SH CP 199

Adult Mental Health

CMHT Standard Operating Procedure
Version: 1

Summary: Southern Health NHS Foundation Trust (SHFT) Adult Mental Health
Service in partnership with other statutory agencies such as Local
Authorities and Police services have developed a way of working
together to provide a community care pathway within Hampshire
and Southampton City.

Keywords: Adult Mental Health, CMHT, Community Care Pathway

Target Audience: Adult Mental Health Staff

Next Review Date: June 2018

Approved & AMH Performance & Assurance Board Date of meeting:

Ratified by: 16/6/2016

Date issued: June 2016

Author: Karen Guy, Area Manager

Director: Mark Morgan, Director of Operations

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Version Control

Change Record

Date Author Version Page Reason for Change

Reviewers/contributors

Name Position Version Reviewed

& Date

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 Adult Mental Health

STANDARD OPERATING PROCEDURE

CMHT

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 Contents

Section Title Page

1. Introduction 5

2. Aim of the Service 5

2.1 Objectives
3. Service Description 5
3.1 Eligibility Criteria
3.2 Exclusion Criteria
3.3 Key roles
4. The Service User Journey within the Pathway. 7
4.1 Referrals
4.2 Screening
4.3 Assessments
4.4 Care Planning & Review
4.5 Risk Planning
4.6 Interventions
4.7 Discharge
4.8 Transfer
5. Support for Carers and Families 10

6. Specialist Functions 7
6.1 Shared Care
6.2 Response
6.3 Social Services
6.4 Psychological Therapy Services
7. Processes & Systems of Governance 12
7.1 Caseload Management
7.2 MDT Shared Care Meeting
7.3 Business Meetings
7.4 Leadership Meetings
7.5 Supervision
7.6 Training
8. Outcome Measures 13
8.1 Research & Audit
9. Customer Care 14

10. Confidentiality 14
10.1 Access to Health and Personal Records
10.2 Freedom of Information
11. Concerns & Complaints 15

12. Resolution of Disagreements 15

13. Untoward or Serious Incidents 15

14. CQC 15

15. Information Governance 15

16. Health & Safety 16

16.1 Lone Working
16.2 Policy for Prevention of Violence
17. Business Continuity 17

18. Appendices 18

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 Adult Mental Health Team
CMHT Standard Operating Procedure

1. Introduction
Southern Health NHS Foundation Trust (SHFT) Adult Mental Health Service in
partnership with other statutory agencies such as Local Authorities and Police services
have developed a way of working together to provide a community care pathway within
Hampshire and Southampton City.

2. Aim of the Service

 To promote and improve mental health and wellbeing.
 To promote independence, self-reliance and recovery
 To promote responsibility and citizenship
 To improve quality of life for patients, families and carers
 To assist individuals to remain within their communities and networks
 To work collaboratively with patients and their families
 To treat all individuals with dignity and respect

2.1 Objectives – which incorporate the WRAP model of Hope, Agency and Opportunity
are:
 To provide person centred recovery focussed care
 To base care on the individuals strengths
 To provide the least intrusive and restrictive of care
 To encourage self-management and choice
 To work collaboratively with all individuals and agencies
 To utilise multi-disciplinary and multi-agency expertise
 To deliver evidence based interventions
 To apply positive risk management whilst maintaining safety

3. Service description
The Community Mental Health Team (CMHT) is available Monday to Friday 09:00 –
17.00hrs with some team bases opening at 08:30. All CMHT’s offer planned shared care
during weekday, weekends and bank holidays

CMHT is an umbrella term for a range of adult mental health community based functions
and interventions that are delivered by a multi-professional, Southern Health NHS
Foundation Trust consisting of nurses, occupational therapists, Clinical Psychologists,
psychological therapists, psychiatrists, and support workers. The CMHT provides a local
single point of access for individuals who present with severe, complex and enduring
mental health problems. The role of the CMHT is to provide assessment and community-
based treatment which is undertaken in partnership with referred individuals and focusses
on individual needs, self-determination and recovery. To achieve this, the CMHT works
closely with other Southern Health services, Acute service, Specialist Services, Primary
Care services, local community networks and other agencies.

