Care Co-ordination – including Care Programme Approach

Care co-ordination is the process used to help and support people with mental health problems to enable them to live their daily lives as independently as possible.

If you are experiencing mental health problems or are caring for someone with mental health problems, the care co-ordination process is here to help you.

The process of care co-ordination aims to:
• Ensure that you have a full assessment of your needs.
• Help you develop your skills and strengths to support you in your day to day activities to work towards recovery.
• Help identify any risks to the safety of you and any others.
• Ensure the areas of help and support identified in your assessment are recorded in your written care plan (this may be in the form of a letter).
• Ensure that your care plan fully explains how you, and the people involved in your care, will work towards meeting your identified needs.
• Provide you with a named person who will keep in contact with you to ensure your care plan continues to meet your needs – this person will be a qualified professional and may be referred to as a care co-ordinator or lead professional.
• Ensure that your care plan is reviewed and updated regularly to support any changes you may need. As a minimum this should be at least once a year.
• Ensure that you receive the best service possible.

At an assessment one or more members of mental health services will ask you questions about your needs. This means talking with you about thoughts and feelings which may be troubling you and other parts of your life where you may be experiencing problems; for example housing, employment or relationships.

The areas discussed will be written into an assessment document so that any needs, risks and strengths are clearly identified. We will then look at how your needs can be supported.

A care plan is a way of recording the help and support you need and it explains how this will be done. The information in your care plan will be written into a document so that it is clear what support has been agreed with you. (This may be in the form of a letter.)

Your care plan should:
• Be written with your full co-operation and involvement whenever possible.
• Be designed to help improve your mental health and social situation.
• Provide you with the contact details of your named person, along with any other people involved with providing your care.
• Provide an agreed crisis plan.
• Include information for people who support you (e.g. family or friends).
• Record any areas you disagree with.

You are entitled to receive a copy of your care plan and for a copy to be sent to others involved in your care plan.

The amount of help and support you will receive depends upon how complex your needs are.

If you:
• have complex needs, which could require more support and guidance;
• have several needs which require services to help and support you

the named person responsible for helping to arrange the support you need will be a qualified mental health professional known as a care co-ordinator. It is likely that there will be other mental health professionals involved in supporting you. This level of need and support is also known as Care Programme Approach (CPA).

If you:
• have a low level of need and are able to manage your own care, with support and guidance

the named person responsible for helping to arrange the support you need will be a qualified mental health professional known as a lead professional. It may be that they are the only mental health professional you see. This level of need and support is also known as Non CPA.

If you don’t understand any of the information provided by mental health services and have any questions, please ask.

Family, friends or advocates providing care and support can be involved in care planning if you wish.

It is important that staff who work within mental health services are aware of who the main people in your life are. This type of information would be discussed during the assessment and care plan stages of care co-ordination.

Family and friends acting as unpaid carers who provide substantial and regular support can get help and support for themselves in the following ways:
• Have a right to a Carers Assessment of their own needs
• Have their own written care plan outlining the support they are to receive
• Be given information of what to do and who to contact in an emergency

Your care plan will be reviewed with you to ensure the help and support you are receiving remains right for you.

You or anyone involved in helping and supporting you may request your care plan to be reviewed.

Your care plan review will:
• Be at a convenient date, time and place
• Involve a carer, family member or friend if you wish
• Be as often as needed, but at least once a year
• Include all the individuals involved in your care

You will be encouraged to attend your care plan reviews as your opinions matter the most and it is extremely important for your views to be heard. However, if you would prefer not to attend, a family member, friend or advocate can attend on your behalf. Your views will always be included in any decisions made.

Information helps to provide high quality care and can be kept both electronically and on paper.

This includes:
• Basic details about you, such as address and next of kin
• Contact we have had with you, such as visits
• Assessment, Care Plan and Reviews
• Relevant information from those who are involved in your care

Sharing information helps:
• Manage the care you receive
• Those who provide support to you, to work together more easily to meet your needs
• Reduce the number of times you are asked for the same information
• Plan future services that can be offered to you and other people who have mental health problems

It is part of the practice of care co-ordination that information is shared with other professionals with whom you have contact e.g. your GP or the people in your care team. This will be discussed with you and you will be asked if there are people you do not want contacted and if you would like copies of letters written by the healthcare professionals involved with you.

