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THE TRIANGLE OF CARECARERS INCLUDED: A GUIDE TO BEST PRACTICE IN ACUTE MENTAL CARE

THE TRIANGLE OF CARE CARERS INCLUDED: A GUIDE TO BEST PRACTICE IN ACUTE MENTAL CARE

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ContentsForeword 2

Executive Summary 3

Introduction 4

The rationale behind the key elements 10

Appendix 1: Triangle of Care Self-Assessment Tool 22

References 26

Glossary of acronyms 29

AcknowledgementsThe creation of Triangle of Care has taken many years and involved many people. It celebrates adeveloping awareness of carers’ needs and demonstrates that in different parts of the country thosepeople who work with and on behalf of carers are creating excellent resources and better outcomes.

The original impetus to identify ways of ‘improving engagement between professionals and carers’grew from a training programme created by carers in Devon. Similar initiatives grew in other places.The work of Lu Duhig in Avon & Wiltshire influenced this resource in many ways.

We acknowledge the thought and effort which has gone into creating the ‘Best Practice Examples’and are grateful for the generosity of carer champions in responding to requests to make themwidely available.

Delivering a Triangle of Care must be work in progress. Services will need to review their practicefrom time to time and many other services not listed may have Best Practice to share.

We ask those working with carers and carer groups to use the web sitewww.acutecareprogramme.org.uk to share emerging ideas and their best practice.

Finally thanks to Yvonne Stoddart and Malcolm Rae who as always provided invaluableencouragement and suggestions and to Bridget Lawless who helped with editing the many drafts.

AuthorsAlan Worthington, Carer Advisor, National Acute Care Programme

Paul Rooney, Lead, National Acute Care Programme


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ForewordCarers are vital partners in the provision of mental health andsocial care services. 1.5 million people care for someone with amental illness in the UK. That is one in every forty people, orone in four of the UK’s six million carers. Carers are increasinglybeing recognised for their expertise and knowledge, and thefact that they can be essential partners in the treatment andrecovery processes. Indeed, caring rarely stops when the personcared for enters acute care services. Carers are often integral to

a service user’s support system, and their input and support can substantially improvethat person’s chances of recovery.

This makes it even more important that carers are meaningfully involved in care and supportplanning, and offered the information and support they need to care safely and effectively. None of us should be forced into the position of offering more care than we would wish, or cansafely provide. This is why it is vital for the carer(s) to be identified and agreement reached forcontinuing involvement.

To this end, the Triangle of Care offers key principles and resources to influence services and other people working with carers to be more effective in involving them within acute care. This will benefit staff, service users and carers themselves. As the largest independent provider ofcarers support services, the Princess Royal Trust for Carers continues to work tirelessly through ouraffiliated network, to ensure carers are recognised and offered appropriate support. The PrincessRoyal Trust for Carers welcomes the production of this essential guide. We look forward to workingwith the National Mental Health Development Unit and partners to ensure its recommendationsform the bedrock of effective carer support and involvement within acute care and related mentalhealth services.

Carole Cochrane, Chief Executive Officer, The Princes Royal Trust for Carers

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The key elements toachieving a Triangle of CareThe essence of this document is to clearlyidentify the six key elements required to achievebetter collaboration and partnership with carersin the service user and carer’s journey through atypical acute episode. For each element wesuggest good practice examples and resourcesthat may be helpful.

The six key elements state that:

1) Carers and the essential role they play areidentified at first contact or as soon aspossible thereafter.

2) Staff are ‘carer aware’ and trained in carerengagement strategies.

3) Policy and practice protocols reconfidentiality and sharing information are in place.

4) Defined post(s) responsible for carers are in place.

5) A carer introduction to the service isavailable, with a relevant range ofinformation across the acute care pathway.

6) A range of carer support services is available.

In addition to the above, there also needs to beregular assessing and auditing to ensure thesesix key elements of carer engagement exist andremain in place. A self-assessment audit tool forcarer engagement can be found in Appendix 1.

Who is this document for?This document is primarily addressed to acuteservices, inpatient and crisis resolution hometreatment (CRHT) staff and their managers, andalso to inform carers, service users and carergroups. Success in achieving change dependsupon staff becoming willing ‘champions’ forbetter partnership working and being able tochallenge practice that excludes carers. A moreinclusive attitude for carers and families shouldbe promoted, where they are listened to andreally heard and consulted more closely.

Better recognition that carers are key partners inthe planning and provision of acute care alsomakes sound economic sense. Both commissionersand providers of acute care services need torecognise that supporting carers through initiativessuch as the Triangle of Care is a sound investmentin safety, quality and continuity of care at relativelylittle financial cost. This said, supporting carersshould not be used as a means, intentionally orotherwise, to substitute necessary statutory supportand responsibilities. Carers support should not beseen as a means to reduce support to service users,or to legitimise inappropriate assumptions fromservices about how much carers can take on.

Documents and Best Practice examples cited in this bookletAll the documents cited in this booklet are listedin the References section and can be located byname on the Acute Care Programme website –www.acutecareprogramme.org.uk. You can alsosearch using the tag word triangle of care. Youcan also search using the tag triangle of care. Youwill find the tag cloud under the Our Work sectionon the website. Alternatively, copy the link in thisbooklet’s reference section into your browser.

Executive SummaryThe ‘Triangle of Care’ is a therapeutic alliance between service user, staff memberand carer that promotes safety, supports recovery and sustains well being.


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The Acute Care Declaration includes animportant commitment from key stakeholders:

“to work together to encourage thecommissioning and provision of highquality care by developing… a servicewhich shows respect for people who useacute mental health services and theirfamilies and carers, and to include them aspartners in care and provide support toother informal care givers when needed.”

Acute Care Declaration 2009

The Triangle of Care approach is aimed atencouraging partnership working with carers atall levels of care from the individual to overallservice planning. The Acute Care Summitcommenced with personal statements from aservice user and a carer about what theywanted from services.

Alan Worthington, a carer with longexperience of engaging with acutemental health serviceson behalf of his family, asked thefollowing questions:

WHAT IF? – A Carer’sjourney through acute care services (With apologies to Rudyard Kipling.)

What would help carers and service users?

When asking for help, what if…

• both my relative and I had a phone numberto call if an acute situation were to develop

• as a carer I could call the staff, tell them the need was urgent and I would get a quick response

• when assessing my relative, the worker(s)talked to me as well, so as to get a clearpicture of how to help

• the worker(s) tried to get a good picture ofwhat my son was like when he was well andaspired to help him to return to this.

When treatment is at home, what if…

• staff gave explanations and offered a choice of options

• treatments were explained and strategies for managing the medication were given

• as a carer I was given the same sort ofinformation, support and coping strategiesthat are now seen in many inpatient settings

• I was given information about the right things to do, with staff offering me

IntroductionIn July 2009 a number of key national organisations including the National MentalHealth Development Unit (NMHDU), The NHS Confederation Mental HealthNetwork, other professional organisations and service user and carer representatives,came together to raise the profile of acute care mental health at a national AcuteCare summit. From this summit an Acute Care Declaration (2009) was developedwith a commitment from those involved to work together to champion thedevelopment of high quality acute care services.

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reassurance when my relative became aperson I couldn’t recognise.

When an admission was being planned, what if…

• the service was close enough to easily keepup family support

• the service could offer alternatives to ahospital bed.

On the ward, what if…

• the staff gave time each day to have goodconversation and give support

• the ward provided a warm friendlyatmosphere with things of interest to do

• there were groups to explore general life andmental health problems, with opportunities tolearn from others and develop companionship

• when I visit the ward I was welcomed as afriend and supporter of the work and staffaccepted that I wished to contribute for myrelative’s benefit and the benefit of others

• I was offered information about the ward and services

• when the named nurse was not available,there was someone else who was willing to talk to me.

