IN THE WELSHPOOL CORONER’S COURT BEFORE SENIOR CORONER MR GRAEME HUGHES IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF:

MR SAMUEL GOMM

_____________________________________________________________ RESPONSE TO REGULATION 28 PREVENTION OF FUTURE DEATHS REPORT _____________________________________________________________

This response is sent in accordance with the direction of HM Senior Coroner Graeme Hughes dated 1 June 2022 that a response from Powys Teaching Health Board and Powys County Council is provided to the Regulation 28 Prevention of Future Deaths Report in the inquest touching the death of Samuel Gomm. This is a joint response on behalf of the local authority Powys County Council (PCC) and Powys Teaching Health Board (PTHB). This response seeks to explain the actions to be taken to address the matters of concern and recommendations as identified by the learned Coroner.

Improvement Risk assessments (self-Harming patients) record keeping systems throughout Powys County Council and Powys Teaching Health Board and Wales

1. Powys Teaching Health Board and Powys County Council provide co-located Mental Health Support to the residents of Powys. Both organisations have agreed to use the Welsh Applied Risk Research Network technique (Welsh Applied Risk Research Network) and the Welsh Community Care Information System for case recordings (WCCIS). This is fully implemented in all Community Mental Health Teams (CMHTs) with plans to expand to other parts of the service, e.g., inpatient, learning disability and primary care. This is being managed by the integrated organisational Gateway Group.

2. As Powys Teaching Health Board inpatient staff are currently only able to read information stored on the Welsh Community Care Information System for case recordings, they have relied on a Welsh Applied Risk Research Network Word Document. This is then uploaded and attached to Welsh Community Care Information System by admin staff. It is accepted that this has led to a duplication of work and the risk of important information being lost. Having identified this, Powys Teaching Health Board are updating training and access arrangements for inpatient staff required to complete the Welsh Applied Risk Research Network document. This will ensure that all Welsh Applied Risk Research Network document will be recorded on the Welsh Community Care Information System and there will no longer be a need to use the Word Document template. It is anticipated that this will be achieved by the 2nd August
2022.
3. There have been concerns that the Welsh Applied Risk Research Network document accessible on WCCIS is distorted and is not compliant with the copyright held by Welsh Applied Risk Research Network authors. To address this, both organisations have worked closely together to change the current document and to ensure that the copyrighted form is used on the WCCIS system. This enables staff to use the research and formulation-based techniques for the assessment and management of serious risk. (Appendix 1)

4. This work will be completed by the end of July 2022 when staff will be advised of the changes and any old Welsh Applied Risk Research Network document templates will be removed.

5. Powys Teaching Health Board currently commission inpatient services from external providers. This can cause difficulties in information sharing. Powys Teaching Health Board will work collaboratively with commissioned services to ensure robust risk assessment utilising their formats with intensive handover of

service users on discharge to include risk information. Their risk assessment will be used to populate Powys Welsh Applied Risk Research Network assessments following this handover.

6. Powys County Council are in the process of updating WCCIS documentation to support practitioners in identifying a list of services/people who should have sight of the completed documentation. This will include the cared for person, their GP, and external commissioned services (for example, Kaleidoscope or Domiciliary Care).

On completion, WCCIS/Practitioners will alert administration staff that key documents are ready to send to those identified. These documents will include, the Welsh Applied Risk Research Network risk assessment, initial assessment and Care and Treatment Plan. Practitioners will have to justify on clinical grounds, why this isn’t appropriate for specific individuals. This will be re-enforced during Social Care Team Meetings. Team administrators will take responsibility for the sending of documents and will keep a record of those sent. Appendix 2, 3, 4

7. “The Welsh Community Care Information System (WCCIS) is intended to enable health and social care staff to deliver more efficient and effective services using a single system and a shared electronic record.” (Welsh Community Care Information System, Report of the Auditor General for Wales, October 2020.) It has been Welsh Governments intention to implement WCCIS in all Welsh Health Boards and Local Authorities. This does not currently include external organisations who do not have direct access to records held by statutory organisations due to IT limitations and Information Governance.

8. The National roll out of WCCIS is taking much longer and proving more costly than expected, with concerns about functionality and performance being reported in the media. National System performance issues were particularly difficult during Autumn 2021, where some organisations found WCCIS

unavailable. These issues were resolved following a Systems upgrade in February 2022 with the system performance now being reported as good both nationally and locally.

9. In February 2022, Welsh Government reported its findings in an Independent Review of the WCCIS programme. A series of actions to “reset” and “course correct” were identified. This included an increase in Welsh Government funding and the recommendation for a new WCCIS business case to support health boards and local authorities. The report also identified the need to simplify processes and reduce its scope with regards to data collection and some of the programmes within Digital Health and Care Wales. It is anticipated that this will allow for greater system stability and improvement of user experience. A further National review will take place in November 2022. (Audit Wales, 1 July 2022).

10. Alongside National consideration, WCCIS remains under review by Powys Teaching Health Board and Powys County Council’s internal Change Management groups allowing for prompt responses to local challenges. Joint initiatives are also improving access to WCCIS training by using a series of open access videos. This is supporting user confidence for both new users and more experienced staffing groups.

Welsh Applied Risk Research Network assessments (content reviews/ integrating systems/ updating of current information)

11. A Risk Assessment is an essential part of Mental Health Work and should be evidence based and carried out in conjunction with cared for persons and their support networks.

12. Welsh Applied Risk Research Network is the current risk assessment tool used by both organisations and is stored on the WCCIS system. Whilst the document should be fluid and regularly updated it cannot remain as a live document on WCCIS. Following completion on WCCIS the form should be closed and re- opened at the point of review. WCCIS automatically copies the information from the previous form to aid completion. This ensures that practitioners are able to clearly see how often and when the Welsh Applied Risk Research Network is updated.