From 1st April 2016, the current S75 agreement between Southern Health NHS
Foundation Trust and Hampshire County Council Adult Services will cease and be
replaced with a memorandum of understanding. The two respective organisations will
continue to be co-located in some bases and the HCC Adult Services will be responsible
for assessing social care needs under Section 9 of the Care Act 2014 and will develop
separate direct contact arrangements by September 2016.

The Early Intervention in Psychosis Service (EIP) is a specialist multi-disciplinary

community team comprising of Medical, Nursing, Occupational Therapy, Support
Workers, Social Worker and Psychological Therapies. The EIP team work with service
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 users aged between 14 and 35 years who are experiencing their first psychotic episode.
The aims of the service are to:
 Encourage liaison between primary / specialist care in the early detection of first
psychotic episode to reduce the Duration of Untreated Psychosis (DUP).
 Provide timely and effective NICE concordant interventions to accelerate remission
and prevent relapse. These interventions include pharmacotherapy, evidence based
psychosocial interventions including Cognitive behavioural Therapy (CBT), early signs
monitoring and family intervention.
 Normalise experiences for young people, minimise stigma and reduce the adverse
consequences in terms of trauma, depression and suicide risk.
 Maximise family, social, educational and work functioning

The 3 EIP teams cover East area, Southampton and a combined North/West area the
teams are often based within a CMHT building and are in the process of developing a
SOP.

South East Area

Bordon & Petersfield CMHT - Petersfield Hospital, Swan Street, Petersfield, Hants, GU32
3LB 01730 264568
Havant & Waterlooville CMHT - Parkway Centre, 51 Leigh Road, Havant, Hampshire PO9
2BF 023 9268 3544
Fareham & Gosport CMHT - Hewat Centre, Gosport War Memorial Hospital, Gosport,
Hants PO12 3PW 02392 511377

North Area
Basingstoke CMHT – Bridge Centre, Basingstoke

West Area
Winchester & Andover CMHT – 68b Junction Road, Andover
Avalon House, Winchester
Eastleigh & Romsey CMHT – Horsefair Mews, Romsey
Desborough House, Eastleigh
New Forest CMHT – Waterford House, New Milton
Anchor House, Totton

Southampton Area
Southampton Central CMHT – College Keep, Terminus Terrace
Southampton West CMHT- Cannon House, Shirley
Southampton East CMHT - Tom Rudd Unit, Moorgreen

3.1. Eligibility Criteria

CMHT services are available to individuals who have a severe or enduring mental health
disorder with one or more of the following associated needs.

 The provision of Mental Health services will improve mental health or prevent
deterioration.
 Poor response to previous mental health treatment in primary care
 History of violence or persistent offending.
 At significant risk of persistent self-harm or neglect
 Dual diagnosis of serious mental illness and substance misuse
 Severe difficulties in living at home safely without support
 Severe difficulties in maintaining independent living without support
 Reliant on a carer who is no longer able to support all of their needs
 Mental health illness which mean that the individual is unable to carry on caring for a
child, or the child may be at risk of harm

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  Neurodegenerative disease with associated mood or psychotic disorder where needs
are best met by Adult Mental Health Services.
 Assessed in IAPT services as needing a specialist mental health treatment
 Military veterans with severe and persistent mental health difficulties which are likely to
be related to their service in the armed forces.
 14 - 35 year old individuals who experience a first episode of psychosis, early
intervention in psychosis will be referred to EIP

Fast Access self-referral –

Patients can access directly within 6 months if identified as part of their discharge
plan and agreed in MDT

3.2. Exclusion criteria

This service is not appropriate for individuals with:
 Autistic spectrum disorder / Aspergers or ADHD, when not combined with a severe
mental illness
 Mild anxiety and depressive disorders (Service provided by IAPT and Primary Care)
 Brain damage. Organic disorders including dementia, and early onset dementia, where
Older persons Mental health service are best placed to provide care
 Anger control and violence without associated severe mental illness
 Somatic problems such as chronic fatigue syndrome, chronic pain in the absence of
severe mental illness
 Disorders of sexual preference (e.g. paedophilia, fetishism) without associated severe
mental illness
 Addictive behaviour (e.g. persistent drug or alcohol misuse or gambling) in the
absence of severe mental illness

3.3 Key roles within the Multi-Disciplinary Team

CMHT services are multi-disciplinary and share a common orientation promoting the
principles of recovery. Each patient will be given a lead professional/ care coordinator
who will take the lead responsibility for their care. However, given the intensive nature of
the team’s work; a collaborative whole team approach is required with clinical
responsibility shared across the team. The skill mix encourages the use of a diverse
range of approaches, interventions and treatments.

