RiO Standard Operating Procedures
J. Care Planning/ Recovery Planning & CPA /Review
Contents
J. Care Planning/ Recovery Planning & CPA /Review...................................................................................................... 1
1. Recovery Coordination. ............................................................................................................................................ 1
1.1 Signing of Care Plans ......................................................................................................................................... 4
1.2 Care Plan Library................................................................................................................................................ 4
1.3 Section 117 Aftercare recording ......................................................................................................................... 4
1.4 Recording Key Safe Details within RiO .............................................................................................................. 4
2. MDT Review Meetings & Supervision ...................................................................................................................... 5
3. MAPPA ..................................................................................................................................................................... 5
3.1 MAPPA Review Form ......................................................................................................................................... 6
1. Recovery Coordination.
Information about the Recovery Approach and Recovery Co-ordination can be found on the DPT Intranet.
http://nww.devonpartnership.nhs.uk/default.asp?a=10301&m=0
Further information about what should be recorded at reviews and about Care Planning in RiO can be
found on the Intranet RiO pages under each team/service. Link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
Where Care Plans relate to care requiring authorisation by IPP, the Recovery Coordinator should create
these in the usual way and against each intervention set ‘Authorised by’ to ‘Panel – pending’. Once panel
approval has been granted, the IPP team should edit the intervention and change ‘Authorised by’ to ‘Panel
– agreed’. This will only be an indication of authorisation if done by a member of the IPP team. The IPP
team should also enter a brief progress note regarding the decision. This process does not remove the
requirement to communicate applications/decisions in the usual way.
For All Non CPA Clients
Care Plan
Record problems/needs and interventions
The identified Recovery Co-ordinator should use the Care
Plan Library to pull up the problem/need and intervention for
the appropriate level of recovery coordination.
All other problems on the Care Plan should start with the name
of the team to help identification of Care Plans in multiworker
situations.
Care Plans should be personal and relate to assessed need
and where possible be developed in collaboration with the
person involved.
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Section 117
Recovery Coordination Level library
Care Plan
See Section 1.3 below. The Section 117 Aftercare plan is
recorded in a Library Care Plan edited and personalised for
the individual. This pulls through to the printable Care Plan
which is sent to both the Social Care panel and the MHA
Office.
The start date should be entered on the recovery co-ordination
Care Plan. When there is a change to the recovery level the
end date should be entered on the existing Care Plan which
should then be closed along with the interventions associated
with it. The new recovery level Care Plan should be selected
from the Care Plan library and a start date entered.
Care Plan contact
Care Plan distribution
Record office and out of hours contacts
Record dates that Care Plan has been distributed to involved
parties. If a copy of the Care Plan is not given to the person
using our services, record the reason why
Crisis Relapse and Contingency
Planning
Record the crisis plan
Record relapse indicators/warning signs
Record contingency plans
The process for accessing services after discharge should be
identified within this form and a copy given to the person and if
appropriate, their carer/ GP
Only used for CPA
Allocate a Care Co-ordinator
Schedule CPA Review
Schedule a Non-CPA Review
Clustering Assessment & Clustering
Allocation
Social Inclusion
Only used for CPA
Review appointments should be booked in the HCP diary with
review as the appointment type and also as the activity.
Found in Outcome Measures. The clustering assessment
should be completed at each review point. Further guidance is
in the Outcome Measures/Clustering Section.
Employment and accommodation information should be
updated by creating a new form at least yearly.
Outcome the CPA Review
Only used for CPA
Outcome the Non-CPA Review
The review appointment should be outcomed in the normal
way ensuring the Review was added as the activity before
outcoming.
The content of the review should be recorded in the Progress
Notes and should cover the following (as relevant):
o clear statements of shared goals and formulation
o who was present at the review and their
relationship to the client
o what has been helpful
o what has not been helpful
o consideration of carer’s needs
o outcome of interventions
o outcome of review.
o Section 117 care plan (if applicable)
o Social Care Contracts (Adult Services only)
Complete the Section 117 review form on RiO. This pulls
through to the printable care plan which should be sent or
emailed to the MHA Office and the Social Care Panel
Section 117 Review
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For Clients on CPA
Care Plan
Record problems/needs and interventions.
