Document Title Community Treatment Order Policy… · 6.1.5 Undertake a risk assessment. CNTW(C)47 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)47: Community

Document Title Community Treatment Order Policy

Reference Number CNTW(C)47

Lead Officer Medical Director

Author(s) (name and designation)

Ken Hartley Mental Health Legislation Nurse Practitioner

Ratified by Business Delivery Group

Date ratified Feb 2019

Implementation Date Feb 2019

Date of full implementation

Feb 2019

Review Date Feb 2022

Version number V04.1

Review and Amendment Log

Version Type of change

Date Description of change

V04 Review Feb 19 Clarification of the treatment certificate requirements.

V04.1 Update Nov 19 Governance Changes

This policy supersedes the following documents which must now be destroyed:

Reference Number Title

CNTW(C)47 – V04 Community Treatment Order Policy

Community Treatment Order

Section Contents Page No.

1 Introduction 1

2 Purpose 1

3 Glossary of Abbreviations used 1

4 Service User Group 2

5 Difference between a CTO and Section 17 leave 2

6 Duties 3

7 Assessment for a CTO 7

8 Care Planning, Treatment and Support in the Community 9

9 Making the Community Treatment Order 10

10 Conditions to be attached to the Community treatment Order 11

11 Capacity 12

12 CTO Patients – Capacity, Competence and Consent 13

13 CTO Patients – Charges for Medication 14

14 Information for CTO Patients and Others 15

15 Monitoring of CTO Patients 15

16 Varying and Suspending Conditions 16

17 Responding to Concerns Raised by the Patients Carer or relatives

17

18 Recall to Hospital 17

19 Procedure for Recall to Hospital 18

20 Detention of CTO Patients Informally in Hospital 20

21 Revoking the CTO 21

22 Deprivation of Liberty while on a CTO, leave or subject to guardian

22

23 Review of CTO 22

24 Extending a CTO 23

25 Discharge from a CTO 23

26 Identification of Stakeholders 24

27 Equality impact assessment 24

28 Training 24

29 Implementation 25

30 Monitoring compliance and effectiveness 25

31 Standards / Key Performance Indicators 25

32 Fair Blame 25

33 Fraud, Bribery and Corruption 25

34 Associated documentation 25

35 References 26

Standard Appendices – attached to policy document

A Equality Impact Assessment tool 27

B Communication and Training check list and Needs Analysis

30

C Audit/Monitoring Tool 32

D Policy Notification Record Sheet - click here

Appendices – listed with the policy

Document No:

Description

1 Mental Health Act Office Addresses

2 Recall Flowchart

3 CTO Forms

4 CTO Roles / Duties Summary

5 Process Flow Chart

RC varying ‘recently’ made CTO conditions

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(C)47

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)47: Community Treatment Order – V04.1-Nov 19

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1 Introduction 1.1 A Community Treatment Order (CTO) allows suitable patients to be safely

treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery

1.2 The CTO provides a framework for the management of patient care in the community and gives the responsible clinician the power to recall the patient to hospital for treatment if necessary. 2 Purpose 2.1 The Mental Health Act 1983 (MHA) sets out the parameters of a CTO.

Cumbria Northumberland Tyne & Wear NHS Foundation Trust (CNTW) will endeavour to work within these parameters while providing the highest quality of care to meet the needs of our service users. This policy should be read in conjunction with the MHA Code of Practice 2015, the MHA, the Mental Capacity Act 2005 Code of Practice, the Mental Capacity Act 2005, and the Deprivation of Liberty Safeguards Code of Practice. It is designed to meet the requirements of this and associated legislation.

3 Glossary of Abbreviations Used 3.1 Acronyms Used

AC Approved Clinician

AMHP Approved Mental Health Professional

AWOL Absent Without Leave

CCG Clinical Commissioning Group

CPA Care Programme Approach

CTO Community Treatment Order

ECT Electro Convulsive Therapy

GP General Practitioner

IMHA Independent Mental Health Advocate

MCA Mental Capacity Act

MHA Mental Health Act

RC Responsible Clinician

SOAD Second Opinion Appointed Doctor

Further references can be found in MHA Code of Practice 2015 3.2 Terms Used

Tribunal - First Tier Tribunal

Part 2 CTO patient - A patient who was detained on the basis of an application for admission for treatment (section 3) immediately before becoming a CTO patient

Part 3 CTO patient - A patient who was detained on the basis of an unrestricted hospital order, hospital direction or transfer direction immediately before becoming a CTO patient

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Responsible hospital - The hospital whose managers have responsibilities in relation to the CTO patient in question. Initially, at least, this will be the hospital in which the patient was liable to be detained immediately before becoming a CTO patient

Approved Clinician (AC) - A mental health professional approved by the Secretary of State (or the Welsh Ministers) to act as an approved clinician for the purposes of the Act. Some decisions under the Act can only be taken by people who are approved clinicians. All responsible clinicians must be approved clinicians and may be a Doctor, Nurse, Psychologist, Occupational Therapist or a Social Worker with the appropriate training and approval.

Responsible Clinician (RC) – The Approved Clinician with overall responsibility for a patient’s case. Certain decisions (such as renewing a patient’s detention or making / recalling/ revoking a CTO) can only be taken by the patient’s responsible clinician.

4 Service User Group 4.1 Only patients who are detained in hospital for treatment under section 3 of the

MHA or are unrestricted Part 3 patients (Section 3, 37, 48 and 51), can be considered for a CTO. Where these patients are receiving, or are to receive, S17 leave for 7 consecutive days or more they must be considered for a CTO. Patients detained in hospital for assessment under Section 2 of the Act are not eligible.

4.2 CTO is an option only for patients who meet the criteria set out in the MHA, which are that:

the patient is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment;

it is necessary for the patient’s health or safety or for the protection of others that the patient should receive such treatment;

subject to the patient being liable to be recalled as mentioned below, such treatment can be provided without the patient continuing to be detained in a hospital;

it is necessary that the responsible clinician should be able to exercise the power under section 17E(1) of the Act to recall the patient to hospital; and

appropriate medical treatment is available for the patient.

5 Difference between CTO and Section 17 Leave 5.1 Leave of absence (section 17) is primarily intended to allow a patient detained

under the Act to be temporarily absent from hospital where further in-patient treatment as a detained patient is still thought to be necessary. It is clearly suitable for short-term absences for a fixed period or specific purpose eg to allow visits to family and to trial living more independently.

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5.2 Leave of absence may be useful in the longer term (more than seven consecutive days) where the clinical team wish to see how the patient manages outside hospital before making the decision to discharge. Leave for a longer period should also be for a specific purpose or a fixed period, and not normally more than one month. For most patients who are able to live in the community, a CTO should be considered a better option than longer-term leave for the ongoing management of their care. Reflecting this, whenever considering longer-term leave for a patient (that is, for more than seven consecutive days), the responsible clinician must first consider whether the patient should be discharged onto a CTO instead. Any decision to authorise section 17 leave for more than seven days on a second occasion should be fully documented, including why a CTO or discharge is not appropriate.

5.3 A CTO (section 17A) is used where it is necessary for the patient’s health or

safety or for the protection of others to continue to receive treatment after their discharge from hospital. It seeks to prevent the ‘revolving door’ scenario and the harm which could arise from relapse. It is a more structured system than leave of absence and has more safeguards for patients. A key feature of the CTO framework is that it is suitable only where there is no reason to think that the patient will need further treatment as a detained in-patient for the time being, but where the responsible clinician needs to be able to recall the patient to hospital if necessary.

5.4 A patient on a CTO is seen as someone who does not need further in- patient treatment at that time, and whose stay in community will be long term. So long as they keep to the conditions attached to their CTO and do not meet the criteria for recall to hospital for treatment. 6 Duties

6.1 Responsible Clinician (RC)

6.1.1 The responsible clinician (RC) is likely to be the senior clinician who has worked most closely with the patient during their detention in hospital. The RC will have overall responsibility for the patient, and will be an approved clinician (AC), but might belong to any of the following professions: nurse, psychiatrist, psychologist, occupational therapist or social worker. The RC, who should be the most appropriate available AC to meet the patient’s needs at that time, will be allocated to take responsibility for the patient’s treatment in the community, calling on other professionals to provide areas of treatment which are not within the RC’s professional competence. It may be agreed in some circumstances that it would be more appropriate for another RC to take over the role when the patient is being treated in the community. However, a patient can only have one RC at any given time.

