Staffing and team procedures
This page contains items from the third sub-scale of the CORE Fidelity Scale.
Item 27: The CRT has adequate staffing levels
Item 28: The CRT has a psychiatrist or psychiatrists in the CRT team, with adequate staffing levels
Item 29: The CRT is a full multi-disciplinary staff team
Item 30: The CRT provides a thorough induction programme for new staff and ongoing training and supervision in core competencies for CRT staff
Item 31: The CRT has comprehensive risk assessment and risk management procedures, including procedures for safeguarding children and vulnerable adults living with CRT service users
Item 32: The CRT has systems to ensure the safety of CRT staff members
Item 33: The CRT has effective record keeping and communication procedures to promote teamwork and information sharing between CRT staff
Item 34: The CRT works effectively with other community services
Item 35: The CRT takes account of equality and diversity in all aspects of service provision
Item 36: The CRT has systems to provide consistency of staff and support to a service user during a period of CRT care
Item 27: The CRT has adequate staffing levels
Target
a) The CRT caseload of service users receiving acute home treatment is not too high (Fully met = median CRT caseload is no more than 25 per 14 full time equivalent clinical staff; partially met = median CRT caseload is no more than 30 per 14 full time equivalent clinical staff).
b) There is all source agreement that the CRT has the resources to carry out same day crisis assessments and home visits to CRT service users.
c) There is all-source agreement that the CRT has the resources to offer home treatment wherever possible to all service users who would otherwise be admitted or who may benefit from early discharge.
d) More than 80% of CRT staff (over the last three months) are permanent staff (not locum, bank or agency staff).
Why this is important
The CRT’s role is an intensive one, and in order to ensure that service users are provided with personalised support and regular visits there must be a sufficient ratio of staff to service users. Department of Health guidance when CRTs were first rolled out nationally was that they should have at least 14 full time staff for a case load of 20-30 service users. In our CRT survey, managers identified adequate staffing as their top priority for improving services.
Ways of doing this well
One way to avoid unmanageable case load sizes is to ensure only clients who would otherwise be in hospital are accepted for treatment.
Recruitment processes are important in order to ensure teams are fully staffed, so working closely with HR can be helpful. Allowing staff from other teams to shadow CRT staff may create interest for future jobs, and trying to have open environment where staff can talk about their career plans helps to avoid unexpected departures.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
- South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
- East South Staffordshire (Tamworth) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Greenwich CRT, Oxleas NHS Foundation Trust
- West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- South Powys HTT, NHS Wales
- Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Hastings CRT, Sussex Partnership NHS Foundation Trust
- Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
- Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
- South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
- South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
- Yeovil CRT, Somerset Partnership NHS Foundation Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- Teignbridge CRHTT, Devon Partnership NHS Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- North Devon CRHTT, Devon Partnership NHS Trust
- East and Mid Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Chichester CRHTT, Sussex Partnership NHS Foundation Trust
- Edinburgh IHTT, NHS Lothian
- Gloucester CRT, 2gether NHS Foundation Trust
- Hammersmith CRHTT, West London Mental Health NHS Trust
- Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
- South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
- Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
Relevant reading
McGlynn (2006) CRHT: A Practical Guide
Size and structure of a CRHT team
The ideal size for a CRHT team depends on:
• the population of the catchment area to be covered
• the level of need in the catchment area
• the number of inpatient admissions from the catchment area prior to the CRHT team commencing operation
• the number of staff needed to maintain an adequate rota, allowing for periods of leave and sickness
• the need for good communication between team members.
The policy implementation guidelines (DH, 2001a) state that there should be 14 clinical staff (not including medical staff ) per 150,000 population but acknowledges that local circumstances mean a team may require a variation from this. Inner city areas may generate far more people in crisis for a given population size than do rural areas because the people living there tend to have more problems and fewer social supports. There is an argument therefore for inner city teams being larger or the population covered being smaller. There are some areas - especially rural areas with small populations - where to follow the guidelines would result in a team with too few staff for an adequate rota. With fewer than 10 or 11 staff a team becomes vulnerable to the effects of holidays and study leave plus unexpected sickness, with the possibility of having only one worker for a particular shift - a situation which could be dangerous.
