2. 2
Care and treatment reviews (CTRs)were introduced in October2014 in order to facilitate planning for discharge of people with
learning disabilities and/or autism who remained in hospital care but without an identified plan for discharge.
Following successfuloutcomes formany patients and positive feedbackon the process,these reviews have been extended to
other parts of the patient pathway, to prevent unnecessary admissions and for those in NHS funded inpatient beds including
Child and AdolescentMental Health Services,and secure hospitals.
CTRS are not intended to replace or undermine the Care Programme Approach, but to enhance the process ofpersoncentred
planning and support at various points along the patient pathway.
The aims of CTR are to:
Support the individual and their family to be partners in the care and treatment process.
Support professionals to work together with the person and family to find alternatives to admissionor support discharge
from hospital
Ask why the personneeds to be in hospital and, if there are care and treatment needs,why these cannot be carried out
in the community?
If the resources are not in place to supportsomeone’s discharge,then to make clear recommendations about what
needs to be done to get to the point of a safe discharge.
The spirit in which the CTR is carried out is as important as the process and the documentation. It is the responsibilityof all
involved to ensure that a CTR is conducted in an atmosphere of:
Openness
Honesty
3. 3
Transparency
Flexibility
Person-centredness
Mutual respect
Whereverpossible the CTR report should include direct quotes from the personwith learning disabilities and their family in
order to maintain a strong personalised focus.
This document represents the core framework for care and treatment reviews. We have prepared addenda for children and for
people in secure hospital settings who may be under a restricted sectionof the Mental Health Act.
The questions in these addenda should be regarded as an enhancement and/or an aid to focusing the emphasis of the
questions in the core framework to match the particular and personal characteristics of the individual whose care is being
reviewed. For each group of key questions in the core framework, there are enhancing questions for that section in the
relevant addendum.
.
4. 4
Local Patient identifier: ………………….. Healthcare Provider: ………….. Location of Review: ……………….. Date of Review: …………………
Originating CCG Area: …………………… CCG Commissioner Representative: ……………………………..
LA Commissioner Representative: ………………………. Specialist Commissioner Representative: ……………………………. Expert Reviewer- Clinical: ..........
Expert Reviewer- Expert by Experience: …………………… Advocate: ……………………… Others: ……………………………………………
Mental Health Act/ Mental Capacity Act Status: …………… MoJ Restriction Order:……………. Details:……………………………..
Guidance for reviewers on structuring information gathering
The review team should structure their questioning and information gathering around the
following themes in order to draw their conclusions on safety, current care & future planning:
Who is the person including: family, schooling, time in 'care', family or care breakdown
stories, forensic history etc. ( A brief pen picture/timeline to be established at the
beginning of the day)
Formulation and Diagnosis(es): including physical health, annual health check. Do any
of these diagnoses necessitate care as an inpatient?
What is the treatment plan that follows from the formulation and diagnoses? Include
drugs, therapy, diet and care that keeps them safe and well. Is there an evidence base for
these treatments and are they effective & leading to discharge?
Can the treatments and care be given in a community setting?
What is the person's view of their needs? What are their hopes and fears?
What is the family's view of the person's needs? What are their hopes and fears?
What does the commissioner and provider think the person needs? What are their
concerns?
What does the Clinician and clinical team responsible for their care think the person
needs? What are their concerns?
5. 5
The checklist below will help in the drawing together of information to support the above themes. It is not
intended to be used as a rigid set of questions but as a guiding framework for discussions and help in drawing
up the findings and recommendations.
RATINGS:
Discharge from hospital, or support to remain in the community, is being prevented or made more
difficult by these issues
Discharge from hospital, or support to remain in the community, is largely unaffected by these issues
Discharge from hospital, or support to remain in the community, is being supported by these issues
6. 6
Question
No
Do I need to be in Hospital?
Response Reviewers notes
1
Is there a current formulation / diagnosis in
place which clearly supports the need for
inpatient care?
2
Is there a comprehensive treatment plan in
place?
3 If yes to the above, do these treatments
have to be delivered in hospital?
4
Are there clear time frames and targets for
my treatment?
5
Am I meaningfully included and supported
to contribute to my care and treatment?
6
Is the treatment I am currently receiving
able to be continued in the community (or
non-hospital setting)?
7
Have people thought about whether being
in hospital will make my problems worse
and making it more difficult for me to
return to the community?
8
Have people thought about whether I have
suffered trauma before admission or during
my hospital stay? If so am I having
treatment for this trauma?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
7. 7
Question
No
Working with me to manage my
risks
Response Reviewers notes
9
Is there a clearand detailed assessment in
place of risk to myself and to others?