At leave or discharge, what if…

• I was involved in the planning and we allworked out “what to do if?” e.g. if there wasa relapse or if the carer became ill

• my relative was given practical help withkeeping his medication sorted and help withremembering to take it.

Afterwards, what if…

• when the episode was over, the servicesasked for feed back and used it to improvethings in the future

• that I knew that my relative would be visitedwithin 2 days of discharge

• that I knew that his physical and mentalhealth would be reviewed at regular intervals

• if necessary, we would be offered familytherapy or talking therapies.

…then our caring duties would diminish to a point when we could look towards our own recovery.

What if your service was responsive enough tobe able to answer all of Alan’s questions with a yes! It would then be well on the way tofulfilling the commitment of the Acute CareDeclaration. We believe the best way to do this is by developing and maintaining…

The Triangle of Care: a carerengagement approach foracute care servicesThe Triangle of Care approach was initiallydeveloped by carers and staff seeking to improvecarer engagement in acute inpatient services. Ithas now been extended to cover both inpatientand home treatment services. Carers frequentlyreport that their involvement in care is notadequately recognised and their expert knowledgeof the ‘well person’ is not taken into account.

A disconnected model of involvement like this can lead to carers being excluded atimportant points.

Professional Service User

Carer


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This leads to gaps in practice which can result inthe carer being left ‘on the outside’ and infailures to share information that may be vital torisk assessment, care planning, and to acting inthe best interests of both service user and carer.

Some Common Problems

“At the time when my relative joined theservice I felt completely lost. Here was aset of new experiences I could not haveimagined. I needed to know the ropes, whowas there to help and what was going on. I especially needed to believe in theprofessionals – that they understood myconnection to this precious person now intheir care. I needed to have confidencethey knew how to help him recover andthat they saw me as part of that recovery”.

Carer speaking about a first episode

“At times I try to imagine how differentthings might have been if the staff hadrealised how close we had been until thebreakdown. If only someone had met meand listened to my part of the events –asked me what help I needed. I do wish theyhad explained to me what they were doingand warned me when she was discharged. I could have been better prepared and wemight still be close friends”.

Carer speaking of a lost relationship

Carers say their wish to be effective iscommonly thwarted by failures incommunication. At critical points and in specificways they can be excluded by staff andrequests for helpful information, support andadvice ‘are not heard’.

A solution is the ‘Triangle of Care’, atherapeutic alliance between service user, staff and carer that promotes safety, supportsrecovery and sustains well being.

The concept of a triangle has been proposed bymany carers who wish to be thought of asactive partners within the care team. It is seenwhen there is collaboration between the mentalhealth professional, service user and carer. Thelink between the professional and patient oftendefines the service, but in most cases the bondbetween patient and carer has pre-existed.

An effective Triangle of Care will only be completeif there is a willingness by the professional andcarer to engage. Most carers recognise that thisthree-way partnership between service user,carer and clinicians, with all the voices beingheard and influencing care treatment decisions,will produce the best chance of recovery. Thisplaces an onus on professionals and services toactively encourage this partnership.

Carers wish to be trusted, involved and becomemore effective. Services may have traditionalways of doing things which create obstacles for carer support. More effective carerengagement will grow from changing attitudesand adopting positive practice. This relationshipcan be reinforced by putting in place keycomponents which invite carer participation,giving information, support and advice in aconsidered manner.

This approach should involve carers in all stages of

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the process including assessment, care planning,treatment, referrals and discharge planning, aswell as decisions in such areas as after careprovision, housing, and employment support.

Why is carer engagement so important in acute care situations?Carers are usually the first to be aware of adeveloping crisis – often at times when professionalhelp has not yet been established or is unavailable.They are often best placed to notice subtlechanges in the person for whom they care, andusually the first to notice the early warning signs ofa relapse. Carers want to see a collaborative teamapproach to care, and be seen as ‘partners in care’.Carers want to be kept involved and informedthroughout the assessment, treatment andaftercare planning of the person they care for. Thisis particularly true in periods of crisis and the needfor acute care, when carers are understandablyextremely concerned about those they care for andwant to contribute to ensuring that the person’scare is the best possible.

Canvassing the views of carers at such times maybe key to ensuring that any risk factors they areaware of are properly evaluated and acted upon.It has been a feature of a number of inquiriesinto serious untoward incidents that failure tocommunicate with and listen to carers andfamilies has been a significant contributory factor.

Crisis events are often the start of the patientjourney and may be pivotal in commencingrecovery. Carers need to be kept informed andbe seen as part of the treatment team, withinformation-sharing at all stages of acute care.

Beyond carers’ ongoing responsibilities for day-to-day care, service users in the acute phase oftheir illness require more intensive input andsupport. Providing this care through the CRHTservice model – in which people who would

previously have been hospitalised remain athome – can have considerable implications forcarers. It is they who carry the principal burdenof care when the professionals are not there,and are commonly faced with providing care toservice users who are acutely unwell. Manyemphasise the benefits of their loved oneremaining within their home environment,providing that these benefits are fully realisedthrough sufficient support and expertise on thepart of the staff team. Crisis Resolution andHome Treatment: The Service User and CarerExperience (NAO 2008), a National Audit Officereview of Crisis Resolution Home Treatment(CRHT) services, found that: “carers appreciatethe benefits of home treatment, but emphasisethe need for adequate support from the team”.

Admission to hospital is also a time when carerengagement needs to be given specialattention. Carers usually remember wardadmission as a traumatic and troubling time,often involving conflicting emotions of guilt andrelief, particularly if it is an enforced/compulsoryadmission. Carer involvement is alsofundamental to good care planning andinformed risk management.

“For me it was hard at the beginning …they didn't want to talk to me. They justsaid, 'I won't talk to you without your sonbeing present.' They didn't understand myson's illness, but he used to tell me everysingle thing… eventually they came to theunderstanding that we are partners in this,working together.”

Akram (carer) Source: NAO Carer Focus Group

Creating the Triangle of CareThe carer quoted above points to some of the common obstacles to good engagementexperienced by carers. In the Triangle of Care we describe ways of achieving bettercollaboration between the mental healthclinician/team/ward, service user and carer,based on the six key elements which make up an effective triangle.


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The rationale for each of these elements isexplained and examples of good practicehighlighted. Planning to achieve an effectiveTriangle of Care is based on recognising thatthe service needs to ensure each element is putin place to create and sustain the engagementrequired to achieve better outcomes.

Many acute inpatient services are now usingsome of these elements of best practice forensuring effective carer engagement. However,having all elements in place is still the exceptionrather than the rule. The HealthcareCommission’s (HC) review of acute inpatientcare The Pathway to Recovery (HC, 2008)found strong evidence that involving carersneeded to be developed further:

“Nearly a third of care records (30%) did notrecord whether or not the service user had acarer. Only 32% of front line staff had beentrained in supporting carers and families, andonly two fifths of wards (40%) had adedicated member of staff responsible forleading on carer issues. One in five wards(21%) did not have an information pack forcarers containing any of the information weasked about, and we identified thatinformation for both service users and carerscould be made more accessible”.

Pathway to Recovery (HC, 2008)

The HC review also highlighted the need formental health Trusts to develop their structuresto promote carer involvement.

The Triangle of Care approach primarily focuseson improving carer-staff interactions in dealingwith acute episodes of care, whether atassessment, home treatment by CRHT or onacute inpatient wards. Carers are usually willingto connect with staff and to do what they canto help resolve the crisis.