The Multi-Disciplinary Team consists of:

 Team Manager / Team Leader
 Consultant Psychiatrists and other medical staff
 Occupational Therapists where available
 Mental Health Nurses
 Mental health Practitioners where available
 Health Care Support Workers/Assistants
 Clinical Psychologists
 Psychotherapists
 Clinical Nurse Specialists
 Admin Support Staff

4. The Service User Journey (within the CMHT pathway)

The CMHT have simplified the operational process to make the pathway easier to follow
for all users of the service. Patients must give consent for engagement and receipt of
interventions and this must be recorded on RIO, whilst it is recognised that a number of
individuals will receive treatments under the Mental Health Act or within an assertive
outreach model of engagement. Consent is implied within RIO and the team indicate if
contrary to this.

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4.1. Referrals
Each CMHT will have in place arrangements to allow for referrals to be accepted,
processed and acted upon within the contractual agreed timescales.
There are a variety of referral routes including telephone, letters, emails and fax. Some
CMHT’s refer urgent assessments to AMHT.

The referrals accepted for CMHT assessment are those categorised as:-
Soon referrals - to be seen within 10 working days
Routine referrals - are to be seen within 7 weeks
Urgent referrals - those to be seen within 24 hours. These referrals are seen by the
Acute Mental Health Team.

For those referrals suspected of First Episode Psychosis if under the age of 35 years will
be referred to the Early Intervention Team for assessment. For those over the age of 35
years will be assessed and allocated within 14 days

4.2. Screening
CMHTs will have robust processes in place to ensure that all referrals are screened daily
and within 4 hours of receipt if urgent. Routine referrals will be screened based on need
within a MDT and with representation from Hampshire County Council if a Hampshire
resident. Screening entails cross checking referrals with RIO, archived notes, and other
services who may be involved in the individuals care. If further referral information is
required to determine appropriate intervention the screener will contact the referrer.

If the referrer has referred the individual as being Urgent then the referral must be treated
as such unless robust communication has occurred with the referee who has agreed an
alternative time scale. This must be documented on RIO. Downgrading of a referral from
urgent cannot occur without agreement from the referrer. If the refer cannot be contacted
a fax must be sent to them outlining the rationale to downgrade the referral to a SOON
referral

The function of screening is to ensure the referred individual receives an assessment by

the most appropriate service to meet their needs if the individual needs are best met by
another service e.g. primary care (IAPT), Acute Mental Health Team, Eating Disorder
service, then the screener based on referral information can refer the individual to the
appropriate service following discussion with the relevant service and will track the
progress and acceptance. The original referrer will be informed by the CMHT.

4.3. Assessments
A comprehensive mental health assessment will be undertaken by an appropriate
member of the team within agreed timescales

Soon assessments - if an individual cannot be contacted by telephone then an

appointment will be posted with a provision that they can contact and rearrange if the date
or time given is not suitable.

Routine assessments - contact will be made with the service user and an appointment
arranged that is suitable to them

CMHTs will ensure procedures are in place to discuss complex assessments within the
wider MDT.

If the assessment identifies first episode psychosis or an ‘at risk mental state’, then the
psychosis pathway will be followed. Those individuals under the age of 35 years will be
referred to the EIP team. Those over 35 years the CMHT will allocate a Care Co-ordinator
within 14 days of the date of referral.

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 If the assessment indicates social care needs the CMHT will refer to the local AMH social
care team.

If an assessor determines that the referred individual presents as Urgent or with risk to
self or others that cannot be managed within the CMHT then the individual will be referred
to the Acute Mental Health Team.