10
Have people got an understanding of my
risks now rather than what people have
said about me in the past?
11
Does the risk management plan clearly
identify both immediate and longer-term
risks?
12
Has the risk assessment involved
me/community staff/commissioners/ my
family?
13
Is there evidence of positive risk-taking –
can management of any risks take place in
the community?
14
Are there any risks to me returning to, or
staying in, my chosen home / family
setting?
15 Have people used physical interventions to
control my behaviour in the last month?
16 If yes to the above question, has this
involved using face-down restraint?
17 Have I been the subject of any safeguarding
procedures in the past 12 months?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
8. 8
Question
No
Communication - My Behaviour
and My Needs
Response Reviewers notes
18 Is there a clearand active plan of
Positive Behaviour Support in place?
19 If yes to the above question, is this
reflected in practice/understood by all?
20 Will I be supported by providers who
can give high quality Positive Behaviour
Support?
21
Do I have an accessible behavioural /
care plan that I help to review and
which helps to understand any
behaviour problems?
22
Are service providers who support me
now or in future confident that they
can do this reliably within the
community?
23
Do I have a communication passport
that supports me in living in the
community?
24
Is there evidence available to illustrate
the progress my carers and I have been
making with any behavioural
challenges?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
9. 9
Question
No
Least Restrictive Options for a
Better Life
Response Reviewers notes
25 Have alternative models of service
provision and support been actively
reviewed and considered?
26
Have providers / commissioners with a
credible track record of experience
been involved in planning my future
support?
27
Do I have a person-centred plan in
place which people regularly use to
help understand my likes, hopes and
dreams?
28 If yes to the above question, is this
being used to design a service
specification for my support?
29
Does my current care team believe that
I can be supported safely and with a
good quality of life in the community?
30
Are there any other significant people
or organisations involved in my life
whose opinion needs to be listened to?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
10. 10
Question
No
The Voice of My Family and
Carers
Response Reviewers notes
31 Have people made sure that they have
clear views of my family/carers about
where I live now and in the future?
32 Do my family/carers feel that they have
been listened to and have they been
helped to be involved in my care and in
my future plans?
33 Do my family want me to return to live
closer to home?
34
Are the family (or will they be) involved
in the development of any tenders and
procurement process for the
son/daughters future care package?
35
Are there any disagreements between
my family / carers and professionals
about my current and future care and
treatment plans?
36
If there are disagreements, have
professionals actively worked hard to
try to reach agreements and / or to
understand their views? Have they had
access to Patient Advice and Liaison
Services / Carers Link or Complaints
processes?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
11. 11
Question
No
My Involvement, My Rights &
Freedoms
Response
37 Are my carers andprofessionalsinvolved
my care protectingandsupportingmy
humanrights?
38
Do I have supportfroman independent
advocate?(IndependentMental Capacity
Advocate (IMCA),IndependentMental
HealthAdvocate (IMHA),Non-instructed
advocate)
39
Have people thoughtaboutwhetherthe
Mental HealthAct or Mental CapacityAct
couldbe usedto helpsupportme safelyin
the community?(e.g.Community
TreatmentOrders,Guardianship,Section
17 leave)
40
Have people assessedmycapacityto make
decisionsaboutmycare and treatment?
41
If people thinkthatI don’thave capacity,
has there beenaproperprocessof
decidingwhatwouldbe inmybest
interests?
42 Do the deprivationof libertysafeguards
applyto me?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
TOTAL SCORE
(+SCORES FROM ADDENDA IF APPLICABLE)
3 + 1 8 + 4 18 + 15
12. 12
Key measurable Outcomes Care and Treatment Review
Local Patient
identifier:
tick
Location: Low Secure √
Assessment&
Treatment
Stepdown
Lockedrehab
Forensicrehab
Other
Outcome fromCTR (NBshaded
boxestobe usedfor a pre-
admissionreview)
Tick
Hospital admissionsupported
for a specifictime periodand
purpose
Hospital admissionnot
necessary
Readyfor discharge,discharge
planin place & discharge date
innext3 months
Readyfor discharge,discharge
planin place & discharge date
innext6 months
Readyfor discharge- no
discharge plan:reasonsforthis
No PersonCentredPlanon
whichto base individual
service specification
Lack of agreementon
13. 13
future plan
No identifiedcare
coordinatorincommunity
Lack of suitable housing
No suitable care provider
Lack of agreementon
funding
Appropriate Clinical skills
not available incommunity
to supportpackage
Responsible commissioner
issues
Treatmentformulation
unclear& absence of
outcomes
PersonsubjecttoMOJ,
discharge couldbe
facilitatedbutneed
endorsementfromMOJ
Legal barrier( egCourt of
Protection)
Other- please specify
Notready fordischarge- needs
to be in a hospital bedforcare
& treatment.
