A digital place for people who access services, carers, staff and partner agencies, to share ideas around care co-ordination & care planning in mental health

Posts tagged ‘CPA’

Mediaclip for staff training – participants wanted

Do you currently receive community services from LYPFT, or have in the last 12 months? Are you a carer of someone accessing LYPFT community services?

If so, and your care is arranged through Care Programme Approach, by sharing your story and experiences digitally you can help improve services through helping us understand what we do well, and where we can improve. Your experience would be used for staff training and for general mental health and carer awareness across the Trust and with the general public.video1-

Areas to understand include: assessment; care coordination; care planning; review; working with others including carers. Also your understanding of recovery and wellbeing.

Digital recording will be on the 17th and 20th of November, it will take no longer than two hours. If you would like to participate or would like more information then please contact Donna Kemp donna.kemp@nhs.net 07985259082

Thank you!inkwell nov


What are your top 3 messages for people planning your care?

What are your top 3 ‘makes a difference’ messages you would give to the people planning and providing your care, support and treatment?

I am keen to include the ‘individuals’ voice’ in training. Why? Because what’s the point in providing training if it doesn’t make a difference to the people accessing services. Training can become a standards checklist unless it relates directly to people’s care support and treatment in a meaningful way. The training has to resonate with the participant on some level if it is to have an impact and influence or change practice. The training has to have some value.


In the NHS we are super keen to measure everything, and it’s not that I am against this; it’s just that the measurable bits are often ‘hard’ – concrete and tangible, but it might be that the ‘soft’ bits are where the quality sits. So for example, with Care Programme Approach, one of the standards is that everyone should have a review at least once a year. This is a ‘hard’ standard; it is a distinct event with a time-frame; it is one that is ‘counted’ and reported on. The quality or ‘soft’ aspect in this standard is harder to count but impacts on the persons experience of care support and treatment – the review should include the person’s views, should be held in a way that the person prefers, the review should be held when needed (a year is a long time when you want to be moving forward……) and the review might be a series of discussions and information gathering to inform the care plan rather than a formal, chaired event. It tends to be the ‘hard’ bits that drive practice. My concern here is that practice gets distilled down to the hard bits and the soft bits fall by the wayside. Don’t get me wrong, often it’s the hard bits that get the job done #performance, but is it at the expense of the soft bits #experience? Perhaps a blend of both is best, but have we got the balance right?

So, what are your top 3 ‘makes a difference’ messages you would give to the people planning and providing your care, support and treatment?

Write your own care plan

Guest Post by Maria

I was recently at a SUN meeting where I was fortunate to hear a lady speak about writing her own care plan; I found this heartening and was delighted when our paths crossed again thanks to social media. Maria agreed to write about her experience of writing her care plan and the effects it has had. She is keen to share her experience and hopes it will help other people……..

How did it come about?

Maria loneliness

By Maria

I had just come out of a really dark and difficult period and was trying to move forward the best I could. My CPN (community psychiatric nurse) and I were talking about my care plan and how ineffective it had been through this time. I expressed my frustration and annoyance at past care plans and how I’d never found them helpful as they were often filled with others perceptions of me, their interpretation of what my life needed, what my goals should be and their beliefs in what would be helpful in my  crisis. Non of them were true reflections of me or what I’d find helpful.

So my CPN handed me a template care plan and said I could read it through and write as much as I’d like, the things I feel should be or want to be mentioned and what I felt would benefit me in crisis. We agreed I would do what I could and she would edit, add to and finish off.

After reading through I found myself excited at the prospect of answering the questions posed. With only recently coming out of a crisis I was able to draw on that experience and what I’d found useful/helpful.

I soon found myself writing each section, my history, my aims, goals long and short term, a true description of myself and my life. What I believed to be my difficulties and how best to deal with them.

I wrote my crisis plan like never before with real difficulties and a realistic approach for all.

To my astonishment my CPN read it and didn’t change a thing.

What difference has it made?

It gave me a massive sense of control and the strength I needed to stand up and say “I can do this, it’s in my hands.”  It was a significant turning point for me were I realised my recovery was up to me and no one else. That services were there to support me whilst I worked on making changes to improve my life and manage myself.

Writing my care plan challenged me to really look inwards and think about myself. To really think about what I found difficult and what I think will help. It also made me think of the things I would like to happen and goals I could obtain. It gave me a glimmer of hope that recovery was a possibility.

My Care plan was now something that gave me an aim, a clear focus on the areas I needed to work on to achieve the things I wanted for myself.  It also made me more aware of the  behaviours and patterns I’d established that were unhelpful and the things I could do to help me manage my day to day life.

The most significant  area I’ve truly benefited from is my crisis plan which is more fitting to my personal needs and how i react in crisis. I wrote it stage by stage and what to do to help me depending on the depths of my despair. I believe it was most helpful to myself because in crisis I’m no longer “rational” me and I find it incredibly difficult to trust anyone, therefore I could read it and trust what it said as it was my rational self who’d written it. This made it easier to accept and follow making the really difficult times shorter in length and better managed.