6.1.2 Wherever possible, the clinician responsible for the care and treatment of children and young people should be a child and adolescent mental health services (CAMHS) specialist.

6.1.3 The decision as to whether a CTO is the right option for any patient. 6.1.4 Consider a CTO as one of the options when reviewing the patient’s treatment. 6.1.5 Undertake a risk assessment.

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6.1.6 Establishing whether the criteria for a CTO are met and seeking the

agreement of an approved mental health professional (AMHP). 6.1.7 The responsible clinician should inform the patient of the essential legal and

factual grounds for the CTO and other information about the CTO both orally and in writing.

6.1.8 Consider a CTO as an option where the Tribunal has recommended it.

However it will be the responsible clinician to decide whether or not the CTO is appropriate for the patient taking into account the relevant factors as described in 6.1.5 to 6.1.8 above. The responsible clinician should record the reasons for their decision in the patient’s case record.

6.1.9 Agree the conditions of the CTO with the AMHP and others, complete the

CTO specifying the date and time when the CTO comes into effect; the reasons why the patient meets the criteria and the conditions which the patient will be expected to keep to once placed on a CTO.

6.1.10 If a patient on a CTO requires treatment in the community, the RC should

ensure that the patient receives this from an appropriate person, who may either be a member of the CMHT, or the patient’s GP. If medicinal treatment is still required after the first month, and where the patient lacks capacity or refuses to consent to the medication, the RC must ensure that a Part 4A certificate signed by a SOAD is obtained (Form CTO 11). If the patient has capacity and consents to the medication then the RC is required to complete form CTO12

6.1.11 The RC should ensure they receive regular feedback regarding the progress

of the patient while on a CTO. 6.1.12 If recall is considered then the RC has the responsibility for coordinating the

recall process unless otherwise agreed. 6.1.13 The RC should consider the discharge planning process at the start of the

CTO and can reach the conclusion that the patient is ready for discharge at any time. It is the RC’s responsibility to ensure the appropriate discharge documentation is completed.

6.1.14 The role of the RC is not delegatable but the role may be occupied on a

temporary basis during the absence of the usual RC. 6.1.15 The RC is required to complete a report which meet the requirements laid

down in the Tribunal Judiciary Practice Direction, Health and Social Care Chamber, Mental Health Cases 23rd October 2013. A suggested report template is set out within CNTW(C)55 – Mental Health Act Policy – PGN MHA-PGN-05 - Tribunal Reports. Where the case is a reference to the tribunal the RC’s report must state if the patient has got the mental capacity to decide whether or not to attend, or be represented at, the hearing.

https://www.cntw.nhs.uk/about/policies/mental-health-act-1983-policy/

https://www.cntw.nhs.uk/about/policies/mental-health-act-1983-policy/

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6.2 Approved Mental Health Professional (AMHP) 6.2.1 The AMHP must decide whether to agree with the patient’s responsible

clinician that the patient meets the criteria for a CTO, and (if so) whether a CTO is appropriate. The AMHP should meet with the patient before deciding whether to agree that the CTO should be made. Even if the criteria for a CTO are met, it does not mean that the patient must be discharged onto a CTO. In making that decision, the AMHP should consider the wider social context for the patient. Relevant factors may include any support networks the patient may have, the potential impact on the rest of the patient’s family, and their need for support in providing care, and employment issues.

6.2.2 The AMHP should consider how the patient’s social and cultural background

may influence the family environment in which they will be living and the support structures potentially available. But no assumptions should be made simply on the basis of the patient’s ethnicity or social or cultural background about what care and support can be provided by the family.

6.2.3 The MHA does not specify who this AMHP should be. It may (but need not) be

an AMHP who is already involved in the patient’s care and treatment as part of the multi-disciplinary team. It can be an AMHP acting on behalf of any willing local authority, and local authorities may agree with each other and with hospital managers the arrangements that are likely to be most convenient and best for patients. But if no other local authority is willing, responsibility for ensuring that an AMHP considers the case should lie with the local authority which would become responsible under section 117 for the patient’s after-care if the patient were discharged.

6.2.4 If the AMHP does not agree with the responsible clinician that the patient

should go onto a CTO, or if they do not agree with the conditions attached to the CTO, then the CTO cannot be made. A record of the AMHP’s decision and the full reasons for it should be kept in the patient’s notes. It would not be appropriate for the responsible clinician to approach another AMHP for an alternative view.

6.2.5 The AMHP must also agree (or not) the extension, conditions and revocation

of the CTO. 6.2.6 The AMHP is to be consulted before an appropriate practitioner makes a

report under section 21B confirming the detention or community treatment of a patient who has been absent without leave for more than 28 days.

6.3 Hospital Managers 6.3.1 It is the responsibility of the hospital managers to ensure that no patient is

detained following recall for longer than 72 hours unless the CTO is revoked. The relevant statutory form (CTO4) must be completed on the patient’s arrival at hospital. Hospital managers should ensure that arrangements are in place to monitor the patient’s length of stay following the time of detention after recall, as recorded on the form, so that the maximum period of detention is not exceeded.

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6.3.2 The hospital managers should also ensure that arrangements are in place to cover any necessary transfers of responsibility between responsible clinicians in the community and in hospital. 6.3.3 If a patient’s CTO is revoked and the patient is detained in a hospital other than the one which was the responsible hospital at the time of recall, the hospital managers of the new hospital must send a copy of the revocation form to the managers of the original hospital. 6.3.4 The hospital managers have a duty to ensure that a patient whose CTO is revoked is referred to the Tribunal without delay. 6.4 Tribunal 6.4.1 When a detained patient makes an application to the Tribunal for discharge,

the Tribunal may decide not to order discharge, but to recommend that the responsible clinician should consider whether the patient should go onto a CTO. In that event, the responsible clinician should carry out the assessment of the patient’s suitability for a CTO in the usual way.

6.5 Second Opinion Appointed Doctor (SOAD) 6.5.1 Patients without capacity to consent to treatment

If the treatment in question is a section 58 or 58A type treatment, then as well as there being authority to give the treatment, it is normally necessary for the treatment in question to have been approved by a Part 4A certificate from a SOAD by using Form CTO11

The SOAD must specify on the certificate the treatments to which it applies and any time limits and conditions to which the approval of any or all of those treatments is subject. The SOAD may also specify which (if any) of the treatments approved on the certificate may be given to the patient on recall to hospital without the need for a separate certificate under Part 4 of the Act

Before issuing the certificate, the SOAD must consult two other people who have been professionally concerned with the patient’s medical treatment. Only one of those two people may be a doctor and neither may be the patient’s responsible clinician or the approved clinician in charge of any of the treatments that are to be specified on the certificate

6.5.2 Patients with capacity to consent to treatment

If the treatment in question is a section 58 or 58A type treatment, the treatment does not need to be certified by a SOAD. Instead, the patient’s approved clinician in charge of that treatment should complete a statutory form (CTO12) certifying that the patient has capacity to consent (or, if they are under 16, is competent to consent) and that they consent to treatment. The CQC no longer accept requests to arrange SOAD visits for consenting patients.

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6.5.3 CTO patients with capacity who refuse treatment

If a CTO patient refuses to consent a SOAD visit can be requested to consider certifying (on form CTO11) that:

Certain treatment proposed for the patient while in the community is appropriate, even though such certification provides no authority to give the treatment where a patient refuses consent; and/or

Certain treatment would be appropriate (and could be given without consent) if the patient was recalled to hospital.

The CQC continue to accept requests to issue these certificates but certificates given in these circumstances provide no legal authority to give treatment to patients in the community if they refuse to consent to it.

If the patient subsequently consents to treatment the patient’s approved clinician in-charge of that treatment must complete form CTO12.

6.5.4 Roles and duties are summarised in Appendix 4. 7 Assessment for a CTO 7.1 The decision as to whether a CTO is the right option for any patient is taken by

the responsible clinician and requires the agreement of an AMHP. The responsible clinician should consider the Guiding Principles within the MHA Code of Practice, in particular the least restrictive option and maximising independence principle. A CTO may be used only if it would not be possible to achieve the desired objectives for the patient’s care and treatment without it. In particular, the responsible clinician should consider whether the power to recall the patient is necessary and whether the patient can be treated in the community without that power. Consultation at an early stage with the patient and those involved in the patient’s care is important, including family and carers, as is the consideration of any advanced statements.

