Cookies notification

In accordance with the EU Cookie Directive we are informing you that we use cookies to track your usage of this website. To find out more about the cookies we use see our privacy statement.

 

I accept cookies from this site

Care Programme Approach

CPA logo

If an individual is involved with secondary or specialist mental health services and needs coordinated support to help with engagement and maintaining safety, then care will be delivered under The Care Programme Approach (CPA) framework.  CPA is an umbrella term to describe the stages involved in supporting the recovery journey.   The individual is central to CPA.   If a person has straightforward needs, then they will receive their care and support by ‘Care Plan’. Assessment of the individual’s strengths and needs will determine if their care is to be supported by the CPA framework or Care Plan.

There are four stages to CPA:

1. Assessment
The individual will be asked questions about most aspects of their life and history – personal, health, social, environmental;  about their safety (this is sometimes referred to as risk); about anyone else all ready involved in their care and support;  any carer involved will be identified and informed of the right to their own assessment.  If the individual agrees, then the carer can participate in this process too.  The focus of assessment will be on strengths, hopes and aspirations.  The aim of the assessment is to determine the individual’s health and social care needs.

2. Care Coordination
A care coordinator will be identified to work closely with the individual and carer to arrange care and support and to review recovery progress.  The Care Co-ordinator may be from the health, social care or voluntary sector.  This may be a nurse, social worker, doctor, psychologist, occupational therapist or community worker.  It will often be the person that has most contact with the service user, but not always.

The function of the care coordinator is to work closely with the service user and carer to:

  • Assess the individuals mental health and social care needs
  • Assess risk and formulate a management plan
  • Assess and respond to carers needs
  • Consider crisis planning and management
  • Formulate care plans and arrange reviews
  • Plan for transfer of care between agencies or discharge


3. Care Plan*
This is a written document describing the individual’s health and social care needs (these were determined at assessment). The care plan states which agencies and services will help with recovery; and what the individual is doing to help themselves.

The care plan is based around the service user. It will be developed with the individual and include a goals; what support is being offered; who is providing the support and when the support will be reviewed.  The carer will be included too if the service user wants this.

The care plan will include:

  • Specific goals agreed - This will vary depending upon the agreed plans and the individual
  • Contingency Plan - In the event of the care coordinator or other’s providing your support being unavailable, then the contingency plan will state the information needed to continue with support. This will include names, plans and contact details
  • Crisis Plan - This sets out the action to be taken if the service user’s mental health is rapidly deteriorating or they become very unwell. The plan should say what the signs of becoming unwell are; it will identify who the service user responds best to and how to contact this person; and it should identify what has helped in the past. Any advance statement should also be mentioned in the care plan



4. Review
These are sometimes called CPA meetings; they will happen at least every 12 months but can be more often. This is where the care plan is reviewed.  This is done by discussing with the service user and carer (with agreement) what is working well and what may need to be changed or improved to support recovery. All aspects of the care plan will be discussed, including safety. Views are expressed by all involved in the care plan, especially the service user and carer and any agreed changes to the care plan are made. The review can be held in a way to suit the service user.

After the review the care coordinator will write up the care plan, the service user will be given a written copy of the revised care plan to check that it records accurately what was discussed and agreed. The service user will be offered a copy to keep. The carer can also have a copy of the care plan if the service user agrees.

What the service user and carer can do to prepare for the review?

Some people find it useful to:

  • Write down what you want to say and any questions you have, take this into the meeting with you
  • Create your own agenda; share this with your care coordinator who will be chairing the meeting
  • Discuss your views with your coordinator before the meeting
  • Ask for the review to be held informally
  • You can request an advocate to support you in expressing your needs and wishes.  Call Advocacy for Mental Health and Dementia on 0113 247 0449 to arrange this
  • If the service user is subject to the Mental Health Act 1983, then they are entitled to the support of an Independent Mental Health Advocate (IMHA), contact details as above
  • Under the Capacity Act 2005 the service user may be entitled to an Independent Mental Capacity Advocate (IMCA), call Articulate Advocacy on 0113 244 0606 or visit their website
  • Assess and respond to carers needs
  • Consider crisis planning and management
  • Formulate care plans and arrange reviews
  • Plan for transfer of care between agencies or discharge



*Care Plan
Care Plan is the term used to describe the care of the individual who is within secondary or specialist mental health services; whose needs are straightforward; and who are seeing only one person in respect of their mental health needs.

The service user and carer can expect:

  • A lead professional identified – this will be the person who delivers the care, they will also plan for any transfer of care or discharge
  • A letter outlining the care plan – this will identify the service user needs, the plan to address those needs plus any other pertinent information. Contact details for the lead professional are provided. The service user will receive the letter, this is the Care Plan
  • Review – This is where progress will be reviewed and any further care plan formulated. Transfer of care or discharge will be planned if appropriate. CPA will also be considered if necessary.


If you require any further information regarding CPA or Care Plan then please contact donna.kemp@nhs.net or call Donna Kemp on 01132 952391