there was ongoing successful engagement. Further transitions occur between the children and adult services, where an overlap has been arranged to ensure that children/young people and their families are comfortable with the new service, before discharge is effected from this service. Name: Fenland Adult Services Lead contact: Sue Tolland All patient transfers take place under the umbrella of CPA. Transfers will take place within CPA handover meetings. For patients from elsewhere the Gateway worker organises the transfer meeting with all appropriate agencies, and staff from the team taking over the care. There are some problems in the transfer of people with a diagnosis of learning disability, this is mainly because of the differing thresholds within the specialist services and Adult Mental health services. This is usually resolved by negotiation between the service wishing to transfer the patient, GP and any other relevant agency. There are also problems in transferring patients from Adult services to older persons services, Again this is due to differing thresholds. Name: AEDS Lead contact: Caroline Nightingale The Community Teams and Ward staff work closely with other Healthcare professionals and through reviews and care planning ensure a smooth transition between services. Each individual is fully involved in their care plans

2 Name: Rehab & Recovery North East Cambridge and South West Cambridge Lead contact: Samantha Roberts Patient would be provided with written information about the proposed change and would meet with the receiving service prior to transfer. Name: Intake & Treatment (Adult Division) North East Cambridge and South West Lead contact: Christine Robertson Cambridge In relation to transitions within CPFT i.e. transfer from Intake & Treatment to any tertiary service this is always discussed through the care plan process and would be prepared for. The method in which this is prepared for may vary depending on the patient s understanding and needs. The patient would be provide with written information about the proposed change and would meet with the receiving service prior to transfer. Leaflets are available to outline that the norm for Intake & Treatment would be up to a 12 month period of treatment, although many are discharged back to primary care prior to that point. Name: Intake and Treatment Team - Peterborough Lead contact: Angela Loynes (Team Manager) Service changes and transitions for all Intake and Treatment Service Users are carefully considered as part of the person s CPA care plan. Risk assessments are carried out if required and the care plan reviewed to accommodate any new interventions/treatments required (see professionals meeting notes/care plan for M45359). The team always try to discuss the change with the person and to involve the service user, and if appropriate carer, in collaboratively devising the care plan. There is a shared weekly meeting to discuss for transitions between Peterborough Intake and Treatment and Peterborough Rehab and Recovery Team is attended by both team managers. A representative form the Intake and Treatment Team attends the weekly Ward Round on Oak 1 & 2 and there is also a weekly interface meeting with the LVGC. The Intake and Treatment Team Manager, Assistant Team Manager and Consultant Psychiatrist have also met to discuss issues in working together and transfer of service users. Transitions to the Complex Cases Service are less smooth and no new referrals have been accepted since January 2012 to the team. This has been raised with the Complex Cases Team Manager and this service is currently being reviewed. Again this is not specific to protected groups and would be experienced in a similar way by the whole patient group. Name: Liaison Psychiatry Lead contact: Dr Jonathan Wood The Service provides comprehensive assessments of its patients and seeks to enable smooth transitions and changes across services on an individualised basis weather barriers to this arise out of a protected status e.g. learning disability or another problem e.g. alcohol dependence. We would ensure that services we refer into offer an appointment. The Service receives informal feedback from patients about barriers to transitions and disseminates these informally across the

3 team within our team meetings. Where feedback relates to a complaint which requires change in practice this would be disseminated to the team via . No key disadvantaged groups are identified. Name: Liaison IAPT, Peterborough, Cambridge, Mid Essex Lead contact: Linda Davies The Service provides comprehensive assessments of its patients and seeks to enable smooth transitions and changes across services on an individualised basis whether barriers to this arise out of a protected status e.g. learning disability or another problem e.g. alcohol dependence. We would ensure that services we refer into offer an appointment. The Service receives informal feedback from patients about barriers to transitions and disseminates these informally across the team within our team meetings. Where feedback relates to a complaint which requires change in practice this would be disseminated to the team via . No key disadvantaged groups are identified. Name: Specialist services Cambridge Forensic Psychiatry Lead contact: Cate Fish Transfer of patients through CPA process. Relevant parties invited to review to discuss the persons needs/ care. internal referrals made or verbal discussions take place via telephone, all recorded in integrated casenotes, CPA and letters to other agencies (GPs). Also in the team meeting minutes. Transfer to secondary mental health services or GP/Primary care close co-working to enable relationship building and ease transfer or even discharge. Name: Cambridge Assertive Outreach and FACE Teams Lead contact: Emma Green CAOT (including Homeless specialist): As outlined above, transitions of care are managed through the CPA process. In addition changes in service provision/transfer to other teams is linked to the principles of recovery such as the inspiration of hope, empowerment and self management. The team works collaboratively with the service user to identify the time for discharge, and discusses how they can re-enter the service as need arises, or access different types of appropriate help. Transfer of care is potentially a vulnerable time for patients who have developed a relationship with their care co-ordinator, and is covered within the Trust CPA Procedural Guidance. To ensure the teams maintain capacity to undertake new referrals/transfers there is a need to be proactive in transferring and discharging service users.