7.2 AMPH’s should work on the principle that in any situation where they believe

that the objectivity or independence of their decision is (or could be seen to be) undetermined, they should not become involved or should withdraw.

7.3 In assessing the patient’s suitability for a CTO, the responsible clinician must

be satisfied that the patient requires medical treatment for mental disorder for their own health or safety or for the protection of others, and that appropriate treatment is, or would be, available for the patient in the community. The key factor in the decision is whether the patient can safely be treated for mental disorder in the community only if the responsible clinician can exercise the power to recall the patient to hospital for treatment if that becomes necessary.

7.4 In making that decision to place the patient on CTO, the responsible clinician

must assess what risk there would be of the patient’s condition deteriorating after discharge, for example as a result of refusing or neglecting to receive treatment.

7.5 In assessing that risk the responsible clinician must take into consideration,

the patient’s history of mental disorder, previous experience of contact with

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services and engagement with treatment. A tendency to fail to follow a treatment plan or to discontinue medication in the community, and then relapsing may suggest a risk justifying use of a CTO rather than discharge into community care.

7.6 Other relevant factors will vary but are likely to include the patient’s current

mental state, the patient’s capacity to make decisions about their care and treatment and the patient’s insight and attitude to treatment, and the circumstances into which the patient would be discharged, and the willingness and ability of family and/or carers to provide support (especially where aspects of the care plan depend on them).

7.7 Taken together, all these factors should help the responsible clinician to

assess the risk of the patient’s condition deteriorating significantly after discharge, and inform the decision as to whether continued detention; a CTO or discharge would be the right option for the patient at that particular time. The responsible clinician should consider the likelihood that a CTO will benefit the patient and take account of the patient’s views about the use of a CTO.

7.8 A risk that the patient’s condition will deteriorate is a significant consideration,

but does not necessarily mean that the patient should be discharged onto a CTO rather than discharged. The responsible clinician must be satisfied that the risk of harm arising from the patient’s disorder is sufficiently serious to justify the power to recall the patient to hospital for treatment. CTOs should only be used when there is reasonable evidence to suggest that there will be benefits to the individual. Such evidence may include:

a clear link between non concordance with medication and relapse sufficient to have a significant impact on wellbeing requiring treatment in hospital

clear evidence that there is a positive response to medication without an undue burden of side effects

evidence that the CTO will promote recovery, and

evidence that recall may be necessary (rather than informal admission or reassessment under the Act)

7.9 Patients do not have to consent formally to a CTO. But in practice, patients

should be involved in decisions about the treatment to be provided in the community and how and where it is to be given, and be prepared to co-operate with the proposed treatment. A CTO is a contract between patients and the clinical teams working with them. A CTO will only work if the patient accepts the conditions. Where a patient explicitly consents to treatment in the community, they can receive that treatment in any local healthcare setting or at home. Treatment cannot be given in the community to a patient with capacity to consent, without getting their consent. The responsible clinician should inform the patient of the essential legal and factual grounds for the CTO and other information about the CTO both orally and in writing.

7.10 The responsible clinician’s decision to place a patient on a CTO should only

ever be made on clinical grounds where the patient meets the criteria in section 17A of the Act.

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8 Care Planning, Treatment and Support in the Community 8.1 Good care planning, in line with the Care Programme Approach (CPA) or it’s

equivalent will be essential to the success of a CTO. A care coordinator will be identified, this may or may not be the responsible clinician.

8.2 The care plan should be prepared in the light of consultation with the patient

and (subject to the normal considerations of patient confidentiality):

the nearest relative

any carers

anyone with authority under the Mental Capacity Act 2005 (MCA) to act on the patient’s behalf

the multi-disciplinary team involved in the patient’s care; and

the patient’s GP (if there is one). It is important that the patient’s GP should be aware that the patient is to go onto a CTO. A patient who does not have a GP should be encouraged and helped to register with a practice

8.3 If a different responsible clinician is to take over responsibility for the patient, it will be essential to liaise with that clinician, and the community team, at an early stage.

8.4 Where needed, arrangements should be made for a second opinion appointed doctor (SOAD) to provide the Part 4A certificate to enable treatment to be given as detailed in section 6.5 above.

8.5 The care plan should set out the practicalities of how the patient will receive treatment, care and support from day to day, and should not place undue reliance on carers or members of the patient’s family. 8.6 Care planning should take particular account of the patient’s age.

Where the patient is under the age of 18 the responsible clinician and the care co-ordinator should bear in mind that the most age-appropriate treatment should be that provided by a child and adolescent mental health service (CAMHS). It may also be necessary to involve the patient’s parent, or whoever will be responsible for looking after the patient, to ensure that they will be ready and able to provide the assistance and support which the patient may need

Similarly, specialist services for older people may have a role in the delivery of services for older patients. Particular care should be taken to ensure that the concepts of participation and proportionality are applied to older patients

Professionals with specialist expertise should also be involved in care planning for people with autistic spectrum disorders or learning disabilities

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8.7 A copy of the care plan to be provided in the community should be attached to the CTO 8.8 Patients on a CTO are entitled to after-care services under section 117 of the

Act. The after-care arrangements should be drawn up as part of the normal care planning arrangements. The clinical commissioning group and local authority must continue to provide after-care services under section 117 for as long as the patient remains on a CTO, but this does not mean that the patient’s need for after-care will necessarily cease as soon as they are no longer on a CTO.

8.9 The care plan should be reviewed regularly, as the services required may vary should the patient’s needs change. 8.10 Independent mental health advocacy services (IMHA’s) provide an additional

safeguard for patients who are subject to a CTO. IMHAs are specialist advocates who are trained specifically to work within the framework of the MHA to meet the needs of patients. The hospital managers must provide CTO patients relevant information both orally and in writing to ensure that patients understand what help is available to them from IMHA services and how they can obtain that help.

8.11 If the patient so wishes, help should be given to access independent advocacy or other support where this is available. Where the person does not have capacity to make decisions about IMHA services the clinical team should make a referral unless there are express reasons for not doing so.

8.12 A CTO does not give anyone the right to treat the patient without their consent

to the treatment, if they have capacity to consent to or refuse that treatment. Restrictive interventions that give rise to deprivations of liberty go beyond what can be authorised by the conditions of the patient’s CTO. If there are indications that the use of any such restrictive interventions may become necessary, this should prompt consideration as to whether the community patient should be recalled to hospital.

8.13 Alternatively where the patient lacks capacity to consent there should be

consideration as to whether a deprivation of liberty authorisation or deprivation of liberty order can be sought under the MCA.

9 Making the Community Treatment Order

9.1 If the responsible clinician and AMHP agree that the patient should be discharged onto a CTO, they should complete the relevant statutory form (CTO1) and send it to the appropriate Mental Health Act Office (Shown in Appendix 1). The responsible clinician must specify on the form the date that the CTO is to be made. This date is the authority for the CTO to begin, and may be a short while after the date on which the form is signed, to allow time for arrangements to be put in place for the patient’s discharge.

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10 Conditions to be attached to the Community Treatment Order

10.1 The CTO must include the conditions with which the patient is required to comply. There are two conditions which must be included in all cases. Patients are required to make themselves available for medical examination:

when needed for consideration of extension of the CTO; and

if necessary, to allow a SOAD to provide a Part 4A certificate of appropriateness of the treatment

10.2 Responsible clinicians may also, with the AMHP’s agreement and following

discussions with the patient, set other conditions which they think are necessary or appropriate to:

ensure that the patient receives medical treatment for mental disorder

prevent a risk of harm to the patient’s health or safety as a result of mental disorder, and

protect other people from a similar risk of harm 10.3 Conditions may be set for any or all of these purposes, but not for any other reason. The AMHP’s agreement to the proposed conditions must be obtained before the CTO can be made. 10.4 In considering what conditions might be necessary or appropriate, the

responsible clinician should always keep in view the patient’s diverse needs and circumstances. The patient, and (subject to the normal considerations of patient confidentiality) any others with an interest such as a parent (and any others with parental responsibility) or carer, should be consulted. The MHA Guiding Principals detailed in the Code of Practice should always be considered.

10.5 The conditions must not deprive the patient of their liberty and should:

be kept to a minimum number consistent with achieving their purpose

restrict the patient’s liberty as little as possible while being consistent with their care plan and recovery goal

have a clear rationale, linked to one or more of the purposes in paragraph 10.2 above; and

be clearly and precisely expressed, so that the patient can readily understand what is expected.

