DOCUMENT CONTROL:

Version: 7.1

Ratified by: Covid-19 Gold Command

Date ratified: 7 April 2020

Name of originator/author: Adult Community Mental Health Service Manager/Nurse Consultant

Name of responsible committee/individual:

Executive Director of Nursing and Allied Health Professionals

Unique Reference Number: 391

Date issued: 1 May 2020

Review date: October 2020

Target Audience Staff working in or associated with learning disability and mental health services and any other staff who are involved in the implementation of this policy e.g. training, audit etc

Description of Changes: Due to the Covid-19 Pandemic Gold Command agreed a review extension from January 2020 to October 2020

Patients with a Mental Health Problem and

Learning Disability,

Management Policy

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Section

CONTENTS

Page No

1. INTRODUCTION 4

2. PURPOSE 4

3. SCOPE 4

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4

4.1 The Board of Directors 4

4.2 The Chief Operating Officer 4

4.3 Medical Director 5

4.4 Care Group Directors 5

4.5 Clinical Director (Consultant Psychiatrist) Adult mental Health Services

5

4.6 Consultant Director (Consultant Clinical Psychologist) Learning Disability Service

5

4.7 Nurse and Occupation Therapy Consultants for Adult Mental Health and Learning Disabilities

5

4.8 Service Managers/Modern Matrons (Adult Mental Health and Learning Disability)

5

4.9 Community Team Manager/Ward Manager (Adult Mental Health and Learning Disability)

6

4.10 Clinical staff within Mental Health and Learning Disability Services

6

5. PROCEDURE/IMPLEMENTATION 6

5.1 Community Pathway 6

5.2 Details of joint working arrangements for community patients 7

5.3 Care and Treatment Review 8

5.4 Deciding Which Inpatient Service to admit to 8

5.5 Patients already subject to an episode of inpatient care. 9

5.6 Section 136 Assessments. 10

5.7 Providing care to patients with a diagnosed learning disability on one of the adult mental health inpatient wards.

10

5.8 Who should be involved in agreeing the shared care pathway 11

5.9 Risk assessment 11

5.10 Undertaking a mental health assessment on someone with a learning disability diagnosis

12

5.11 Additional considerations when assessing the capacity of someone with a learning disability

13

5.12 Enhancing staffing levels 13

5.13 Care planning 13

5.14 Patient Information 14

5.15 Information/Support for Carers/Relatives 14

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Section

CONTENTS

Page No

5.16 Responsibilities in respect of any identified continuing care /specialist placement needs

15

5.17 Discharge arrangements for patients on a shared care pathway

15

5.18 Process to be followed where a difference of opinion is apparent between professionals

15

5.19 Support for staff 16

6. TRAINING IMPLICATIONS 16

7. MONITORING ARRANGEMENTS 17

8. EQUALITY IMPACT ASSESSMENT SCREENING 18

8.1 Privacy, Dignity and Respect 18

8.2 Mental Capacity Act 18

9. LINKS TO OTHER PROCEDURAL DOCUMENTS 18

10. REFERENCES 18

11. APPENDICES 19

Appendix 1 – Flowchart for Patients Presenting with a Suspected/Actual Learning Disability, or a Suspected/ Actual Mental Health problem

20

Appendix 2 - Mental Health Crisis Pathways 21

Appendix 3 - Screening Tools 22

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1. INTRODUCTION

The Trust aims to provide high quality, safe and effective services for people with mental health problems, which are accessible to all who need them in line with No Health without Mental Health. Green Light for Mental Health (DH, 2004) and Valuing People Now – A three year strategy for people with learning disabilities (DH, 2009) recommend that people with a learning disability and associated mental health problems should access main stream mental health services with specialist support from learning disabilities services where required. This policy aims to ensure access for this patient group by working together to provide integrated care and treatment to meet the needs of people in line with current government policy and guidance.

2. PURPOSE

The purpose of this policy is to set out the service access pathway arrangements and care responsibilities of both learning disability and mental health services.