It may be determined on assessment that the referred individual’s needs are best met at
step 2 or 3 interventions as per stepped care. The assessor will liaise with italk and in
agreement arrange transfer to their services.

In cases where non statutory services are recommended, signposting and information
sheets will be provided.

All assessments will be discussed in an Assessment Feedback multi-disciplinary meeting

at least weekly and if it is considered appropriate a lead professional / Care Co-ordinator
will be allocated to develop and co-ordinate the agreed plan of care.
Following allocation the lead professional / care co-ordinator will make contact with the
service user within 10 working days.

4.4. Care Planning & Review

“CPA and care planning are simple terms for describing the process of how services help
people to assess their own needs, plan ways to meet them and check that they are being
met” SHCP172 Care Planning & Care Programme Approach Standard Operating
Procedure for Adult Mental Health Services will be adhered to.

4.5. Risk Assessment and Management

The individual risk assessment for each patient will be recorded in the Consultant letter or
the risk assessment section of RIO.

SHCP27 The Assessment & Management of Clinical Risk Policy. This policy
describes the processes SHFT uses to ensure risks relating to the clinical presentation of
patients and their care and support are assessed and managed. It should be read in
conjunction with the Practice Guidance for Managing Clinical Risk Document
(SHCP28) which supports the implementation of this policy.

4.6. Intervention and Support

Interventions provided are based on the needs of the individual patient and may include -

 Specialist psychiatric treatment of severe and enduring mental health disorders

 Formal specialist psychological therapies – in line with best practice guidelines and
Trust clinical pathways, including Cognitive Behavioural Therapy (CBT), Dialectical
Behavioural Therapy (DBT) and Cognitive Analytic Therapy (CAT) and
Psychodynamic Psychotherapy
 Psychologically informed work – may be delivered by MDT staff with support and
supervision from psychological therapies to ensure necessary governance, e.g.
Emotional Coping Skills (ECS), anxiety management, psychologically based
practitioner clinics
 Practitioner clinics
 Care Coordination
 Medication management (neuroleptics, clozapine, monitoring and medication reviews)
 Relapse prevention, development of crisis and contingency plans to prevent relapse in
collaboration with their families and social networks.
 Recovery focused work including use of Wellness Recovery Action Plans (WRAP),
Recovery Star
 Weekly liaison and contact with case loaded patients within the acute inpatient setting
 Physical health monitoring in liaison with primary care

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  “Activities of daily living” may be under taken by the CMHT Occupational Therapist and
the outcome will contribute to the overall plan of care where available.
 Review of health funded high cost placement

4.7. Discharge
Recovery is the focus of all mental health interventions and discharge from services is
planned in partnership with the individual at their initial assessment and reviewed
regularly. Discharge is based on the individual completing a recovery focused
intervention, or no longer benefitting from or accepting of support. Families and Carers
will be involved in the discharge process in collaboration and agreement with the patient.
All imminent discharges should be discussed with the Team Leader or at weekly
meetings. At discharge care clustering should reflect improved recovery.

Prior to discharge, it is essential that the Section 117 Mental Health Act 1983 status of the
Service User is reviewed and Local Authority staff should be involved.

A written discharge summary will be provided to both the individual and their GP within 10
days of discharge and much sooner in most cases.
Disengagement of individuals with on-going mental health needs who are deemed at risk
to self and others will not automatically be discharged from the CMHT – please refer to
the Clinical Disengagement / Did Not Attend Policy SHCP 97.

The discharge summary will include:

 A summary of interventions provided.
 The effectiveness of those interventions.
 All current CMHT recommended medication doses, frequency and ongoing monitoring
arrangements should be specified.
 Recommendations for the ongoing or future treatment (including medication);
 Identified triggers and / or an indication of the early warning signs of future
deterioration of the individual’s mental health
 Diagnosis (this will also be entered in the RIO diagnosis field)
 Arrangements for referral back to Mental Health services

Within the first 24 hours of an individual being discharged from Acute Inpatient Care the
CMHT or AMHT will arrange a face-to-face follow up to occur within 7 days of the Acute
discharge.