10.6 The nature of the conditions will depend on the patient’s individual circumstances. Subject to paragraph 10.2 above, they might cover matters such as where and when the patient is to receive treatment in the community; where the patient is to live; and avoidance of known risk factors or high-risk situations relevant to the patient’s mental disorder.

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10.7 The reasons for any conditions should be explained to the patient and others,

as appropriate, (e.g. the patient’s independent mental health advocate (IMHA), family and carers and, in the case of a child or young person, the person(s) with parental responsibility, see chapters 4, 5, 6 and 19 of Mental Health Act 1983: Code of Practice (2015) on children and young people) and recorded in the patient’s notes. It will be important, if the CTO is to be successful, that the patient agrees to keep to the conditions, or to try to do so, and that patients have access to the help they need to be able to comply. It is helpful if families can have access to support so they can help the patient to comply. The patient should have a discharge CPA meeting and a copy of the care plan before they are discharged from hospital onto the CTO

10.8 Conditions that amount to a deprivation of the patient’s liberty can only be

applied to a CTO for a capacitated patient with the consent of the patient. Where the patient lacks capacity to consent, authority for any deprivation of liberty must be obtained from the Supervisory Body or the Court of Protection.

11 Capacity

11.1 ‘Capacity’ in adults (aged 16 or over) should be decided in accordance with s2 of the MCA and all the principles of the MCA. All practitioners working directly with patients on a CTO should be familiar with the provisions of the MCA. 11.2 Where a child under 16 is judged to lack competence and lives with his or her parents, the practitioner treating the child should consult with the parents about the treatment. 11.3 A donee or deputy appointed under the MCA who has the necessary authority, or the Court of Protection, may consent to treatment on behalf of adult CTO patients who lack capacity. 11.4 Otherwise, apart from emergencies, an adult or child (under 16) who lacks

capacity or ‘competence’ to consent may only be treated under a CTO in the community if:

the treatment is delivered by an approved clinician or someone working under his/her direction

the patient, if over the age of 18 years, has not made a valid and applicable advance decision refusing the treatment

giving the treatment would not go against the decision of someone else with the authority to make treatment decisions on the patient’s behalf under the MCA

the patient does not object to the treatment, or if the patient does object, force is not needed to give the treatment

11.5 Force cannot be used to give a treatment if the patient objects to it, except in an emergency (see below).

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12 CTO Patients - Capacity, Competence and Consent 12.1 ‘Treatment for mental disorder in the community’ means that the CTO patient

may be treated at home, in another community-based setting or even in hospital if they have agreed to go and have not been recalled there.

12.2 Medical treatment for mental disorder may not be given (by anyone, in any

circumstances) to CTO patients who have not been recalled to hospital, unless the requirements of Part 4A of the Act are met. (The only exception is treatment given in accordance with section 57).

12.3 The requirements of Part 4A are of two types – authority and certification:

In all cases, the person giving the treatment must have the authority to do so

In most cases, if the treatment is a section 58 or 58A type treatment the certificate requirement must also be met - see section 6.5 above in relation to when a SOAD is required and when a RC can issue a certificate

12.4 Whether or not the certificate requirement also applies, there must always be

authority to give the treatment. 12.5 If the patient has the capacity to consent to the treatment in question, the patient’s own consent provides the authority for giving it. 12.6 Patients aged 16 or over have the capacity to consent unless they lack the

capacity to make the decision, as defined in the Mental Capacity Act 2005 (MCA).

12.7 Unless the person giving the treatment reasonably believes that the patient

lacks the capacity to consent, they cannot treat the patient unless the patient consents. If the patient does not consent, the treatment cannot be given unless the patient is recalled to hospital; or

12.8 If the person giving the treatment reasonably believes that the patient lacks

the capacity to consent, then treatment can be given but only if the strict criteria are met. Among other things, this means that, except in an emergency, physical force cannot be used in order to give the treatment against the patient’s objections (unless the patient’s attorney or deputy, or the Court of Protection has consented to it on their behalf).

12.9 Where patients have an attorney or deputy who can consent to the treatment

on their behalf, that person’s lawful consent provides authority to give the treatment. Conversely, except in emergencies, treatment cannot be given if it goes against a lawful decision of such an attorney or deputy.

12.10 Similarly, treatment can be given if it is authorised by the Court of Protection

and, except in emergencies, it cannot be given if it goes against a decision of the court; and, except in emergencies, treatment cannot be given contrary to a valid and applicable advance decision by the patient to refuse the treatment.

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12.11 As in Part 4, treatment is immediately necessary if it is:

immediately necessary to save the patient’s life; or

a treatment which is not irreversible, but which is immediately necessary to prevent a serious deterioration of the patient’s condition, or (unless it is a section 58A treatment)

a treatment which is not irreversible or hazardous, but which is immediately necessary to alleviate serious suffering by the patient; or

a treatment which is not irreversible or hazardous, but which is immediately necessary to prevent the patient from behaving violently or being a danger to himself or to others, and represents the minimum interference necessary to do so

12.12 Advance Decisions to Refuse Treatment:

Patients may have made an Advance Decision or statement of wishes about treatment to which practitioners need to have regard. Patients who lack capacity cannot be given treatment in the community which goes against a valid and applicable advance decision, unless it is an emergency (as defined above). To be given the treatment, they would have to be recalled to hospital.

12.13 Emergency Treatment under section 64G (only applicable to CTO

patients) 12.14 It is an emergency only if the treatment is immediately necessary to:

save the patient’s life

prevent a serious deterioration of the patient’s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed

alleviate serious suffering by the patient and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard; or

prevent the patient behaving violently or being a danger to themselves or others, and the treatment represents the minimum interference necessary for that purpose, does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard.

13 CTO Patients - Charges for Medication 13.1 The National Health Service (Charges for Drugs and Appliances) Amendment

Regulations 2008 provide that CTO patients must not be charged for medication they need for mental disorder (as defined in the Mental Health Act), provided that the medication is supplied via direct supply by the CCG or Trust or by a health professional through a Patient Group Direction. If the

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patient is prescribed medication through the community pharmacy route, by means of a prescription on form FP10, the exemption will not apply. Any CTO patient entitled to exemption from charging on other grounds will of course remain entitled on that basis.

13.2 Arrangements should be made at local level to ensure that CTO patients can

receive their medication via the routes described above, so that charges do not apply. It is expected that this will in most cases be consistent with systems already in place to deliver medication to patients on Section 17 discharge from hospital under the Mental Health Act.

14 Information for CTO Patients and Others 14.1 As soon as the decision is made to discharge a patient onto a CTO, the

responsible clinician should inform the patient and others consulted of the decision, the conditions to be applied to the CTO, the services which will be available for the patient in the community, their rights, including the continuing right to an IMHA and information around CTO. Will also be explained and written in information given at this time.

14.2 There is a duty on hospital managers to take steps to ensure that patients

understand what a CTO means for them and their rights to apply for discharge. This includes giving patients information both orally and in writing and must be done as soon as practicable after the patient goes onto the CTO. The CTO patient information leaflet is available on the patient information centre website (click link below), as well as from Mental Health Act Offices.

Section 17A – Community treatment order for Part 2 patients

Section 17A – Community treatment order for Part 3 patients

15 Monitoring CTO Patients 15.1 It is important to maintain close contact with a patient on a CTO and to monitor

closely their mental health and wellbeing after they leave hospital. The type and scope of the arrangements will vary depending on the patient’s needs and individual circumstances and the way in which local services are organised. All those involved will need to agree to the arrangements. Respective responsibilities should be clearly set out in the patient’s care plan. The care coordinator will normally be responsible for co-ordinating the care plan, working with the responsible clinician (if they are different people), the team responsible for the patient’s care, family, carers and any others with an interest.

15.2 Appropriate action will need to be taken if the patient becomes unwell,

engages in high-risk behaviour as a result of mental disorder or withdraws consent to treatment (or begins to object to it). The responsible clinician should consider, with the patient (and others where appropriate), the reasons for this and what the next steps should be. If the patient refuses crucial treatment, an urgent review of the situation will be needed, and recalling the patient to hospital will be an option if the risk justifies it. If suitable alternative treatment is available which would allow the CTO to continue safely and which

https://www.ntw.nhs.uk/resource-library/section-17a-cto/

https://www.ntw.nhs.uk/resource-library/section-17a-community-treatment-order-part-3-patients/

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the patient would accept, the responsible clinician should consider such treatment if this can be offered. If so, the treatment plan, and if necessary the conditions of the CTO, should be varied accordingly (note that a revised Part 4A certificate may be required).