From the experience of the early teams, a team of 14 can deal with an area that produces about 400 hospital admissions per annum before the team’s commencement.
In some areas of the country there are teams that are quite large, with more than 30 staff covering a population of around 350,000. This can create potential problems with staff communication; team handovers need to be handled with firmness and skill, for example, to ensure that they do not take an inordinate amount of time. Nevertheless some of the larger teams have produced good outcomes, so it is too early to say whether they should be recommended or not. (p.14)
Mental Health Foundation (2012) Take Control: Self-management in care and treatment planning
6. Staffing Size
The service should aim to have enough staff to cover two shifts per day, seven days a week. At the same time, team size must be kept manageable enough for communication purposes - between 10 and 15 staff.
Staffing and skill mix
How much work the service can take on will be dictated by both the funding and staffing levels.
General staffing considerations:
• Inner city populations will generate more work than rural or suburban populations.
• There need to be adequate staff to manage the treatment phase. A good rule of thumb would be to plan for a maximum of twice daily visits.
• In urban areas, there should be two shifts daily seven days per week, (i.e. a morning and afternoon/evening shift). Night shifts can be covered by ‘on call’ staff. Overtime situations may arise when crises emerge at the end of evening shifts. (p.9)
Item 28: The CRT has a psychiatrist or psychiatrists in the CRT team, with adequate staffing levels
Target
a) Total psychiatric cover is at least 1.0 full time equivalent (fte) per median CRT caseload size of 30, involving some cover on at least 5 days per week (fully met); at least 0.6 fte per caseload of 30 involving some cover on at least 3 days per week (partially met).
b) Total consultant psychiatrist time is at least 0.6fte per median caseload of 30 involving some cover on at least 3 days per week (fully met); at least 0.3fte per caseload of 30 (partially met).
c) The CRT can obtain advice and arrange urgent psychiatric assessments within 4 hours for CRT service users from a psychiatrist within the local service system throughout the CRT’s opening hours.
Why this is important
Having psychiatrists within the CRT team is the best way to ensure CRT service users can receive medical review or medication prescription promptly when needed. Our review found there is some evidence that CRTs including a psychiatrist were more effective in reducing hospital admissions.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
- West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
- Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
- Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Bromley HTT, Oxleas NHS Foundation Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
- Tower Hamlets HTT, East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
- Hastings CRT, Sussex Partnership NHS Foundation Trust
- Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
- Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
- West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- Hounslow HTT, West London Mental Health NHS Trust
- Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
- North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
- Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
- South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
- South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
- South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- North Devon CRHTT, Devon Partnership NHS Trust
- East and Mid Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Edinburgh IHTT, NHS Lothian
- Gloucester CRT, 2gether NHS Foundation Trust
- Hammersmith CRHTT, West London Mental Health NHS Trust
- Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
- Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
- South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
- Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
Relevant reading
Mental Health Foundation (2012) Take Control: Self-management in care and treatment planning
Medical input - general guidelines:
• Input from psychiatrists is essential for crisis resolution services.
• A consultant psychiatrist should have designated medical responsibility for home based crisis service clients.
• The consultant psychiatrist should be available for a minimum of two weekly sessions to go out and review the cases. In addition, it should also be possible to have access to associate specialists for urgent consultations.’ (p. 9)
Item 29: The CRT is a full multi-disciplinary staff team
Target
CRT staffing includes dedicated time from at least 8 of the following groups:
i) nurses; ii) occupational therapists; iii) clinical or counselling psychologists; iv) social workers; v) psychiatrists; vi) service user-employees; vii) other support staff without professional mental health qualifications; viii) pharmacists ix) Approved Mental Health Professionals or equivalent; x) non-medical prescribers; xi) family therapist; xii) accredited cognitive behavioural therapist.
