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Children and Adolescent Mental Health Services

Summation of findings

The following is a summation of findings and recommendations across all areas of this National Care Review. 

Admission Pathway:
Although the current admissions may be appropriate, consideration should be given as to whether there is any opportunity for the development of alternative care pathways to prevent/reduce future admissions between secure children’s homes and medium secure care, NHS Wales CAMHS acute units and PICU/low secure units.

Care Coordination:
We must ensure that all children have a care coordinator, case manager, or other professional to maintain frequent contact with services. These persons must ensure that: all of the child’s needs are being met, they act as an advocate, ensure any complaint or incident is investigated and that any restrictive intervention is necessary and proportionate.

Care Planning:
We must ensure all Care and Treatment Plans are co-produced by the child, and reviewed regularly. Local care teams must ensure they are involved in developing and reviewing the Care and Treatment Plans. 

Commissioning Outcomes:
We should ensure that there is a robust set of outcomes agreed between the commissioner and provider for all placements. We should ensure progress towards meeting these outcomes is closely monitored so we can ensure all journeys through care for children placed in CAMHS hospitals is as rapid as possible.

We should ensure that services consider the needs of children with an Autism Spectrum Condition as different, although sometimes interconnected, from those with a mental illness.

We should ensure all children, where it is safe and therapeutic, are enabled to engage in community or home leave.

Length of Current Admission:
Some lengths of stay, especially in low secure, appear extensive. We should ensure that all children stay no longer than necessary for the provision of appropriate assessment, care and treatment.

Levels of Care:
We should ensure the issues around the following are explored: Safety – all but 2 children were in the anticipated range for their care type, with one being lower than expected and one being higher. Activities – all children were in the anticipated range for their care type.Medication – all but one child was in the anticipated range for their care type, with 1 being higher than expected.

We should ensure that all medications are regularly reviewed to ensure they are prescribed at the minimal dose possible to achieve the desired reduction in symptoms. We should ensure that medication being administered for the purpose of subduing disturbed behaviour has been used only as an intervention of last resort. We should explore all opportunities to reduce the use of PRN.

Medication Side Effects Monitoring:
We should ensure all children in receipt of prescribed psychotropic or hypnotic medications are regularly monitored for potential side effects using a recognised tool and regular physical health checks are undertaken if appropriate.

Mental Health Act:
This information demonstrates that we have pathways in place to ensure children with criminal justice and mental health issues receive appropriate assessment and care. We must ensure that these pathways are accessible for all children and that they are as robust as possible.

Primary and Urgent Healthcare:
We should ensure that all children have access to primary healthcare services on a regular basis and as required. We should ensure that environments of care are safe so as to minimise the requirement to access urgent care services. We should ensure all children have access to emergency care when required.

Quality [Care Planning]:
Overall, a holistic and personalised approach is taken by most providers to assess the individual, meet their needs and make sure that they are in control and informed. We need to ensure that all units hold regular reviews of care and treatment. 

Quality [Education]:
All units attempted to meet the educational needs of the child whilst balancing against risk and safety concerns. Assessments need to include educational needs and pre-admission issues.

Quality [Nutrition]:
Overall, units provide a healthy and well-balanced diet and access to dietetic support. Some issues were not identified through the initial assessment processes.

Quality [Pharmacological Interventions]:
Overall, medication is actively being dispensed, administered, monitored and externally audited. There was a lack of process to identify possible side-effects of medication and instead an over-reliance on staff skills.

Quality [Physical Health]:
Physical health checks are undertaken on the majority of units, with many producing robust physical health plans. All children should have a physical health care plan.

Quality [Restrictive Interventions]:
Overall, restraint is being used proportionally and appropriately but needs to be individualised, discussed and documented as part of the care and treatment plan. Seclusion is used infrequently, but when it is used it needs to be for the shortest possible time. Blanket bans are common. All blanket restrictions should be regularly reviewed to ensure they are necessary and carefully balanced against personal freedoms.

Quality [Staff]:
Overall, staff are highly skilled, experienced and trained although reliance on agency staff should be reduced. Children feel staff are supportive.

Quality [Safety Observations]:
Overall, safety observations were regularly reviewed to ensure that they are justified, fulfilled and documented.

Quality [Safety and Welfare]:
Overall, risk assessment and management is undertaken and regularly reviewed. Safeguarding processes are in place. Children’s opinions and suggestions are sought.

Quality [Therapeutic Interventions]:
All children had access to a variety of individual and group psychological and therapeutic support.

Restrictive Interventions – ‘Blanket’ Restrictions:
We should ensure that all blanket restrictions are considered, proportionate, documented, reviewed and applied for the minimum period necessary.

Restrictive Interventions – Restraint / Segregation:
We should ensure that the single incident of prone restraint was undertaken as an action of last resort. We should explore the high levels of incidents of ‘verbal de-escalation’ to ensure that all actions are being taken to promote a positive culture and atmosphere on the wards. We should explore the high levels of incidents of ‘hands on (not restraint)’ to ensure that this is not, by nature or degree, restraint. We should explore the frequent use of ‘time out’ to ensure they are not, by nature or degree, seclusion. We should ensure all incidents of ‘seclusion’ are a last resort, undertaken in a suitable environment, robustly recorded and for the minimal period necessary.

Risk Behaviours:
We should ensure that providers are taking all appropriate actions to reduce the high levels of verbal aggression, especially with male children. We should ensure providers are taking all appropriate actions to reduce the high levels of threatening behaviour, especially with male children. We should ensure providers are taking all appropriate actions to reduce the high levels of violent behaviour, especially with male children. We should ensure providers are taking all appropriate actions to reduce the high levels of deliberate self harm, especially with female children. We should continue to closely monitor the risky behaviour of children in hospitals to ensure this behaviour is appropriately managed and reduced through the use of a person-centred, values-based approach by experienced, skilled and trained staff.

We should ensure that each provider employs and deploys a multi-professional team to formulate, assess, treat and review clinical, therapeutic and psychosocial interventions and approaches in order to provide effective, evidence-based care within a culture of positive regard and hope for every child.