What key message would you give to other people about writing care plans?

Maria quote 1Service users have to be involved in their care plan. A CPN and service user need to work together  to collaborate a care plan that’s a true reflection of the service user with realistic  goals, expectations and what’s effective short and long term, crisis or not.

Services need to trust and understand that we know ourselves better than anyone, therefore ask us what’s helpful and unhelpful. Ask us what we want to change, ask us what our recovery looks like because we know better than anyone.

Service users need to take charge of their recovery and accept the professionals role. Services are there to help, support and understand as much as possible but can not nor will not make you better. Only you can can make recovery happen with the right support, so let your care plan be the start.



Service User Experience of CPA Reviews – final report

People receiving care, support and treatment from Leeds and York Partnerships Foundation Trust (LYPFT) should have a care plan and this should be reviewed regularly. Care may be arranged through ‘Care Programme Approach (CPA)’  or through ‘Standard Care Plan’ if needs are more straightforward.

LYPFT sent out a brief questionnaire to people on CPA to find out what their experience of their review was; you can read a bit more about the questionnaire here.

The results from the questionnaire, the full report can be found here:final report

  • People being offered or given a copy of their care plan was 54.5%.
  • Understanding what is in the care plan, being involved in agreeing the goals and being aware that other people could be involved in the review are areas identified for improvement.
  • Areas where the results should be celebrated are that people are aware of who their care coordinator is, that they were asked how they were feeling, that they had their say and that they found the review overall helpful.
  • Results from 2013 to 2014 are overall improving.
  •  The response rate to the questionnaire was lower than anticipated at just over 7%.

In response to the questionnaire results LYPFT are focusing training on improving service user involvement in planning care. There are monthly awareness sessions across Leeds and York – dates for these are available here; they are open to people accessing services and carers as well as members of staff across LYPFT and partner organisations. The Planning Care Workplan Implementation Group are tasked with overseeing LYPFT activity in relation to planning care – you can find out more about this group here.

Many thanks to those of you who participated in completing the questionnaires.

Donna Kemp | CPA Development Manager



Planning Care: Awareness Sessions

training sessions




Planning Care Checklist

Planning Care Checklist

Join the conversation here.

Planning Care in Assertive Outreach

I was fortunate enough to spend some time with Leeds Assertive Outreach Team (AOT) this week.  Assertive Outreach teams have been around for some time and are intended to support people with severe mental health difficulties who find it difficult to work with traditional services. You can read more about AOT’s in this Rethink information leaflet.

I initially met with AOT late last year to hear about how they were using Care Programme Approach (CPA) to co-ordinate, plan and review care. There were 3 questions considered:

1. How does CPA works within Assertive Outreach?

Around care plans it was identified that most people did not want a copy of their care plan; that reviews held varied interest to the service user – from ‘something to be endured’ to ‘very keen’.  In response to this the coordinators use a number of flexible methods to complete the review.  Where the person is in hospital the coordinators take the opportunity to spend time with the person developing the care plan for when they are discharged; it was acknowledged that the in-patient CPA review was not always conducive to agreeing goals and detailed plans following discharge. There was some variation in the way the CPA documentation was completed.

2. Why does CPA works within Assertive Outreach?

The team reflected that their ability to be flexible contributed to CPA working well within the team, factors impacting this were their level of experience, good understanding of care management/planning and proactive engagement with people using the service and partner agencies.  Capacity was also identified as a factor, that coordinators have around 12 people on their caseload.

3. What could be better?

  • Inpatient reviews being held more flexibly
  • Summary – a one page summary would be useful alongside the full care plan; it would also capture initial plans.
  • Documentation – The running order of the CPA Care Plan could be improved; the language could be simpler; the review questions should be revised.

The full report is available here.

Having met with AOT again this week, it is apparent that they continue to use CPA well to provide co-ordination, care planning and reviews.  The coordinators find a way to involve the person in planning their care despite on the face of it the person not necessarily wanting to be involved.  The involvement comes through negotiation, flexibility, working with the persons priorities first and through getting to know the person, and their carer(s)/networks/supporters well.

Of the CPA documentation, there are changes planned following a review of what we have and feedback from service users, carers and clinicians.  You can read about the changes in full here; but the headlines are:

  • CPA Care Plan name changing to My Wellbeing & Recovery Plan
  • Change in wording used for the care plan headings – to be straightforward, plain English
  • Goal setting and care planning section made simpler
  • Additionally,  a ‘one page care plan’ to be included within the Integrated Care Pathway trial

How does CPA work in your team?

What would make CPA better?

If you access services or are a carer: What is your experience of  being involved in developing your care plan and in your review?

If you have recently had a review, then you should receive a brief questionnaire through the post, alternatively, you can complete this online here.






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