Why this is important
The Department of Health’s Mental Health Policy Implementation guide outlines the need for an appropriate mixture of staff to ensure that a full range of interventions can be provided within the team. The National Survey showed that CRT staff members greatly valued being part of a multi-disciplinary team. It was felt having multiple perspectives allowed a more flexible and responsive attitude towards service users’ needs, and for more appropriate care to be provided.
Ways of doing this well
Sessional staff
If it is not possible to employ staff such as psychologists or pharmacists on the team directly, bringing in such staff from other teams on a sessional basis can help to expand the expertise available.
Advertising for staff
West Kent CRHT Case Study
West Kent CRHT is a full multidisciplinary staff team.
Within West Kent CRHT we have the benefit of having staff from numerous backgrounds, along with our Support Time and Recovery workers who bring with them a wealth of life and practical experiences, we also have registered mental health nurses, occupational therapists, psychologists, social workers (with approved mental health act practitioner status) and speciality doctors attached to the team.
This means that we are able to offer access to a wealth of opinions and assessments that will very accurately inform a person’s signposting for future care, and ensuring that they are suitably cared for in the community.
We have achieved this by opening our vacancies as “community mental health workers”, rather that just nurses or social workers for example, meaning that we can recruit from the wider professional pool, obviously in terms of our psychologist and medical staff these are specific roles, designed to perform specific functions of assessment and diagnosis within the team, which add to the compliment of diverse skills we can offer anyone accessing our team.
As a team this diverse skill base is extremely important in the service we offer and the thoroughness that we apply to our assessments, we are able to look at needs and risks from a number of differing points of view, which enables better care planning and hence more positive outcomes.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
- Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
Relevant reading
McGlynn (2006) CRHT: A Practical Guide
Multidisciplinary working
Professional differences may occur in any team and this is not necessarily a bad thing. The real danger is if this is allowed to impinge on the package of care delivered to an individual and, worse still, if it compromises risk management. There is value in diversity and teams consisting of many disciplines can have diversity in abundance. While a team can bring together a wealth of experience, both from training and from life experiences, it can also create some differences in methodologies and approaches.
Effective leadership and a commitment to a shared philosophy usually assist in the cohesion of teams. If this is in place then they can reduce the risks significantly. Members of the CRHT team need to be able to trust each other and respect their opinions and experiences in order to enable positive risk management. The role of the team manager/leader is paramount in securing and fostering a culture where staff can practise in a manner that does not inhibit therapeutic, creative and innovative approaches. (p.36)
Sainsbury Centre for Mental Health (2001) Crisis Resolution
Skills mix
A good skills mix should be sought when recruiting the staff. The team should be multidisciplinary and include nurses, social workers, support workers, occupational therapists, psychologists and medics whose skills will help serve the local population best. For example, staff may be recruited based on specific skills around dual diagnosis. The team should reflect the local population in terms of race representation, major local languages and ethnicity. (p.14)
Department of Health (2001) Mental Health Policy Implementation Guide
The table below gives details of suggested staffing levels and skill mix for a team with a caseload of 20 to 30 service users at any one time.
Designated named workers: Key skills: • High energy level • Team player • Ability creatively to engage service users • Understanding of needs of service users, including specific needs related to cultural background/age/gender etc • Able to co-ordinate care and provide broad range of interventions | Total 14 per team Team leader plus up to 13 others Designated named workers include: CPNs ASW OT Psychologists Support workers including service users Appropriate mix of staff is needed to ensure that all the interventions listed can be provided within the team |
Medical staff • Active members of the team • 24 hour access to senior psychiatrists able to do home visits is vital | • Involvement from both consultant and middle grade psychiatrists • Level of psychiatric input to be determined by local need and service configuration |
Specialist skills • These skills should be available within the team either by employing a fully qualified practitioner or by training other team members • External supervision, support and training needed for ‘non specialists’ providing these interventions | • OT/OT skills • Psychologist/psychology skills • ASW/strong links to social services and ability to undertake thorough assessment and activate services as needed |
Support workers • People with health, social care or appropriate life experience or personal experience of mental health problems/treatment | • Number of support workers to be determined by the team • Support workers to reflect the demography of the local population |
| Programme support | • 1 wte administrative assistant • IT, audit and evaluation support may also be needed |
(p.20-21)
Item 30: The CRT provides a thorough induction programme for new staff and ongoing training and supervision in core competencies for CRT staff
Target
a) Induction for new staff involves at least 12 hours of CRT-specific training for staff who have not previously worked in CRTs.
