Aftercare following a Hospital Admission under the Mental Health (Bailiwick of Guernsey) Law 2010

The need to provide aftercare services begins when the young person leaves hospital and planning should start as soon as possible after they are admitted. The Committee along with key partner agencies should take reasonable steps to identify appropriate after-care services for young people in good time for their eventual discharge from hospital. This work should be undertaken using a structured team around the child approach and where suitable adopting the “Child’s Plan” as the multi-agency assessment tool to collate planning.

After-care should be planned in the following way:

After-care planning requires a thorough assessment of the young person's needs and wishes. It is likely to involve consideration of:

• Continuing mental healthcare;
• The psychological needs of the young person and of their family;
• Physical healthcare;
• Daytime activities or employment;
• Appropriate accommodation - if the aftercare plan includes the provision of accommodation, and the young person has committed one or more criminal offences, the circumstances of any victims of the offence(s) and of their families should be taken into account when deciding where the young person should live;
• Identified risks and safety issues;
• Any specific needs arising from, for example, co-existing physical disability, sensory impairment, learning disability or autistic spectrum disorder;
• Any specific needs arising from drug, alcohol or substance misuse;
• Any parenting or caring needs;
• Social, cultural or spiritual needs;
• Counselling and personal support;
• Assistance in welfare rights and managing finances;
• The involvement of other agencies, for example, the Probation Service or voluntary organisations;
• Contingency plans (should the young person's mental health deteriorate); and
• Crisis contact details.

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

After-care planning should take account of the young person's age and should involve their parent/carer (as appropriate) to ensure that they will be ready and able to provide the assistance which the young person may need.

In order to ensure that the After-care Plan reflects the full range of needs of the young person, it is important to consider who needs to be involved. Subject to the views of the young person, this may include:

• The young person's responsible clinician;
• Nurses and other professionals involved in caring for the young person in hospital;
• A practitioner psychologist, community mental health nurse and other members of the community mental health team;
• GP and primary care team;
• Any carers who will be involved in looking after the young person outside hospital including, where relevant, those with parental responsibility;
• The patients' nearest relative or other carers;
• A representative of any relevant voluntary organisations;
• MAPPA co-ordinator if applicable;
• Probation Service if applicable;
• A representative of States housing if accommodation is an issue;
• An Independent Mental Capacity Advocate, if the young person has one;
• Legal Advocate if applicable;
• Any other representative nominated by the patient; and
• Anyone with authority under the Mental Health(Bailiwick of Guernsey) Law, 2010 to act on the young person’s behalf.

The practitioners concerned, in discussion with the young person, should agree an outline of the young person's needs and a timescale for implementing the various aspects of the Aftercare Plan. All key people with specific responsibilities should be identified.

It is important that those who are involved in discussions about Aftercare Plans are able to make commitments about their own continuing involvement and the services to be provided or commissioned. If the worker will need to seek approval for this, extra time must be set aside for planning so that this causes no delay to the implementation of the after-care plan.

The After-care Plan aims to ensure a transparent, accountable and co-ordinated approach to meeting wide ranging physical, psychological, emotional and social needs associated with the young person's mental disorder. It should set out the practicalities of how the young person will receive treatment, care and support day-to-day and should not place undue reliance on the young person's carers.

Included within the After-care Plan are:

• A Treatment Plan which details medical, nursing, psychological and other therapeutic support for the purpose of meeting the young person's individual needs promoting recovery and/or preventing deterioration;
• Details regarding any prescribed medications;
• Details of any actions to address physical health problems or reduce the likelihood of health inequalities;
• Details of how the young person will be supported to achieve their personal goals;
• Support provided in relation to social needs such as housing, occupation, finances etc.
• Support provided by carers;
• Actions to be taken in the event of a deterioration of the young person's presentation; and
• Guidance on actions to be taken in the event of a crisis.

After-care Plans should include details of any areas of need which are critical to preventing behavioural disturbance and should provide guidance on how staff/carers should respond if behavioural disturbance does arise.

The After-care Plan should identify a named individual as the Lead Professional who has responsibility for co-ordinating the preparation, implementation and evaluation of the After-care Plan.

The After-care Plan should be regularly reviewed including within six weeks of discharge from inpatient services, then annually thereafter, or sooner if circumstances change.

It will be the responsibility of the Lead Professional to arrange reviews of the Plan until it is agreed between all parties, including the young person, that it is no longer necessary.