4 Transfer or Discharge planning will form an integral part of the service user s Care Plan and will be discussed at the CPA Review meeting. Liaison with other involved agencies will take place early in any work undertaken to ensure continuity of care Should a service user be unwilling to continue with the team the situation will be discussed within a multi-disciplinary team meeting. Risks will be assessed and an action plan, dependent on risks and need, agreed. The GP will be informed. Discharge to GP Where service users have shown good recovery and are able to continue their recovery journey without support from the Assertive Outreach Team, they will be discharged back to their GP. In these circumstances the discharge should be accompanied by a comprehensive Discharge Plan which gives advice to the service user and to the GP about ongoing management. Those people in receipt of a social care package will require ongoing monitoring and review. Rapid re-access to services: The Blue Zone Some service users will be allocated to the Blue Zone for rapid re-access to services. Service users or their carers can contact the Assertive Outreach Team to request an assessment of their mental health. This will be carried out by a member of the multidisciplinary team. If the service user requires intervention with the team a care co-ordinator will be allocated. Criteria for blue zone access are that the service user has a severe mental illness which is at risk of rapid relapse, that they or their carer are able to recognise early warning signs of relapse, and are able to make contact with secondary care services. Other service users can re-access the service by re-referral from the GP. Transfer to other community based CPFT services Service users who have improved sufficiently to be discharged from the team but who still require psychological treatment may be transferred in a step down to the Rehab and recovery Teams. Admission to Hospital Some service users in contact with the Assertive Outreach team may also be referred to the Crisis Resolution Home Treatment teams (CHRT) or admitted to in-patient wards for assessment and intervention.

5 The Assertive Outreach Team maintains close liaison with the in-patient wards and Home Treatment Teams (CRHT) The decision to discharge people from in-patient care is made in a multi-disciplinary meeting and all the relevant staff invited or informed. Follow- up for people discharged from the ward should be within 7 days unless clearly indicated and documented as not required. If the patient does not attend the first follow-up appointment offered a clinical decision will be taken to determine the action required. For those people subject so S117 aftercare who are transferred out of the Trust area, there may be a continuing responsibility on behalf of the local authority to monitor and review their care. Out-of-area Placements Decisions about out-of area placements for treatment or management will be made by the responsible clinical team and the Service Development Manager for Out-of-Area placements. FACE: As outlined above transitions of care are managed through the CPA process, in addition as part of the intensive case management process the care plan will identify the service that will have responsibility for the ongoing responsibility for the Frequent Attender. Transfer to this service/care coordinator will be part of the negotiated care package. Much of the work undertaken by Face will be related to multi agency working. In recent years, multi-agency working has received much attention and has been the focus of some political agendas. There are five recognised models of multi agency working: decision making groups; consultation and training; centre based delivery; operational Team delivery; coordinated delivery. The FACE Team will use the coordinated delivery model. A coordinator will pull together different services and will operate between the strategic and operational levels. Delivery of services to the frequent attenders will be carried out by different professionals who may not have contact with each other but will be able to gain knowledge of other agencies work through the coordinator. Important factors that support and promote multi-agency working: Clear and realistic aims and objectives which are understood and accepted by all agencies Clearly defined roles and responsibilities, so everyone knows what is expected of them and of others, and clear lines of