13. The Welsh Applied Risk Research Network document should be considered alongside other Care and Treatment documentation which assists the writer in considering whether a formal Mental Capacity Assessment is required.

14. Along with meeting the requirement of data collection, this ensures that the fluidity of risk is reflected, drawing workers attention to any changes. Supporting staff to easily identify when a change of risk management is required. This has been identified as the preferred method by Welsh Applied Risk Research Network authors. To ensure that all risk activities are easily captured, WCCIS has introduced an embedded Chronology. This allows for all events to be recorded, supporting practitioners to recognise when there is a change to risk behaviours. Non-Welsh Applied Risk Research Network assessors can add to the Chronology and events reported by partner agencies can be included, supporting the sharing of information and highlighting any need for re- assessment of risk management.

15. Monitoring and reviewing changes are an essential part of effective care and treatment and risk management. Completion of the Welsh Applied Risk Research Network document should be part of the initial care planning process for everyone under Secondary Mental Health Services. Along with the Care and Treatment Plan, the Welsh Applied Risk Research Network should be reviewed

a minimum of once in a 12-month period and at any change of circumstances that might impact on risk and wellbeing. (Mental Health Measure Wales, 2010).

16. This would include but is not limited to events such as, relationship breakdown, loss of carer, increase in substance use, increase in contact with services, particularly out of hours. All significant self-harming events should be recorded on the document, this includes disclosure of thoughts of self harm. To support this WCCIS will be updated to include a Chronology of events to enable workers to keep a succinct and easily accessible record. This will allow staff to easily identify if there has been a recordable event, creating a clear timeline of presenting risks. This will alert practitioners to any changes or patterns of behaviour and enable better dynamic risk assessing.

17. Whilst this function will be only accessible to registered WCCIS users, it will enable staff to update incidences/concerns easily, without necessarily being involved in the full Welsh Applied Risk Research Network assessment. For example, support workers recording concerns following a visit in addition to reporting this to Care Coordinator/or Senior Member of staff. This will be implemented by the end of July 2022.

18. External agencies without access to WCCIS will be provided with an up to date Care Plan which will include the contact details for involved Powys Teaching Health Board and Powys County Council staff. They will be advised of both organisations Information Sharing Protocol at the start of their input and on regular occasions in line with Care and Treatment Reviews. Whilst external agencies are currently unable to use WCCIS, they will be supported to contribute to the development of Welsh Applied Risk Research Network by statutory staff who will then provide a copy of the updated assessment as detailed above.

19. Alongside any notable changes of circumstances, the Welsh Applied Risk Research Network will be updated at the following points:

(a) Admission and discharge from Psychiatric Inpatient Care/CRHTT (b) Referral to internal risk panels (REP, IRIS) (c) Referral and review at MAPPA (d) Inclusion in Crisis Care Forum Multiagency discussion

20. Any concerns noted by the receiving team regarding the timeliness of Welsh Applied Risk Research Network assessment update or divergent staff views should be reported via Powys Teaching Health Board Datix system and through Powys County Council line management structure. This will ensure that both systemic and independent practitioner concerns are captured.

21. Staff will be updated on the new processes when complete by Welsh Applied Risk Research Network Lead and Quality and Safety Team for each organisation.

22. In October 2021 and April 2022 Powys Teaching Health Board undertook an internal audit of Welsh Applied Risk Research Network documentation. Compliance with reviews and the quality of content was rated as good. Powys Teaching Health Board will continue to audit Service User records on a 6 monthly basis.

23. Prior to entering business continuity through Covid, Powys County Council undertook regular monthly in-depth random audits, which included feedback from service users and carers as appropriate.

24. Part of this process included analysis of the Welsh Applied Risk Research Network and CTP (care and Treatment Plan) documentation, alongside case recordings. Audit feedback was provided to Powys County Council Senior Managers and staff both at supervision and in team meetings. Powys County Council Team meetings are used to support staff in understanding when improvements need to be made but also to celebrate good practice.

25. Unfortunately, Audits were stopped due to Covid Business Continuity and increased pressures on the local authority. A small number of audits have taken place during this time but there will be a full rollout of mental health audits by the end of August 2023.

26. Recommendations by the Welsh Applied Risk Research Network author from this case will be used to inform training for both Powys Teaching Health Board and Powys County Council staff.

Welsh Applied Risk Research Network assessments (format/ ease of accessibility / infrequent users/ new users)

27. Work is currently in progress to ensure that the correct Welsh Applied Risk Research Network is available on the WCCIS system by the end of July 2022. This will enable all Community Staff to have access to the copyrighted version, stored in an easily accessible part of the database. This can be accessed by both Powys Teaching Health Board and Powys County Council. To enable the Welsh Applied Risk Research Network to maintain its evidence base it needs to remain in its original state and cannot be altered to provide additional prompts or data collection. The accompanying CTP documentation focuses on areas not directly included in Welsh Applied Risk Research Network. For example, capacity is

considered within the CTP assessments, asking the practitioner to consider whether an additional WCCIS embedded Capacity Assessment also needs to be completed. The practitioner is directed to offer the support of an advocate through this non-Welsh Applied Risk Research Network document.

28. As the lead agency for Welsh Applied Risk Research Network, Powys Teaching Health Board facilitate initial and refresher training. ESR (Powys Teaching Health Board Electronic Staff Record) system will provide information on Powys Teaching Health Board staff requiring updates to ensure appropriate targeting.

29. Powys County Council will use their Business Insight process to identify workers requiring Welsh Applied Risk Research Network updates and infrequent users. This will ensure that refresher training is undertaken within the specified guidance of 3 years. Both organisations will use their Welsh Applied Risk Research Network trainers as “Champions” who can act as a point of contact for infrequent users supporting them to develop skills and confidence and ensuring that completed Welsh Applied Risk Research Networks are of an acceptable standard.