4.8. Transfer
There are arrangements for transfers between the CMHT and other Southern Health
services. Transfers will be facilitated by liaison between the services or teams and RIO
transfer mechanisms,

Allocation to a Care Coordinator or lead professional will be determined based on

identified need and will always take place within 48 hours of acceptance to the CMHT.

The default position will be the Team Manager, Team Leader or designated deputy. The
Care Plan / Care Programme Approach (CPA), will be collaboratively reviewed and
revised by the allocated worker in the CMHT 4 weeks after transfer, or sooner if indicated.

5. Support for Carers and Families

In addition to the needs of the service user, the CMHT will also work with carers and
families. The CMHTs follow best practice guidelines for liaising with friends and family
about the mental health services, as well as care of the individual service user. This
allows the CMHTs to establish links and support family members even when the service
user declines involvement in their care.

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 All individuals who provide care for a person on the team’s caseload should be offered an
assessment of their own mental and physical health needs and referred to Social
Services to undertake this.

The CMHT will ensure that carers are meaningfully engaged and involved in individual
care planning and will also identify any opportunity where a carer is expressing a wish to
become further involved in aspects of service design and delivery.

The sharing of sensitive information can be difficult but is often crucial to the wellbeing of
both patient and carers. Often it is the carer or family who knows the person best and it
is important that the CMHT recognises these existing relationships and work with the
family and carer to manage clinical situations appropriately. The wellbeing of the carer
and risks to the individual can be greatly improved if they can be encouraged to be
involved in the care provided.

The Mental Health Act 1983 and 2007 has set out various roles and responsibilities which
relate to carers. When a service user is assessed using the Mental Health Act, the
Nearest Relative has certain legal rights which all teams need to ensure are respected
and adhered to. When treating a person under the Mental Health Act, family members
and other carers should be proactively involved wherever possible

6. Specialist Functions

6.1. Shared Care

Shared Care provides high levels of planned care to a proportion of CMHT service users
who are most in need. It is not a crisis response service and does not have the facility to
provide urgent assessments.

Service Users meet the criteria for Shared Care if they require more intense clinical
intervention, for a time limited period, than a Care Co-ordinator can reasonably give them
within their normal working week, and the risks associated with their presentation are
complex enough to raise significant concerns for themselves or others

Shared care provides planned visits for those most in need. This can include those
showing signs of relapse, increasing risk and facilitate early discharge with joint working
with AMHT

Teams have daily shared care meetings and provide planned contact up until 8pm
weekdays and interventions may include regular daily telephone contacts, increased visits
up to daily or visits, planned weekend work, monitoring of medication, enhanced liaison
with police, and other relevant agencies, and increased family intervention as agreed.

6.2. Local Authority Adult Social Services Team

The Care Act 2014 replaces almost all of the principle adult service care standards and
introduces a statutory eligibility criterion for Adults as well as placing safeguarding as a
statutory obligation and clarifying what carers can expect from Local Authority Adult
Services Departments.

The Mental Health Social Work Team will arrange for the investigation of safeguarding
concerns under the framework of the Safeguarding Adult Multi-Agency policy. This will
include assessing the seriousness of the situation, the level of risk and any action needed
to ensure the safety of the concerned.

In addition the role of social care is:

 To offer support, advice and signposting to adults who are identified as ‘vulnerable
adults’ but who may not meet the criteria for secondary mental health intervention or
the Care Act 2014 eligibility criteria.
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  To safeguard and promote the welfare of children in line with ‘Working Together to
Safeguard Children’ (A guide to inter-agency working to safeguard and promote the
welfare of children).
 To undertake assessments in the respect of the duty to Carers, to provide care under
section 10 of the Care Act 2014.
 To promote and to register adults assessed as being disabled.

Social Care also performs the statutory Local Authority duty of the Approved Mental
Health Practitioner role (AMHP). This requires the AMHP arranging and performing
Mental Health Act assessments following referral.

6.3. Psychological Therapies

Psychological therapies are an integrated component of the CMHTs. Psychological
therapies staff are responsible for ensuring the delivery and governance of psychological
interventions in line with best practice guidelines and Trust clinical pathways. This
includes formal specialist therapies, including CBT, DBT, CAT and psychodynamic, as
well as psychologically informed work that may be delivered by MDT staff with support
and supervision to ensure governance, e.g. ECS, anxiety management, psychologically
based practitioner clinics.