Where Section 117 applies, this Care Plan should be pulled
through from the Care Plan library and edited accordingly.
Each item on the Problem/needs list should have at least one
intervention related to it. The person responsible must e
identified in each case.
Problems on the Care Plan should start with the name of the
team to help identification of Care Plans in multiworker
situations.
Section 117
Care Plan contact
Care Plans should be personal and relate to assessed need
and where possible be developed in collaboration with the
person involved.
See Section 1.3 below. The Section 117 Aftercare plan is
recorded in a Library Care Plan edited and personalised for the
individual. This pulls through to the printable Care Plan which
is sent to both the Social Care panel and the MHA Office.
Record office and out of hours contacts.
Care Plan distribution
Record dates that Care Plan has been distributed to involved
parties. If a copy of the Care Plan is not given to the person
using our services, record the reason why
Crisis Relapse and Contingency
Planning
Record the crisis plan
Record relapse indicators/warning signs
Record contingency plans.
Allocate a Care Co-ordinator
Allocate a care co-ordinator
Choose CPA level ‘Enhanced’
Schedule CPA Review
Invite participants
Clustering Assessment & Clustering
Allocation
Found in Outcome Measures. The clustering assessment
should be completed at each review point. Further guidance is
in the Outcome Measures/Clustering Section.
Employment and accommodation information should be
updated by creating a new form at least yearly.
Social Inclusion
Outcome the CPA Review
Record outcomes from the CPA review;
 Review unmet needs
 Person using our services view
 Carer view (Note: this does not appear on the printable
Care Plan like the other sections of this form)
 What worked well
 What did not work well
 Other notes.
Other notes should include the involvement of family/carer
and their expectations/comments.
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Validate the CPA Review
Review type:
 Referral review: for 1st review (referral source should
match what was recorded when the referral was added to
RiO)
 Discharge review: for review prior to discharge from the
service
 Other review: for all others
HoNOS and social inclusion information can be pulled through
to the CPA outcome screen providing they have been
completed in RiO prior to outcoming the review.
This must be ticked to validate the review
Book future CPA Review
Schedule the next CPA review to allow this to pull through to
the printable Care Plan.
Section 117 Reviews
Complete the Section 117 review form on RiO. This pulls
through to the printable care plan which should be sent or
emailed to the MHA Office and the Social Care Panel.
1.1 Signing of Care Plans
The Care Plan should be printed and presented to the person for whom it was developed and discussed.
The outcome of the agreement should, where possible, be the signing of the Care Plan by the individual.
This should then be recorded and the signed Care Plan scanned and saved to the record. The Care Plan
distribution form must be completed as well to indicate that the Care Plan has been shared with the person.
1.2 Care Plan Library
RiO has a number of pre-written Care Plans available in the Care Plan library. These are generally for
specific purposes such as identifying the level of Recovery Co-ordination, recording Section 17 Leave, etc.
Most of these will require editing in order to make them relevant to the person whose care they relate to.
Decisions regarding the content of the Care Plan library are made by the RiO Clinical Governance
Committee.
1.3 Section 117 Aftercare recording
Section 117 Aftercare is recorded in Care Planning in RiO using a Library Care Plan. The
Recovery Co-ordinator should select the relevant intervention headings to save to the record. This
Care Plan needs to be edited to suit the person’s situation and details of their needs in each of the
relevant areas must be added along with details of the interventions planned, the anticipated
outcomes and the person responsible. ‘Authorised by’ should be set to ‘Section 117’. When
reviewing Section 117 Aftercare (either within CPA or separately) the Section 117 Review form in
RiO should be used. This pulls through to the printable Care Plan. The printable Care Plan should
be sent (mail or email) to the MHA Office and the Social Care Panel at the beginning of Section
117 Aftercare and at each review point.
1.4 Recording Key Safe Details within RiO
This information MUST NOT be recorded in the address field in RiO as this makes it accessible via the
national spine. Where it has been agreed that staff will access a person’s home using a key safe, this
should be recorded in a Care Plan. The reason for the use of the key safe should be indicated in the
problem /need box along with the names of staff authorised to use this and the key safe details in the
intervention. The person’s consent to this should be indicated in the text of the Care Plan and where
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possible by them signing their whole Care Plan including this aspect and this signed document being
scanned and uploaded to RiO.