30. Powys County Council induction policy will be extended to include Welsh Applied Risk Research Network training as mandatory as is the case in Powys Teaching Health Board. This will be overseen by Powys County Council Service Improvement Manager and Powys Teaching Health Board Quality and Safety Team.

31. Staff changes, particularly agency staffing, will create extra pressures for training. Whilst Welsh Applied Risk Research Network training is currently provided by Powys Teaching Health Board, the local authority Powys County Council will nominate 2 workers to train as trainers, to support this programme.

We anticipate an integrated approach to WCCIS training across both organisations, with Powys Teaching Health Board and Powys County Council staff delivering joint Welsh Applied Risk Research Network training.

Welsh Applied Risk Research Network and associated assessments – reviews/ quality assurance monitoring/updating of current needs/ access by relevant bodies)

32. The Welsh Applied Risk Research Network document sits alongside additional Care and Treatment paperwork (Assessment, Care and Treatment Plan). It is an integral part of the assessment and treatment process. Powys Teaching Health Board and Powys County Council will continue to follow their own internal audit as detailed above.

33. Along with considering the Welsh Applied Risk Research Network document, Powys County Council’s audit process extends to include additional electronic records and feedback from service users/carers. This process is overseen by Powys County Council Service Improvement Manager and outcomes are fed back to Senior Management and to individual workers through supervision and during team meetings if appropriate.

34. Outcomes of these audits are embedded in Service User records and available to Powys Teaching Health Board. Powys Teaching Health Board have identified greater service user/carer involvement as a piece of work following their most recent audit in June 2022.

35. Powys Teaching Health Board audit outcomes are discussed in monthly Learning and Development Group and disseminated to front line staff, with

service improvements and action plans delivered directly by Service Managers and overseen by Operational Leads.

36. The offer of advocacy is a legal requirement of both the Mental Health Measure (2010) and the Social Services Well Being Act, 2014. This is reflected in Care and Treatment Programme documentation, where staff are directed to offer advocacy and to confirm whether it is required. This is reported on through Powys County Council Business Insight programme and in Powys County Council audits. Advocacy clinics have been reinstated in CMHT’s and inpatient units following Covid19. These are advertised in patient access areas and can be booked directly with the advocate if preferred.

37. The Information Sharing protocol is explained to a cared for person during any initial assessment, where the person is advised that any information provided may be shared with supporting agencies. The need to break confidentiality in relation to concerns about risk is included within this explanation. Workers shall remind cared for persons of this duty at all reviews and further will do so should a requirement to inform partner agency arise. (Appendix 6).

38. To support understanding of this protocol, Powys County Council are in the process of updating their “privacy notice” which includes a guide written for those using services. This is currently in the process of being ratified, with no changes expected. This is attached as Appendix 7.

Welsh Applied Risk Research Network assessment tools – accessibility to Patient / integration referral process to secondary services, working together optimisation approaches
39. The Welsh Applied Risk Research Network as per all other CTP documentation should be written in conjunction with the cared for person where possible and unless this leads to increased risk to self or others. The Welsh Applied Risk Research Network is one part of an assessment process and should be considered alongside the Initial Assessment which provides an overall view of a person’s life and helps develop an understanding of the impact of any mental health problem and what matters to them as individuals. Both documents should sit together to form a Care and Treatment and Risk Management Plan. Powys Teaching Health Board currently use the All Wales Assessment Document held on the Welsh Applied Risk Research Network. Powys County Council have not implemented this document as they felt it did not align with the Social Services Wellbeing Act. This view was shared by a visiting Inspector from the Care Inspectorate Wales at the time the decision was made. Regardless of which documentation is used the plans should be done in partnership with identified individuals and organisations.

40. To improve communication, staff will be directed to identify those that are involved in the person’s care. Administration officers will be notified by WCCIS and will ensure that the correct documentation is sent directly to them. This will include, the cared for person, the GP and any other organisation providing care and support.

41. On completion the document should be shared with the cared for person’s GP and other appropriate agencies as documented in the care plan. Any changes that affect risk are to be communicated with appropriate partner agencies. External agencies who do not have direct access to the Welsh Applied Risk Research Network document should ensure that their information is passed to

the Care Coordinator or representative. This can then allow for review of the Welsh Applied Risk Research Network documentation held on WCCIS system. It is not possible for external agencies to have access to the WCCIS system due to the level of information governance compliance required.

42. Identification and management of risk is a shared responsibility and partner agencies should work closely together to protect the safety of service user, staff and members of the public. External agencies without access to WCCIS will be provided with an up-to-date Care Plan covering both a relapse plan and 24-hour contact details for statutory services. Whilst this is routinely available on the WCCIS system, staff will be advised of the need to share risk information with involved agencies under the appropriate framework.

43. External agencies who are not included in the WCCIS programme will be encouraged to report any changes in risk to statutory staff, normally the Care Co- ordinator or their deputy. The details will be added to the chronology and used to inform robust risk assessment. This will be communicated to involved partner agencies.

44. Whilst staff may have concerns about the sharing of relevant information, they should be supported to understand the legal framework that facilitates partnership working. Once approved a copy of the Powys County Council’s Privacy Notice will be forwarded to staff to ensure that staff are comfortable in this process.

45. Any referral to external agencies should be accompanied by an up to date Welsh Applied Risk Research Network and Care and Treatment Plan, which will include relevant contact details and a relapse plan. These documents will be

embedded in WCCIS and forwarded to agencies in their preferred means, digital or paper.

