Publications reference: PRN00117

Introduction

Dynamic support registers (DSRs) are the mechanism for local systems to identify children, young people and adults (with consent) who are at risk of admission to mental health inpatient services without access to timely dynamic support. They provide the tool to:

• use risk stratification to identify people at risk of admission to a mental health hospital
• work together to review the needs of each person registered on the DSR
• mobilise the right support (for example, a Care (Education) and Treatment Review, referral to a keyworker service for children and young people, extra support at home) to help prevent the person being admitted to a mental health hospital.

The DSR enables systems to identify adults, children and young people with increasing and/or complex health and care needs who may require extra support, care and treatment in the community as a safe and effective alternative to admission to a mental health hospital. Additionally, they play a role in ensuring that people’s needs are included in commissioning plans, financial plans, service delivery and development.

Community Care (Education) and Treatment Reviews (C(E)TRs) are focused on those children and young people who either have been or may be about to be admitted to a mental health hospital.

Community Care and Treatment Reviews (CTRs) are focused on adults (without an education, health and care plan), who either have been, or may be about to be admitted to a mental health hospital.

Inpatient Care (Education) and Treatment Reviews and inpatient Care and Treatment reviews are for children, young people and adults who are currently admitted to a mental health hospital.

There are different key lines of enquiry for children and adults and inpatient settings and community settings.

Community and inpatient C(E)TRs and CTRs bring together people at risk of admission to hospital and people in hospital with their families, carers, network of professional support and an independent panel. This network of professional support should include:

• people responsible for commissioning and providing services (from the provider collaborative, NHS England or integrated care system)
• health care teams (consultants, responsible clinicians, nurses, therapists)
• social workers
• education teams (special educational needs coordinators, teachers, special educational needs and disabilities commissioners)
• other health, education and social care professionals.

The person, their carers, family and network of professional support will come together with an independent panel who will provide an independent clinical opinion and the lived experience of children and young people, adults and families from diverse communities with a learning disability, autism or both.

Purpose

This Code of practice and the accompanying toolkit highlight the processes and core principles that bring the policy into real life. This includes the dependencies between each element that make it one systemic approach to supporting autistic people and people with a learning disability in their community.

We have aligned the process for dynamic support registers (DSRs), Care (Education) and Treatment Reviews (C(E)TRs) and oversight arrangements into one framework guide to help you develop a process in your local area that works for your system and joint commissioning arrangements.

The principles highlight the spirit in which a C(E)TR should be undertaken and serves as a useful reminder to panel members and commissioners of the values that they should hold at the forefront of any review.

Part 1: Dynamic support register

Consent

A Care (Education) and Treatment Review (C(E)TR) cannot take place or a name added to a dynamic support register (DSR) without the person’s informed consent (see shared decision making to comply with national legislation and policy). Consent must be formally documented.

The date consent to inclusion on the DSR was obtained is part of the DSR minimum dataset; consent should be checked at least annually and the dates it was checked added.

The responsible integrated care system must ensure that consent has been sought from the person for both the process and the information sharing that enables it. C(E)TRs take a person-centred approach, and this requires the sharing of personal and sometimes sensitive information.

See section 2.4 of the policy for more details in relation to consent.

Referral onto the dynamic support register

As well as being referred by professionals, individuals can now self-refer to their local area dynamic support register (DSR).

Integrated care boards are accountable for DSR across their footprint. Local areas must have processes in place to receive all referrals to be added onto the DSR. This process should include notification to the person and the person submitting the referral that it has been received. Notification of receipt should take place within five working days.

Local areas must publish their co-produced criteria, process and point of contacts for both DSRs and C(E)TRs on local integrated care board websites, including the Local Offer website for special educational needs and disability (SEND). It may be helpful to work with stakeholders to include information about the DSR, referral and consent processes on their websites, such as NHS Foundation trusts, local authorities and parent and carer forums.

Review of referrals for inclusion on the dynamic support register

Once a referral has been received, local areas should work in partnership with colleagues across children’s social care, adult social care, special educational needs and disabilities local authority teams, commissioners, mental health practitioners and keyworkers to review referrals for the dynamic support register (DSR), stratify the risk of a person and consider whether they should be included on the DSR.

Local areas should facilitate regular multi-agency review meetings to manage the DSR, stratify risk and agree appropriate cross-system actions and support. There must be a shared process of accountability with a clear structure of escalation for red/amber cases. This will involve named senior managers across health and local authority services.