6 responsibility and accountability Commitment of both senior and frontline staff which is aided by involvement of frontline staff in development of policies Strong leadership and multi- agency steering or management group An agreed timetable for implementation of changes and an incremental approach to change Linking projects into other planning and decision- making processes Ensuring good systems of communication at all levels, with information sharing adequate IT systems. Shared and adequate resources, including administrative support and protested time for staff to undertake joint working activities. Recruitment of staff with the right experience, knowledge and approach. Joint training and Team building. Appropriate support and supervision for staff Monitoring and evaluation of the service, with policies and procedures being reviewed regularly in the light of ever changing circumstances and new knowledge. Name: HMP Peterborough Inreach service Lead contact: jc pragliola short All changes to care are discussed with the client and care plans up dated, signed and copies offered. All transfers have appropriate information and paperwork go to receiving establishments/external services/hospitals CPA reviews are held within the prison to allow client to attend. Liaisons with other teams such as CARATs, IDTS to provide effective through care between services within the prison so that people are not treated unequally due to presentation of multiple problems such as drug and mental health. Liaison worker re: resettlement to prevent inequalities that may present for prisoners once in the community e.g. services not taking them due to forensic issues Name: MHIRT HMP Whitemoor Lead contact: Sara Hart These would done on a 1:1 basis, the Trust changes would not necessary affect the service it would only be the team changes that would effect the service user or if they had been referred to another service. This would be evidenced through care plans 117 meetings hospital to prison. Transferring of notes or request of notes to new team. If there was a change of care co ordinator then they would be normally introduced by their original care co-ordinator and there would be an ending of the professional relationship. Also would request for consent from the service user to discuss with receiving team eg if service user was being discharged from secondary to primary level.

7 Name: R&R North Adult Lead contact: Sarah Fleming Strengths Staff/care coordinator gets direct feedback from service users Some locally designed tools to get service user feedback for specific interventions Improvements Recent consultation regarding services changes patients not consulted widely enough. Staff are not aware of any of our serive users being a part of the consultation/having any info from the Trust All info about service changes is sent in English, no large print offered etc Currently no structured way of asking for feedback local designed tools only No structured evidence or feedback to staff regarding service user opinion Name: Specialist services HMP Littlehey MHIRT Lead contact: Jan lovelock Transfer of secondary clients through CPA process. Relevant parties invited to review to discuss client s needs/ care. If transferred though the prison system internal referrals made or verbal discussions take place via telephone, all recorded in prisoners medical records and discharge care plans. Also in the team meeting minutes. Name: Intake and Treatment Team - Central Lead contact: Denise Bowyer (Team Manager) Others involved Karen Lomas (OT) and Karl Taylor (Clinical Psychologist Service changes and transitions for all Intake and Treatment Service Users are carefully considered as part of the person s CPA care plan and the Trust has polices outlining the process for transition between a number of pathways e.g. CAH to Adult and Adult to Older Adult. The CPA Policy also gives guidance on this. Risk assessments are carried out if required and the care plan reviewed to accommodate any new interventions/treatments required (see professionals meeting notes/care plan for M45359). The team always try to discuss the change with the person and to involve the service user, and if appropriate carer, in collaboratively devising the care plan. There is a shared guideline/protocol (flow chart) in place for transitions between Huntingdon Intake and Treatment and Huntingdon Rehab and Recovery Team. A representative form the Intake and Treatment Team attends the weekly Ward Round on Oak 1 & 2 and there is also a weekly interface meeting with the Huntingdon Acute Care Service. The Intake and Treatment Team Manager, Assistant Team Manager and Consultant Psychiatrist have also met to discuss issues in working together and transfer of service users and local guidelines for referral from ACS to Intake and Treatment

8 have been developed. This does remain a challenge and conversations relating to this are on-going and are true for all service user groups not just the protected groups identified in this document. Transitions to the Complex Cases Service are less smooth. This has been raised with the Complex Cases Team Manager and this service is currently being reviewed. Again this is not specific to protected groups and would be experienced in a similar way by the whole patient group. The team do have a dual diagnosis lead and a number of people accessing drug and alcohol services locally are also seen by the team. Transitions into Intake and Treatment that maybe experienced as more challenging may be from IAPT. Quarterly meetings are held with the local IAPT Team Leader and Clinical Lead to discuss how best to resolve these issues. There is no evidence to indicate that the challenge in transition is in relation to protected groups. The main issues are around level of clinical need and different assessments in relation to urgency of treatment. There is no evidence from the limited data available e.g. PALS and Complaints that service users, or their carers, from any of the protected groups experience a different transition to people from non-protected groups. Name: Assertive Outreach Team Lead contact: Stuart Whomsley 1 Referrals to other agencies are discussed with clients. 2 When a client moves to another team we carry out a Moving-on formulation to share our experience with the new team. 3 Moves occur over a period of time, changes are not sudden. Work being done in relation to We are working to minimise the impact on clients of changes to the service.

9 Overall Grading for Outcome 1.3 Organisational Grade: Developing Reasons for rating: