West Cork Catchment Area
Bantry, Ctb, Sheep’s Head Head
Skibb/Schull/Mizen
Clon/Dway/Ballineen
Mental Health Agenda
USER VOICE:
RECOVERY
AGENDA
SERVICE
DEVELOPMENT
AGENDA
COMMUNITY
DEVELOPMENT
AGENDA

Well established Community focus and links – West Cork Carers, National
Learning Network, Rehab Care, Employability, Co-Action

Home Focus Team (with NLN) have a recovery focus on training and has
support from recovery mental health worker

Attitudinal change within own Service

Recovery document “Moving WCMHS in a Recovery Direction” –
disseminated to staff in 2011; Arts/Health MH Coordinator Pilot Project

User, Carer and Advocate involvement within our service a priority over
past 8 years

‘Windows’ Group in 2009 - engaging with individuals interested in
improving our Mental Health services. The group have formed a good
working relationship; developed a comprehensive on-going agenda
whereby the existing services and external agencies can improve the
treatment/care being delivered to the people of West Cork; carers have
attended Management meetings; renamed the Psychiatric Unit “Centre
for Mental Health Care and Recovery.”

Collaborative working with Users, Carers and Service Providers in DCU
Leadership programme - 4th year in West Cork. Throughout this process
we have identified needs and have implemented:

Trialogues, a group for family & friends of those in mental distress, an
Open Dialogue’ training for family work in community.

‘Genio’ funding - Recovery Bus, Recovery worker for one year in
community; p/t Family worker for one year to help with family work
project

This gap in service identified in early 2005

Reason: Relatively high turnover of Medical, Nursing and MDT staff

On-going issues – 6 month rotation of NCHD’s, plus internal rotation of
NCHD’s between teams.

User feedback

GP Frustration: No one consistent approach and contact

Changing the nature of day to day interactions and the quality of the
experience for the service use

Needed single point of access
The West Cork Mental Health Service is also involved with community
organisations, voluntary sector organisations and individuals from West
Cork

An informal network of stakeholders who provide community supports
for people with mental health problems

It provides a channel for service users, identifies support for families and
engages with the local community to challenge the stigma of mental
illness.

A large community event is arranged around the time of World Mental
Health Week. This deepens collaboration with all the other stakeholders
in the area and with the local community in the debate about mental
illness and our response to it.

Mad Pride Event last year, one planned 2012
GP/Primary Care Teams
ANP/Family
Therapist in
Primary Care/MH
West Cork Carers
Support Group
CNS Counselling/
Psychotherapy
TEAM
Team Co-ordinator
WORKING
CROSSSERVICE
USER
Carer
FUNCTIONAL
WORKING
Team working/
cross functional working
Employability
Home Focus Team
Collaborative Learning
DCU
Windows
Local
Management
Business Mtg
National Learning
Network/Rehab Care
Centre for MH Care
and Recovery
Community
Mental Health
Forum
The clinical function of our team is managed by the Team
co-ordinator. This includes:





the triage of referrals
liaising with GP & primary care professionals
chairing sector team meetings/support team to work in a
multi-disciplinary way
liaising with community agencies (including Service Users
&Carers)
clinical/management role
The administration and triage of referrals in
consultation with Consultants and team
members

Non-urgent referrals are sent to Team Coordinator / Consultant
and discussed/ triaged at team meetings (the single point of
entry as described in VfC)

Urgent referrals are by phone/fax from GP’s to
Team Coordinator/ NCHD’s (out of hrs-on call NCHD);TC helps to
facilitate urgent referrals.

Advice on referral pathways for GP’s, service users & carers,
and other agencies in community



Telephone advice for GP’s & other primary care professionals
on potential referrals and existing users
Follow up on referrals/’chase’ referrals
Available to PCT clinical meetings or case confs.
This approach has led to:
 Improved & more positive relationships with GP’s in West
Cork
 A more fluid communication of information between PCT
and mental health service
 A more efficient pathway for referrals
Referral by GP/Other member of PCT
Single point of Entry to CMHT
Identify Mode of Assessment, e.g. urgent r/v, home visit,
outpatient clinic or other (ie counselling)
Identify Team members to complete Assessment.
Assessment
Outcomes: Signposted to another agency
Advice given and discharged back to GP
Treatment offered –
Therapy/Social/Medication/Inpatient/Outpatient/Other
Referral passed to CBT/Psychology/Psychotherapy
Services/Social Worker/OT/Group work
MDT for Discharge: Discharge summary to GP/PCT
new & re-referrals discussed and allocated to the most
appropriate team member for assessment
 urgent referrals seen the previous week are discussed by
NCHD’s
 CMHT client reviews
 patient recovery care plans (Centre for MH Care & Recovery)
 peer support
 communication of AOB

This helps to:
 ensure CMHT runs inclusively and cohesively which
leads to its effectiveness and increased cooperation
 encourage sharing of expertise amongst the team
 ensure good work practices/improves communication
 feedback to GP’s
 positive working with administration
 The Recovery Care Plan is a collaborative approach between
the Service User (SU) and the MDT. This involves self
assessment by the SU, and reviews with the treating team
 The Recovery Care Plan is also discussed at the MDT. Family
and carers are included if consent given by the SU
 Weekly reviews by SU and team
 Discharge Care Plans – discharge is discussed as soon as is
appropriate; written Recovery Discharge Plans are now
encouraged (with help of a WRAP approach)

Clinical meetings for joint service users with Rehab Care and
National Learning Network

Member of the West Cork Carers Issues Forum (research into
Carers needs)

Member of West Cork Mental Health Forum

Management meetings re: Home Focus Team, with NLN

Attend local mental health events

Liaise with Heads of Disciplines and other disciplines
about clinical/management issues/audit.

Performance Indicator stats for CMHT

Member of the local Management Team

Policy reviews with MDT

Clinical caseload of 4-5 clients

Joint assessments/joint home visits with other members of
CMHT/urgent home assessments

Point of reference to Home Focus team
c
Challenges

Recovery Care Plans for service users in community/
? Recovery Star tool

MDT assessment tool

MDT team meetings serves both community & inpatient
service which has advantages and disadvantages
THANK YOU