3. SCOPE

The policy applies to all patients with a learning disability and an associated mental health problem. The policy applies to all staff involved in the provision of services for those with a learning disability and a mental health problem. Due to the complex nature and needs of this patient group, this policy should be read in conjunction with the relevant Mental Health Act policies, Mental Capacity Act Policy and the Deprivation of Liberty Safeguards Policy

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1 The Board of Directors

It is the duty of the Board of Directors to oversee that all individuals receiving care, treatment and support from the Trust, receive high quality care based on an individual assessment of the range of their needs and choices. The Board of Directors delegates authority to the Chief Executive.

4.2 Chief Executive

The Chief Executive has overall responsibility for the implementation of this policy, and in turn this responsibility is delegated to the directors and senior managers.

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4.3 Medical Director

The Medical Director is responsible for providing clinical leadership within the Trust and for the provision of senior clinical advice to the Board of Directors. The Medical Director line manages the Clinical Directors within each directorate. The Medical Director is responsible for resolving issues where there are differences of opinion, which cannot be resolved by the Clinical leads in Adult Mental Health Services and Learning Disability Services.

4.4 Care Group Directors

are responsible for:

The implementation of the policy across the specified services

The on-going review of the policy to keep it up to date with current best practice

Providing reports to the Senior Leadership Team (SLT) and the Operations Management Meeting (OMM) on any issues associated with the implementation of the policy

Facilitating effective joint working with internal and external partners and stakeholders

4.5 Clinical Director (Consultant Psychiatrist)

The role of the Clinical Director is to provide advice to colleagues

within Mental Health Services and Learning Disability Services. The role is supportive and facilitative. The Clinical Director may be asked to advise and/or provide a second opinion for patients with complex needs where there are professional differences of opinion between services.

4.7 Nurse and Occupation Therapists Consultants for Mental Health.

The Nurse and Occupation Therapists Consultants are responsible for:

Advising the relevant Care Group Directors in relation to staffs training needs, and the content of the training

Keeping up to-date with any changes to National policy / NICE guidance which may have implications for clinical practise in relation to this policy

Advising the Care Group Directors of any changes which are required to keep practise in line with National policy /NICE guidance

Advising and supporting clinical staff when dealing with complex cases which fall under the remit of this policy

4.8 Service Managers / Modern Matrons (Adult Mental Health and

Learning Disability)

Service Managers and Modern Matrons are responsible for the implementation of the policy within their areas of responsibility

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They are the next point of escalation in cases where there are differences of opinion at team manager and/or at pathway meetings

They will ensure all relevant staff access the agreed training plan

4.9 Community Team Manager / Ward Manager (Adult Mental Health and Learning Disability)

Community Team Manager / Ward Managers are responsible for initiating and organising the joint assessment process where it is indicated that this is required

The Manager identifies the appropriate numbers and levels of staff and the training required for those staff to deliver safe and effective services

The Community Team Manager is responsible for the appropriate allocation of patients to staff

4.10 Clinical staff within Mental Health and Learning Disability Services

It is the responsibility of all clinical staff working in these areas to:

Be familiar with, and follow the guidance as set out in this policy

Attend any training which has been identified for them in relation to this policy

Report any breaches in relation to compliance with this policy

5. PROCEDURE/IMPLEMENTATION

5.1 Community Pathway

The Trust provides both specialist learning disabilities services and mental health services (including in-patient services). Each patient should be able to access mainstream mental health services, specialist learning disability services, or a combination of both these services based on their individual needs. Initial referrals may present in either Learning Disability or Mental Health services. It is the responsibility of the service receiving the referrals to make the initial decisions for assessment based on the protocol attached (see appendix 1).

a) Where both are present then a joint assessment should be undertaken and the care plan agreed based on identified need. Where no learning disability is identified then Mental Health Services should assess and offer treatment as appropriate. Where no mental health issues are identified, but there is a clear learning disability identified then the referral should be transferred to Learning Disability services

In the event of a Mental Health Crisis - adults with a learning disability who have been identified as having additional complex needs and are