Appendix 1 The new Welsh Applied Risk Research Network now available on WCCIS system 2 Assessment – All Wales (used by Powys Teaching Health Board) 3 Assessment – used by Powys County Council 4 Care Plan - All Wales (used by Powys Teaching Health Board) 5 Care Plan – Powys (used by Powys County Council 6 Powys County Council Privacy Notice 7 Joint Action Plan

APPENDIX 1

Powys - MHM – Welsh Applied Risk Research Network Risk Formulation (CTP4) Service User Details

Risk Formulation and Management Plan This document provides a template to allow the accurate recording of your risk assessment.

Please give as much detail as possible Assessment Start Date

Assessor Details

Name of Assessor

Team

Designation

CCIS ID

NHS No

First Name Middle Name

Last Name

Date of Birth:

Age

Age if Estimated

Gender

Nationality

Religion

Ethnicity

Primary Address

Post Code

Email Address

Home Phone

Mobile Phone

Work Phone

Preferred Language

Preferred Contact Method

Interpreter Required

RISK FORMULATION 5Ws What What is the nature of the risk (describe) remember there can be more than one risk area, remember children/vulnerable adults. Please put as many details as possible

Who Who are the likely victims, either specifically or the type or nature of the likely victims if this can be specified. Remember risks to other children/ vulnerable adults. Do not forget risk to self.

Why What are the likely trigger situations for risk related behaviour: e.g., response to feeling threatened, arguments with others, command hallucinations etc.

Where Where is the risk posed (in the context it is most likely to occur - e.g., home, hospital, community setting etc.) Are there any protective environments (e.g., a grandparent's house, school/college, foster care, etc)?

When

How imminent is the risk likely to be? When is the risk most likely to occur? Are there any dates that indicate a particular vulnerability (e.g., Christmas, anniversary of a death or of trauma, etc)? Is there any time of day when risk is increased (e.g., night-time)?

Key Risk Indicators Those factors most associated with the risk increasing e.g., drug/alcohol use, being in confined space (ward), command hallucinations, lack of insight into illness.

Risk Reducing Factors Those factors that can decrease the risk (e.g., being at home/in school, being with a family member, good relationship with a teacher, involvement of Social Services, compliance with medication).

Please give as much detail as possible. Select the appropriate category. Probability: What is the likelihood that the risk behaviour will occur Risk Category

Severity: Describe the impact of the risk behaviour on self or others Risk Category

Imminence: When do you consider the risk behaviour is likely to occur? Consider presence of active risk indicators Risk Category

Summary of Risk Formulation:
- Include RISK REDUCING FACTORS: those factors that can decrease the risk
e.g., being at home/in hospital, being with a family member/compliance with medication.

CLINICAL FORMULATION - 4 Ps Predisposing Factors Things that make a person vulnerable to developing psychological problems (e.g., childhood trauma, physical health problems, or family history of mental illness).

Precipitating Factors Things that happened in a person's life that seems to trigger an episode of illness/change in functioning (e.g., significant life changes, bereavement or loss of job).

Perpetuating Factors Things that seem to keep a person in their current state of distress (e.g., pervasive negative thinking, lack of close relationships, or lack of adherence to medication).

Protective Factors Things which seem to keep a person well and if maintained or strengthened decreases the likelihood of the problem reoccurring e.g., strong relationships, a skill/strength in a specific area, or good sense of humour (personality traits).

Risk Management Plan:
• Clearly highlight the measures that you feel are necessary to manage the identified risks.
• Consider what you need to do now, as well as longer term options.
• Include contingencies (e.g., what if mental state changes?)
• Who do you need to inform of your formulation/plan? Consider your responsibilities to inform external agencies (e.g., If children have been identified as at risk inform Child and Family Social Services and/or the police).
• Remember "What I Can Do (WICD)"

REVIEW What signs/symptoms/circumstances/events would prompt an urgent review before the planned review date?

Future Reviews Due? Yes No

Date of Next Planned Review DD MM YYYY Comments/Action

Form Data Entry Owne r Actua l Start Date Statu s Modifie d On Modifie d By Completio n Date Complete d By User

Appendix 2

Person Information Is the person information in the banner up to date? Yes No

Is the person a veteran Yes No

Consent to Share Information Consent to share information within health /social care professionals is covered by GDPR. Record consent or refusal to share information with individuals ( rather than care professionals). Consents Conse nt Given Sta rt Dat e En d Dat e Consent ed To Mod e Wh o Free Text Nam e Conse nt Given to Perso n Conse nt Given to Provid er Refus al Reas on Remov al Reaso n

Social Context Emergency Contact

Last Name First Name Property No Property Name Postcode Phone Address Phone 1

Carer Is the person a carer?

Does this person have a carer? Yes No

Language Languages Language Fluency Preference Are there any language accessibility needs Yes No

Interpreter Required Yes No

If yes please specify:

About this Assessment Please be aware of any ceiling of care documents or agreements. These may include but not limited to: Do Not Attempt Resuscitation (DNAR)/Do Not Attempt CPR (DNACPR); Advance directives/ decisions/ refusal of treatment; Living will; Lasting power of Attorney.

Confirmation that an Active Offer to have this Assessment undertaken in the Welsh Language has been made Yes No

Assessment Start Date

Location of Assessment

Assessing Service

Type of Assessment

MHM Care Coordinator Professional (User) Start Date End Date Who Has Been Involved/Contributed to this Assessment

Date Name Designation Location Involvement/C ontribution

First/Follow/Reassess/Repeat

Name of Assessor

Designation

Person Engagement Do you have any concerns about the person's capacity to engage in this assessment Yes No

Is there a record/concerns of Deprivation of Liberty Safeguards (DoLS) Please specify any restrictions and expiry date (maximum 12 Months)

What other agencies, care & support that have been / are involved? Detail any Services/Agencies that have supported you in the past, and what care & support you are currently receiving.