15.3 If the patient is not complying with any condition of the CTO the reasons for this will need to be properly investigated. Recall to hospital may need to be considered if it is no longer safe and appropriate for the patient to remain in the community. The conditions may need to be reviewed – for example, if the patient’s health has improved a particular condition may no longer be relevant or necessary. The responsible clinician may vary conditions as appropriate. Changes may also be needed to the patient’s care or treatment plan. 15.4 Alternatively, after review it may be concluded that the CTO is failing to

promote recovery and then consideration needs to be given to discharging the CTO and taking a different approach.

16 Varying and Suspending Conditions 16.1 The responsible clinician has the power to vary the conditions of the patient’s

CTO, or to suspend any of them. However when changes apply to recently agreed conditions, it has been agreed between CNTW and our local authorities that the responsible clinician will discuss any variation or suspension with the AMHP. The responsible clinician should record the reasons for varying conditions in the patient’s notes. A copy should also be placed with the care plan or its equivalent. Where a condition variance has funding implications there should be prior discussion/agreement with the relevant local authority or senior trust management and the section 117 plan amended accordingly. See appendix 5

16.2 Suspension of one or more of the conditions may be appropriate to allow for a

temporary change in circumstances, for example, the patient’s temporary absence or a change in treatment regime. Suspending conditions may be a useful way to test whether they are still needed and could be part of a planned reduction of conditions leading to the patient’s possible discharge from the CTO. The responsible clinician should record any decision to suspend conditions in the patient’s notes, with reasons.

16.3 A variation of the conditions might be appropriate where the patient’s treatment needs or living circumstances have changed. Any condition no longer required should be removed. 16.4 It will be important to discuss any proposed changes to the conditions with the

patient and to ensure that the patient, and anyone else affected by the changes such as their family and carers (where appropriate, and subject to the patient’s right to confidentiality), knows that they are being considered, and why. As when the conditions were first set, the patient’s views about the changes should be sought and considered before a change is made; and the responsible clinician should discuss with the patient whether they will be able to keep to any new or varied conditions. The patient and their nearest relative (where appropriate) should be informed of any changes to the conditions. Any help the patient needs to comply with them should be made available. Families and/or carers should be supported to help the patient

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16.5 Any variation in the conditions must be recorded on the relevant statutory form (CTO2) and send it to the appropriate Mental Health Act Office (Shown in Appendix 1). 17 Responding to Concerns Raised by the Patient’s Carer or Relatives 17.1 Particular and prompt attention should be paid to carers and relatives when

they raise a concern that the patient is not complying with the conditions or that the patient’s mental health appears to be deteriorating. The team responsible for the patient, needs to give due weight to those concerns and any requests made by the carers in deciding what action to take. Carers and relatives are typically in much more frequent contact with the patient than professionals, even under well-run care plans. The carers have a formal right to prompt a care review of how SCT is working for that patient and whether the criteria for recall to hospital might be met. Their concerns may prompt a review of how a CTO is working for that patient and whether the criteria for recall to hospital might be met or whether more support in the community should be put in place. The managers of responsible hospitals should ensure that local protocols are in place to cover how concerns raised should be addressed and taken forward.

18 Recall to Hospital 18.1 The recall power is intended to provide a means to respond to evidence of

relapse or high-risk behaviour relating to mental disorder before the situation becomes critical and leads to the patient or other people being harmed. The need for recall might arise as a result of relapse, or through a change in the patient’s circumstances giving rise to increased risk. The responsible clinician does not have to interview or examine the patient in person before deciding to recall them.Recall provisions help provide a safety net and a breathing space, when relapse seems imminent, in which the patient may quickly receive treatment and the situation be stabilised. (See Appendix 2 – Recall Flowchart)

18.2 The responsible clinician may recall a patient on a CTO to hospital for

treatment if:

the patient needs to receive treatment for mental disorder in hospital (either as an in-patient or as an out-patient), and

there would be a risk of harm to the health or safety of the patient or to other people if the patient were not recalled.

18.3 A patient may also be recalled to hospital if they break either of the two

mandatory conditions as detailed in 10.1 above. The patient must always be given the opportunity to comply with the condition before recall is considered unless there is a risk of harm to their health or safety or to others. Before exercising the recall power for this reason, the responsible clinician should consider whether the patient has a valid reason for failing to comply, and should take any further action accordingly.

18.4 The responsible clinician must be satisfied that the criteria are met before

using the recall power. Any action should be proportionate to the level of risk.

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For some patients, the risk arising from a failure to comply with treatment could indicate an immediate need for recall. In other cases, negotiation with the patient and with the nearest relative and (unless the patient objects or it is not reasonably practicable) carers and, in the case of children and young people, person(s) with parental responsibility, might resolve the problem and so avert the need for recall.

18.5 The responsible clinician should consider in each case whether recalling the

patient to hospital is justified in all the circumstances. For example, it might be sufficient to monitor a patient who has failed to comply with a condition to attend for treatment, before deciding whether the lack of treatment means that recall is necessary. A patient might also agree to admission to hospital on a voluntary basis. Failure to comply with a condition (apart from mandatory conditions in 10.1 above) does not in itself trigger recall. Only if the breach of a condition results in an increased risk of harm to the patient or to anyone else will recall be justified.

18.6 However, it may be necessary to recall a patient whose condition is deteriorating despite compliance with treatment, if the risk cannot be managed otherwise. 18.7 Recall to hospital for treatment should not become a regular or normal event

for any patient on CTO. If recall is being used frequently, the responsible clinician should review the patient’s treatment plan to consider whether it could be made more acceptable to the patient, or whether, in the individual circumstances of the case, CTO continues to be appropriate.

19 Procedure for Recall to Hospital 19.1 The responsible clinician has responsibility for coordinating the recall process,

unless it has been agreed that someone else will do this. It will be important to ensure that the practical impact of recalling the patient on the patient’s domestic circumstances is considered and managed. For example, wherever possible, the responsible clinician should give the patient (or arrange for the patient to be given), oral reasons for the recall before it happens, taking into account any risks arising from giving notice of the recall. The family and carers involved in providing support to the patient should also be informed.

19.2 If the patient is admitted and if it is necessary, the RC and AMHP should agree who will take responsibility for ‘closing’ the patient’s residence – that is, for doing everything which a resident would need to do before leaving home for an indefinite period, as the recall could be for up to 72 hours or become an in-patient episode. It should be the aim to plan for this eventuality within the care-plan to make it easier 19.3 In every case the responsible clinician must complete a written notice of recall

to hospital (CTO3), which is effective only when served on the patient. A copy of this should be kept in the notes so as to be available to the on call team who may be required to follow-up the recall process. It is important that, wherever possible, the notice should be handed to the patient personally. This should not be done by a lone worker and consideration should be given to using other agencies to assist / accompany staff i.e. other care staff, Police.

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Otherwise, the notice is served by delivery to the patient’s usual or last known address.

19.4 Once the recall notice has been served, the patient can, if necessary, be treated as absent without leave, and taken and conveyed to hospital (and a patient who leaves the hospital without permission can be returned there). The time at which the notice is deemed to be served will vary according to the method of delivery. 19.5 It will not usually be appropriate to post a notice of recall to the patient. This may, however, be an option if the patient has failed to attend for medical examination as required by the conditions of the CTO, despite having been requested to do so, when the need for the examination is not urgent. First class post should be used. The notice is deemed to be served on the second working day after posting, and it will be important to allow sufficient time for the patient to receive the notice before any action is taken to ensure compliance. 19.6 Where the need for recall is urgent, as will usually be the case, it will be important that there is certainty as to the timing of delivery of the notice. A notice handed to the patient is effective immediately. However, it may not be possible to achieve this if the patient’s whereabouts are unknown; or if the patient is unavailable or simply refuses to accept the notice. In that event the notice should be delivered by hand to the patient’s usual or last known address. The notice is then deemed to be served (even though it may not actually be received by the patient) on the day after it is delivered – that is, the day (which does not have to be a working day) beginning immediately after midnight following delivery. 19.7 If the patient’s whereabouts are known but access to the patient cannot be

obtained, it may be necessary to consider whether a warrant issued under section 135(2) is needed. Section 135 - Removal of a Patient from a Private/ Locked Residence to a Place of Safety should be followed in this case.