All professionals have a duty to keep information about you private and confidential. However, in certain circumstances there may be occasions where it is necessary to share information without your consent; for example, to protect you, a child or someone else from harm. In these circumstances, the information shared will always be kept to the minimum necessary and if at all possible a member of your care team will explain what information must be shared and with whom before they do so.

You can obtain a copy of the information that is held about you in your health records by writing to:

The Disclosure Team
Information Governance and Medico Legal Department St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle NE3 3XT

People who care for you want to help you recover as quickly as possible so you can manage your own needs without support from services.

Recovery is an individual experience. A length of time cannot be given on how long you will need to be involved with mental health services, but the aim is always to give you the right help and support no matter how long or short that time is.

When your mental health has improved enough for you to no longer need help and support from secondary mental health care services, your care co-ordinator/lead professional will write to your GP explaining that your care can now be managed between you and your GP.

Your GP will be given information of who to contact if they need to discuss any part of the care you have received.

If you want to make a comment, suggestion, compliment or complaint you can:
• Discuss them with your care co-ordinator/lead professional
• Complete a feedback form by requesting this from your care co-ordinator/lead professional
• telephone the Complaints Department 0191 245 6672
• email [email protected] Please note that information sent to the Trust via email is sent at your own risk
• Contact the Patient Advice and Liaison Service (PALS)
North of Tyne – Tel: 0800 032 02 02
South of Tyne – Tel: 0800 328 4397
• Complete a feedback form online
• Contact Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Complaints Department, St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne, NE3 3XT

Further information about Care Co-ordination/CPA and Mental Health Services can be obtained from the following organisations:

Independent Mental Health Advocacy Services
Cumbria
n|compass
Cumbria IMHA Hub
Tel: 0300 3030 622
Cumbria IMHA Hub website

Gateshead
Connected Voice Advocacy
Tel: 0191 232 7445
Connected Voice Advocacy website

North Tyneside
Independent Advocacy North East
Tel: 0191 259 6662
Independent Advocacy North East website

South Tyneside and Newcastle
Your Voice Counts
Tel: 0191 478 6472
Your Voice Counts website

Northumberland and Sunderland
Voiceability
Tel: 0300 303 1660
Voiceability website

Coram Voice – for young people
Coram Voice
Tel: 0808 800 5792
Coram Voice website

Patient Advice and Liaison Service
• Sunderland, Gateshead and South Tyneside areas Tel: 0800 328 4397

• North of Tyne Tel: 0800 032 02 02

• MIND infoline 0300 123 3393 (9am – 6pm, Monday to Friday)
• SANEline: Crisis Line 0300 304 7000 (6pm – 11pm daily)
• Rethink’s National Advice Service 0300 5000 927 (9.30am-4pm, Monday to Friday)

Blissability Care Act Advocacy Service
34-36 New Green Street, South Shields, NE33 5DL
Tel: 0191 427 1666
Tel: 0191 496 7573 (minicom)
Email: [email protected]
Blissability website

Carers Northumberland
107 and 109 Station Road, Ashington, NE63 8RS
Tel: 01670 320 025
Email: [email protected]
Carers Northumberland website

Carers Trust Tyne and Wear
The Old School, Smailes Lane, Highfield, Rowlands Gill, NE39 2DB
Tel: 01207 549 780
Email: [email protected]
Carers Trust Tyne and Wear website

Carer Support Carlisle and Eden
Penrith Office:
The Office, Mardale Road, Penrith, CA11 9EH
Telephone: 01768 890280
Carlisle Office:
Moorhouse Courtyard, Warwick–on-Eden, CA4 8PA
Telephone: 01228 580214

Gateshead Carers Association
John Haswell House, 8-9 Gladstone Terrace, Gateshead, NE8 4DY
Tel: 0191 490 0121
Email: [email protected]
Gateshead Carers website