Person Perspective and 'What Matters' Include the individuals own words. If the person isn't able to communicate this, an advocate can provide the answers. Person's Current Circumstances Tell me a bit about what's happening/ What concerns you most? / Presenting Needs

Presenting need

Background/Personal History

MHA Section 117 Applicable

Accommodation need

Accommodation Status

Property Access Arrangements

Children the person has contact with

Name DOB Relationship to child if known In household

Yes No

Person's Education

Year Grou p Curre nt Year Yea r End Dat e Establishme nt Type Statu s For m / Clas s Person Educatio n Year Year Grou p Education Establishme nt Person's Employments Employment Status Employment Type Start Date What Matters

Supporting person's perspective Supporting persons’ view

Physical Health Is the person currently pregnant

Physical Health

Has the person received information / had a conversation about how to manage their lifestyle choices? Yes No

Height and Weight

Weight Kilograms Height Metres Date/Time Taken Date/Time of Next Screening BMI Score Waist Circumference Measured in centimetres

Client Disability/Impairment Diagnose d Date Disability or Impairmen t Disabilit y Impairmen t Registere d Disability No Severit y Star t Dat e End Dat e Allergies Allergy Type Allergen - What Substance Caused the Reaction Reaction Start Date and Time Level Surgery/Practice

GP Name

Surgery/Practice Address

Surgery/Practice Phone Number

Is the person in regular contact with their GP

Does the person smoke or use a vape

Current Alcohol Intake – weekly

Other substances misused including prescribed and over the counter

Current Medication/Treatments at The Time of This Assessment Is the person currently taking any medication Yes No

The Person's Experiences of Treatment & Responses To Medication

Mental State Examination Person's view of their current mental health conditions

Objective Mental State Examination

Safety and risk screening Past Risk History

Forensic History

What What is the nature of the risk (describe) remember there can be more than one risk area, remember children/vulnerable adults. Please put as many details as possible

Have risks that require management been identified? Yes No

Person risks Role Type Details Created On Review Date End Date End Reason Clinical Measures Undertaken and Scores What, if any, other assessment tool(s)/ outcome measure(s) have been completed

Assessment Date of previous Assessment Previous score Date of Assessment Score following current assessment

Other tool/s completed

Measure Date of previous Assessment Previous score Date of Assessment Score following current assessment

Outcome of Assessment Agreed Needs

Agreed Need Eligibility

Personal Outcomes

Personal Outcome National well- being outcome Care and Treatment Plan Outcomes Baseline self- assessment measure (1-10) What does this look like? Baseline self- assessment goal What does this look like?

Recommended next actions

Recommended actions and immediate next steps and by who Target Date

Formulation This is a summary of how the person's life events, and circumstances have led to the current difficulties, and the impact and meaning this has had. This should be shared and agreed with the person if appropriate

Is a safeguarding referral required? Yes No

Outcome of Assessment

If Signposted Enter Name of Service(s)

Eligibility decision

Assessment Information

Confirm the current assessment is complete

Has the individual been offered a copy of the assessment

Date Offered DD MM YYYY Name of Assessor

Designation

Assessment last Modified On

Assessment last Modified by Whom

Appendix 3

CTP Assessment Service User Details

CTP Assessment Assessment Date DD MM YYYY Location of Assessment

Assessor

Designation CCIS ID

NHS No

First Name Middle Name

Last Name

Date of Birth:

Age

Age if Estimated

Gender

Nationality

Religion

Ethnicity

Primary Address

Post Code

Email Address

Home Phone

Mobile Phone

Work Phone

Preferred Language

Preferred Contact Method

Interpreter Required No

Referrer

Name

Address

Telephone

Initial/Full/Re-assessment

Source Of Information/Contributors

Service User

Referrer

Past Notes

Family/Carer

Other

Carer Name

Address

Telephone

Carer's Assessment Offered?

Carer's Assessment Accepted / Declined?

Is this person a young carer

Issues of confidentiality & consent have been explained

Consent to approach your Carer / Next of Kin / Advocate

Details of advocacy requirements

Service user and Carer Perspective Service users expectations/outcomes

Carer's Perspective

Presenting Problem History of presenting problem, previous contact with mental health services and interventions.

Mental Health Speech, presentation, mood, symptoms, insight, cognitive ability.

Medical history, family history of mental illness, childhood, and schooling

Are there any particular risks to children due to the service user's mental illness?
i.e. delusional beliefs / suicide plans involving children. If yes, a referral to Children's Social Services should be made. Does the service user care for children?

How many children, of what ages?

Does the service user's mental health affect their role as a parent?

Are there any other significant carers?

Does the service user need support in their role as a parent?

Is the child on the Child Protection Register? Yes No

Is a referral to Children's Social Services required?

Date of Referral DD MM YYYY

Substance Misuse Alcohol use - If use is problematic, should assessment of this be made?

Tobacco and caffeine use

Use of other substances

Day To Day Living & Environmental Resources Personal care, sleeping pattern, mobility/falls.

Budgeting, financial circumstances, benefits, keeping warm, transport, exercise and leisure, shopping, cooking, eating and drinking, household tasks, work or education.

What are the factors supporting the service user? What are their personal strengths?

Social Circumstances Current social circumstances, housing needs, family circumstances, cultural needs, spirituality, needs for support. What support is available from others?

Are there any immediate issues / decisions requiring an assessment of mental capacity?

Does a Mental Capacity Assessment and Best Interest Decision Form need completing?

Is there a need to consider whether a Deprivation of Liberty Assessment should be made?

Physical Health Physical illnesses, chronic pain, mobility/falls, sensory deprivation

Medication At Time of Assessment N.B. Medication changes frequently. This information should not be relied upon as an accurate reflection of current prescribed medication

This page to be sent to GP following completion of initial assessment Current Medication Frequency Dose Date Commenced

Does a review of medication need to be made?