19.8 The patient should be conveyed to hospital in the least restrictive manner possible. If appropriate, the patient may be accompanied by a family member, carer or friend. 19.9 The responsible clinician should ensure that the hospital to which the patient is

recalled is ready to receive the patient and to provide appropriate treatment. While recall must be to a hospital, the required treatment may then be given on an out-patient basis, if appropriate.

19.10 The hospital need not be the patient’s responsible hospital (that is, the hospital

where the patient was detained immediately before going onto the CTO) or under the same management as that hospital. A copy of the notice of recall, which provides the authority to detain the patient, should be sent to the managers of the hospital to which the patient is being recalled. (See appendix 1 for some guidance.)

19.11 When the patient arrives at hospital after recall, the clinical team will need to

assess the patient’s condition, provide the necessary treatment and determine the next steps. The patient may be well enough to return to the community

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once treatment has been given, or may need a longer period of assessment or treatment in hospital. The patient may be detained in hospital for a maximum of 72 hours after recall to allow the responsible clinician to determine what should happen next. During this period the patient remains a CTO patient, even if they remain in hospital for one or more nights. The responsible clinician may end the recall period at any time within the 72-hour period. Once 72 hours from the time of admission have elapsed, the patient must be allowed to leave if the responsible clinician has not revoked the CTO. On leaving hospital the patient will remain on the CTO as before. Section 5(2) cannot be used to extend the 72-hour period.

19.12 In considering the options, the responsible clinician and the clinical team will

need to consider it was necessary to exercise the recall power and whether CTO remains the right option for that patient. They will also need to consider, with the patient, the nearest relative (subject to the normal considerations about involving nearest relatives), and any carers, what changes might be needed to help to prevent the circumstances that led to recall from recurring. It may be that a variation in the conditions is required, or a change in the care plan (or both).

19.13 Where there is an urgent need to recall the patient and the usual RC is not

available this role may be occupied on a temporary basis by the duty AC. 20 Detention of CTO Patients Informally in Hospital 20.1 Where a CTO patient is admitted to hospital as an informal patient,

subsequently decides to leave and the nursing staff are concerned that there would be a risk of harm to the health or safety of the patient, or to other people if he/she were allowed to leave; then consideration needs to be carefully given to the authority to detain the patient as the provisions for an informal CTO patient differ from those of an informal patient.

20.2 The patient should be recalled using recall notice CTO 3. As stated in Section

17E(4) “Nothing in this section prevents a patient being recalled to a hospital even though he is already in the hospital at the time when the power of recall is exercised, references to recalling him shall be construed accordingly.”

20.3 The holding powers contained in sections 5(4) or 5(2) can not be used for a

CTO patient informally in hospital (Section 5(6)). 20.4 Where the patient’s capacity has been assessed and a reasonable belief

formed that they lack the mental capacity to consent to their care and treatment in hospital and the care and treatment would amount to a deprivation of the patient’s liberty, then if their treatment is either fully or in part for mental disorder then they are not eligible to have their detention authorised under the Deprivation of Liberty Safeguards. As a result detention can only be authorised by issuing the patient with a notice of recall.

20.5 Where the patient has mental capacity then the power to prevent the patient

from leaving can found in common law which provides further powers to restrain and/or detain both detained and informal patients. These include; R. (on the application of Munjaz) v Mersey Care NHS Trust; R. (on the application of the Laporte) v Chief Constable of Gloucestershire Constabulary

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[2006]; Black v Fosey, 1987. The combination of these powers provide sufficient authority for a mental health professional or members of the public to act swiftly to prevent a mentally disordered person from causing harm to himself; to another person or property as long as the force used is both necessary and proportionate to the harm threatened. It must be emphasised that these powers only allow for an informal patient to be detained for a limited period and will fall away when the crisis has subsided; they cannot be used as an alternative to the procedures set out in the Act.

20.6 Clear records should be made in the person’s health record detailing what

power was used to detain the person. 20.7 In summary - If the (CTO) informal patient wants to leave then the usual

professional assessment needs to be carried out. If the patient or others are at risk and the patient needs to stay in hospital they should be recalled. If the RC is not available and the patient won’t wait neither 5(4) nor 5(2) can be used, the patient can be prevented from leaving using Mental Capacity Act 2005 (for incapacitated patients) or common law.

21 Revoking the CTO 21.1 If the patient requires in-patient treatment for longer than 72 hours after arrival

at the hospital, the responsible clinician should consider revoking the CTO. The effect of revoking the CTO is that the patient will again be detained under the powers of the MHA. An AMHP should be contacted as soon as the decision has been made to revoke the CTO to avoid any delays in process. The RC and the AMHP should reassess the patient before revoking their CTO. They must do so if necessary to satisfy themselves that the patient again needs to be admitted to hospital for medical treatment under the Act.

21.2 The CTO may be revoked if:

the responsible clinician considers that the patient again needs to be admitted to hospital for medical treatment under the MHA; and

an AMHP agrees with that assessment, and also believes that it is appropriate to revoke the CTO

21.3 In making the decision as to whether it is appropriate to revoke a CTO, the AMHP should consider the wider social context for the patient, in the same way as when making decisions about applications for admissions under the MHA. 21.4 As before, the AMHP carrying out this role may (but need not) be already

involved in the patient’s care and treatment, or can be an AMHP acting on behalf of any willing local authority. If no other local authority is willing, responsibility for ensuring that an AMHP considers the case should lie with the local authority which has been responsible for the patient’s after-care.

21.5 If the AMHP does not agree that the CTO should be revoked, then the patient

cannot be detained in hospital after the end of the maximum recall period of 72 hours. The patient will therefore remain on the CTO. A record of the AMHP’s decision and the full reasons for it should be kept in the patient’s

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notes. It would not be appropriate for the responsible clinician to approach another AMHP for an alternative view.

21.6 If the responsible clinician and the AMHP agree that the CTO should be

revoked, they must complete the relevant statutory form (CTO5) for the revocation to take legal effect, and sent to the appropriate Mental Health Act Office (Shown in Appendix 1). The responsible clinician or the AMHP must give the patient (or arrange for the patient to be given) oral reasons for revoking the CTO before it is revoked. The patient is then detained again under the powers of the Act exactly as before going onto a CTO, except that a new detention period of six months begins for the purposes of review and applications to the Tribunal. Written reasons for the revocation should also be given to the patient and (where appropriate) their nearest relative. Hospital managers should notify the patient and (where appropriate) their nearest relative when they have referred the patient’s case to the Tribunal.

22 Deprivation of liberty while on a CTO, leave or subject to guardianship 22.1 Patients who are on a CTO or on leave, and who lack capacity to decide

whether or not to consent to the arrangements required for their care or treatment, may occasionally need to be detained for further care or treatment for their mental disorder in circumstances in which recall to hospital for this purpose is not considered necessary. They might also need to be admitted to a care home or hospital because of physical health problems.

22.2 If they will be detained in a care home, a deprivation of liberty authorisation

(DoL authorisation) or Court of Protection order under the Mental Capacity Act 2005 (MCA) must be obtained. Deprivation of liberty under the MCA can exist alongside a CTO or leave of absence, provided that there is no conflict with the conditions of the CTO or leave set by the patient’s responsible clinician.

22.3 If they will be detained in a hospital for further treatment for mental disorder

(whether or not they will also receive treatment for physical health problems), they should be recalled to be treated under the Act. The MCA cannot be used to authorise the deprivation of their liberty.

22.4 For guidance on the use of a DoL authorisation or Court of Protection order in

relation to a patient who is subject to guardianship, refer to chapter 30 of the MHA Code of Practice, on guardianship.

23 Review of CTO 23.1 In addition to the statutory requirements in the MHA for review of a CTO, it is

good practice to review the patient’s progress on the CTO as part of all reviews of the CPA care plan or its equivalent.

23.2 Reviews should cover whether a CTO is meeting the patient’s treatment

needs and, if not, what action is necessary to address this. A patient who no longer satisfies all the criteria for a CTO must be discharged without delay.

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24 Extending CTO 24.1 Only responsible clinicians may extend the period of a patient’s CTO. To do

so, responsible clinicians must examine the patient during the two months leading up to the day on which the patient’s CTO is due to expire and decide, whether the criteria for extending the CTO under section 20A of the Act are met and whether discharge is appropriate. They must also consult one or more other people who have been professionally concerned with the patient’s medical treatment. The responsible clinician must make this decision on the basis of clinical factors only and should fully document the reasons for this decision in the report to the hospital managers.