Mental Health Carer Support Service South Tyneside
Unit 12, Cookson House, South Shields, NE33 1TL
Tel: 0191 217 2934
Email: [email protected]
Mental Health Concern website

Newcastle Carers
135-139 Shields Road, Newcastle upon Tyne, NE6 1DN
Tel: 0191 275 5060
Email: [email protected]
Newcastle Carers website

North Tyneside Carers Centre
Suite 9, Saville Exchange,Howard Street, North Shields
NE30 1SE
Tel: 0191 643 2298
Email: [email protected]
North Tyneside Carers website

South Tyneside Adult Carers Service
Salvation Army Building, Wawn Street, South Shields, NE33 4EB
Tel: 0191 406 1531
Change Grow Live website

Sunderland Carers Centre
Thompson Park, Thompson Road, Sunderland, SR5 1SF
Tel: 0191 549 3768
Email: [email protected]
Sunderland Carers Centre website

West Cumbria Carers (Allerdale and Copeland)
Suite 7F, Lakeland Business Park, Lamplugh Road, Cockermouth, Cumbria, CA13 0QT
Tel: 01900 821 976
Email: [email protected]
West Cumbria Carers website

South Tyneside Young Carers Service
Wilkinson Five, The Clervaux Exchange, Clervaux Terrace, Jarrow, South Tyneside, NE32 5UP
Tel: 01325 731 160
Email: [email protected]

• Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Patient Information Centre – access to health and wellbeing information
• Helplines Partnership
• The NHS website

• CNTW(C)20 – Care Co-ordination and Care Programme Approach Policy
• Refocusing the Care Programme Approach, Policy and Positive Practice Guidance, Department of Health, March 2008

Advocate. Someone who acts on your behalf to support you in making decisions.
Assessment. The process of identifying your needs and establishing how your needs can be best supported.
Care Co-ordination. The process used to help and support people with
mental health problems.
Care Co-ordinator. If you have complex needs, this is the person who will be your main contact and who will ensure you receive the care you need.
Care Plan. A way of recording the help and support you need that explains how this will be done.
Care Plan Review. To look over the care plan you have to make sure the help and support you receive is still appropriate.
Care Team. Those people who are involved with providing help and support to you.
Carer. This could be a family member, friend or advocate who provides care and support for you.
Carers Assessment. The process of identifying a carer’s needs and establishing how their needs can be best supported.
Consent. Where you have given your agreement.
CPA – Care Programme Approach. A term that may be used to describe your care if you have complex needs.
CPN. Community Psychiatric Nurse.
Crisis Plan. A step by step plan of what needs to happen in an emergency or when you are unwell to allow you to be appropriately supported.
GP – General Practitioner. Your doctor that you would usually see if you were physically unwell.
Lead Professional. If you have low level needs, this is the person who will be your main contact and who will ensure you receive the care you need.
Mental Health Problems. Unable to manage and cope with stress and challenges of life.
Named Person. This could be a Social Worker, Community Psychiatric Nurse (CPN), Occupational Therapist (OT), Psychologist/Therapist or Consultant.
Next of Kin. This is the person who is most closely related to you.
Non CPA. This is a term that may be used to describe your care if you have low level needs.
OT – Occupational Therapist. This professional is trained to work with people to help them improve their ability to cope with daily living as independently as possible.
Qualified Professional. This could be a Social Worker, Community Psychiatric Nurse (CPN), Occupational Therapist (OT) or Consultant.
Recovery. When you are more able to manage and cope with stress and challenges of life and manage your daily living needs.
Social Worker. This professional would assess your social care needs and provide support to help meet them.

This leaflet has been collaboratively produced by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Service Users, Carers, and Local Authority Partners.

Further information about the content, reference sources or production of this booklet can be obtained from the Patient Information Centre. If you would like to tell us what you think about this leaflet please get in touch.

This information can be made available in a range of formats on request (eg Braille, audio, larger print, BSL, easy read or other languages). Please contact the Patient Information Centre Tel: 0191 246 7288

Published by the Patient Information Centre
2022 Copyright, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Ref, PIC/383/0723 July 2023 V12
www.cntw.nhs.uk Tel: 0191 246 7288
Review date 2025