They value the professionals temporarily takingover the responsibility from them and givingthem space to reflect and get moreunderstanding of how to manage their caringduties and how to get support in doing so.

“I experienced a great sense of relief. Theprofessionals had taken over my burden. Itfelt much safer for James now”.

Adult carer

“There is new hope for answers to myquestions and they might find solutions to my wife’s problems”.

A carer and husband

The key elements toachieving a Triangle of CareThe essence of this approach is to clearlyidentify the six key elements required to achievebetter collaboration and partnership in theservice user and carer’s journey through atypical acute episode. For each component wesuggest good practice examples and resourcesthat may be helpful.

1) Carers and the essential role they play areidentified at first contact or as soon aspossible thereafter

• carers’ views and knowledge are sought,shared, used and regularly updated asoverall care plans and strategies to supporttreatment and recovery take shape.

2) Staff are ‘carer aware’ and trained in carerengagement strategies

• staff need to be aware of and welcome the valuable contribution carers can makeand be mindful of carers’ own needs

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• staff need knowledge, training and support to become carer aware.

3) Policy and practice protocols re confidentiallyand sharing information are in place

To ensure proactive engagement carers need to be part of the care planning andtreatment process across the care pathway,i.e. for both inpatient and home treatment,the service should have clear policy andmechanisms to ensure these are routinelyused, including:

• guidelines on confidentiality and forsharing information – a three-way process between service users, carers and professionals

• information release forms and protocols

• advance statement forms and protocols.

4) Defined post(s) responsible for carers are in place including:

• carers’ lead or champion for the ward and CRHT

• carers’ links delegated for each shift.

5) A carer introduction to the service and staffwith a relevant range of information acrossthe acute care pathway is available including:

• an introductory letter from crisis team orward explaining the nature of the serviceprovided and who to contact, includingout of hours

• an appointment with a named member of theteam to discuss their views and involvement

• ward orientation/induction procedure and leaflet

• carer information packs

• discharge planning and aftercare support.

6) A range of carer support services is available including:

• carer support

• carer needs assessment

• family work in acute care.

There also needs to be regular assessing andauditing to ensure the six key elements ofcarer engagement exist and remain in place.

A self-assessment audit tool for carerengagement can be found at Appendix 1.


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1) Carers and the essentialrole they play are identifiedat first contact or as soonas possible thereafter

Staff need to identify the carer(s), i.e. thepeople who are providing significant support.They need to listen to and respect carers’ viewsand ensure this knowledge is recorded andshared within the team providing care. Carersoften possess crucial information as a result oftheir close relationships, and often almostconstant contact with the service user. Theirearly involvement will help provide the mostaccurate assessment on which to plan treatmentand assess risk. The carer needs to be part ofgiving and receiving information and be helpedto develop coping strategies vital for successfulcare and recovery. Staff should be mindful ofgender, ethnicity and cultural needs, includingreligion, which may influence the caring role.

Who are the carers?The word “carer” is relatively new in health andsocial care, though the concept of what a careris or does is more widely understood. Somepeople who ‘care’ are relatives, and prefer to usethat word. Others have close friendships and arecaring for people they live with who are notrelatives. Some are carers of friends or clientssuch as tenants. Some do not accept that theyare carers or even shun the concept. If someoneis involved with and gives significant support toanother person irrespective of whether they livewith that person or not, they should beconsidered to be a carer and be activelyengaged by the care team. This applies even ifthe cared for person is unable, or even unwillingto acknowledge the carer’s involvement.

Carers can be parents, children, siblings,partners or friends. What they have in commonis wanting to help the person they care for tobe safe and recover. When mental healthproblems mask the ‘well’ person’s’ personality,family and friends cherish the memory of thewell person and strive for his or her recovery.

Recognition and respect are major issues forrelatives and friends who provide care and arecentral to confident care giving.

“It was as though they didn’t realise who I was and why I needed to be in the roomfor that meeting – I was the one personwho knew my son”.

A carer

“Carers want prompt access to help whenthe person they care for is becoming ill.They want information, practical advice,emotional support and occasional respite.Most of all they want decent care for their loved one”.

Professor Louis ApplebyThe NSF for Mental Health: Five years On (DH, 2004)

All members of the mental health team need toknow which carer(s) have taken primaryresponsibility for caring for an individual. Thisinformation needs to be recorded. If the personis a parent with a young family or a young carerthemselves, then any burden on the otherchildren needs to be recognised and a referralto Young Carers services discussed.

Many carers do not realise that as such theyhave rights to both information and support.Some may, for example, qualify for equipment

The rationale behind the key elements

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and financial resources. It is an essential part ofan acute services responsibility to promoteawareness amongst carers about their rights.

Best Practice Examples1

• Standards for Inpatient Wards, Working-AgeAdults (RCPsych – AIMS) – See ‘Carers’section points 14.1 to 14.

• Carers Checklist (AWP) – This approachapplies to all inpatient admissions where acarer has been identified, and the writtenconsent of the service user has been given for carer involvement.

• Carers Project Process Summary andChecklist (Bristol AWP) – A checklist ofactions, time frames, including appointments.

• Carers Included (NWT) – Copies of thishandbook are available on all admission wards.It spells out how carers should be involvedwhen the person they care for is admitted.

2) Staff are ‘carer aware’ and trained in carerengagement strategies

Do all the front line staff understand“being in the carer’s shoes”?The Health Commission review found that“only 32% of front line ward staff had beentrained in supporting carers and families,although this ranged from all ward staff havingbeen trained to none.” (HC, 2008). Many frontline staff reported that they needed moreexperience and skills in how to conductconversations with carers.

Underpinning the effective delivery of a Triangleof Care is the ability of staff to listenempathetically to the experiences and concernsof carers and discuss with the carer the bestways of dealing with them. All staff need towork to a whole person approach and shouldhave received carer awareness training. Staffneed to be aware of the valuable contributioncarers can make to the assessment and care ofthe service user, be mindful of carers’ ownneeds and confident when talking to carers.This does not happen automatically. To helpthem to meet their obligations, staff needknowledge, training and support. They shouldbe capable of dealing with carers’ questions andconcerns, and of pointing them towards sourcesof support where the carer can find further helpto meet his or her needs. It has been shown tobe highly effective to have carers taking part inthe planning and delivery of training.

Staff who undertake assessment and careplanning should have received specific trainingin how to involve patients and carers. This isparticularly important in home treatmentsituations which are often reliant on the level of support provided by carers.

Successful long term outcomes are most likelywhen the staff team accept the benefits of carerinvolvement and collectively promote theconcept of a therapeutic triangle formed bythemselves, the patient and carer(s). When allthree parties work together they create theTriangle of Care most likely to optimise safety,opportunity and recovery for the service userand be most helpful for the carer.

“I wanted to be part of the team. After all, my daughter was coming backhome very soon and I would then be onmy own. I would have to take over fromthe professionals”.

Jane, a carer

1 See Glossary of acronyms for full Trust names. Many more examples of good practice can be found in the Resourcessection on the Acute Care Programme website www.acutecareprogramme.org.uk. You can also search using the words‘best practice’ or ‘triangle of care’ in the tag cloud under Our Work.


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Best Practice Examples

• TalkWell: Encouraging the art ofconversation on mental health wards(Star Wards 2009)

• Carers Strategy 2008-11 (Oxleas NHS Trust)– A strategy for improving the carerexperience

• Weston Ward Staff Training (Weston Ward, AWP) – A mature programme usedTrust-wide which continues to be extended. It can be delivered by carer trainers athandover time to all inpatient staff overseveral sessions.