24.2 Where responsible clinicians are satisfied that the criteria for extending the patient’s CTO are met, they must submit a report (CTO7) to that effect to the appropriate Mental Health Act Office (Shown in Appendix 1). Before responsible clinicians can submit that report, they must obtain the written agreement of an AMHP. The role of the AMHP is to consider whether or not the criteria for extending CTO are met and, if so, whether an extension is appropriate. The AMHP should be contacted in good time to avoid delays in the process and allow adequate time to consider the aspects relevant the CTO and the patient.

25. Discharge from CTO 25.1 It is very important that patients should not remain subject to a CTO once it is

no longer necessary, i.e. if the answer to any of the following questions is ‘no’.

Is the patient still suffering from mental disorder?

If so, is the disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment?

If so, is it necessary in the interests of the patient’s health or safety or for the protection of other persons that the patient should receive such treatment?

Is it still necessary for the responsible clinician to be able to exercise the power to recall the patient to hospital, if that is needed? (For example, if a patient has been on a CTO for an extended period without the need to exercise the power to recall, it may not be appropriate to continue on a CTO)

Is appropriate medical treatment available for the patient?

25.2 CTO patients may be discharged in the same way as detained patients, by the Tribunal, the hospital managers, or (for Part 2 patients) the nearest relative. The responsible clinician may also discharge a CTO patient at any time and must do so if the patient no longer meets the criteria for a CTO. A patient’s CTO should not simply be allowed to lapse. Discharge should be notified using local form: Form RC Notification of Discharge from Detention/CTO H23L on RiO.

25.3 The reasons for discharge should be explained to the patient, and any concerns on the part of the patient, the nearest relative or any carer should be

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considered and dealt with as far as possible. On discharge from a CTO, the team should ensure that any after-care services the patient continues to need under section 117 of the Act will be available. 25.4 If guardianship is considered the better option for a patient on CTO, an application may be made in the usual way. 26. Identification of Stakeholders 26.1 This is an existing policy reviewed with no significant changes that has

previously been circulated for Trust wide consultation to the following:

North Locality Care Group

Central Locality Care Group

South Locality Care Group

Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

27 Equality and Diversity Assessment 27.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 28 Training 28.1 Training will be part of a rolling programme and incorporated into the existing

MHA training programme. This will require that staff generally will be made aware of CTO and its implications for practice at the appropriate level for their role. Day to day advice and guidance is also available from Mental Health Legislation Office.

28.2 Levels of Training

Awareness of CTO– This incorporated into the overall rolling training sessions delivered for the MHA and is targeted towards all mental health / learning disability care staff.

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Understanding CTO– A specific training session aimed at those staff who use and support CTO i.e. AC / RC, AMHP, CPN and other frontline community and inpatient staff.

28.3 Training will be required initially and will need updating inline with legislation /

practice changes and in response to organisational issues. Due the nature of the new practices CTO introduces and developing case law regular updates of 3 years are required for this training - See Appendix B – Training Checklist and Needs Analysis

29 Implementation 29.1 The continued implementation of this policy will be monitored by the Medical

Directorate. If at any stage there is indication that there are any concerns regarding the operation or implementation of this policy the Mental Health Legislation Committee will consider the development of an action plan.

30 Monitoring and Compliance 30.1 This policy will be audited using the Statements in Appendix C, via the Mental

Health Legislation Steering Group which reports to Mental Health Legislation Committee.

31 Standards / Key Performance Indicators 31.1 The use of CTO will be monitored using activity data and reference to any

incidents via the Mental Health Legislation Steering Group. 32 Fair Blame

32.1 The Trust is committed to developing an open learning culture. It has

endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

33 Fraud, Bribery and Corruption 33.1 In accordance with the Trust’s policy CNTW(O)23 – Fraud, Bribery and

Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

34 Associated Documentation

CNTW(C)03 Leave Policy

CNTW(C)05 Consent Policy

CNTW(C)20 Care Coordination Policy

CNTW(C)34 Mental Capacity Act Policy o MCA-PGN-02 – Advance Decision to Refuse Treatment and

Advance Statements

CNTW(C)55 Mental Health Act Policy PGNs:-

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o MHA-PGN-02 - Section 5(2) and 5(4) Holding Powers o MHA-PGN-03 - Renewal of detention under the MHA 1983 o MHA-PGN-05 - Tribunal Reports o MHA-PGN-10 - Tribunal Discharge Guidance o MHA-PGN-12 - Section 135 - Removal of a Patient from a Private/

Locked Residence to a Place of Safety

35 References

Mental Health Act 1983 Code of Practice TSO, 2015.

Reference Guide to the Mental Health Act 1983 TSO, 2015

Mental Health Act Manual, Richard Jones, 2015

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Chris Rowland February 2019 February 2022 Mental Health Legislation

Policy to be analysed Is this policy new or existing?

CNTW(C)47– V03 Community Treatment Order Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

A Community Treatment Order (CTO) allows suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery CTO provides a framework for the management of patient care in the community and gives the responsible clinician the power to recall the patient to hospital for treatment if necessary. The Mental Health Act 1983 as amended by the Mental Health Act 2007 (MHA) sets out the parameters of CTO. Cumbria Northumberland Tyne & Wear NHS Trust (CNTW) will endeavour to work within these parameters while providing the highest quality of care to meet the needs of our service users. This policy should be read in conjunction with the MHA Code of Practice 2015, the MHA and the Mental Capacity Act 2005 and is designed to meet the requirements of this and associated legislation

Who will be affected? e.g. staff, service users, carers, wider public etc

Service users – the policy is deemed to have a neutral impact, however the pointers below are worthy of consideration in the implementation of the policy. Overriding issue to ensure independence of advocacy.

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability There is a need to ensure independent advocacy for people with a learning disability on a CTO. We will also need to ensure that reasonable adjustments required in the management of the CTO are provided – for example BSL interpretation for a Deaf service user on a CTO so that they can interact effectively with the RC etc.

Sex

Race

Age Children - There will need to be sensitive management of cases where the child’s wishes override those of -parent/carers consent to treatment, balancing children’s and parental rights

Young People - There will need to be sensitive management of cases where the child’s wishes override those of -parent/carers consent to treatment, balancing children’s and parental rights

Gender reassignment (including transgender)

Sexual orientation.

Religion or belief BME faith Groups who may already lack trust in mental health services may become even more fearful of working with services due to anxieties about the new Act.

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Marriage and Civil Partnership

Pregnancy and maternity

Carers

Other identified groups – Black and Minority Ethnic People (BME)

Need to ensure the provision of interpretation where required for the management of the interactions between RC etc and a service user on a CTO whose first language is not English. This will also apply for information provision about their rights to advocacy, especially if English not first language and/ or if they are minors, for example unescorted young asylum seekers.

RECOMMENDATIONS

Training in new Mental Health Act for Carers and Community Groups

Training on working with advocates and interpreters for Approved Mental Health Practitioners

Training on working with ethnic minorities and faith issues for Approved Mental Health Practitioners

Training for Approved Mental Health Practitioners to take account of equality issues in assessment process

Mental health services should work in partnerships more with BME groups

Arrangements in place to inform people of their rights, including access to advocacy, particularly for those for whom English is not first language or who are under 18

Carers assessments for those carers who have mental health problems themselves

Continued development of Chaplaincy services and other forms of spiritually-based support

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through Policy Review Process

How have you engaged stakeholders in testing the policy or programme proposals?

Through Policy Review Process

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Appropriate policy review author/team

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Full Impact Assessment (EIA) needs to be incorporated as part of the policy review process. A group will need to form to evaluate the impact of Community Treatment Orders and the overall impact of the new Mental Health Act. Inclusion and representation of key partners from advocacy, service users and carers groups, as well as multi-agency professionals is suggested.

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Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Neutral impact

Advance equality of opportunity Neutral impact

Promote good relations between groups Neutral impact

What is the overall impact?

Neutral impact

Addressing the impact on equalities Neutral impact

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? No

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Chris Rowlands Date: February 2019

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing Policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

Change in legislation has resulted in new application of the Mental Health Act 1983 with the introduction of Community Treatment Orders (CTO). Introduces new systems, processes and documentation. These systems or continuing to be embedded in the organisations.