b) At least 80% of CRT staff have received supervision at least monthly during the last 6 months.
c) The CRT has a programme of ongoing CRT service-specific training for CRT staff with sessions at least every two months.
d) The CRT manager or senior staff conduct field mentoring of at least 80% CRT staff at least once each year.
e) At least 80% of CRT staff have had a formal appraisal within the last year.
Why this is important
Working in the CRT is a specific role requiring particular skills, and it is important that new staff members are given the opportunity to develop those skills through a structured induction programme. Steps can be taken to ensure that staff are supported to maintain and develop those skills, including regular supervision, CRT specific training, and field mentoring by senior staff. Individual appraisals have been linked to better morale for mental health staff.
Ways of doing this well
Crisis specific induction and training
Sunderland Initial Response Team ensure that all their new staff receive a thorough induction to ensure they fully understand the roles and responsibilities of working in crisis.
Read their case study below to see what they do:
- Sunderland IRT Induction Case Study (.doc)
- Sunderland IRT Induction Policy (.doc)
- Sunderland IRT Induction Pack (.doc)
- Sunderland IRT Tutorial Plan (.doc)
- Brighton and Hove CRHT Induction Plan for New Staff (.doc)
South Staffordshire and Shropshire Foundation Trust CRTs use this induction checklist to ensure that all new staff have been given a thorough induction to the trust.
- SSSFT Induction checklist (.doc)
SSSFT also facilitate ongoing CRT specific training for staff working in crisis teams to ensure that staff have a broad range of training in relevant areas.
- SSSFT CRT Specific staff training list (.doc)
Supervision
- Sunderland IRT Clinical Supervision Peer Review (.pdf)
- Adur, ArundeL & Worthing Supervision Policy (.pdf)
West Essex CRHT scored highly on the Fidelity Item about supervision. Read about their practices below:
West Essex CRHT Case Study
Given the nature of Crisis Resolution Home Treatment Teams (CRHT) and the ever increasing demands made upon the service, clinical supervision can be easily overlooked and cast to one side as other pieces of work take priority. Yet, if ever there was a service in which clinical supervision was vital it has to be the CRHT given the complexity of presenting cases and high levels of risk the service has to manage on a daily basis.
In the West Essex CRHT at the South Essex Partnership NHS Foundation Trust we believed the best way forward to meet this need was via a group supervision approach, implemented once a month, each session lasting around one hour. This educational activity provides a unique opportunity to update the knowledge base and maintain resilience in the team.
The supervision took the form of a training session based around the clinical presentation and needs of any particular difficult case the CRHT had on its caseload. The Consultant Psychiatrist for the CRHT would facilitate the session and other Consultants, medical trainees and senior clinicians would be invited to give a presentation on various topics relating to work the CRHT was currently undertaking, such as “crisis assessment and management of elderly patients”; “Drugs and alcohol, risk and crisis”; “anxiety disorders/crisis management” to name but a few. As the training sessions progressed the levels of engagement and interest in the sessions of MDT rose. Feedback from those attending has been very positive. Since we started this approach we have noticed a distinct increase in the number and regularity of those attending the sessions and the quality of documentation in case notes and feedback at the twice weekly MDT clinical review.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Tower Hamlets HTT, East London NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Chichester CRHTT, Sussex Partnership NHS Foundation Trust
Item 31: The CRT has comprehensive risk assessment and risk management procedures, including procedures for safeguarding children and vulnerable adults living with CRT service users
Target
a) Risk assessment: a structured risk assessment proforma is used documenting identified risks of self-harm or suicide, self-neglect, exploitation by others and harm to others + clearly identifying contact with children and vulnerable adults and potential related risks to them for at least 80% of service users.