• The risk stratification process should take place within four weeks of receiving a referral for the DSR.
• The outcome of the risk stratification process should be communicated with the person and/or parent, carer or referrer verbally with an update of what will happen next, even if the person is not eligible for inclusion on the DSR.

Dynamic support register risk stratification process (section 4 of the Dynamic support register and Care (Education) and Treatment Review policy)

The Dynamic support register and Care (Education) and Treatment Review policy endorses the Cheshire and Wirral risk stratification process (appendix 2 of the policy) to determine whether a person should be included on the dynamic support register (DSR) at red, amber and green.

The risk stratification/RAG rating processes must take account of:

1. The person’s view about their current situation, with advocacy support in line with this policy and legal entitlements (see section 16.8 and appendix 5).
2. The family’s view about the current situation, with support from local parent carer forums, special educational needs and disabilities advice and support services or other locally commissioned services.
3. Risk assessment using locally developed tools.
4. Professional judgement, which must include structured multi-agency assessment and regular review meetings.

How risk stratification decisions are made should be recorded with clear rational for the decision which must be shared with the person and the person who has referred them and recorded on the DSR. 

If a person is identified at red, a Care (Education) and Treatment Review (C(E)TR) must take place immediately, local areas may need to consider whether it is appropriate to hold a local area emergency protocol (LAEP) meeting. For children and young people, a referral must be made to the Keyworker Service if they are not already known.

If a person is identified at amber, a multiagency meeting and/or a C(E)TR must take place, and for children and young people a referral to the keyworker service should be made if they are not already known.

Further information about keyworkers is available on our website.

If a person is identified at green, contact must still be made with the person/and or their parent, carer or referrer to signpost to appropriate services to ensure they access the help they need to stay well in their community and prevent future escalation. There should be clear identification of partners who would need to be involved in a C(E)TR if required.

Integrated care systems should work with all local authorities in their footprint to include on DSRs children and young people who are in 52-week residential schools and colleges. Using your local area risk stratification process you should determine whether they identify as red, amber or green. The child or young person should be regularly discussed in the DSR multi-agency review meeting to ensure they are effectively monitored, and that care RAG rating is appropriate to the level of need they present.

A child’s risk of admissions should be monitored against the risk stratification criteria to determine when and how often a C(E)TR should take place. This could be monitored through other child in care processes which should feed into the DSR multi-agency review meeting. This meeting should discuss children in 52-week residential placement regularly to ensure appropriate monitoring and consideration of presenting levels of need and risks of admission.

If a person is an inpatient in a mental health hospital, they must be included in the DSR and their risk reviewed in every C(E)TR. They should be considered in DSR multi-agency review meeting on a regular basis, as a minimum aligned to C(E)TR and discharge timescales. Additionally, people discharged from a mental health hospital should be included on the DSR for a period of review. This period should be determined by the timing of post-discharge C(E)TRs/multi-agency meetings, risk stratification process and any post-discharge plans.

If a person does not meet the criteria for inclusion on the DSR, processes must be in place to contact the referrer and person/their carer/family to discuss the reasons for this and signpost onto other relevant help and support, using no wrong door principles.

Once a person’s risk has been stratified, the outcome of the review must be communicated to the referrer and person/their carer/family to discuss next steps, this might include when it may be appropriate to consider referral to the DSR in the future.

The outcome of a DSR risk stratification should be communicated within 24 hours of a decision being made.

The process for receiving referrals, stratifying risk and informing the referrer and person/their carer/family of the outcome should be completed within four weeks from the point of the referral being received.

Information to include on the dynamic support register for each person

The dynamic support register (DSR) should capture relevant information about a person, as a minimum, this includes (3.2 from the policy):

• identifiable information (name or NHS patient number)
• name of the lead health and/or social care professional responsible for the multiagency care plan
• name of current service provider or support in place through a personal budget
• whether or not the person has a current care plan and any contingency planning
• if a risk assessment is in place
• date of last review of care plans and risk assessment
• whether or not the person is at immediate risk of placement breakdown and/or admission (including their RAG rating)
• date community Care (Education) and Treatment Review (C(E)TR) held and key actions to be undertaken
• reason why the person is at risk of placement breakdown and/or admission
• whether the person has been offered a personal budget, personal health budget or integrated personal budget where this is appropriate
• date consent given for inclusion on DSR.