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at immediate risk, to themselves, or others, or harm that requires in-patient admission, staff in the Mental Health Access Team should follow the guidance identified in Mental Health Crisis Pathway document for their locality (see appendix 2)

b) Learning Disability Services. Where both mental health problems and

learning disability is present, then a joint assessment is to be undertaken.

c) Where no significant Mental Health or Learning Disability problem is

identified then the referrals should be referred onto the most appropriate service that is available

d) If referral is specifically for memory service assessment/ dementia

diagnostic services then joint memory service pathways have been developed and should be followed; in the first instance staff working in specialist learning disability services will initiate this process

5.2 Details of joint working arrangements for community patients

A key objective of this policy is to facilitate more effective systems

for joint working between services. Where it is agreed that individuals who have a learning disability and identified mental health problems (dual diagnosis) require further treatment they will be placed under the Care Programme approach (CPA). In these circumstances, following a joint assessment, a decision is made as to which is the most appropriate service to take the lead and care coordinate, and which will act in a support/advisory role If adult mental health services are considered the most appropriate service to lead, then a mental health worker will be identified as the Care Programme Approach (CPA) Care Coordinator, and Learning disability workers will provide advice on reasonable adjustments required for people with severe and enduring mental illness who have co-existing learning disability to ensure that services and treatment meet their individual needs. They may also become co-workers delivering care planned with the person’s care coordinator under Care Programme Approach (CPA) policy and procedures. Where a person being cared for by the learning disability service develops a severe mental illness. If, following joint assessment, a decision is reached that Adult Mental Health services are the most appropriate service to lead, then care co-ordination will transfer to Mental Health Services according to the agreed care pathway. The learning disability worker would then become the co-worker and remain involved in the on-going care of the person. There is no expectation that all care would transfer to Mental Health Services as a result. Adult Mental Health Service staff will similarly provide advice to learning disability services on treatment interventions for people who have

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developed less severe mental health problems and who it is agreed it is appropriate to remain the responsibility of learning disabilities services. It is essential that mainstream and specialist services work collaboratively to meet individual patient needs, utilising their respective specialist knowledge and skills to support each other in the delivery of integrated care and treatment. The Care Programme Approach (CPA) should be used as the framework for planning and coordinating support and treatment necessary for patients with a learning disability and mental health problems. Care plans should clearly identify the contribution of mental health and learning disability services, which will provide care coordination and which professional / multi- disciplinary team members are responsible for each component.

5.3 Care and Treatment Reviews

The Care and Treatment Review (CTR) process is triggered at the point when a person is identified as ‘at risk’ of being admitted to a specialist learning disability or mental health inpatient setting. The CTR facilitates a process of seeking alternatives to admission if possible and, if not, follows them through any subsequent admission, period of assessment/treatment and towards discharge. The aim of the CTR is to bring a person-centred and individualised approach to ensuring that the treatment and differing support needs of the person with learning disabilities and their families are met and that barriers to progress are challenged and overcome. In the event of admission being required there should be an informal dialogue between the services Consultant Psychiatrists or team managers to agree which is the “most competent” service to meet the patients identified needs. These discussions should also take into account the commissioning arrangements and service specification, and should where possible include the views of the patient and their family. Staff should refer to NHS England Care and treatment review: policy and guidance 2015 for further guidance relating to these reviews.

5.4 Deciding which inpatient service to admit to

The decision as to where the patient being assessed as requiring a period of inpatient care is to be admitted, will be made on the basis of their primary need, and on this basis the following applies: Learning disability Primary Need - Individuals with significant learning disability and mental health needs who cannot appropriately be admitted to general psychiatric wards, even with the provision of additional support from Learning Disability Services i.e. anyone with very limited communication skills (i.e. verbal ability limited to use of few words and