• Positive Example or Story re Acute CareTemplate (East Sussex) – A format andprogramme to assist staff by exploringsections of the framework such as Awareness,Confidentiality, Carers’ Pack.

3) Policy and practiceprotocols re confidentialityand sharing informationare in place

“Put a group of carers in a room and verysoon the issue of confidentiality will comeinto the discussion”.

Carer Support Worker

Confidentiality is often seen as a problem areain creating a Triangle of Care. The therapeuticrelationship between worker and service user isbased on having ‘confidence’ or trust that whatis said will not be disclosed without theiragreement. This agreement needs to beconsidered in the context that the carer mayhave key information relevant to safe andeffective care planning for the service user. Theymay also be required to take on roles andresponsibilities to achieve the best care plan inthe home or once the service user is discharged.

Carers are likely to know the history of thecrisis, and have known the ‘well person’. They are aware of what may influence his orher recovery. They should therefore beencouraged to share this information, not only because it will help the clinical assessmentand treatment, but also because it gives them a positive role and confidence in theprogramme. Consideration needs to be given to the fact that crisis, especially involving theneed for compulsory treatment and/oradmission may provoke user/carer conflict that may temporarily prevent consent tosharing information.

Staff need to understand ‘the confidentialityprinciple’ that is:

“Information provided or discovered in thecourse of the professional relationshipcannot be disclosed without consent...Theservice user does not have the right toprohibit a professional from engaging witha carer or from the carer being giveninformation, advice and support, nor fromtalking to the carer about the patient,provided that no confidential informationis divulged...Confidential information maybe disclosed with the service user’s consent,(express or implied), regarding specificinformation and to specific individuals”.

Graham Machin, Carers and Confidentiality:Law and Good Practice

Carers say professionals are understandablyreluctant to engage with them in a nodisclosure situation. Staff should be aware that this can lead to a failure to provide generalinformation and can inhibit the carer fromsharing valuable information and insights. With the support of a Carer Support Worker (or other advocate) the carer can be helped to focus on general issues and alternativesources of help.

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A suggested example of good practice:

1) A discussion with the service user is held toestablish if there is anyone providingsignificant care. This is recorded and shared.

2) If a carer is involved, then discussionestablishes what level of information thepatient agrees may be shared with the carer.This may be full, partial or no disclosure.

3) This decision is recorded. Some services haveforms with a detailed menu of areas in whichinformation can or cannot be shared.

4) If the service user wishes no disclosure, thesewishes must be respected, but staff shouldregularly revisit this decision. In this scenariocareful consideration is needed on how thecarer(s) can still be offered support andgeneral information. (North London PICU)

Wards make Care Plans for both patients andcarers. It is good practice to hold the Carer’sCare Plan, notes and letters in a separate sectionof the patient’s notes. This can reduce the risk ofdisclosure of carer or service user confidences.

It is vital to emphasise that the above applies onlyto information that is personal to the service user,i.e. patient identifiable information such as theservice user’s diagnosis, treatment options andother personal details. Carers can always receivenon-confidential information from staff, i.e.information that is already in the public domainabout mental health conditions, the workings ofthe Mental Health Act, local services available forboth carers and service users, and so on. Staff canbuild stronger relationships with carers by offeringand sharing non-confidential information, even ifsharing of the service user’s information may notbe appropriate in that situation.

Similarly, carers have the same rights toconfidentiality of information they disclose asservice users do. It is vital for staff tounderstand and respect carers’ rights as theywould service users’.


• Confidentiality and Information Sharing with families and carers (SMP) –A comprehensive review of issues and recommendations

• Confidentiality and Carers Guidelines (DPT)– Guidelines to support best practice

• Carers and Confidentiality in Mental Health(RCPsych & PRTC) – A short leaflet for staffworking with carers

• Confidentiality in Mental Health (SuffolkFamily Carers) – A guide by a local Carers’Centre and local services outlining goodpractice in information sharing

• Confidentiality and Carers, Guidelines (DPT)– A good practice guide including scenariosand case studies.

Some Trusts use advance statements (alsoknown as advance directives). These statementscan set out in clear detail the service user’swishes about what should happen and whichcarer(s) to contact should they become toounwell to engage in such discussion. Staff andcarers should make a point of knowing if such astatement has been prepared, where thestatement is held and how to activate it.


• Advance Statement (CWP) – Comprehensiveinformation for staff, flow diagram. Forms tocopy covering: Advance Medical Statement;Medical and Personal Life; Involvement ofCarer (if user becomes unwell)

• Writing an Advance Decision/Statement(HFT) – Explains the purpose of advancestatements for service user and showsexample of forms

• Advanced Permission to Share Information(HPT) – Forms of authorisation includinginformation identifying carers.


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Some services have also adopted wellness andrecovery action plans (WRAPs). These plansidentify relapse symptoms and develop andrecord contingency plans for relapsemanagement. WRAPs should identify who themain carer is and how they are to be engagedin the case of a potential relapse.


• An Introduction to WRAP (CSIP) – Anintroduction for mental health workers

• Benchmark for Recovery OrientatedApproaches (SS&SFT) – A best practiceassessment tool.

4) Defined post(s)responsible for carersare in place

When asked about carers’ issues, some servicesclaim: “all the staff do it!” While it isfundamentally important that all staff should becompetent in working with carers, this workneeds to be coordinated, managed and led.

Ward and service carer links/leads/championsshould be appointed. They then have the task of promoting carer engagement andoverseeing the relationship with carers. They make sure that necessary measures are in place and operate effectively. Careful thoughtabout carers’ matters suggests that this work is made up of a number of disparate parts, most of which may not require great effort but are all necessary and depend on co-ordination. If one or two designated teammembers always have them in mind, they aremore likely to receive the required attention.Likewise, these arrangements must bemonitored to ensure that carers’ leads do notbecome a ‘dumping ground’ for carer work –rather that they help coordinate whole-teamattention on carers’ issues.

The Healthcare Commission review found thatonly 40% of wards had a carer lead, which theydefined as a dedicated staff member responsiblefor leading on carer issues – includingoverseeing and developing strategies to supportcarers at ward level.

Designated carer leads will also promote goodpractice among colleagues, i.e. making sure thatstaff know of any carer involvement in eachservice user’s care plan and are aware of newcarers needing orientation to the service or theward. They can also be the contact betweenindividual carers and staff at meetings andreviews, and can promote carer resources withcommissioners. Wards that have appointed acarers lead say there is quickly an improvedrelationship between staff and carers.

“Jasmine, my daughter’s named nurse wasnever on the same shift as my visits. Theother nurses would have a few words but itwasn’t the same as talking to Jasmine”.

Carer speaking about daughter

Carers often say they find it difficult to monitortheir relative or friend’s progress because theward shift system means the service user’sprimary nurse is not on duty when they visit. Inaddition to the carer lead, wards can appoint amember of staff to act as a carer link for eachshift. This person would provide additionalcontinuity in receiving and sharing information– and be a clear point of contact.


• Carers Champions (NTW) – Invitation andoutline of roles

• Northumberland Carer Champion Network(NTW) – Publicity material

• Carer-Link checklist (CWP) – Actions to becarried out by Carer Link

• Carer Link Standard/Process (CWP) – Pathwayfor establishing Carer-Link relationship.

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5) A carer introduction to the service and staff with a relevant range of information across the acute care pathway is available


• Carer Pathway for Family Interventions inAdult Mental Health (CNWL) – Template forcarer pathway checklist

• Good Practice Regarding Carer Support(NTW) – Rationale of carer support andCRHT role.