Thought will need to be given to the distribution of the Care Plan when it contains this kind of information
and where possible the person using our services should decide who should receive this. The printable
Care Plan can be edited before printing/ sending to other parties to remove this information if necessary for
security reasons.
2. MDT Review Meetings & Supervision
When a team is reviewing a person’s record or progress, a projector will be available to allow all attendees
to view and update the patient record during the meeting.
Supervision should include the review of records such as progress notes and assessments in RiO to
support best clinical practise and identify any issues arising including training needs.
Clinical information/ outcomes should be recorded in the progress notes.
3. MAPPA
Guidance regarding MAPPA can be found on the DPT Intranet under Safe Services or by following
the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11522&m=0
There will also be an e-learning course available via the Online Course Programme.
The following guidance is taken from the draft Memorandum of Understanding for Devon &
Cornwall MAPPA:
Devon Partnership NHS Trust has a statutory duty for the responsibility of identifying MAPPA eligible
offenders. Therefore Devon Partnership NHS Trust need to ensure that systems are in place to indentify
MAPPA nominal’s under mental health supervision or care and ensure that the data is available, ideally
through a dedicated database. Once identified a clear ‘MAPPA eligible’ indicator flag/label on internal
case management systems should be created, to alert those involved in the management of the
offender/patient.
It is part of statutory duties to provide details of MAPPA nominal’s to MAPPA co-ordinator. It is a
requirement that Devon Partnership NHS Trust notify the relevant local MAPPA Administrator with brief
details of relevant offender using the MAPPA form G. These details will be recorded and filed but it is
the responsibility of the Devon Partnership NHS Trust to review and inform the MAPPA administrator of
any changes.
It is important to remember that all MAPPA minutes are confidential and closed under the
Freedom of Information Act 2000.
All minutes/information is securely stored electronically or in paper records in accordance with the
MAPPA guidance 2009 and the Data protection Act 1998. Minutes are not to be shared with the
offender/patient or 3rd parties unless approval is sought from the Chair of the meeting as stated in
guidance.
MAPPA minutes can be stored on RIO.
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MAPPA co-ordination is the responsibility of the Responsible Authority. Reference to MAPPA meetings
should be recorded in the RiO progress notes with reference to any agreed actions and risk management
plans. The Care Plan should describe any intervention planned from DPT.
Scanned documents should be uploaded as document type ‘Meeting Minutes/Notes’ and the document
details box should be used to identify the document as highly confidential and sensitive and any limitations
on access. These comments will be for guidance only as access cannot be restricted. Where minutes are
regarded as pertaining to a current legal case, guidance on their secure storage should be sought from
Information Governance Department.
The MAPPA review form should only be used to record meetings if DPT is the lead agency e.g.
Level 1. Further policy guidance is currently being developed in the Trust.
3.1 MAPPA Review Form
Field
Date of Review
Mark as complete
Date of MAPPA referral
Community Consultant
MAPPA review date
Venue
Who was present
Who was absent
Who sent apologies
Those providing input but not present
Review unmet needs
Client View
Carer View
What worked well
What did not work well
Other notes
Offender Category
MAPPA level
Agencies Involved
Comments
Guidance
Date of the Review the form relates to
Tick this box to indicate that the form is
complete. This locks the form and prevents
further editing.
Date of the original referral to MAPPA
Select from the drop down list
Not configured at present – contact AST to get
a venue added
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Anything not covered above
Select from drop down list
Tick the boxes – the drop down lists are not in
use, record details in comments box below
Detail the agencies involved
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