b) Risk management: there is an individualised risk management plan covering all identified risks, which states the current CRT response and plans in the event of an increase in risk, for at least 80% of service users.
c) There is evidence that risk assessments and management plans are reviewed by staff during CRT care and changed where appropriate as perceived risks change and/or management plans require change.
d) CRT staff training in safeguarding children and vulnerable adults is up-to-date in line with service guidelines and staff show awareness of thresholds for contacting other agencies; (met = at least 80% of staff team trained within time period specified in national and local guidelines).
e) High risk service users are identified and prioritised at CRT team level (e.g. specifically discussed at handovers, on team boards).
f) The CRT can provide staff to stay with service users at home for extended periods (up to 4 hours) to manage risks in exceptional circumstances (e.g. carer absence, start of medication).
Why this is important
Service users under CRT care are likely to present with higher levels of risk, which may change rapidly over the period of care. It is therefore crucial that the CRT has robust risk assessment and risk management procedures which are fully documented. Procedures should be in place for higher risk service users, both in terms of continued management of the risks they present and the ability of the CRT to respond flexibly and intensively to any changes in risk.
Ways of doing this well
Risk Assessment
- Crawley CRHT Risk and Mental Health Care Plan (.doc)
- Camden CRT Clinical Risk Assessment and Management Guide (.pdf)
- Clinical risk management guidance (.pdf)
- Department of Health - best practice in managing risk (.pdf)
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Pontypool CRHTT, NHS Wales
- Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
- South Powys HTT, NHS Wales
- Waltham Forest HTT, North East London NHS Foundation Trust
- Hastings CRT, Sussex Partnership NHS Foundation Trust
- Manchester North, Manchester Mental Health and Social Care Trust
- Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
- North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
- Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
- South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- Teignbridge CRHTT, Devon Partnership NHS Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Chichester CRHTT, Sussex Partnership NHS Foundation Trust
- Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
Relevant reading
McGlynn (2006) CRHT: A practical guide
‘Managing risk in CRHT teams
CRHT teams have challenged some of the traditional ways of working and have adopted a different approach to service delivery, including:• working in a more collaborative manner with service users;• providing a service in the least restrictive environment as possible for the service user;• adopting a ‘gatekeeping’ role for people with the potential for hospital admission.These may prove to be extremely challenging concepts for some. The thought of leaving a person at home while they are experiencing an acute mental health crisis may appear, in some cases, to be somewhat negligent. In addition, working alongside a person in the community who is in crisis may appear a daunting task for practitioners who may not have had the opportunity to experience working in this way.Positive risk management is about examining and analysing the possibilities available at any given time in any given situation, and being able to support an action that is the ‘best’ for the service user within that context. This, however, does not mean taking unnecessary risks or being cavalier in approach. It is a way of weighing up the options and being able to make the ‘right’ choice based on the information available rather than feeling forced into a choice based on previous patterns of care or invalid perceptions of risk. While the literature states that the least restrictive environment should be utilised, this may still mean that an admission to hospital is the right decision and as a consequence should not be seen as a failure on the part of the team.’ (p.35)
Item 32: The CRT has systems to ensure the safety of CRT staff members
Target
a) The CRT/local organisation has clear lone worker and safety check-in policies which are adhered to.
b) The CRT adopts practical solutions where required to allow a service to be provided to higher risk service users (e.g. visits in pairs, same gender workers, facilities to see service users on health service premises).
c) At least 80% of staff are up to date with local safety training procedures (e.g. “break away” or conflict resolution training).
d) The CRT manager or senior staff provide same day debriefing/reflection for CRT staff following a threatening or upsetting incident.
e) Serious untoward incidents involving staff safety are specifically recorded and reviewed at least annually to identify necessary changes to safety arrangements.
Why this is important
CRT work involves lone working and home visits, sometimes with people who are not well known to services or whose clinical presentation may be changing rapidly. Robust systems to ensure staff safety are therefore very important.