An introductory letterIn an acute crisis, carers are bound to beanxious about what lies ahead and beconcerned for the person they care for. Carerscan at this time be exhausted and fragile, andmay not be in their most receptive state toreceive and retain information. Many carers findtheir first meeting with the CRHT team or visitto the ward an ordeal which may often havebeen compounded by a series of distressingevents prior to seeking help in a crisis. Anintroductory letter from the named nurse orresponsible team member can help providereassurance and give the carer much neededbasic information such as the names andcontact details of key staff and other localsources of advice and support.

Best Practice Example

• Letter from ward to carer (DPT) – Simpleintroductory letter to carer giving names androles, especially Carer Support Workers.

An appointment with a named member of the staff team.The letter should also offer an early appointmentwhere the carer can share concerns and familyhistory. Good care planning and effective riskmanagement can best be achieved with earlycarer involvement. A formal appointment shouldbe set up between a carer and member of staff –to give the latter a chance to listen to the carer’s sstory and concerns, and take a good history. Themeeting will also give the carer the chance to askquestions of personal concern in more detail.


• First Admission Carer’s Letter (HPT) –Introduction, explanations and invitation to meet.

Ward orientation/carer inductionAdmission to a psychiatric ward is often a dauntingexperience for both service user and carer –especially on acute wards where staff are managinga range of people with difficult or disturbedbehaviour. Some carers and families feel a sense offailure when someone they care for is admitted.

“I couldn’t manage and feel responsible forcalling in the crash team and for thesection. It was horrible!”

A carer

Many carers argue that admission proceduresneed to be more carer-friendly, with recognitionof the value of carer input and respect for theiropinions. Some Trusts have created thoughtfulmeeting and greeting protocols to help toreduce carers’ distress. On arrival, a careraccompanying a service user at time ofadmission should be met, greeted and shown toan appropriate private area where they candiscuss any pressing matters of concern inconfidence and be offered refreshments.


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National guidance and best practice recommendsthat carers should be given an explanatory leafletor similar document as part of the admissionprocess focusing on immediate matters. Carersshould be given this leaflet, which provides basicinformation about the ward, at the time ofadmission or as soon as possible afterwards. Thismay include what practical items the service userwill need in hospital, visiting arrangements andfacilities for seeing visitors in private, anexplanation of any ward procedures such aslocked doors, rules regarding prohibited items,arrangements regarding smoking and mobilephones and safety procedures. Information needsto be given about the roles of involved staffmembers and how and when they can becontacted. Some excellent ward leaflets havebeen produced by staff in collaboration withservice users and carers. These leaflets oftendescribe the layout of the building, its facilitiesand services and basic information about theward routines.

Some wards produce both a leaflet for serviceusers and one for carers, relatives and friends.Although some information will be common toboth leaflets, this approach recognises that theneeds of service users and carers are differentand they should be offered different solutions.


• Welcome to the Department of Psychiatry(HPT) – Information for family and friends ofservice users, detailing what to expect from astay on the ward

• Welcome to James Ward (CNWL) – Anexplanatory leaflet about James Ward

• Carers Included (NTW) – A resource from aPICU explaining what carers can expect.

Staff may think a carer is ‘angry’ or ‘hostile’ butthis may be an indication that the carer isparticularly stressed or concerned and needsadditional support.

“The staff complained about Jan’s husband.Whenever he visited, it was mid eveningwith few staff on duty. He was intimidating,aggressive, loud and impatient. Iinvestigated and discovered that the manwas going home after a long day shift,feeding the children and organising thehome before visiting his wife. After he hadtold his story and I had shared it with theteam, future encounters were much better”.

Modern Matron

Carer information packs

Either as part of the home treatment initial careplan or as support to the principal carer of aninpatient, a more in-depth carer informationpack should be provided. This should providecarers and families with information needed tounderstand mental illness conditions, the likelyconsequences, what the carer and family can doto help, their rights as carers and the servicesand supports locally available to them and theperson they care for.

Carers often begin their journey of caring forsomeone with mental health problems withvery limited or inaccurate knowledge of whatthe illness might mean both for the person theycare for and for them as carers. They can beunaware of what resources they may need andwhere to find them and as result can feelconfused, anxious and depressed themselves.

Mental health staff can provide informal, verbalsupport and information, but the provision by theservice of a designated information pack helpsreinforce the central importance of the carer’s roleto both carer and staff. It formalises the extent ofthe knowledge and skill required from the carerand acknowledges the need for support.

In The Pathway to Recovery (HC, 2008), theHealthcare Commission noted that goodinformation, given in a format that makes senseto carers, also has the potential to increaseconfidence in statutory services.

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This may be particularly important for carersfrom black and minority ethnic (BME) groups.Steps should be taken to ensure that thecultural and language needs of families or othercarers are taken into account in preparing howbest to provide carer information. TheHealthcare Commission also found thatinformation packs for carers were scarcer thanfor service users and that performance was veryvariable. Although about a third of all wards(32%) had a welcome pack for carerscontaining all of the information they askedabout, about one in five wards (21%) had none of this information available.

The ideal pack should be clearly written, wellpresented and capable of being updated atregular intervals. It should provide local andgeneral sources of support and will need to beflexible and adaptable – broadly for eachmental health diagnosis. The carer might wantor need to refer to information at any time. We recommend staff automatically give all new carers a pack.

“The information packs were really useful because I could have a quiet readwhen I was ready. I could re-read thingswhich were difficult. I keep the pack in an obvious place and it is reassuring toknow that there are lots of contacts when I need them”.

A carer

Managing information resources is a challenge to mental health services. Resourcesneed to be up-to-date, provided in a timely way and used, rather than languishing onsome forgotten shelf in the office. These dutiesare more likely to be done well if they are onestaff member’s responsibility. It will help to beclear whether the responsibility forcommissioning, storing and issuing the packslies with a lead CRHT or ward staff member or a designated carers lead post.


• Carers’ Information (CNWL) – An outline of services and signposting

• Carers Pack (AWP) – Sample of contents to be included in a carers pack

• Information Handbook for Carers (Oxleas NHS Trust) – Comprehensive guidance for carers

• The Mental Health Carers' Manual (SWLStG)– Sutton Carers' Centre resource pack

Discharge planning and aftercare supportPlanning for discharge should be an integral partof the care pathway, with goals and, wherepossible, timelines in mind when the care plan isdeveloped. Aftercare engagement and supportmust be included in this planning for the patient’sjourney to recovery to continue effectively.Coordination between the relevant communityteams, families and carers and the service userthemselves needs to be established beforedischarge, and the service user needs to knowwhat support is available and how to access it.


• A Positive Outlook (NIMHE/CSIP) – toolkitfor improving discharge from inpatient care.

Carer supportMental illness can cause a rift between theservice user and those who are closest to them– if only for a short time. This separation,particularly if it comes because an individual isheld under a section of the Mental Health Act,can produce anger and frustration from theservice user. The carer can often be the butt ofthese hostile feelings at the same time as theyhave to deal with their own thoughts andfeelings of confusion, anger, guilt and sadness.


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All acute care services should have a carersupport service in place, including access tocarer advocacy services. Support services maybe provided by either the mental health Trust orthe local authority social services, or jointly.There are a variety of models of carer supportwork, including posts that work across bothhome treatment and inpatient settings.

Some services have a dedicated worker(s) forthe adult mental health service overall or adesignated link to specific wards. Somesupplement this with provision of independentadvocacy services, usually managed by localvoluntary organisations. All carers should beoffered referral to the Carer Support Service.Some may decline for good reasons at thatpoint, but their decision should be revisitedfrom time to time.