Assessment Date DD MM YYYY RISK ASSESSMENT

Ensure all appropriate risk assessment tools are completed, in addition to this assessment form. Evaluation of Risks (including Forensic History)

Date of Welsh Applied Risk Research Network Risk Assessment DD MM YYYY Is a referral to POVA required?

Date of Referral DD MM YYYY Formulation / Summary of Needs

Fair Access to Care (FaC) Eligibility

Health & Safety

Autonomy

Managing Daily Routines

Involvement

Plan

Does the individual have complex health needs that require further assessment?

Does the individual have needs that could trigger eligibility for Continuing NHS Health Care?

Concerns Consider: concerns / issues re: discharge, home circumstances, accommodation, ability to manage, carer issues, large packages of care, the need for specialist equipment, the nature, intensity, complexity and unpredictability of the individual's needs.

Are any Specialist Assessments Required?

Specialist Assessments required

Reason If Outcome is Assessment Completed for S4 please state reason Referral Passed To Role Organisation Date Referred Date Returned

Data Protection Act 1998 All 'data subjects' can apply for access to records held about them, this could include this assessment document. Please indicate whether or not access should be given, in the event of an application, in your opinion:

Reasons for access not being given

If the Service User is unable to sign, please state the reason below

Assessed Person Name

Date

Initial Assessor Name

Date

Joint Assessor Name

Date

Manager Name

Date

Appendix 4

This is the care and treatment plan of

who lives at

The care coordinator who has prepared this care and treatment plan is

who can be contacted at

The care coordinator has been appointed by, and is acting on behalf of,

Name of relevant patient Full usual address of relevant patient Name of care coordinator Name of Local Health Board or Local Authority that appointed the care coordinator

CARE AND TREATMENT PLAN Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn rhannol yn Saesneg This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in English

Telephone number, postal address, and where appropriate, email address of care di

This plan was made on

and is to be reviewed no later than

However,

his or her carer(s), or adult placement carer(s), may request a review of this care plan at any time.

Date plan was made and date by which the plan must be reviewed

49

This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those outcomes. Area of life Outcome to be achieved What services are to be provided, or actions taken When Who by

The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help from the care team (these are sometimes called relapse signatures):

If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be contacted):

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Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh Language) ought to be recorded here:

The views of the person on this care and treatment plan, the Mental Health services that are to be provided, and any future arrangements that ought to be considered, are:

This care and treatment plan has:

Date Care and Treatment Plan Agreed/Not Agreed with Person

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DD MM YYYY

So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health services set out in this care and treatment plan are provided: Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health services to the relevant patient

Has the individual been offered a copy of the Care and Treatment Plan

Date copy of Care and Treatment Plan was offered DD MM YYYY The relevant patient may sign the care and treatment plan, if they wish- Did they? Yes No

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Individuals Electronic Signature Date Care and Treatment Plan Made

Date Care and Treatment Plan last Modified

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Appendix 5

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Care and Treatment Plan Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn rhannol yn Saesneg This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in English Mental Health (Wales) Measure 2010 Section 18 – Care and Treatment Plan This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure CCIS ID

NHS No

First Name Middle Name

Last Name

Date of Birth:

Age

Age if Estimated

Gender

Nationality

Religion

Ethnicity

Primary Address

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This is the Care and Treatment Plan of:

Care Coordinators The care coordinator who has prepared this care and treatment plan is

Who can be contacted at

The care coordinator has been appointed by, and is acting on behalf of

Date of Care & Treatment Plan DD MM YYYY

Post Code

Email Address

Home Phone

Mobile Phone

Work Phone

Preferred Language

Preferred Contact Method

Interpreter Required No

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And is to be reviewed no later than However, the patient, his or her carer(s) or adult placement carer(s) may request a review of this care plan at any time DD MM YYYY Care Plan This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those outcomes. The planned outcome(s) included in the following part of the plan must relate to one or more of the areas listed, and include an explanation of how each outcome relates to each area. Outcomes also may be achieved in other areas, and are to take into account any risks identified in relation to the relevant patient. This part of the plan should also set out details of the services that are to be provided, or actions taken, to achieve the planned outcomes, including when, and by whom those services are to be provided or actions taken. Outcomes to be achieved must be agreed in relation to at one of the following areas: Accommodation Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

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Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

Yes No

Education and training Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

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Related Outcome Number Intervention When Who by Completed

Yes No

Finance and money Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

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Yes No

Medical and other forms of treatment, including psychological interventions Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

Yes No

Parenting or caring responsibilities

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Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

Yes No

Personal care and physical well-being Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

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Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

Yes No

Social, cultural and spiritual Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

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Related Outcome Number Intervention When Who by Completed

Yes No

Work and occupation Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

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Yes No

Outcomes to be achieved may also be agreed in relation to other areas Outcomes to be achieved may also be agreed in relation to other areas Outcomes to be achieved

Outcome Number Outcome to be achieved Completed

Yes No

What services are to be provided, or actions taken

Related Outcome Number Intervention When Who by Completed

Yes No

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Relapse signatures The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help from the care team (these are sometimes called relapse signatures):

Crisis plan If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be contacted):

Language or communication requirements Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh Language) ought to be recorded here:

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Person views Record any views that the relevant patient wishes to be included (including past and present wishes and feelings about the matters covered by the plan) and include any statements about any future arrangements which may apply. If the patient does not have any views or statements on these matters, or the patient's views cannot be ascertained, this ought to be recorded also. The views of the person on this care and treatment plan, the mental health services that are to be provided, and any future arrangement that ought to be considered, are:

This care and treatment plan has:

Date Care and Treatment Plan Agreed/Not Agreed with Person DD MM YYYY Provider and sharing of information So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health services set out in this care and treatment plan are provided Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health services to the relevant patient

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Has the individual been offered a copy of the Care and Treatment Plan