It is expected that people referred for formal psychological therapies will have received a
recent psychological assessment by a member of the CMHT to ensure s/he has
consolidated any previous psychological treatment.

Psychological Therapy is always time limited and the psychological therapist is expected
to contract all interventions with the service users.

7. Process and System of Governance

To ensure the effectiveness of CMHT and the safety of all who receive services there are
a number of governance measures in place over and above contractual, legislative and
professional regulations.

7.1 Caseload Management

All staff within the CMHT will receive monthly clinical case management from a senior
colleague

Case management includes review of potential or existing clinical risks, reflective practice,
caseload capacity, outcome measures and discharge planning.

7.2 Multidisciplinary Team Meetings and Shared Care Meetings

MDTs are attended by Consultant Psychiatrists, Assessment Practitioners, Care
Coordinators, Psychological Therapists, Social Services representatives and Support
Workers. Team Manager, Team Leaders or deputy will chair the MDT. Through
discussion, support, and further investigation decisions and outcomes will be determined
within the forum and recorded on RIO to ensure the aims and objectives of the service are
maintained in the best interest of the referred individuals. The CMHT may hold a weekly
Shared Care meeting or the function is integrated into the MDT. It is essential that the
multidisciplinary approach is utilised for individuals requiring Shared Care. A database is
maintained and updated at the weekly meeting and agreed degree of intervention
required maintaining patient safety and preventing further deterioration. Individuals who
DNA appointments or who are disengaging from the service will also be discussed at
MDT and actions recorded within RiO records.

7.3 Business Meetings

Each CMHT will hold a monthly business meeting to ensure good communication among
all team members to discuss the following:

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  Team brief
 Quality issues and Key Performance issues
 Local issues to include Local Authority and Case Law updates
 Health and Safety
 Learning from incidents/complaints/audit etc.
 What’s going well/what we can do differently
 Hotspots
 AOB

This meeting will need to maintain robust records, these will provide evidence of the work
the teams are doing to ensure that the core business is appropriately monitored, reviewed
and developed and the team are kept informed.

7.4 Leadership Meeting

To ensure key operational issues which affect the CMHT performance and operational
working are addressed, there will be a monthly meeting attended by senior team
members including the CMHT Manager, Consultant Psychiatrist, Health Team Leader,
Lead Psychologist and Senior Administrator.

7.5 Supervision
The CMHT Manager is responsible for ensuring that each team member receives
management, clinical and professional supervision according to individual need and
experience. Where this involves someone other than the line manager, this will be ratified
by that manager.

The CMHT place significant importance on supervision and have developed a supervision
strategy. (Appendix 19)

The supervision process will inform the annual appraisal process, to ensure that staff
professional training and development needs are addressed. This will include
opportunities to access professional group supervision

7.6 Training
All staff within the CMHT are required to complete a yearly appraisal and undertake
statutory and mandatory training that is monitored by the Trust’s Learning, Education,
Appraisal Department (LEAD). Each staff member is responsible in ensuring they remain
compliant with statutory and mandatory training.

Other training needs will be identified at the yearly appraisal, or sooner if required, to
ensure staff have the relevant skills and knowledge to provide the appropriate evidence
based interventions and meet service needs.

8. Outcome measures
PREMS
All individuals following assessment, completion of interventions and or on discharge will
receive a standard patient experience form (appendix). These will be collated and
outcomes disseminated to the team to improve future performance.

PROMS
Patient reported outcome measures should be offered to service users close to initial
assessment, routinely at care plan reviews and wherever possible prior to discharge.
Content from the Hope, Agency and Opportunity PROM (appendix 29) should be used to
populate care plan documents (appendix 30)

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8.1. Research & Audit
Research and audit is undertaken to ensure the effectiveness and safety of our services
and for services to be innovative in introducing new approaches. Research and audits are
registered with the Trust to ensure they are carried out appropriately and within guidance.
Various audit models may be used but the Plan, Do, Study, Act is the most common. No
research should be undertaken without the Trust’s permission and the individual’s
informed consent.