Dynamic support register multi-agency review meetings and link to oversight and assurance panels

In order for local areas to add and monitor children, young people and adults on the dynamic support register (DSR), processes should be in place for the commissioner, clinical team, children’s social care, adult social care and education teams to meet regularly. The discussion should include:

• review of new referrals and existing people’s RAG rating using a risk stratification process and rational
• current presentation, identify challenges and any actions to be carried out and by who (including whether a person requires a Care (Education) and Treatment Review (C(E)TR) and/or a referral to keyworker services etc)
• outstanding C(E)TR actions and progress
• unpaid carers and consideration for carers assessments.

Local systems should develop terms of reference for the DSR multi-agency review meeting. This should include the membership, frequency of meetings and the governance framework.

Local areas will need to implement an information sharing agreement to ensure effective information sharing is available, so that information can be shared prior to and after DSR multi-agency review meetings.

The DSR multi-agency review meeting should feed into Oversight and Assurance Panel processes, ensuring appropriate governance is in place.

Part 2: Care (Education) and Treatment Review

Care (Education) and Treatment Reviews (C(E)TRs) are an essential person-centered process. They seek to ensure system partners are working with people and families to provide the right care, education and treatment to avoid the need for an admission to a mental health hospital and ensure good care for all.

A C(E)TR is a person-centred review to ensure the care, education (for children and young people) and treatment and support needs of the individual person and their family are met, and that barriers to progress and/or discharge are challenged and overcome. The C(E)TR process is underpinned by a set of principles outlined in the Dynamic support register and Care, (Education) and Treatment Review policy and guidance, January 2023:

• Person (child, young person or adult) centred and family centred
• Evidence based
• Rights led
• Seeing the whole person
• Open, independent, and challenging
• Nothing about us without us
• Action focused
• Living life in the community

What triggers a Care (Education) and Treatment Review?

Section 13 of the policy includes clear descriptors of the triggers for a Care (Education) and Treatment Review (C(E)TR). Children, young people and adults who identify as red and amber on the dynamic support register (DSR) trigger a C(E)TR as they have been identified as at risk of admission into mental health inpatient settings.

New triggers for a C(E)TR, are included in 13.1 of the policy:

• Six weeks after admission to hospital if a community C(E)TR has been undertaken.
• If a person is transferred to another hospital or to a setting within the same hospital with a different security level.
• If a person receives a diagnosis of autism or a learning disability during their admission in hospital.
• If a clinical review identifies that someone has been incorrectly diagnosed with autism or a learning disability and removal of the diagnosis is proposed.

People are also able to request a C(E)TR outside of these timescales and trigger points. 

Local areas will need processes in place to receive requests for C(E)TRs, this process should include who will receive the request (responsible commissioner or case manager in a provider collaborative or specialised commissioning), how a decision will be made and communicated along with timescales and who will respond to key issues identified.

Local areas will need processes to enact a local area emergency protocol (LAEP) in circumstances where an admission is unplanned, urgent or someone is in ‘crisis’. It is recognised that a C(E)TR may be, on a practical level, very difficult to set up due to short time scales, level of risk and the need for urgent action.

It is important to note that the LAEP does not replace the community C(E)TR and should only be used by exception. Where a community C(E)TR has not taken place, the pathway for a post-admission C(E)TR must be followed.

Organising a Care (Education) and Treatment Review

• Identify the person needing a C(E)TR and ensure they consent.
• Identify if there are any reasonable adjustments to be made for the C(E)TR.
• Identify if there are any requirements for particular experts, for example, gender specific experts, experts in autism, etc.
• Identify potential date and ensure this is convenient for the person and their family.
• Book a meeting room and plan the agenda.
• Arrange for the person and their family/carers to receive the My care and treatment review and the My C(E)TR planner booklets.
• Ensure that enough time (ideally two weeks) is allowed for the person and their family/carers to give their consent (see planner booklet) and for them to decide who they would like to invite to their C(E)TR, and for those people to be invited to attend by you or the provider as agreed.
• Ensure you have considered all of the relevant agencies and individuals that need to be invited for the particular circumstance – refer to the policy for more detail in relation to this.
• Ensure that you or the lead community/service provider team member has time booked in with the person to prepare for the C(E)TR.
• Arrange for the expert by experience and clinical expert to be booked and ensure that they have invites and agendas sent to them, and have all the necessary support to attend, for example, travel, proof of identity document/badge if needed, health or support needs planned for the day.
• Ensure that you or the service provider have got all the necessary documents together for the C(E)TR panel.