Carer support posts, or ward or team staff with designated carer responsibilities, shouldensure opportunities exist for families and othercarers to meet through educational or peersupport forums. They may hold carer supportmeetings which provide the opportunity formutual support between carers. Staff can find it challenging to run a carers’ meeting on aninpatient unit. The rate of service user turnovermay mean that a carer may be only able toattend one or two meetings. Work or familycommitments and staff shift patterns can alsolimit carers’ opportunities to be available atdesignated times.

Useful work can be undertaken with families or other carers to develop strategies to dealwith challenging or difficult situations they may experience in their role as carers. Carersupport groups that cover both inpatient and home treatment carers may provide better opportunities to provide ongoing support and reassurance.

While carer group support meetings are muchvalued, provision for one-to-one support forindividuals is also needed. Most carers are likelyto have specific and confidential issues whichthey need to discuss. This can prove difficult ifthey are part of a group.

Some services use an appointment system toorganise one-to-one support for carers,especially those new to the service/ward.Having someone to talk to who is well versed incarer issues is an effective way of addressingthe trauma of being a carer of someone whohas become acutely ill. Carer support workers orcarer advocates may helpfully attend wardround or review meetings when carers are inattendance and need support.

“I valued the one-to-one with the workerbut best of all was meeting and listening toother carers. I learned so much from theold hands. One said things like: “You aretrying too hard, back off a bit, your relativewill come back when they are ready”. Shemeant that eventually the love will comeback and I know now this was right. At thetime it gave me hope”.

A carer


• Commissioning for Carers (DH) –Commissioning guidance to ensure carers getthe support and recognition they deserve

• What to Include in a Carers Plan (AWP) –Guidance for producing a carers plan

• Forensic inpatients assessment ofRelative/Carer Support Need and SupportPlan (NTW) – Assessment of what relativesand carers know and understand about theirrole and what is needed for their support.

An assessment of carer’s own needs If the carer provides a lot of care and support tothe service user, then the carer is entitled by lawto a Carers Assessment (Carer’s (Recognitionand Services) Act, 1995, amended by Carersand Disabled Children Act 2000, Carers (EqualOpportunities) Act 2004. They are an importantcomponent of carer support in the community.

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The purpose is to ensure carers’ own needs arerecognised, are being met, and that they areaware of their rights to support, financial andother help in carrying out their carerresponsibilities. Carers’ Assessments are theresponsibility of the specific local authority.Some are carried out by Care Coordinators,some by Carer Support Workers and someservices delegate the responsibility to fundedposts, using protocols agreed by social services.

Carer Support Workers confirm that many carersdecline the referral for assessment because theyare reluctant to discuss their own needs. However,ensuring that the carer’s own needs are assessed isnot just in the carer’s interests but in the interest ofthe service user and the service as a whole. It isessential that every effort is made to ensure carersreceive all the support they are entitled to, giventhat they will often have the primary responsibilityfor assisting the service user once they have lefthospital or when they are not receiving formalsupport. CRHT and ward staff should confirm thatthe carer is aware of the ‘right to an assessment’,and, if necessary, refer them.

Carers should benefit from the dialogue involvedin the process. It is never sufficient to carry out aCarers’ Assessment in a one-off interview. Thismay be the first occasion when the carer’sinterests have been addressed and their primaryneed maybe to off-load and explore better carefor the person they care for, rather than theirown needs. As rapport and confidence in theprocess develop there will be a more meaningfulexchange of information and insights. Asindividual needs are met during the assessmentprocess, carer confidence should increase.


• Bromley and Oxleas Carers Focus Group(Oxleas NHS Trust) – A focus group prompt sheet

• Assessment of Carers Needs: InitialAssessment/Review (AWP) – A prompt sheetfor workers

• Local Resources and Information for Carers(HPT) – Example of local support for carers.

Family work in acute careTraditionally, adult acute mental health services havefocused primarily on the individual. In the past, theyhave not offered a broad range of treatments, suchas the routine availability of ‘talking treatments’,including support for the family. There is a longestablished and strong evidence base for theeffectiveness of family work, but more needs tobe done to develop family work in inpatient andacute services, and crisis/home treatment teams.

Family work requires skill and capacity and isusually carried out in non-acute communitysettings by staff with specific training. There are difficulties in delivering family work on the wards. Shorter lengths of stay may makecontinuity difficult; inpatients are oftenextremely unwell and so may be less able to beinvolved. Carers may wish to have respite fromconfronting recent painful experiences and sobe unwilling to participate.


• Engaging with Carers During an AcuteEpisode (SLAM) – Families can be referreddirectly from the ward weekly meeting

• Triangle of Care Programme: SupportingFamily Work (SWLG) – The team works bothon the ward and in the community,recognising that people would never receiveadequate help if the team’s work was solelycommunity-based

• Working with Carers and Families (SMPT) –Inpatient staff training.

Regular assessments and audits mustbe undertaken to ensure the six keyelements of carer engagement are inand remain in place The Triangle of Care approach has beendeveloped from the experience of scores ofcarers who say that too often some or all of thekey elements are not in place and from thegood practice of those services striving to createan effective partnership with carers.


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Reviewing current practice andbenchmarking where you are The first stage for a local acute care servicewishing to review its practice is to take stock ofthe current situation and to develop a plan to putall the required elements in place. This exerciseshould be undertaken with local carers (andservice users) to benchmark and identify anyareas that carers regularly report as problematic,and to get their ideas on what is most needed. Tohelp, we have included a simple self-assessmentbenchmarking checklist that uses the ‘Red,Amber, Green analysis tool. (See Appendix 1).

Regular auditingThe second stage is to regularly audit to ensure thatthe six key elements are in place and are workingwell. Only by a system of regular feedback fromcarers themselves will services be able to know howwell they are operating a Triangle of Care approach.It is important to look across the entire carepathway to get a clear overview of the wholeprocess and any weak spots. Feedback shouldbe gathered both after an acute episode, andseparately, to gain understanding of the carer’soverall or ‘global’ satisfaction.

Best Practice ExamplesEpisode:

• Crisis Team Carer’s Questionnaire (NTW)

• Acute Inpatient Ward, Carer Survey (SPT) –A short, simple exit survey

• Satisfaction Survey, Visitors/Relatives/Carers(CNWL) – To obtain ward feedback.

Global:

• Carer’s Checklist (AWP) – A review ofcomponents of engagement

• An Assessment Tool for relatives who are incontact with Acute Inpatient Services (DPT) –Survey for relatives and carers

• Carer questionnaire 2009 (CNWL) –Comprehensive questionnaire.

Closing comments Better engagement by acute mental healthservices with service users and carers as activepartners is a necessary underpinning of moreeffective planning and delivery of acute care.

Creating the ‘Triangle of Care ‘will help ensurethe ‘What if? challenge posed in theintroduction is being responded to positively.The implementation of the six key elements willmean carers feel the contribution they canmake is adequately recognised and their expertknowledge is properly taken into account with aconsequent impact on their lives. There is agreater need for professionals to improveengagement and support.

Carers provide an enormous amount of care inthe community for people with mental healthproblems. The ongoing development of home-based care at times of acute illness is furtherevidence of the need to give considerableattention to the views and needs of carers. Theshift of care from hospital to home can meanmuch greater reliance on carers, with aconsequent impact on their lives and a greaterneed for engagement and support.

Developing the ‘Triangle of Care’ model mayrequire some investment in staff training andpractical support for carers. Benefits can mostimportantly include better quality careoutcomes, but also more cost effective servicedelivery through decreased admission rates andreduced length of stay.

