Model of Care – Mental Health and Personality Disorder

This leaflet provides information about the Model of Care for secure services in Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW).

The information in this leaflet will describe our Model of Care, how it was developed and how it shapes your recovery journey. If there is anything you do not understand, or you would like further information, please ask a member of staff.

A model of care describes the way health services are delivered.

Our Model of Care outlines how we work together to promote recovery. Our goal is to make sure that care is delivered collaboratively with patients, carers, families and staff, so that everyone has a positive experience of the recovery journey in secure care. The aim is to improve the lives of patients, increasing their confidence and empower them to lead meaningful lives.

Our Model of Care aims to provide high-quality, person-centred care. It is based on a set of core values, which are at the heart of everything we do:

• Dedication
• Empowerment
• Respect
• Opportunity
• Identity
• Hope and optimism
• Collaboration

We believe that people in secure services should be supported to manage their own recovery as much as possible, to allow them to live satisfying and meaningful lives in the least restrictive setting possible. This means:

• Being recognised and valued as individuals with their own needs and preferences
• Encouraging collaboration, self-management and independence
• Being as healthy and active as possible and spending time doing valued activities

Staff pledge to patients – to provide quality care to every person, every day.

Recovery Star secure mental health – Our recovery journey

• Dedication
• Empowerment
• Respect
• Opportunity
• Identity
• Hope and optimism
• Collaboration

It is important that our Model of Care reflects the needs of the people who use secure services.

When we were developing our Model of Care we asked patients in secure care to tell us about their experiences of being in our service, from the point they arrive through to when they are getting ready for discharge.

We have used their feedback to think about what is most important in their recovery journey and have developed our Model of Care around this.

We had a team’s call before arrival

I was given a welcome pack on my arrival

Staff are helpful and caring

I feel a face to face meeting before arrival would have been best

I am very happy and feel I am making progress

Sometimes there are too many people in the meetings

I know about my recovery star and my goals

Very happy with staff, so helpful and feel that they listen

I have received a good experience and was happy to receive info on arrival

I know about my risks and care plans, and I feel very involved with them all, I had 1 care plan changed because I didn’t agree with it

The wording is too difficult to understand at times. It needs to be broken down, maybe a debrief afterwards with bullet points

Our Recovery Journey maps out what you and your loved ones can expect from the care we provide during your time with us, from before you arrive on our wards, through your admission and inpatient stay, to getting ready for discharge. You are at the heart of the care we provide, and your thoughts and ideas are central to your Recovery Journey.

Throughout your time in our service, we will work together to identify the goals that are important to you and develop care plans that help you work towards achieving your goals. We want to make sure that it is always clear to you what will help you to keep making progress.

Our Recovery Journey uses the Recovery Star Secure to help us plan your care and review the progress that is being made towards your goals.

At each stage, when entering or moving between our services we aim for it to be a collaborative experience for you and your family.

• We will welcome you and your family
• We will answer any questions or concerns that you have
• We will provide you with additional information about the ward and what you can, and can’t, bring into hospital
• We will aim to answer any questions about your inpatient stay
• We will provide you with information about the Recovery Star Secure
• We will arrange monthly contact with your named nurse to help build a therapeutic relationship
• We will share a video of your ward/hospital

• We will introduce members of the nursing team and multi-disciplinary team (MDT)
• We will involve carers and families
• We will discuss formulation. This is when together we summarise your difficulties, to explain why they may be happening and make sense of them
• We will discuss care and treatment plans
• We will explain your rights under the Mental Health Act
• We will talk to you about confidentiality and how information about you is shared
• We will talk with you about how we can support your spiritual, cultural or gender needs
• We will answer any further questions

• We will show you around the ward and introduce you to the team
• We will work together as an MDT to ensure that your care and treatment is person centred
• Together we will discuss what therapies are available and develop a plan of care. There are several therapies such as Structured Clinical Management, and you will be fully involved in your Formulation
• We will work together to assess and manage any risk behaviours and develop safety plans
• Together we will complete your Recovery Star Secure and review your goals on a regular basis
• We will continue to work with you and your family
• Together we will complete meaningful, individual care plans linked to your Recovery Star goals, which will be supported by the nursing team and other professionals. They will focus on individual strengths as well as your needs. They will be reviewed collaboratively every month
• We will ensure your stay is recovery focused
• We will provide person-centred care, and we will be inclusive in the care that we deliver
• We will support you to maintain a healthy lifestyle and offer support around stopping smoking, healthy eating and exercise
• We will introduce you to the Recovery College