During the Care (Education) and Treatment Review

• Take the relevant Care (Education) and Treatment Review (C(E)TR) key lines of enquiry template (community/inpatient/child/adult) to the review and ensure the experts are broadly aware of this and how they can contribute to it during the C(E)TR.
• Follow the agenda.
• Ensure that reasonable adjustments are made, if necessary, for the person, family and panel members and that non-technical language is used where possible.
• Complete the key lines of enquiry template and agree the findings and recommendations with the panel members.
• Feedback to the person, their parent or carers and to the service provider or community team in non-technical language.
• Agree with provider and all present who will carry out actions, timescales and who will be responsible for ensuring that actions are carried out.

Post Care (Education) and Treatment Review work

• Send a copy of the key lines of enquiry template to the person, their family or carers or other relevant people (consent to share information should be checked) within two weeks of the Care (Education) and Treatment Review (C(E)TR).
• Raise any safeguarding concerns with the local authority and any alerts with the Care Quality Commission.
• Ensure that the recommendations and actions are carried out and embedded in dynamic support register.
• Ensure that experts are supported to discuss their feelings about the C(E)TR.
• Ensure that experts have handed back all the person’s records, their own notes made during the C(E)TR and that they clearly understand about transmission and destruction of secure information in line with NHS policy.

Recommendations from the C(E)TR should be shared with the DSR lead to be recorded on the DSR and for C(E)TR actions to be monitored in the DSR multidisciplinary meeting discussion across health, social care and education.

Local areas should consider their approach to monitoring actions from the C(E)TR if a person does not consent to be on the DSR.

Part 3: Oversight and assurance panel (section 18 of the Dynamic support register and Care (Education) and Treatment Review policy)

The Integrated Care System Oversight Panel’s overall aim is to co-ordinate and support activity (and where necessary formal intervention) so that implementation, outcomes and actions of Care (Education) and Treatment Reviews (C(E)TRs) are targeted when needed. The panel should review the escalated C(E)TR report and actions, assure themselves that the person is safe and well, and consider if any further action is needed to support the person’s progress or discharge.

It is recommended that whoever leads on the local area dynamic support register sits on the oversight and assurance panel to share regular updates and ensure that there is a two-way line of communication.

Part 4 Commissioner oversight visits and link to dynamic support register and Care (Education) and Treatment Reviews and Oversight Panel

Commissioner oversight visits should take place for children, young people and adults with a learning disability and/or who are autistic placed in inpatient services. For children under 18 years old, these should take place every six weeks, and for adults, aged over 18 years old, they should take place at least every eight weeks. These visits do not replace other visits or a Care (Education) and Treatment Review (C(E)TR).

Local systems should consider how the actions from the commissioner oversight visits are captured and included in the dynamic support register (DSR) and C(E)TR to ensure there is regular review, duplication is prevented and actions are followed up.

More information related to commissioner oversight visits is available on our website.

The principles of a Care (Education) and Treatment Review

At its core the Care (Education) and Treatment Review (C(E)TR) has a set of principles based around the word PERSONAL which the C(E)TR panel should always uphold. Panel members each have an equal role in making sure these principles are followed.

Principle 1: Person centred and family centred

Before a C(E)TR, the responsible commissioner will ensure that the person has given consent or if the person lacks capacity, that a best interests decision has been made.

The person and their family will be given information about the C(E)TR in advance. This includes supporting the person to get ready for the C(E)TR using the My care and treatment review and My C(E)TR planner booklets.

Reasonable adjustments should be made to the C(E)TR process as required to ensure that the person is fully involved, present and able to participate as they wish.

The commissioner is responsible for ensuring that the person’s needs are understood and that an appropriately skilled and experienced clinical expert is present on the C(E)TR panel.

The panel will make time available to meet separately with the person and their family carer. This could be meeting them all together or separately according to the person’s wishes.

The C(E)TR panel will ensure that they have provided basic information about themselves (for example name and photograph) to the person and their advocate/family and carers to introduce themselves when they meet the person.

Following a C(E)TR the person and their family are supported to understand what will happen next and they know who to contact and how.

Principle 2. Evidence based

C(E)TRs use a standardised, structured approach to the review of a person’s care by using specifically designed key lines of enquiry (KLOE).

Information to help answer the KLOEs should be collected before the C(E)TR takes place. See document checklist in the appendix below for a list of information that may be collect prior to the C(E)TR.

The C(E)TR will look for evidence to support its findings and note these on the KLOE. Specifically, the C(E)TR will look for evidence that clinical and best practice guidance has been followed; this must be recorded on the KLOE. Panel members should consider carefully what information they need to review ahead of the C(E)TR to ensure they are familiar with the person’s presentation, care and support needs.

Principle 3. Rights led

Where there is concern that the person’s human rights may not be being upheld appropriately this will be identified on the KLOE template and relevant action taken.