Having a Triangle of Care in place will ensurethe views of carers in formulating care plansand policy is translated into their inclusion at alllevels of the process and their often crucial roleis supported through practical means.

Services for users In some locations in England, services for carersmay be provided by voluntary organisations andsometimes these also manage Carers’ Support

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Workers. All frontline staff should makethemselves aware of their local carer supportprovision and other services.

The following is a short list of voluntarynational organizations. There are many morelocally based organizations. Contact your localNHS Trust for details.

National organisations

The Princess Royal Trust for Carers

The Princess Royal Trust for Carers was createdon the initiative of HRH The Princess Royal in1991. It is the largest provider of comprehensivecarers’ support services in the UK and has aunique network of 144 independently managedCarers' Centres, 85 young carers services andthree interactive websites.

address: The Princess Royal Trust for Carers,Unit 14, Bourne Court, Southend Road,Woodford Green, Essex IG8 8HDtel: 0844 800 4361website: www.carers.orgfor professionals: www.carers.org/professionalsfor young carers: www.youngcarers.netemail: [email protected]

Rethink

Rethink is a leading national mental healthmembership charity that works to helpeveryone affected by severe mental illnessrecover a better quality of life.

address: Rethink, 89 Albert Embankment,London SE1 7TPtel: (General enquiries) 0845 456 0455tel: (National advice and information) 0207 8403188 or 0845 456 0455website: www.rethink.orgemail: [email protected]

Making Space

Making Space is an organisation dedicated toimproving the long-term welfare of people whohave mental health problems and those whocare for them.

address: Making Space, Lyne House, 46 Allen Street, Warrington, Cheshire WA2 7JBtel: 01925 571680website: www.makingspace.co.uk


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Appendix 1: Triangle of CareSelf-Assessment ToolThis tool uses the Red Amber Green system to assess the current status of each criterion.

Element 1: Carers and their essential role are identified at first contact or as soon as possible afterwards

By when?

Bywhom?

Evidence ofachievement

Actionplan

Where arewe now?

GARCriteria

The carer is routinely identified withthe service user when carrying outan assessment

Special circumstances of carer arerecorded e.g:

• Parent of young family

• Single parent

• Caring for parents

• Young carer

• Carer with MH problems

• Friend

• Partner

• Relative

Carer views and knowledge soughtthroughout the assessment andtreatment process

Written consent of service user routinely obtained re carer involvement

Carer is regularly updated andinvolved re care plans and treatment

Treatments and strategies formedication management areexplained to the carer

Carer has access to advice readvocacy, equipment and welfare rights

1.1

1.2

1.3

1.4

1.5

1.6

1.7

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Element 2: Staff are ‘carer aware’ and trained in carer engagement strategies

Element 3: Policy and practice protocols re confidentiality and information sharing are in place

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

All staff have received carerawareness training

The training includes:

• Awareness of care needs

• Carer expectations re assessment,treatment and support

• Dealing with carer queries andconcerns

• Advising on sources of help

• Advising on treatments, strategiesand medicine management

• How to involve and engage withcarers and service users

Training is delivered by carer trainers

2.1

2.2

2.3

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

Service user consent is sought toshare confidential information withthe carer

Agreement is reached with serviceuser about the level of informationwhich can be shared with the carer

If service user wishes no disclosure,staff regularly revisit this decisionwith the service user

Carer is offered support and generalinformation when the service userwishes no disclosure

Carer is encouraged to shareinformation re service user to informthe assessment and treatment

Carer’s Care Plan, notes and lettersare kept in a separate section of theservice user’s notes

Advanced statements or directivesare routinely used

Wellness and recovery action plans(WRAPs) are in place

Practice guidelines re informationsharing with carers are in use

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9


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Element 4: Defined post(s) responsible for carers are in place

Element 5: A carer introduction to service and staff and a range of information is available across the acute pathway

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

Carer lead posts are in place on each ward

A member of staff is identified onthe ward to act as the carer link oneach shift

A carer champion network or peersupport forum is in place locally toprovide carer support

4.1

4.2

4.3

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

The CRHT provides the carer with anintroductory letter which explainsthe service and points of contact

An early formal appointment isoffered to the carer to hear story,history and address carer concerns

Upon admission, the ward hasmeeting and greeting protocols inplace to reduce carer distress andaddress concerns

As part of the admission process,carers are routinely given aninformation leaflet coveringimmediate practical matters

Locally developed carer informationpacks are provided to new carerseither as part of the initial hometreatment plan or upon admission ofthe service user

The cultural and language needs ofcarers has been addressed in thepreparation of the information pack

The format of the information packis flexible and regularly updated

A member of staff is maderesponsible for commissioning,storing and issuing the packs

Ward staff offer carers theopportunity to have a conversationand provide support

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

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Element Six: A range of carer support is available

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

The carer is involved in the dischargeplanning process and is clear about“what to do if…”

The carer is asked for feedbackregarding the service provided aspart of service monitoring andimprovement

5.10

5.11

By when?

Bywhom?


Actionplan

Where arewe now?

GARCriteria

A carer support service is in placelocally with dedicated Carer SupportWorkers in post

Carer has access to local careradvocacy services

Carer has access to 1:1 supportwhen needed

A new carer is automatically offered a Carer’s Assessment andsupport plan

The carer’s needs and plans areregularly re-assessed

Family therapy or talking therapies are offered to carers and family if required

6.1

6.2

6.3

6.4

6.5

6.6


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References A Positive Outlook (NIMHE/CSIP) www.acutecareprogramme.org.uk/silo/files/a-positive-outlook.pdf

Acute Care Declaration (NMHDU, Mental Health Network 2009)www.acutecareprogramme.org.uk/silo/files/acute-care-declaration-leaflet.pdf

Acute Inpatient Ward – Carer Survey (SPT)www.acutecareprogramme.org.uk/silo/files/acute-inpatient-ward—carers-survey.pdf

Advanced Permission to Share Information (HPT)www.acutecareprogramme.org.uk/silo/files/advanced-permission-to-share-information.pdf

Advance Statement (CWP) www.acutecareprogramme.org.uk/silo/files/advanced-statement.pdf

An Assessment Tool for relatives who are in contact with Acute Inpatient Services (DPT) www.acutecareprogramme.org.uk/silo/files/an-assessment-tool-for-relatives-in-contact-with-acute-inpatient-services—.pdf

Assessment of Carers Needs: Initial Assessment/Review (AWP) www.acutecareprogramme.org.uk/silo/files/assessment-of-carers-needs-initial-assessmentreview.pdf

An Introduction to WRAP (CSIP) www.acutecareprogramme.org.uk/silo/files/an-introduction-to-wrap-wellness-recovery-action-planning.pdf

Benchmark for Recovery Orientated Approaches (SS&SFT) www.acutecareprogramme.org.uk/silo/files/benchmark-for-recovery-orientated-approaches.pdf

Bromley and Oxleas Carers Focus Group (OXLEAS) www.acutecareprogramme.org.uk/silo/files/bromley-and-oxleas-carers-focus-group.pdf

Carers and Confidentiality in Mental Health (RCPsych & PRTC) www.acutecareprogramme.org.uk/silo/files/carers-and-confidentiality-in-mental-health.pdf

Carers and Confidentiality: Law and Good Practice (Graham Machin)www.acutecareprogramme.org.uk/silo/files/carers-and-confidentiality-law-and-good-practice.pdf

Carers at the heart of 21st Century families and communities (DH)www.acutecareprogramme.org.uk/silo/files/carers-at-the-heart-of-21stcentury-families-and-communities.pdf