• We will work together regarding your discharge/transition, and your voice and family/carer’s voice will be heard
• We will include you and your family/carer in meetings about your care and where you will be discharged/transferred to
• We will make sure that all professionals who need to be involved to support your transition/discharge are involved at the earliest opportunity

The Recovery Star Secure is an outcome measure that supports discussion and review of your progress and planning goals for your recovery.

It is part of your clinical meetings where your goals are discussed between you and your team.

You and members of your team will regularly use the Recovery Star Secure as a guide to discuss and assess areas of progress and identify any further areas for goal planning.

This will be an ongoing process, with regular reviews and updates incorporated into your recovery journey.

The Recovery Star Secure recognises that people are at different stages on the journey of change when they are in secure services.

Some people will be at earlier stages on the journey of change and might feel stuck in the process of recovery. They are likely to rely on the team’s understanding of their needs and more intensive support to help them work toward their goals.

In the later stages of the journey of change, people are often able to determine their recovery goals more independently and utilise skills and resources to work towards these.

The person-centred approach of our Model of Care means that the support and interventions we offer are adapted to the needs of the person wherever they are in the Recovery Journey.

• Being recognised and valued as individuals with their own needs and preferences
• Being able to self-manage and have as much independence as possible
• Being as healthy and active as possible and spending their days in meaningful ways
• Having the opportunity to contribute and being allowed and enabled to do things for themselves where this is safe

The successful use of the Recovery Star Secure depends on the efforts of both the person in secure services and of the professionals who are helping them.

In the early stages of the journey of change, progress relies on professionals understanding someone’s needs and setting things up to meet those needs as much as possible.

In the later stages of the journey, the patient learns more about their own needs and what works for them, including:

• Managing mental health
• Trust and hope
• Dealing with strong feelings
• Addictive behaviour
• Risk to others
• Physical health
• Social skills
• Relationships
• Meaningful activities

Our Recovery College provides a safe space where people can connect, gain knowledge, and develop skills. Courses are co-developed and co-delivered.

Students can share and learn from each other’s insights, skills and lived experiences. Some of the types of courses that are available include:

• Photography
• Creative Wellness
• Wellness and Recovery Action Plan Awareness
• Peer Mentoring
• Making Recovery a Reality
• Maths and English Courses

We provide care incorporating CNTW’s Trust wide patient safety initiative Talk 1st. We work to reduce violence, aggression, and restrictive interventions.

Talk 1st aims to promote innovation and share good practices across wards to ensure positive care for patients. It also focuses on considering service user voices and collaborative working towards better patient care.

In secure care, our commitment to patients and carers is ensuring that our care is collaborative through:

• Recovery Star Secure
• Family Meetings
• Collaborative Care Planning
• Inclusion in meetings
• Providing a range of psychological therapies and meaningful activities to meet your individual needs
• Working together to understand risk
• 5P + Plan Formulation

We will continue to encourage innovation and review our services to ensure that we are always looking at ways we can improve. We will continue to listen to our staff, patients, and carers to support us to deliver the best person centred care.

NHS-Led Provider Collaboratives include providers from a range of backgrounds, including the voluntary sector, other NHS trusts and independent sector providers.

We work in collaboration with Tees, Esk and Wear Valleys NHS Foundation Trust and form the North East and North Cumbria Mental Health, Learning Disability and Autism Partnership.

Further information about the content, reference sources or production of this leaflet 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 (Braille, audio, larger print, easy read, BSL or other languages). Please contact the Patient Information Centre on 0191 246 7288

Published by the Patient Information Centre
2026 Copyright: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Ref: PIC/948/0226 February 2026 V1
Review date 2029

Website: www.cntw.nhs.uk