Ways of doing this well
The West Suffolk HTT have trialled two different personal alarm systems, which they outline in the case study below:
Case study: lone worker devices
The West Suffolk HTT are currently involved with a Trust pilot project looking at lone worker devices for community working. The geographical area of the Trust covers many rural areas where mobile phone reception is not reliable. Whilst the Trust has a lone worker policy this focuses on knowing where staff are and what risks may be associated with the individual receiving a service rather than how staff would seek support or help in a difficult situation.
It has been highlighted that if a member of staff needed to call assistance whilst in the community there are 2 potential problems. One is the lack of mobile phone service and the second is that there may be a need to discretely call for assistance so not to antagonise the situation further.
The Trust contacted several different suppliers of devices and are currently trialling 2 favoured devices. The HTT have taken part in the pilot due to the acute nature of service they deliver. Service Users behaviour can often be unpredictable whilst acutely unwell and therefore staff may find themselves at unexpected risk. The 2 devices trialled both had advantages and disadvantages. The first device was the more discrete option as you can slot it alongside your I.D badge. However it was unclear at times whether staff had succeeded in activating it prior to entering the service users home. It worked by alerting a call centre that you had entered a property. The second device was easier to use however more bulky in appearance making it less discrete. Staff have reported feeling more confident at seeing service users at home knowing that they have a device they can call for help on however there needs to be some refinement of the devices to make them fit for purpose.
The first device was useless as it was difficult to know if the device was even turned on. The second device was more useful but is bulky. I could see staff leaving it at home or in their cars due to its bulk. If the second device was as light and transportable as the first, it would be ideal for our purpose.
The 1st unit
Failings:
• It did not clearly show that it was on or off after a period of time the led lights did not function unless you do the start up process again.
• Battery life was poor
• The Buttons were very hard to press and at times I did not know if I would end up breaking them with the amount of force used
• Not user friendly
Pros:
• The unit looking like a card holder made it discreet when out in the community
The 2nd unit
Failings:
• Not discreet and very bulky when using the badge holder and this came across as obvious to the clients
• It easily can set off an emergency by mistake due to the weak buttons (when in your bag, pocket etc)
Pros:
• More user friendly and easier to understand how to use
• With the added feature of phone calling your base is useful
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Greenwich CRT, Oxleas NHS Foundation Trust
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- Pontypool CRHTT, NHS Wales
- Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Bromley HTT, Oxleas NHS Foundation Trust
- Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Tower Hamlets HTT, East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
- Hastings CRT, Sussex Partnership NHS Foundation Trust
- Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
- West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Manchester North, Manchester Mental Health and Social Care Trust
- Hounslow HTT, West London Mental Health NHS Trust
- Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
- East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
- North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
- Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
- South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
- South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
- Ealing CRHTT, West London Mental Health NHS Trust
- Yeovil CRT, Somerset Partnership NHS Foundation Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- Teignbridge CRHTT, Devon Partnership NHS Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- North Devon CRHTT, Devon Partnership NHS Trust
- East and Mid Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Wandsworth CHTT, South West London and St George’s
Item 33: The CRT has effective record keeping and communication procedures to promote teamwork and information sharing between CRT staff
Target
a) The CRT has handover meetings between each CRT shift.
b) All day time shifts start with handovers reviewing clinical status and immediate action steps for all current CRT service users.
c) The CRT has whole-team meetings at least once per month to address staff issues, team procedures and organisation (clinical discussions of clients are not held at this meetings).
d) CRT staff contacts with service users are written up in patient records the same day at least 90% of the time.
e) CRT staff have immediate out-of-office access to read and write patient records.