Carers Champions (NTW) www.acutecareprogramme.org.uk/silo/files/carers-champions.pdf

Carers Checklist (AWP) www.acutecareprogramme.org.uk/silo/files/carers-checklist.pdf

Carers Included (NWT) www.acutecareprogramme.org.uk/silo/files/carers-included.pdf

Carers’ Information (CNWL) www.acutecareprogramme.org.uk/silo/files/carers-information.pdf

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Carer-Link checklist (CWP) www.acutecareprogramme.org.uk/silo/files/carerlink-checklist.pdf

Carer Link Standard/Process (CWP) www.acutecareprogramme.org.uk/silo/files/carer-link-standardprocess.pdf

Carer Questionnaire (CNWL) www.acutecareprogramme.org.uk/silo/files/carer-questionnaire.pdf

Carers Pack (AWP)www.acutecareprogramme.org.uk/silo/files/carers-toolkit-carers-assessments.pdf

Carer Pathway for Family Interventions in Adult Mental Health (CNWL) www.acutecareprogramme.org.uk/silo/files/carer-pathway-for-family-intervention-in-adult-mh-services.pdf

Carers Project Process Summary and Checklist (Bristol AWP) www.acutecareprogramme.org.uk/silo/files/carers-project-process-summary-and-checklist.pdf

Carers Strategy 2008-11 (Oxleas NHS Trust) www.acutecareprogramme.org.uk/silo/files/carers-strategy-20082011-oxleas.pdf

Commissioning for Carers (DH) www.acutecareprogramme.org.uk/silo/files/commissioning-for-carers.pdf

Confidentiality and Carers Guidelines (DPT) www.acutecareprogramme.org.uk/silo/files/confidentiality-and-carers-guidelines.pdf

Confidentiality and Information Sharing with Families and Carers (SMP) www.acutecareprogramme.org.uk/silo/files/confidentiality-and-information-sharing-with-families-and-carers.pdf

Confidentiality in Mental Health (Suffolk Family Carers) www.acutecareprogramme.org.uk/silo/files/confidentiality-in-mental-health-suffolk.pdf

Crisis Resolution and Home Treatment: The Service User and Carer Experience (NAO 2008) www.acutecareprogramme.org.uk/silo/files/crisis-resolution-and-home-treatment-the-service-user-and-carer-experience-.pdf

Crisis Team Carer’s Questionnaire (NTW)www.acutecareprogramme.org.uk/silo/files/crisis-team-carers-questionnaire.pdf

Engaging with Carers During an Acute Episode (SLAM) www.acutecareprogramme.org.uk/silo/files/engaging-with-carers-during-an-acute-episode.pdf

First Admission Carer’s Letter (HPT) www.acutecareprogramme.org.uk/silo/files/first-admission-carers-letter.pdf

Forensic inpatients assessment of Relative/Carer Support Need and Support Plan (NTW) www.acutecareprogramme.org.uk/silo/files/forensic-inpatients-assessment-of-relativecarer-support-needs-and-plan.pdf

Good Practice Regarding Carer Support (NTW) www.acutecareprogramme.org.uk/silo/files/good-practice-regarding-carer-support.pdf

Information Handbook for Carers (Oxleas NHS Trust) www.acutecareprogramme.org.uk/silo/files/information-handbook-for-carers.pdf


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Letter from ward to carer (DPT) www.acutecareprogramme.org.uk/silo/files/letter-from-ward-to-carer.pdf

Local Resources and Information for Carers (HPT) www.acutecareprogramme.org.uk/silo/files/local-resources-for-carers-and-families.pdf

National Service Framework for Mental Health 1999 (DH) www.acutecareprogramme.org.uk/silo/files/national-service-framework-for-mental-health.pdf

National Service Framework for Mental Health: Five Years On 2004 (DH)www.acutecareprogramme.org.uk/silo/files/national-service-framework-for-mental-health-five-years-on.pdf

Northumberland Carer Champion Network (NTW) www.acutecareprogramme.org.uk/silo/files/northumberland-carer-champion-network-mental-health.pdf

Positive Example or Story Re Acute Care Template (SPT) www.acutecareprogramme.org.uk/silo/files/positive-example-or-story-re-acute-care-template.pdf

Satisfaction Survey – Visitors/Relatives/Carers (CNWL) www.acutecareprogramme.org.uk/silo/files/satisfaction-survey-visitorsrelativescarers.pdf

Standards for Inpatient Wards – Working-Age Adults (RCPsych – AIMS) www.acutecareprogramme.org.uk/silo/files/standards-for-inpatient-wards-working-age-adults-aims.pdf

Talkwell: Encouraging the art of conversation on mental health wards (Star Wards)www.acutecareprogramme.org.uk/silo/files/star-wards-talkwell.pdf

The Mental Health Carers’ Manual (SWLG)www.acutecareprogramme.org.uk/silo/files/the-mental-health-carers-manual.pdf

The Pathway to Recovery (HC 2008) www.acutecareprogramme.org.uk/silo/files/the-pathway-to-recover—a-review-of-nhs-acute-inpatient-mental-health-services—.pdf

Triangle of Care Programme: Supporting Family Work (SWLG) www.acutecareprogramme.org.uk/silo/files/triangle-of-care-supporting-family-work.pdf

Welcome to the Department of Psychiatry (HPT) www.acutecareprogramme.org.uk/silo/files/welcome-to-the-department-of-psychiatry-.pdf

Welcome to James Ward (CNWL) www.acutecareprogramme.org.uk/silo/files/welcome-to-james-ward.pdf

Weston Ward Staff Training (Weston Ward, AWP)www.acutecareprogramme.org.uk/silo/files/weston-ward-staff-training.pdf

What to Include in a Carers Plan (AWP) www.acutecareprogramme.org.uk/silo/files/what-to-include-in-a-carers-plan.pdf

Working with Carers and Families (SMP) www.acutecareprogramme.org.uk/silo/files/working-with-carers-and-families.pdf

Writing an Advance Decision/Statement (HFT) www.acutecareprogramme.org.uk/silo/files/writing-an-advanced-decisionstatement.pdf

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ACD Acute Care Declaration

AIMS Accreditation for Inpatient Mental Health Services

AWP Avon and Wiltshire MentalHealth Partnership NHS Trust

CSIP Care Services ImprovementPartnership

CNWL Central and North West LondonNHS Foundation Trust

CRHT Crisis Resolution and Home Treatment

CWP Cheshire and Wirral PartnershipNHS Foundation Trust

DH Department of Health

DPT Devon Partnership NHS Mental Health Trust

HC Healthcare Commission

HFT Humber MH Teaching NHSFoundation Trust

HPT Hampshire Partnership NHSFoundation Trust

NAO National Audit Office

NCCSDO National Co-ordinating Centre for NHS Service Delivery andOrganisation Research andDevelopment

NIMHE National Institute for MentalHealth in England

NMHDU National Mental HealthDevelopment Unit

NTW Northumberland, Tyne and WearNHS Foundation Trust

PICU Psychiatric Intensive Care Unit

PRTC Princess Royal Trust for Carers

RCPsych Royal College of Psychiatrists

SLAM South London and MaudsleyNHS Foundation Trust

SMP Somerset Partnership NHSFoundation Trust

SPT Sussex Partnership NHSFoundation Trust

SWLG South West London and StGeorge’s NHS Foundation Trust

SS&SFT South Staffordshire and Shropshire NHS Foundation Trust

TEW Tees Esk and Wear Valleys NHSFoundation Trust

WRAP Wellness and Recovery Action Plans

Glossary of acronyms