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inability to speak in sentences) along with significant sensory/motor impairment (mobility restricted to 50 yards or wheelchair-bound) and dependency needs for care should be accessing specialist Learning Disability Service for their mental health problems. Within the Rotherham and Doncaster localities any admission Monday to Friday 9-5 will be to the Learning Disability Assessment and Treatment units. Outside of these hours and during bank holiday periods patients with a learning disability primary need are to be admitted to the Adult Mental Health inpatient services and a planned admission to the Learning Disability unit will be facilitated at the earliest opportunity i.e. next working day. Within the North Lincolnshire locality there is no Learning Disability Inpatient service commissioned, so the local commissioners are responsible for sourcing an out of area placement. There will be occasions when people with a learning disability but without a diagnosed mental illness need hospital admission in a state of crisis, either informally or under the Mental Health Act. Typically, these will be people who might previously have fallen under the (now defunct) legal category of mental impairment, that is, have a learning disability and/or an autistic spectrum disorder and manifesting aggressive, challenging or self-harming behaviour. An association with such behaviour remains a necessary precondition for the compulsory admission to hospital under a treatment order of any individual with a learning disability i.e. in the absence of any other mental disorder of a nature or degree warranting such admission. Patients not previously known to services and who are without a formal learning disability or mental health diagnoses - If an episode of inpatient care is required these patients will be admitted to the Adult Mental Health Inpatient services for assessment. Any decision as to the need for the patient to later be transferred to the care of the Learning Disability Services or for a shared care pathway to be implemented will be made on the basis of the assessment. Patients with a dual diagnoses of learning disability and mental health problems - The decision as to which service these patients are to be admitted to will be based on the outcome of the care and treatment review and their primary presenting need. It needs to be recognised that this can change and any decision as to the level at which a shared care pathway is to be implemented will be determined by the patients’ current presentation.

5.5 Patients already subject to an episode of inpatient care

It is not uncommon for people with learning disabilities admitted to the assessment and treatment wards to also experience mental health problems but usually these can be assessed and treated within the Learning Disability Services. However if it is felt that a patient on one of the Trust Learning Disability wards is showing evidence of more severe

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mental health problems a joint mental health/learning disability multi-disciplinary review will be held to determine the future care of the patient, and the level and type of input required from the Mental Health Services. In the event of the assessment showing that the patient’s primary need is in respect of their mental health problems the clinical team will need to decide if:

The patient can remain within the Learning Disability Service with support from a mental health worker, or

Due to the patients identified needs a transfer is needed to one of the Adult Inpatient wards.

If it is suspected that a patient on one of the Adult Mental Health wards has an undiagnosed learning disability the clinical team are to refer the patient to the local Learning Disability Service requesting a formal assessment and diagnosis. However formal intellectual assessment can only be completed when the individual’s level of functioning and well-being is at its most stable point as undertaking formal cognitive assessments when mentally unwell distorts the true level of functioning. In view of this such an assessment should be undertaken once the patient’s mental health has stabilised. The patient is to remain under the care of the Adult Mental Health services and a joint mental health/learning disability multi-disciplinary review will be held to determine the future care of the patient, including the level and type of input required from the Learning Disability Services. If the assessment indicates that the patient’s primary need is in respect of their learning disability a transfer to the Learning Disability Inpatient unit or community team will need to be considered, and agreement reached as to any on-going support required from Mental Health Services.

5.6 Section 136 Assessments

The Trust has dedicated 136 assessment suites in the Doncaster, Scunthorpe, and Rotherham localities and all 136 assessments regardless of any known diagnoses will take place in these. However staff must refer to section 5.4 of this document for guidance in the event of a decision being made to admit for a period of inpatient assessment.

5.7 Providing care to patients with a diagnosed learning disability on one of the Adult Mental Health Inpatient wards

If a patient who has a mild learning disability and mental health problems can be supported via reasonable adjustments they should access the adult mental health wards. Shared care or joint working will be negotiated where issues specific to the persons learning disability have been identified. Mental health practitioners should contact the relevant learning disability services to their area to request support and advice. The level of support required from the Learning Disability Services will be

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different for each patient and determined through their individual need. Where possible the shared care pathway is to be agreed prior to the patient’s admission /transfer and will detail:

The frequency of contact from the Learning Disability Services whilst the patient remains on the ward.

