Tools and resources

Working with adults to ensure person-centred care and support for admission to and discharge from inpatient mental health settings

1. Delivering services that are person-centred and focused on recovery

1. Delivering services that are person-centred and focused on recovery

The guideline and legislation

Sections 24 and 25 of the Care Act 2014 outline that people should be in control of their support and should be actively involved in influencing their care and support. The act states that "the guiding principle in the development of the plan is that this process should be person-centred".

One of the overarching principles of the guideline is that care and support should be person-centred and focused on recovery (recommendation 1.1.1). This can be achieved through working with people as active participants in their own care and transition planning (recommendation 1.2.2).

The NICE guideline and the act together provide a useful practice and legislative framework to support development of person-centred, recovery-focused services.

Example

The 'I' statements were developed by people who use mental health services and practitioners to ensure a focus on the needs of the person in planning and support. The statements are:

  • Who I am.

  • What's important to me.

  • How I wish to be supported.

  • How people behave with me.

Jointly published by Think Local Act Personal and National Voices, No assumptions: a narrative for personalised, coordinated care and support in mental health is part of the Making it Real programme and provides more information about the 'I' statements and has a number of examples of putting them into practice.

Local learning

Discussions at the workshop covered several key themes relating to delivering person-centred, recovery-focused services: systems; involving people; joint working; care and support planning; services; and culture.

Systems

Successful transition from an inpatient mental health setting to a community or care home setting is dependent on services that are person-centred and have a focus on recovery.

A core component of person-centred, recovery-focused services is effective joint working. Joint working can be supported by commissioning 'recovery-focused' services, including housing support services. Practitioners can also use discussions around section 117 aftercare rights as an opportunity to work together across health and social care. (Section 117 of the Mental Health Act 1983 entitles people to free aftercare following a stay in hospital under certain sections of the act.)

Starting care and support planning on admission enables good transition on discharge from hospital (recommendation 1.3.7 and 1.5). Using the "I" statements helps to ensure that planning is focused on the person. The Care Programme Approach (CPA) informs care planning beyond admission.

Person-centred support

Working with family members from an early stage is critical to supporting person-centred practice. If the person using services does not want their family directly involved, practitioners may need support to communicate with them in an appropriate way (recommendation 1.4). For example, practitioners can still listen to family members without compromising confidentiality.

Other factors that contribute to a positive experience for the person are:

  • Including risk assessment and management in planning.

  • Ensuring that there are enough skilled staff to work with people in crisis on wards.

  • Making sure that there is no delay once a person is well enough to move on from hospital.

  • Ensuring that commissioning to support recovery includes the role of housing in the pathway and working with housing landlords and management to prevent people from losing tenancies.

  • Promoting mental health advocacy services.

  • Supporting access to peer support.

  • Ensuring that therapeutic relationships are maintained.

  • Focusing post-discharge follow-up on recovery goals and the needs of the person.


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