Date copy of Care and Treatment Plan was offered DD MM YYYY The relevant patient may sign the care and treatment plan, if they wish- Did they? Yes No

Actual Start Date

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Appendix 6

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Privacy Notice Powys County Council Adult Social Care Purpose This privacy notice has been developed by Powys County Council’s (the Council) Adult Social Care (ASC) service, to ensure its transparency with collecting and processing personal information. Anyone receiving a service from ASC will have a record kept about them. We collect personal information to enable us to provide you with social care services, in partnership with other agencies and voluntary organisations. This privacy notice also includes the processing of personal information that takes place by the Social Services Customer Feedback Team in order to improve our services. This notice explains what information we collect, why we collect it and how we keep it secure. It also explains your rights and our legal obligations. The Legal Basis ASC have considered appropriate lawful grounds for collecting and processing your data. Your personal information is needed so that we are able to carry out our legal responsibilities. In some cases, this may result in a legal requirement for information to be provided and collected. If you refuse to provide the data we require, this could result in us not being able to provide you with services. Some of the key pieces of legislation that ASC work under includes:
• Social Services and Wellbeing (Wales) Act 2014
• Wales Safeguarding Procedures 2019
• Mental Health Act 1983
- Mental Health Act Code of Practice for Wales
- Mental Health (Wales) Measure 2010

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• Mental Capacity Act 2005
- Deprivation of Liberty Safeguards (soon to be replaced by the Liberty Protection Safeguards)
• Regulation and Inspection of Social Care (Wales) Act 2016 The Data Protection Act 2018 The Council is a Data Controller under the Data Protection Act 2018 which is the UK’s implementation of the General Data Protection Regulation. The Council’s Data Protection Officer (DPO) can be contacted at the Information Compliance Team at information.compliance@powys.gov.uk or at 01597 826 400. What information we hold about you ASC will store any details relating to your situation in a way that will assist us in supporting you to meet your, and / or your family’s, care and support needs as well as our responsibilities regarding the protection of adults at risk from abuse and neglect. Categories of personal data obtained ASC may obtain the following categories of your personal data:
• Name
• Address
• Date of Birth
• Gender
• Contact Details
• National Insurance Number We may also obtain and hold more specific information, including:
• Details about your care and support needs
• Information about other members of your household
• Details of family relationships in and outside of your household

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• The names and contact details of your close relatives and/or carers
• Information used to assess your situation, such as assessments and reports
• Things that other organisations (such as health, schools, or care homes) tell us to help us understand your situation and needs and co-ordinate your care services more effectively
• Recordings of any visits or contact you have made, or we have made with you
• Any additional needs or disability
• Financial information
• Details of your mental health and capacity
• Details of your physical health
• Details of your wellbeing
• Details of your personal outcomes
• Details about your lifestyle
• Details about your engagement with ASC
• Culture, religion/ belief
• Criminal record
• Restorative justice
• Allegations of abuse or neglect towards you
• Allegations or concerns raised regarding your conduct or safeguarding concerns from you about others. Source of the personal data
• You
• Your representative/ advocate/ legal representative
• Your family
• Police
• Health authorities
• Education authorities
• Other local authorities
• Housing associations/ registered social landlords

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• Regulatory bodies, such as Care Inspectorate Wales/ Health Inspectorate Wales
• Partner Agencies
• Medical professionals/ General practitioners
• Disclosure and Barring Service
• Members of the public
• Domiciliary Care Agencies
• Residential and Nursing Care Homes
• National Prosecution Service
• Secure Estates (prisons)
• Others (including professionals/ volunteers/ carers) who may be involved in your care
• Your employer Is Personal Information shared with anyone else? The sharing of your information will be undertaken in line with our tasks and the applicable legislation. We will only share information with an organisation if they need it to do their job, or where the law requires or allows us to do so, for example:
• Partner organisations that provide care and support services
• If a Court orders that we provide the information
• Regulatory bodies (such as CIW) that inspect and monitor our work
• Organisations such as the police, health, education services and third sector partners who work jointly with us to provide services and protect individuals. Retention of Personal Information ASC will retain your information for some time after we have stopped delivering services to you. The Retention Periods are specified within the Council’s Corporate Retention Schedule. After this time records are safely destroyed. Further information

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For more information as to how the Council uses personal data, and on your data protection rights, please visit the Council’s privacy notice here: Data Protection and Privacy - Powys County Council

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Appendix 7

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POWYS TEACHING HEALTH BOARD and POWYS COUNTY COUNCIL PATIENT SAFETY INCIDENT ACTION PLAN from Regulation 28. FOR WEB39318. June 2022.

REF ISSUE ACTION MHLD LEAD OUTCOME PROGRESS AND/OR ACTION AT REVIEW DATE COMPLETION DATE AND ACTIONS TAKEN
1. Welsh Applied Risk Research Network assessments content reviews/ integrating systems/ updating of current information. a) Copyrighted Welsh Applied Risk Research Network to be added to WCCIS database.

a) Service Improvement Manager/Powys County Council Powys Teaching Health Board IT Service Manager

a) Correct evidenced based Welsh Applied Risk Research Network available on a) July 2022- correct form has been built and currently in testing stage.

a) Early August 2022

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b) Powys Teaching Health Board Inpatient Staff to be given improved WCCIS access to enable them to complete documentation.

c) Powys Teaching Health Board to work with external partner agencies to improve risk sharing information with commissioned inpatient care.

d) National and Local Review of WCCIS

b) Powys Teaching Health Board Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead.

c)Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead

shared IT system

b) Inpatient staff able to use WCCIS Welsh Applied Risk Research Network, avoiding duplication and possibility of lost information.

b) July 2022 Increased authorisations in progress. Digital training available to support increased permissions.

d) WCCIS stability has improved – July 2022

b) Acute General adults to be in place by September 2022, Older adults to follow.

d) Further National monitoring November 2022, monthly monitoring via internal Gateway Group

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d) Welsh Government/ Powys Teaching Health Board/Powys County Council gateway group d) Ongoing monitoring of WCCIS system performance

2. Welsh Applied Risk Research Network assessments format/ ease of accessibility / infrequent users/ new users. A) Approved Welsh Applied Risk Research Network form will be placed on the person level in WCCIS so this is accessible to both services in Powys County Council and PtHB.

b) Chronology form added to WCCIS, replicating that recommended by Welsh Applied Risk Research Network.

a) Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. Head of MH services Powys County Council.

b) Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. a) Updates to include new format and form will enable a consistent approach to risk assessments and evaluation for Powys County Council and PtHB staff.

b) This will allow for all risk activities to be added in an easily accessible way by internal practitioners. a) July 31st
2022.