Who will provide this contact?

Who to contact in the event of staff having any queries in respect of the patients’ learning disability needs.

Who needs to be involved in discharge planning for the patient?

When a person with learning disabilities is admitted to an Adult Mental Health Inpatient unit, the Responsible Clinician role will be fulfilled by the inpatient Consultant. In all cases there will be liaison between the Responsible Clinician and other Consultant colleagues involved in the care of the individual. Where an Adult Mental Health Consultant has taken the role of Responsible Clinician, medical responsibility will be passed back to a Learning Disabilities colleague when the patient is transferred back to Learning Disabilities services under Care Programme Approach (CPA).

5.8 Who should be involved in agreeing the shared care pathway

The development of a shared care pathway for each individual patient is to

be multi-disciplinary and involve senior clinical staff from both the Trust Adult Mental Health Inpatient and Learning Disability Services. Where possible a meeting is to take place prior to the patient being admitted /transferred to one of the Adult Mental Health Inpatient wards. In the event that it is an emergency situation the meeting should take place at the earliest opportunity following transfer /admission. Attendance at the meeting will vary according to patient need but as a minimum it is expected that the following will be present:

The Ward Managers and Modern Matrons (or their deputies) from the Adult Mental Health and Learning Disability Assessment and Treatment wards.

The Responsible Clinicians from both services to agree responsibility

The patients Care Co-ordinator.

5.9 Risk assessment

Due to the nature of their presentation including potential risk to self and, or others all patients admitted to the Adult Acute Mental Health or Learning Disability wards will have a full FACE Risk Assessment completed. For anyone with a dual diagnosis the decision as to which module of the risk assessment to use will be based on their primary presenting need. However there may be some patients where due to their presentation it is clinically appropriate to use both the Learning Disability and Mental Health module from the FACE risk assessment tool to ensure that all potential

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risks are captured. When undertaking a clinical risk assessment for any patient with a learning disability admitted to one of the Adult Mental Health Inpatient wards staff must take account of the vulnerability of the patient in such a setting as they may be more at risk of abuse or exploitation from other patients. If a patient is identified as being highly vulnerable on the Adult Mental Health ward and steps cannot be taken to protect them for example through the use of increased nursing observation it may be more appropriate for them to be transferred to a specialist Learning Disability service. As the risk assessment will inform care planning, decisions relating to leave and discharge it must be current, and reflective of the patient’s presentation, taking into account both past and present risks. For all patients the risk assessment must be reviewed and updated as minimum:

At admission.

Weekly for all acute patients during the first month of their admission, then monthly thereafter.

Prior to any periods of leave.

Following periods of leave.

Prior to discharge.

Following any significant change to the patient’s mental state, or social circumstance.

In the event of any new and significant information becoming available. When completing the risk assessment it is important to identify the sources of information recorded.

5.10 Undertaking a mental health assessment on someone with a diagnosed learning disability

In 2010 the Royal Collage of Nursing issued their document “Mental Health Nursing of Adults With Learning Disabilities“ which recommends that although the assessment process for someone with a learning disability will be similar it is important that:

The assessing clinician works in partnership with the patient, their carers, support staff, and other professionals involved in the patients care.

Someone is there to support the patient.

The duration of the assessment is adjusted to meet the needs and concentration span of the patient. Some may need additional time whilst for others the assessment may need to take place over a number of short meetings

Consideration is given to the fact that someone with a learning disability may become anxious during the assessment.

Any communication difficulties the patient may have are taken into

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account, and advice sought as to what assistance the patient may need. If the patient has been assessed by Speech and Language Therapy services a copy of their report should be sought. For some patients using pictures can help them identify their emotions.

Medical jargon is avoided and words which are easy for the patient to understand are used.

Any questions the patient is unable to understand are rephrased.

The assessing clinician checks the patients understanding throughout the assessment by summarising and recapping what has been covered.

5.11 Additional considerations when assessing the capacity of someone

with a learning disability

Staff should refer to the Trust Mental Capacity Act 2005 Policy for full details however must assess on the basis that the assessment of a person’s capacity is time and decision specific and based on whether or not the person can:

Understand the information which is relevant to the decision.