14. 14
ADDENDUM FOR INDIVIDUALS IN SECUREPLACEMENTS AND THOSESUBJECTTO RESTRICTION ORDERS
NB. Please use this alongsidethe core CTR template
What section of the Mental Health Act is the individual detained under?.....................
Are they subject to MoJ retrictions?...........................
Names and roles of other key individuals involved (not listed in core framework) e.g. Specialist Commissioner, NHS Gatekeeper, Victim Liaison
Officer……………………………..
Question
No
Do I need to be in Hospital?
Response Reviewers notes
43
If I am transferredfromprison(onalongtariff)
isit clearwhy I shouldcontinue toremainin
hospital ratherthanreturnto prison?(offender
pathwayratherthan hospital pathway)
44
Doesany of my planned care and treatment
have to take place in a SECURE hospital?
45
Am I takingpart inany time-limited
psychological therapies(e.g.Modifiedsex
offendertreatmentprogramme,CBT)
46
If I have toremain inhospital forcare and
treatmentcouldthistake place ina lesssecure
setting?
47
If I have beenina secure hospital foralengthy
time,isthisaffectingmywellbeingandabilityto
move onfrom an institutionalisedwayof life?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
15. 15
Question
No
Working with me to manage my
risks
Response Reviewers notes
48
Do my risk assessments and management
plans take into account well enough any
restrictions that are in place? (details of
restriction orders)
49
Do my risk assessment and management
plans take into account well enough how to
manage any risks to victims ?
50
Do my risk assessment take into account
well enough any involvement of the
Ministry of Justice or the Probation service?
51
Could my risk assessment and management
plan be delivered in a setting of lesser
security – or non-secure?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
Question
No
Communication - My Behaviour and
My Needs
Response Reviewers notes
Has a My Shared Pathway been completed
with me?
If I am in a mainstream secure provider, do
my care plans address specific identified
16. 16
behaviours within My Shared Pathway?
52
Does My Shared Pathway identify my
communication needs and how these could
be supported in an alternative setting?
53
Are providers with clearcapacity for
delivering effective management of my
identified needs being considered as part of
my discharge planning?
54
Is there clear, documented evidence of
progress in reduction of my risks ?
55
Do I have an accessible behavioural plan/
care plan which I help to review and which
helps me to understand and manage my
own risky behaviours better?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
Question
No
Least Restrictive Options for aBetter
Life
Response Reviewers notes
56
Has the relevantNHSgatekeeperreviewedmy
case withinthe last12 months?
17. 17
57
If I am transferredfromprisonissomeonefrom
the National OffenderManagementService
involved?.
58
Have my Care CoordinatorandSecure
Commissionerbeenupdatedonmycase
/invitedtoCPA meetings/peerreviewsinlast
6-12 months
59
Doesanyone involvedinmycare and
treatmentthinkthatI shouldbe moved
(returned) toacustodial placement?
60
Are there any othersignificantstakeholders
whose viewshave notbeenheard? e.g.Victim
LiaisonOfficer,Ministryof Justice,MAPPA,
Local Commissioner,NHSGatekeeper
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
Question
No
The Voice of My Family and Carers Response Reviewers notes
61
Have my family ‘s / carer’s views been
taken into account in My Shared Pathway
or any other Care Pathways?
18. 18
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
Question
No
My Involvement, My Rights &
Freedoms
Response Reviewers notes
62
Are the limitations of a secure placement
and / or legal restrictions having an
unacceptable impact on my human rights?
How are these being addressed?
63
Is this the least restrictive placement that
could care for me and manage my risks
effectively and safely? If not, what are the
challenges to achieving this?
RELEVANT
QUOTES
FROM
INDIVIDUAL
/ FAMILY
SCORE
19. 19
CAREAND TREATMENTREVIEWFINDINGS & RECOMMENDATIONS
( to be complete by the leadcommissioner withcontributions from the reviewpanel)
Submit to …………………. For datacollectionpurposes ( please ensurenoname, originating postcode or DOB is on the form )
Copy to individual, and others involvedincare and treatment as appropriate.
Area Findings Recommendations Who responsible? By when?
Safety
(NB- please
note if CTR led
to alertin
relationto
safetyviaCQC
or safeguarding
board)
CurrentCare
Future planning