The approved form is going live and has been agreed/ approved by the author.

b) July 2022 Developed and in testing stage.

a) This will be completed by 01 August 2022

b) To be completed by 01 August 2022

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c)Organisational Staff record to be used to identify staff requiring Welsh Applied Risk Research Network training.

Head of MH services Powys County Council.

c)Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. Quality Improvement Manager, and CMHT Team Manager for Powys County Council.

c)Staff requiring initial and refresher training will be identified and monitored.

Names of Powys County Council staff requiring training will be given to Powys Teaching Health Board who lead on training, enabling them to target staffing groups. This will be reviewed on a 3 monthly basis.

c)Powys County Council staff records updated to reflect Welsh Applied Risk Research Network training as mandatory

c)Identification of staff ongoing.

d)Training is dependent on courses being run by

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d)Identification of Powys County Council practitioners to train as trainers.

e) Business Insight programmes used to identify infrequent Welsh Applied Risk Research Network users. This will allow targeted support for those less confident via contact with Champions. Powys County Council CMHT Team Manager

d)Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. Quality Improvement Manager, and CMHT Team Manager for Powys County Council

d)2 Powys County Council Welsh Applied Risk Research Network Practitioners will be trained as trainers to support ongoing programme.

e) Practitioners will feel more confident in undertaking Welsh Applied Risk Research Network assessments.

d)Powys County Council Staff have been identified and their names will be submitted to Welsh Applied Risk Research Network authors by 01 August 2022.

e) The need to link in with Champions to be reiterated through Powys Teaching Health Board Learning and Development Group and through Powys County Council Team Meetings. Welsh Applied Risk Research Network authors. No dates have been set but it is hoped that they will occur in Spring 2023.

e) August 2022

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Alongside supervision.
3. Welsh Applied Risk Research Network and associated assessments – reviews/ quality assurance monitoring/updating of current needs/ access by relevant bodies.

a)Audit processes to continue through Powys Teaching Health Board.

b)Powys County Council to restart Quality Assurance Audit a)Clinical Lead Quality & Safety. Consultant Nurse . Welsh Applied Risk Research Network Lead. Head of MH services in Powys County Council. Head of MH services in Powys County Council.

b)Clinical Lead Quality & Safety. a)6 monthly audits to target learning and to identify any development to be completed jointly by Powys County Council and PtHB.

b)Powys County Council to reinstate

b)Service Improvement Manager is currently restarting a)next audit scheduled for October 2022.

b)To be restarted in September 2022, with results fed back via Senior Management, supervision and

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Consultant Nurse Welsh Applied Risk Research Network Lead. Quality Improvement Manager, and CMHT Team Manager for Powys County Council

randomised monthly audits focussing on all electronically held documentation. This process requires the auditor to speak directly with the person cared for and if appropriate, their Carers. Audit findings to be shared with Senior Managers and at Team Meetings. Also discussed with involved practitioners during their monthly supervision. random audits, with each identified auditor allocated 2 per month.

Learning and Development Group on completion.

4. Welsh Applied Risk Research Network assessment tools – accessibility to Patient / integration referral process to secondary a)Greater users/carer involvement in the assessment process and the sharing of that information as identified as a piece of work a)Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. a)Feedback provided by the author of Welsh Applied Risk Research Network Dr a)October
2022.

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services, working together optimisation approaches

following the last audits completed by PtHB. Confirmed this will be part of the training moving forward with the Welsh Applied Risk Research Network trainers to be delivered to Welsh Applied Risk Research Network assessors in both PtHB and Powys County Council.

b) Powys Teaching Health Board and Powys County Council to support practitioners in understanding how and when to share information.

Head of MH services in Powys County Council.

b) Clinical Lead Quality & Safety. Consultant Nurse Welsh Applied Risk Research Network Lead. Quality Improvement Manager, and CMHT Team Manager for Powys County Council supported by Head of Data Protection. Gray has provided good learning and development to take forward to improve and imbed future collaborative working, audit and review of the Welsh Applied Risk Research Network.

b) Powys Teaching Health Board to share information sharing processes via Learning and Development Group.

Powys County Council are in the process of updating its Privacy Statement,

b) Ongoing and on a monthly basis.

This was sent for ratification at the end of June 2022 and is expected to be approved. This will then be shared with practitioners.

August 2022

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c)The People we Care for should remain integral in assessment process. Assessments should be shared routinely with them unless there is a risk to self or others.

which can support Practitioners and those we care for to understand the need to share information. (Attached as Appendix 6)

c)Practitioners to be reminded of the need to coproduce documents with those we care for. Practitioners to update admin Powys County Council Professional Lead for Data Protection invited to Teams Meeting, to support practitioners understanding of information sharing process.

c)Practitioners reminded of need during Team Meetings and throughout supervision. To be considered through audit process.

October 2022

Completed and ongoing

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staff when documents are completed and ready to share with those identified in care plan, including external agencies, subject to appropriate authorisation.

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