Retain the information long enough to make a decision.

Weigh up the information and make a choice.

Communicate their decision. Timely and relevant information is key to a person being able to make a decision, and a patient can only be assessed as having or lacking capacity once they have been given the appropriate support and information to help them make the decision. As someone with learning disability might have difficulty understanding the information they will need to be supported as much as possible in the decision-making process. This support will also involve providing them with the relevant information to aid their decision making in a format they will understand (such as pictures, symbols or audio) and allowing them enough time to process and understand the information. The following website www.easyhealth.org.uk provides information which may be useful.

5.12 Enhancing Staffing Levels

Patients with severe learning disabilities and mental health needs who are being nursed in adult mental health units may require additional dedicated support staff. If there is a need for extra staff this should be agreed at admission and reviewed under CPA. Extra staff will be accessed through the bank staff pool if necessary. Decision about extra support should not prevent inpatient staff from receiving extra training and/or skills development to enable them to provide safe and effective care to a patient with severe learning disabilities who has mental health needs.

5.13 Care planning

Effective care planning is dependent on good communication between the

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staff and patient and whilst patients with a learning disability may sometimes have significant communication needs it is essential that clinicians adapt their approach to accommodate these. If a patient has communication difficulties staff should:

Check if the person has had a speech and language therapy assessment, and if there are any recommendations that have arisen from it

Prepare appropriately for any one-on-one interactions.

Use simple everyday language ,and try to think of easier ways of saying a word, for example using ‘sad’ instead of ‘depressed’

When introducing fresh information to someone use no more than two new information-carrying words in a sentence and provide an explanation, perhaps using alternative methods, to support this

Consider the use of photographs, pictures and symbols to support communication.

Avoid abstract words or concepts and use concrete terms where ever possible.

As far as possible the care plan must be written in terms which can be easily understood by the patient and carer where appropriate. There are tools available which staff can access to support this, some examples are: Health action plans Person centred support plans WRAP Traffic Light Assessment. (acute health)

5.14 Patient information

As highlighted throughout this policy the type of information and the way in which it is presented to anyone with a learning disability may require tailoring to meet each patient’s individual need. Information is available in various formats and can be accessed through the Trust web site by clicking on the Learning Disability Business Division heading which will bring up the link to the Learning Disability Information Resource Centre. http://nww.intranet.rdash.nhs.uk/business-divisions/community-learning-disability-services/learning-disability-information-resource-centre/

5.15 Information/support for Carers/ Relatives

On admission it is important that clinical staff establish who the patient’s carer/relative is and if possible the extent of the information the patient is willing to share with them about their care and treatment whilst on the ward. Regardless of the patient’s wishes in respect of information sharing, all carers/relatives are to be given a copy of the ward carers’ pack, and where appropriate should be consulted in regards to the planning of periods of leave and/or discharge from the ward.

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5.16 Responsibilities in respect of any identified continuing care / specialist placement needs

Responsibility for leading the assessment and submission of any request to fund a specialist placement will rest with the inpatient service the patient is receiving care from. This will also include liaising with and keeping the patients identified relatives/ carers informed. However in the event that the patient is on one of the Adult Acute Mental Health wards clinical staff from the Learning Disability Services will provide:

Support and advice as to the most suitable placement to meet the patients identified needs.

Any required specialist assessments from their service.

Advice around the safe transportation of the patient to the new placement.

5.17 Discharge Arrangements for patients on a shared care pathway

No patient on the shared care pathway should be discharged without a full

multi-disciplinary pre-discharge meeting with clinical representatives present from both the Mental Health and Learning Disability Services. This must take place to ensure the safe discharge of the patient. Any discharge from an episode of inpatient care will comply with the standards set out in the Trust Policy for the Discharge/Transfer of a patient from inpatient services.