Why this is important
Because CRTs use a whole team approach and a shift system, good information sharing can be a challenge. Clear systems to achieve this are needed. CRT staff interviewed for the CORE study valued shift handovers as an effective way to share information and plan care for CRT service users.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Islington CRT, Camden & Islington NHS Foundation Trust
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Item 34: The CRT works effectively with other community services
Target
a) Communication and joint meetings between CRT and involved staff from other community mental health services are evident for at least 80% of service users with involved community services during CRT care.
b) CRT discharge plans and treatment summaries are routinely sent to GPs and involved mental health services promptly (within 3 days) at the end of CRT care (for at least 80% of service users).
c) The CRT has an identified link worker or equivalent for at least one key community mental health service who visits the service at least monthly to discuss joint working issues.
d) CRT and community mental health service managers meet at least every two months to review care pathways and referral protocols and address issues re joint working.
e) There is all source agreement that there are good working relationships between the CRT and other community teams.
Why this is important
The work of the CRT will often join up with that carried out by other community services. Many service users will already have an involved community service, and others might benefit from this input when they exit CRT care. It is therefore important that the CRT is able to cultivate effective relationships with other community services, both through links at a management level and through frequent joint meetings between workers from the CRT, other services, and the individual service user.
Ways of doing this well
Good working relationships
The CRT in Wales prioritises communication to ensure good working relationships with other services, including the voluntary sector:
- Wales CRT case study (.doc)
The Chichester team use a standard fax form to request information from GPs:
- Chichester fax form to request medical information from GPs (.doc)
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Pontypool CRHTT, NHS Wales
- West Gwent CRHTT, NHS Wales
- West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Tower Hamlets HTT, East London NHS Foundation Trust
- Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- South Hams and West Devon CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Chichester CRHTT, Sussex Partnership NHS Foundation Trust
- Edinburgh IHTT, NHS Lothian
Relevant reading
McGlynn (2006) CRHT: A practical guide
‘Meet with other CRHT teams
Staff from the team should attend CRHT team forums to exchange information about the good things teams have done, and the hazards teams have faced, to support each other and to unite to take action to deal with threats to their sustainability.’ (p.20)
National Audit Office (2008) CRHT: The Service User and Carer Experience
‘Continuity between teams - the need for a whole systems approach to the mental health care pathway is a key focus of recent Department of Health policy guidance. Service users and carers echo the Department’s stated need for ‘overall service system coordination and coherence’ and ‘shared values, principles and processes across the whole service system’, and feel confused and disappointed when that system appears to break down:
‘You’re left in limbo, if you’re not like familiar with it all, and for someone who is first approached by mental illness it can be a little bit about […] co-ordination. Yes, it’s like the right hand doesn’t talk to the left hand. And that goes right down to the GP.’
Tiffany (carer)
Source: NAO carer focus group
‘I thought, “If he’s taken the pills, that’s really bad”, so I rang the crisis line […] They said, ‘Who’s the CPN? I’ll get in touch with them in the morning’. This was Tuesday
night. By Friday I hadn’t been able to get out of the house. I was in tears. I rang the CPN, and they hadn’t even left him a message.’
Mandy (carer)
Source: NAO carer focus group
‘When I was discharged, two weeks later, I had an appointment with my consultant who had not had my file back from the Home Treatment team. So Home Treatment had not informed him of my medication […] and I just think it was a shambles.’
Susan (CRHT service user)
Source: NAO service user focus group’ (p.23)
Item 35: The CRT takes account of equality and diversity in all aspects of service provision
Target
a) The CRT can access interpreters to attend in person/video conference within 24 hours and by phone within 4 hours for at least 90% of service users for whom this is needed.
b) The CRT monitors service accessibility.
c) The CRT team broadly reflects the demographics of the local population.
d) The CRT can demonstrate at least one active attempt during the last 12 months relevant to the local population to make the CRT service more appropriate for a minority group.
e) There is all-source agreement that the CRT provides a service which is sensitive to diversity and responds to service users’ and families’ needs regarding disability, race, gender, ethnicity or sexuality.
Why this is important
It is important that CRT teams are able to communicate and meet the needs of all service users. Diversity within the CRT staff team can help the team provide a culturally sensitive service. Priorities for achieving equality in service provision will vary between teams, so active attempts to meet local needs are important.
