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Care planning and reviews

Care plans are the way in which health and social care teams document and share information about the care and treatment being provided for an individual. Care plan reviews are how multidisciplinary teams can jointly review an individual's progress against the goals set in his or her care plan and make decisions about future care and treatment.

Care delivered under the Mental Health (Care & Treatment)(Scotland) Act 2003 should be in line with the principles of the Act, one of which is reciprocity.This means that where an obligation is placed on an individual to comply with a programme of treatment of care, there is a parallel obligation on the health and social care authorities to provide safe and appropriate services that are of benefit to the person. This includes ongoing care following a person's discharge from compulsory treatment. Delivering for Mental Health  also refers to the need to look beyond the ill-health and focus on the full range of needs and capabilities of the individual. A social circumstances report written by the person's MHO should make a valuable contribution to this.

During this monitoring programme our practitioners reviewed individual care plans and used their professional skills and experience to make a judgement on whether these were satisfactory.We have previously issued guidance on care plans and we were keen to see to what extent this had been utilised in the preparation of care plans for people on STDCs.

We looked at 4 dimensions of care and treatment. These were:

  • meaningful involvement;
  • holistic care;
  • delivery of appropriate services; and
  • responsiveness to change.

Extracts from our guidance Mental Health Act Care Plans: best practice guidance in the preparation of care plans for people receiving compulsory care and treatment are quoted at the beginning of each section.

Meaningful involvement

"There are many ways of involving the person - even in situations where compulsion is required to ensure treatment is received, or participation appears to be difficult to achieve. The use of advance statements, where these have been made, the creation of "Staying Well" plans and the involvement of named persons, primary carers or independent advocacy are all pointers to the inclusion of the individual."

For 88% of cases it was our view that they were appropriately involved in care and treatment discussions and decisions:

"Good admission notes and thorough physical examination on admission and good information re personal history. Care plans reviewed regularly, good record of multi disciplinary input and patient has signed most of the care plans"

"Good notes on file by named nurse, indicating clearly when she has seen T, when she has sat down with her on a 1:1 basis to review care plans, and what the content of 1:1 contact was. T clearly felt that she was being involved in decisions taken and was happy with how she was being treated"

However this was not always the case:

"Mrs D complained that she did not know the result of a recent scan (which was reported clearly in her file) or whether a CTO application was being progressed.I brought the Charge Nurse in who told her the result of her scan and that a CTO was being progressed"

It is clear that services are trying to involve people in their care and treatment. However, inevitably the ability of the person to understand, make sense of and retain information about the complex processes surrounding compulsory treatment can be limited. We think services could make more effort to help individuals understand what is happening. We found that, when asked, only 57% of individuals said that they understood what was happening to them.

We also looked at whether all the appropriate people, such as carers, relatives and named persons appeared to have been involved in the assessment process.

We found that in 85% of cases relatives and carers had participated in assessments and reviews. In most of the other cases attempts were made but failed and the issue was addressed as soon as possible afterwards. In the very few cases where it appears this requirement of the legislation was ignored, we followed this up with the care team.

Holistic care

"An individual's physical health, social and recreational, spiritual and financial needs may all have a bearing on their recovery. This is not to say that the care plan should cover all these aspects of an individual's life on all occasions, but there should be evidence that a broad approach has been taken to the creation of the care plan. The focus should be on the person and not just on the illness"

For 70% of the people we visited there was evidence of a holistic approach being taken and there was overwhelming evidence (93%) that the individuals we saw were receiving services appropriate to their needs such as in this case:

"Good admission assessments including learning disability specific health assessment, and thorough care plans in place - plan in place to increase community outings, re-integrate him gradually back into day activities with support staff fully involved in this plan."

Delivery of appropriate care

"The principle that a person who is required by law to accept care and treatment against his or her will should be provided with appropriate care and treatment is not set out in absolute terms in the act. However, the legislation does require that persons who are discharging functions under the act "shall have regard to" the importance of providing appropriate services to patients subject to emergency and short-term certificates and to patients on compulsory treatment and compulsion orders. This principle also applies to persons no longer subject to a certificate or order."

For nearly every person we visited we found evidence that appropriate care was being provided.Where no review of care had taken place this was mostly because the person had only recently been admitted.

"There is a good care plan in place, re-written with information from reviews held since admission. There is also a detailed description of circumstances prior to admission included in the assessment form completed by the doctor granting the STDC, including a brief personal history and family circumstances. There is a detailed letter on file sent to the GP to give an update following their referral"

Responsiveness to change

"Care plans should be evolving documents and an integral part of the recovery journey.The idea that care planning - and the production of required care plans at specific points in the journey - is a separate process from the day to day provision of care, support and treatment, is one which fundamentally fails to understand the concept of care planning and the recording of treatment and progress".

We found evidence in two out of three reviews (67%) of continuous planning that was responsive to the changes in the individual's mental health and future needs.It is essential that care teams are thinking about the person's future from an early stage in the admission, as decisions have to be made regarding whether a CTO is going to be needed.For some individuals it was apparent there had been more than one STDC since first admission to hospital due to a lack of careful planning.

For others we found evidence, even quite late on into the 28 day period, of uncertainty amongst nursing staff whether a CTO application was planned or not. In many cases this was due to the clinical complexity of an individual's presentation.Occasionally, applications for a CTO were being made so late it caused difficulties and anxiety for the person concerned.

Best practice according to the code of practice is that the decision to proceed with an application should be taken after a multi-disciplinary case conference.The RMO should consult with the MHO well in advance of any such decision. The individual's case conference should also involve all relevant parties including multi-disciplinary health care staff, the patient's advocate, named person, relatives and/or carers. A more organised approach should lead to fewer delays in the Mental Health Tribunal process.