5.18 Process to be followed where a difference of opinion between professionals is apparent

Wherever possible, any disagreements about the management of an initial referral, requests for case transfer or joint working should be resolved at local level, between team managers and Consultants. Joint assessments may assist in resolving such disagreements. With particularly problematic or contentious cases, it may be helpful to convene a joint planning meeting, with important decision makers from both services attending. In the event that the difference of opinion cannot be resolve at local level the following escalation process should be followed (close and timely liaison between services is essential):

Escalate to the relevant Service Managers

If the issue remains unresolved it must be swiftly escalated to the relevant Associate Directors/Clinical Directors

The final point of escalation is to the Medical Director/Chief Operating Officer, who will resolve the difference of opinion.

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5.19 Support for staff

It is recognised that patients who have a mental health problem and learning disability may be challenging for staff to work with, and it is therefore essential that managers:

Have effective systems in place for allocating work appropriately to staff

Have robust systems for local induction, supervision and performance and development review as per Trust policy, and that appropriate training is accessed by all relevant staff

Effective working practises will be supported by:

Access to additional clinical supervision as required

Robust joint working arrangements

Use of other staff support systems such as counselling through the Occupational Health Department

6. TRAINING IMPLICATIONS

Staff groups

requiring

training

How often

should this

be

undertaken

Length of

training

Delivery

method

Training

delivered by

whom

Where are

the records

of

attendance

held?

All staff working in Adult Mental Health Service e.g. Doctors Nursing staff Social workers Allied Health Professionals e.g. OT, Physio etc Psychologists Support staff

Once for all staff with updates as determined through any changes to the pathway

Training and awareness will be delivered by a combination of: •3 hour learning disability awareness session. •Staff completing the learning disability education booklet. •Inclusion of specific sessions around caring for people with a learning Disability and Mental Health problems on the staff practice development days

Local Induction for New Starters

The Trusts learning and development department in conjunction with internal facilitators (including patient) and Nurse and Occupation Therapists Consultants

Electronic Staff Record system (ESR)

All staff working in Learning Disability services e. g. Doctors Nursing staff Social workers

Once for all staff with updates as determined through any changes to the pathway

Training and awareness will be delivered by a combination of: •Mental Health First Aid Training •Inclusion of

Local Induction for New Starters

The Trusts learning and development department in conjunction with internal facilitators and Nurse and Occupation

Electronic Staff Record system (ESR)

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Staff groups

requiring

training

How often

should this

be

undertaken

Length of

training

Delivery

method

Training

delivered by

whom

Where are

the records

of

attendance

held?

Allied Health Professionals e.g. OT, Physio etc Psychologists Support staff

specific sessions around caring for people with a learning Disability and Mental Health problems on the staff practice development days

Therapists Consultants

7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported to Frequency

Implementation of the policy

Base line of current practice

Care Group Directors

Clinical Audit? Effectiveness

Team

Adult Mental Health and Learning Disabilities Care Group Services

Green Light Steering Group

Annual

Adherence to the service access and pathway arrangements

Clinical records audit

Staff interview

Care Group Directors

Effectiveness Team

Clinical Audit

Adult Mental Health and Learning Disabilities Care Group Services

Green Light Steering Group

Annual

Difference of opinion

Clinical records audit

Staff interview

Care Group Directors

Effectiveness Team Clinical audit?

Adult Mental Health and

Learning Disabilities

Care Group Services

Green Light Steering Group

Annual

Compliance with training

Training records

Care Group Directors

Head of Learning and Development

Adult Mental Health and Learning Disabilities Care Group Services

Green Light Steering Group

Annual

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8. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this policy’s webpage on the RDaSH website.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court

Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9 LINKS TO OTHER PROCEDURAL DOCUMENTS

Care Programme Approach (CPA) Policy, Clinical Policies

Mental Capacity Act Policy, Clinical Policies

Deprivation of Liberty Safeguards Policy, Clinical Policies

10. REFERENCES

National Service Framework (1999) Department of Health

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Department of Health (2001) Valuing People: A new strategy for learning disability in the 21st Century

Department of Health (2004) Green Light For Mental Health

Valuing People Now – A three year strategy for people with learning disabilities

(2009)

Department of Health (2009) New Horizons

11. APPENDICES

Appendix 1 – Flowchart for patients presenting with a suspected/actual learning disability or a suspected/actual mental health problem

Appendix 2 - LD screening information to quickly establish likely eligibility to specialist LD Services.