9. Customer Care
We work with people to promote diversity and should an interpreter be required we are
able to provide service users with one. (See appendix 24)

As staff, we will be:

 Respectful
 Approachable and easy to talk to
 Pleasant and friendly at all times
 Willing to listen and really hear
 Aware of individuals varying needs
 Dressed professionally

As an organisation, we commit to:

 Involve and inform Service Users and Carers /family about their care
 Wear name badges; introduce ourselves to the Service User, family and Carers.
 Answer the telephone – all calls should be received by a live person or forwarded to
someone else that can help
 Help individuals access the right care and the right person to contact
 Always protect individuals’ privacy and their confidential information
 Take action –if we see something that needs doing, we will never say, ‘it isn’t my job’
 Respond promptly to Service User/Service Users’ needs – put them first
 Listen to feedback – complaints and concerns are both welcomed

We will ensure to:

 Continue to improve our services by listening positively to your concerns, suggestions
 Actively encourage people to comment about our services. Keep them informed
about the progress of any complaints they may make
 Learn by our mistakes
 Offer ongoing support staff and ensure that their wellbeing is maintained

10. Confidentiality
The policy, SHIG46 Information Sharing Policy outlines the principles of confidentiality,
and establishes an interagency code of conduct with regard to the confidential
management of service user information by Hampshire County Council Adult Services,
Southampton City Adult Services and Southern Health NHS Foundation Trust. The policy
applies to all service user information managed in all work undertaken by employees of
the parties working in Southampton and Hampshire.

 All paper/electronic records must adhere to the Trust/Local Authority recording policies
and in accordance with professional standards to provide an objective overview of all
contacts and actions relating to the individual service user.

 All records, paper or electronic are kept within the guidelines of the Data Protection Act
and are treated a confidential documents. Information is only shared on a ‘need to
know’ basis with the service user’s permission and under the scrutiny of the Caldecott
principles, unless the situation meets necessary risk requirements which would require
those rights to be breached.
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  SHIG47 Disclosure of Information to Police Procedure

10.1. Access to Health and Personal Records Procedure

 This guidance has been written to assist all staff with a responsibility for dealing with
requests for personal data from service users.
SHIG12 Access to Personal Clinical records Procedure.

10.2. Freedom of Information – Summary for Staff

 From 1 January 2005 the Freedom of Information Act 2000 (FOI) gives a general right
of access to all types of recorded information held by the Trust. This Act gives rights to
know whether or not information is held by the Trust, and if so, the right to have that
information communicated to the applicant.
SHNCP52 Freedom of Information Policy

11. Concerns, Complaints and Compliments

Any complaints are initially passed to the Team Manager who will consider whether it is
appropriate to locally resolve and respond formally in writing. Should it not be deemed
appropriate or the complaint is deemed complex/serious other courses of action maybe
required as detailed within the SHFT/Local Authority complaints procedure.

Compliments will also be passed to the Team Manager and then be recognised formally
within Team Meetings and Trust Bulletins.

Should a Service User or carer wish to comment about the service they have received the
Customer Care Team offers a means of resolving concerns of service users and carers at
an early stage of the process.

12. Resolution of Disagreements

In principle all differences of opinion should be managed within the local teams. Where
these disagreements occur across interfaces the local senior managers should try to seek
resolution. If resolution cannot be sought then it should be referred to the Divisional
Director and Clinical Service Director.

13. Untoward or Serious Incidents

All incidents to be managed using the following procedure
SHNCP17 Procedure for Reporting & Managing Incidents

14. CQC
The Team Manager will ensure that the CMHT meets and maintains the requirements for
CQC registration.

All staff are to be made aware of requirements and professional accountabilities.

15. Information Governance

All paper/electronic records must adhere to the Trust recording policies and in accordance
with professional standards to provide an objective overview of all contacts and actions
relating to the individual service user.

All records, paper or electronic are kept within the guidelines of the data protection act
and are treated as confidential documents. Information is only shared on a ‘need to know’
basis with the service user’s permission and under the scrutiny of the Caldecott principles,
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 unless the situation meets necessary risk requirements which would require those rights
to be breached.