Ways of doing this well
Monitoring service users’ demographics is an effective way of ensuring that teams recognise if there is a need to address any issues regarding equality and diversity. As West Berkshire’s Crisis team monitored the demographics of their service users they were able to see that the service they were providing was not accessible for a specific minority group. Read their case study below:
West Berkshire Case Study: Improving Access to Mental Health Services for South Asian Community
The acute inpatient service and CRHTT conducted a joint audit in January 2013 to identify admission trends of BME groups to Inpatient and CRHTT services. The audit identified that South Asian groups were represented significantly higher within the inpatient service in comparison to CRHTT. An in depth analysis of cases identified that there is a reluctance to seek help from secondary mental health services at the early stages of mental health crises for the following reasons:-
• Interpretation of cultural factors by assessing clinicians
• Cultural stigma
• Lack of understanding and awareness relating to mental health conditions
• Lack of awareness of services available and accessing services
To address the above findings, CRHTT in collaboration with Inpatient services designed and delivered a training day to develop competencies and skills required to minimise cultural barriers and enhancing clinician’s awareness of cultural characteristics of the South Asian community.
The day included activities in developing clinician’s skills to reduce the stigma and cultural barriers associated with mental health and associated services so that the clinician’s develop a clear understanding of the types of strategies which they can utilise. The workshop also focused on the importance of protecting and involving the service users’ family members in achieving better mental health outcomes.
The overall feedback received by the clinicians who took part highlighted that the workshop was highly useful and they all achieved a greater understanding of cultural and religious beliefs related to the South Asian community.
Berkshire Healthcare organisation has now extended this workshop to both mental health and primary care clinicians as part of improving South Asian cultural awareness to enhance the care delivered by the organisation to this identified population.
North West Sussex CRHT wrote a case study documenting the way in which support was made appropriate a service user, respecting their cultural beliefs:
- North West Sussex CRHT Case Study (.doc)
A number of Crisis teams use the easily accessible Language Line for translation purposes if they need quick access to an interpreter. Click on the link below to visit the website for more information:
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
Relevant reading
Healthcare Commission 2008
‘Support for people from black and minority ethnic groups Higher proportions of people from black and minority ethnic groups are admitted to mental health hospitals and detained under the Mental Health Act.10 National policy recommendations for BME service users include: • Recording and monitoring ethnicity data. • Providing access to interpreters where needed, to ensure that care is assessed, planned, delivered and evaluated effectively. • Ensuring that information is available in different languages and formats. • Ensuring that inpatients are able to have their spiritual and religious needs met. • Access to worship space, faith leaders, and religious and faith groups.34’ (p.31)
Item 36: The CRT has systems to provide consistency of staff and support to a service user during a period of CRT care
Target
a) The CRT allocates a named worker or equivalent for each service user who is responsible for ensuring key care tasks for that service user are completed.
b) Service users and carers are made aware who their named worker is (at least 80% of service users).
c) The CRT has effective systems to limit the number of staff seen by a service user during an episode of CRT care.
d) There is all-source agreement that CRT staff arrive with up-to-date information about the service user and treatment and succeed in avoiding unnecessary duplication of questions/information and provide a coherent treatment approach.
Why this is important
When interviewed, service users and families repeatedly stress the need for more consistency in CRT care. Seeing the same workers from one visit to the next is highly valued, and is felt to be key to building a therapeutic relationship. Generally service users and families are aware that seeing a number of staff is often unavoidable given the nature of crisis care shift patterns and the ways in which they work, however service users experience of this can be greatly improved if staff ensure they turn up to visits well-informed and up-to-date. Named workers have been positively received where a named worker system is in place.
Ways of doing this well
Key Workers and mini teams
The Edinburgh Intensive Home Treatment Team (IHTT) operate a system of small key worker groups within the larger team, which means that staff have more detailed knowledge of the service users they see.
- Edinburgh IHTT Case Study (.doc)
Listen to the audio clip below to hear Dr Bryn Lloyd-Evans talk about ways of improving the consistency of staff visiting service users.
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- North Somerset Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Sandwell CRHTT, Black Country Partnership NHS Foundation Trust