Appendix 3 – Mental Health Crisis Pathway – Learning Disability

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MENTAL HEALTH CRISIS PATHWAY – LEARNING DISABILITIES (LD) Doncaster Rotherham & N.lincs

KEY RISK INDICATORS RISK

LEVEL

ACTIONS

IMMEDIATE DANGER:

Patient or others in danger

4 Telephone the Police - 999

HIGH RISK

Definite plans

Available means

High levels of hopelessness

Insufficient social support

3 Ask the person to remain with you in a place of

safety & refer to existing risk management / CPA

crisis plans if available.

MEDIUM RISK

Indefinite plans

Some available means

Moderate levels of hopelessness

Some social support

2

Formulate a risk management plan and

agree the plan with the patient in a MDT

meeting.

Notify area LD Psychiatrist of risk

Notify Community Nurse of risk

Notify staff/carers working with patient of

risk.

NUMBERS AS ABOVE

LOW RISK

No definite plans

No means

Low levels of hopelessness

Sufficient social support

1

Monitor the person.

If not known to the service or out of hours.

Call the access Team to assess need & consider home support or admission to a local adult in-patient unit. Doncaster

Call the Access Team 798400 Rotherham

01709 336080 N.Lincs

01724 382019 If known to the LD service & during weekday working hours (9-5). Doncaster

LD Psychiatry 794085 or 798100l Community Nurse 796145 CAIS 798151 Rotherham

01709 302800 or 01709 302834

N.Lincs

01724 298222

APPENDIX 2

Page 22 of 23

MENTAL HEALTH CRISIS PATHWAY – LEARNING DISABILITIES

Who is this pathway designed to support?

Adults with a learning disability who have been identified as having additional complex needs and are at immediate risk to themselves or others or harm that requires in-patient admission.

Additional complex health needs may include significant difficulties in the following areas:

suicidal intent mental illness not responding to interventions in community settings severe challenging behaviours

and may:

require use of legislation be resistant to treatment be inter-related to other bio-psycho social needs require more than one professional and a multi-disciplinary team to meet their needs require care programme approach (CPA) continued support

Emergency/Crisis Point of Contact

Police – 999

If there is an immediate risk to your safety, the safety of others or the patient, seek emergency support from the police.

What can patientpatients expect?

Assessment of biopsychosocial factors and clarification of diagnosis Risk assessment and management plans Pharmacological and psychological based approaches Planned discharge with a suitable care package

Who can refer to acute specialist learning disability services?

We have an open referral process which includes:

GPs NHS clinicians Community learning disability teams Social services

ASSESSMENT & MANAGEMENT OF RISK GUIDELINES

Key principles

Keep the person safe

Keep other people safe

Keep yourself safe

APPENDIX 3

Page 23 of 23

Indicators of risk

Risk assessment is an on-going process and should always be at the forefront of any practitioner’s clinical thinking. Be alert for the following: Referral

Information on suicide attempts, self-harm threats and threats to others.

A history of depression and/or psychosis.

A forensic history.

Borderline Personality Disorder (BDP).

Young men and older people are more at risk. History

Previous attempts.

Major life changes.

Substance misuse problems.

Recent discharge from inpatient care.

Serious physical illness. In session factors

Threats or plans to harm self.

Hopelessness / no sense of a positive future.

Current unmet need / lack of a social network / isolation.

Mental health practitioner intuition and concern.

Proactive assessment of risk

Ask about the following:

Level of intent: Are there definite plans?

Degree of hopelessness?

Problem solving: Are there alternative ways out – possible solutions?

Social support: Are there people at home? Can these people help?

Access to means: Does the person have access to a means to hurt themselves?

Harm to others: Are other people at home, carers or children at risk from the behaviour?