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur

Yes by law the Trust needs to introduce and operationalise CTO into practice and continue this process by monitoring.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

Approved Clinicians, Responsible Clinicians, Professionally Qualified In-patient Staff, Community based Staff in Mental Health and Learning Disability. MHA Administration staff.

Is there a staff group that should be prioritised for this training / awareness?

1. Awareness of CTO 2. Understanding CTO

Training will is required initially and needs updating inline with legislation / practice changes and in response to organisational issues. Due the nature of the new practices CTO introduces and developing case law regular updates of 3 years are required for this training

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning

Facilitated sessions by competent staff; e-learning; workbooks

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Admin needs etc.

Mental Health Legislation Development Lead and Training and Development.

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Appendix B - continued Training Needs Analysis

Service Area Staff / Professional Groups

Level of Training Frequency of Training

1 All frontline Mental Health and Learning Disability Services

Qualified Nursing Unqualified Nursing Medical

Awareness of CTO What it is and when it’s used. This incorporated into the overall awareness sessions already being delivered for the MHA amendments and is targeted towards all mental health & learning disability staff.

Update 3 years

2 All front line Mental Health and Learning Disability Services

AC / RC, AMHP, CPN and other frontline community and inpatient staff expecting to be using and supporting CTO

Understanding CTO What it is, how it’s used, policy, systems and processes. A specific training session aimed at those staff who will be expected to be using and supporting CTO.

Update 3 years

Should any advice be required, please contact: - 0191 245 6777 (internal 56777- Option 1)

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Appendix C

Monitoring Tool Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)47 – Community Treatment Order - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where Results & Any Associate Action Plan Will Be Reported To & Monitored; (this will usually be via the relevant Governance Group).

1. Patient’s rights are given at the point the CTO is made or extended.

Monitored via H3L forms on Rio

Mental Health Legislation Administrator on a monthly basis.

Mental Health Legislation Manager will report to the Mental Health Legislation Steering Group and to the Effective Sub Groups

2. Consent to treatment certifications are requested within legal timescales.

Monitored via process by Mental Health Legislation Administrator on a monthly basis.


3. When patient’s have their CTO conditions varied within the first month following making a CTO this will be identified.

Monitored on receipt of CTO variation Form by Mental Health Legislation Administrator on a monthly basis.


4. Staff attend training and training is updated in response to evaluation and operational use of the Mental Health Act and The Code of Practice

Training records, dashboards by agreed operational management structure on a monthly basis.

Agreed operational management structure to report to Effective Sub Groups and Q+P.

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Appendix 1

Mental Health Act Offices

Newcastle/Gateshead

Mental Health Legislation Office St Nicholas Hospital Jubilee Road Gosforth Newcastle upon Tyne NE3 3XT Tel. 0191 225 6745

St Georges Park

Mental Health Legislation Department St George’s Park Morpeth Northumberland NE61 2NU Tel. 01670 501 810

Sunderland - South Tyneside

Mental Health Legislation Office Hopewood Park, Waterworks Road Ryhope Sunderland SR2 0NB Tel. 0191 566 7058

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Appendix 2

CTO Recall Flowchart

2. The community team keeps in touch with the RC who reviews the case.

3. After review and discussion, the patient remains at home and the CTO remains unchanged, or the CTO is subject to variation (RC completes form CTO2)

5. The patient is informed about their recall to hospital in writing through the recall notice (Form CTO3) and then either stage 6 or 7 occurs

8. With the help of the ambulance service and/or police (if necessary), the patient is taken to hospital

6. The patient agrees to return to hospital with a member of the community team and Form CTO4 is completed by the Hospital Mangers on the patients return.

7. The patient refuses to return and the team decides they need assistance to convey him or her.

4. The RC decides that treatment is needed urgently and completes a recall notice (Form CTO3)

9. A copy of the notice of recall (Form CTO3) is given to the hospital managers, and Form CTO4 is completed

12. The patient is still too ill to return home within the 72 hours. The RC and the AMHP decide that the CTO should be revoked. The patient is re-admitted to hospital under section 3 of the Act, or the equivalent and a new renewal period begins. The hospital managers are supplied with a copy of Form CTO5 completed by the RC and the AMHP.

10. The patient is detained in hospital for treatment for up to 72 hours

11. Within 72 hours, if the patient’s condition stabilises and the patient is discharged, the CTO continues. If variations are made to the conditions, the RC completes form CTO2. The patient may agree to remain in hospital on a voluntary basis for further treatment

1. There are signs that the patient’s mental health is deteriorating. The carer may be worried or the patient may have broken one of the conditions, such as not turning up for treatment on some occasions.

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Appendix 3

Link for CTO Forms on Mental Health Act Developments Intranet Site

http://nww1.CNTW.nhs.uk/services/?id=1717&p=2780&sp=1

http://nww1.ntw.nhs.uk/services/?id=1717&p=2780&sp=1

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Appendix4

Roles and Responsibilities

WHO WHAT

Secretary of State for Health Refer to Tribunal

Hospital Managers Decide who provides information to patient and nearest relative about CTO.

Ensure patient understands what CTO means and its effects (orally and in writing).

Inform patient about the availability of Independent Mental Health advocates.

Ensure patient understands right to apply for discharge tribunal (orally and in writing).

Provide information to nearest relative regarding what CTO means and its effects.

Identify an authorised person(s) to receive nearest relative discharge notices.

Ensure protocols are in place to cover how concerns raised by relatives and carers are addressed and taken forward.

Inform nearest relatives of extensions to the CTO (in writing).

Advise nearest relatives of AWOL assessments.

Inform nearest relatives of discharge of CTO.

Give recall information to the patient (orally and in writing).

Advise patient re Part 4 (treatment without consent) rules.

Receive changed conditions notices.

Receive revocation notices.

Record the recall to detention time.

Monitor recalls (length of stay).

Send copy of revocation notice to originating hospital.

Ensure arrangements are in place for the transfer of Responsible Clinician.

Refer patients whose order has been revoked to the Tribunal.

Provide transfer information.

Identify an authorisation officer to authorise transfers.

Authorise an officer to transfer a patient.

Discharge a CTO.

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Nearest Relative Discharge of CTO (Part 2 to patients).

Make application to the Tribunal.

Authorise any doctor or Approved Clinician to examine the patient and inspect records.

Responsible Clinician Decide if CTO is the right option.

Set conditions of the CTO.

Inform patient and others consulted of conditions of the CTO.

Vary or suspend conditions of the CTO order.

Remove conditions of the CTO order.

Discuss changes to the conditions of the CTO order – with patient and relevant others others.

Recall patient to hospital.

Co-ordinate the recall process.

Complete recall documentation and send copy to original hospital if different.

Complete written notice of recall.

Ensure the hospital to which the patient is recalled is ready to receive the patient.

Manage the patient during the period of recall.

AWOL reporting.

Keep the patient’s circumstances under review.

Examine the patient prior to extending the CTO.

Bar Nearest Relative discharge notice.

Revoke the CTO.

Discharge the CTO.

Care Co-ordinator Must be identified.

Co-ordinate the care plan.

Tribunal Recommend CTO.

Discharge the CTO.

SOAD Provide Part 4A certificate

AMHP Consider the making of CTO order.

Consider additional conditions of the CTO order.

Consider the revocation of CTO.

Consider extending CTO.

Be consulted re AWOL patients.

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Independent Advocacy Provide support to patients

Consultees Nearest relative.

Carers.

Anyone with authority under MCA 2005.

MDT involved in the patient’s care.

Patient’s GP (should have one).

PCT Provision of S117 Services.

Local Authority Provision of S117 Services.

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Appendix 5

Process Flow Chart

RC varying ‘recently’ made CTO conditions

CTO made with conditions included

RC decides to vary conditions

Telephone discussion with AMPH

RC completes CTO2 forward to MHLO

(RC records on RIO)

RC complete CTO forward to MHLO

(RC records on RIO)

AMPH discusses concerns with RC

AMPH documents concerns & escalates

to AMPH Lead

AMPH Leads Notifies MHL office of

disagreement for monitoring purpose

Exception report to Medical Director / MHLC by MHL Manager

MHL office makes a record

Agree Disagree

Defining ‘recently’ as within 1 month (only in relation to when the CTO is made)

Rationale-link with certificate requirement Usually a change of RC so this might be the first time RC in community sees patient

Documents

Document Title Community Treatment Order Policy… · 6.1.5 Undertake a risk assessment. CNTW(C)47 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)47: Community