Each team will have a range of standard letters to ensure effective, consistent
communication with referrers, service users, carers and other services. Consent to share
forms will be completed with all Service Users and RIO will be updated accordingly.

RIO is the primary method for recording clinical information, secondary paper files for
each individual are also held and must be referred to by the CMHT when accepting
referral for individuals who are not known to the service or who have not been with the
service for over 24 months.

List of items to be filed in secondary care records can be found in the RIO handbook.
Standard letters for use in clinical practice can be found in the editable letters section of
RIO these can be adapted for local use and new templates requested from the RIO team.

All records must adhere to the Trust/Local Authority recording policies and in accordance
with professional standards to provide an objective overview of all contacts and actions
relating to the individual.

All Care Plans, Crisis Plans and Risk Assessments are to be recorded on RIO in line with
Trust policy. All records, paper or electronic are kept within the guidelines of the Data
Protection Act and are treated as confidential documents. Information is only shared on a
‘need to know’ basis with the individual’s permission and under the scrutiny of the
Caldecott principles, unless the situation meets necessary risk requirements which would
require those rights to be breached.

16. Health and Safety

It is the responsibility of the Team Manager to ensure that all staff attend relevant Health
and Safety and Ligature Assessment training as determined in the essential training
programme or if identified by local risk assessment.

16.1 Lone Working

This policy is designed to reflect good practice in relation to the protection of lone
workers. The term ‘Lone Worker’ is used in the policy to describe a wide variety of staff
who work, either regularly or occasionally, on their own, without access to immediate
support from work colleagues, managers or others. This could be inside a hospital or
similar environment, or in a community setting; there is no single definition that
encompasses those who may face lone working situations and, therefore, increased risk
to their security and safety. SHNCP24 Lone Working Procedure

16.2 Policy for the Positive Prevention and Management of Violence and Aggressive
incidents
Incidents of violence and aggression are a recognised risk when working in a healthcare
environment; however, such incidents are unacceptable whatever form they take and
whatever reasons are given for the persons actions.

The Trust accepts that the prevention of violence and aggression towards staff requires a
high level of management commitment, professional competence and adequate
resources. Furthermore, it recognises that actual or threatened violence and aggression
towards staff can be very frightening and / or traumatic. The Trust recognises that the
nature of being a Mental Health, Learning Disabilities and Social Care Trust, will mean
caring for Service Users who at times exhibit challenging behaviours and/or display
behaviours which can be aggressive and/or violent. As such, The Trust will provide
appropriate training to meet the diverse needs of our workforce in line with all national
guidelines. SHNCP74 Management of Violence and Aggression Procedure

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17. Business Continuity
A folder is to be held within each team base describing their business continuity plan for
that team/unit and an area process will be in place to raise issues.

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Appendices

Appendix Number and Document Name Embedded Document(s)

1. italk SOP

Italk_SOP_Insert_(FI
NAL_DRAFT)_25_01_1111.docx

2. Talking Therapies

Talking Therapies a
four year plan dh_123985.pdf

3. SHCP199 - AMHT SOP See the Intranet, search using the reference
number SH CP 199

4. NICE Guidelines Amended Depression

CG23NICEguidelinea
mended depression.pdf

5. NICE Guidelines Amended Anxiety

CG022NICEguideline
amended anxiety.pdf

6. Patient Opt In Letter 1

PtOptIn 1 (Ver 1.0

Aug 14).doc

7. Patient Opt In Letter 2

PtOptIn 2 (Ver 1.0

Aug 14).doc

8. Patient DNA Letter 1

PtDNA1 (Ver 1.0 Aug

14).doc

9. GP No Opt in Letter

GPNoOptIn (Ver 1.0

Aug 14).doc

10. GP Patient DNA Letter 1

GPDNA1 (Ver 1.0 Aug

14).doc

11. GP Patient DNA Letter 2

GPDNA2 (Ver 1.0 Aug

14).doc

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12. Demographics

Demographics.doc

13. Discharge Procedure

Discharge procedure
CMHT.docx

14. IAPT Step Pyramid

IAPT History.mht

15. Working Definition of SMI

Serious and
Persistent Mental Illness.docx

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