The C(E)TR will investigate the provision of independent advocacy for the person.

The C(E)TR will investigate legal representation for the person (for example, at tribunals)

Principle 4. Seeing the whole person

Each C(E)TR should take around a day to complete.

The C(E)TR will include the people who are important to the person being reviewed.

People who are, or who will be, supporting the person should be part of the C(E)TR – including social care partners and education partners.

The review will ask about physical health, mental health and general wellbeing.

Principle 5. Open, independent and challenging

The review panel is made up of three people and must include the chair (the person’s commissioner) and two independent advisers (an expert by experience and a clinical expert).

The chair will ensure at the beginning that everybody who takes part, knows what a C(E)TR is about. The panel members will all declare if they have any conflicts of interest. The review team will have completed Care and Treatment Review training.

The C(E)TR will question aspects of care and treatment that are not consistent with good practice or evidence-based guidelines.

The C(E)TR will keep asking whether the person’s care and treatment could be delivered in a non-hospital setting.

The chair should be able to demonstrate that they have worked in partnership with the panel members including agreement on the content of the report. Where a C(E)TR panel does not reach agreement, the differing opinions will be noted in the KLOE template and clear escalation route and timescale agreed to resolve any disagreement.

The C(E)TR will ensure that the reasons for, and the expected outcomes of, an admission/continued admission are clearly recorded in the KLOE and actions are included in the dynamic support register for oversight to ensure actions are delivered.

A follow-up C(E)TR must review previous C(E)TRs and check actions have been completed, and where they have not been completed understand why and what still needs to be done.

Principle 6. Nothing about us without us

Every person will be supported to fully engage in their own C(E)TR considering reasonable adjustments including, how the person is supported to use their preferred method and/or tools of communication.

The C(E)TR must identify the lead point of contact for a person, their family or carer who will communicate progress of actions and who will be contact point for the person, their family or carer. 

Following the C(E)TR, the commissioner will write a report about the review in words that all involved can understand. The commissioner will make sure the person, their family/carers and others who need a copy get the report within two weeks.

Principle 7. Action focused

C(E)TRs check that people are safe. When a C(E)TR finds that people may not be safe, a panel member will discuss this with the person, record this on the KLOE and raise concerns to the relevant authority or agency. It is the responsibility of the chair of the C(E)TR to make sure that any safeguarding concerns that are raised during the review are escalated in accordance with this guidance and in compliance with local safeguarding partnership arrangement. Further guidance is available on the NHS Safeguarding website.

The C(E)TR must review a person’s risk rating for the DSR using the locally agreed risk stratification process. This review must be updated onto the DSR with a rational for the decision making.

The C(E)TR will identify gaps in the person’s care and treatment. The panel will make recommendations to address these gaps to ensure appropriate treatment and discharge plans are in place.

The outcomes of the C(E)TR will identify the named individuals in the person’s care team who will make sure the recommendations are actioned and embedded in other relevant assessment and planning processes along with clear timescales. C(E)TR actions must be included in the DSR. It may also be appropriate for actions to be included in education health and care plans, child in need plans, adult social care plans, etc.

C(E)TRs must cover long-term planning to support discharge; this should include consideration of housing and/or bespoke care packages that may be required. Long term planning should be considered and planned for at the earliest opportunity including the engagement of competent service providers to ensure people are in hospital no longer than medically necessary. Local funding streams must be investigated as early as possible to avoid delays.

The commissioner is accountable for follow up after a C(E)TR and ensuring recommended actions are being carried out on time. Where actions are not carried out, the commissioner will explain to the person and their family why this is. Actions must be included in the local area DSR to ensure they are monitored through the multi-agency DSR meeting.

Principle 8. Living life in the community

DSRs and C(E)TRs are essential elements of the pathway, providing people with a learning disability and autistic people with appropriate support and care at the right time so they can lead the lives they want to and meet their ambitions and aspirations, and can stay safely and healthily in the community or return to this as soon as possible.

If someone with a learning disability or an autistic person does need to be admitted, this should be for the shortest time possible and during their stay they should receive high standards of mental health and physical healthcare.

For community C(E)TR, they will ask about what the person needs to live their life in their community and stay well. C(E)TRs should consider whether there are any gaps in support and provision and if so, how these could be addressed. 

For inpatient C(E)TRs a record of the reasons why the person’s care and treatment cannot be carried out in the community must be included in the KLOE. C(E)TRs must cover planning to support discharge, this should include consideration of housing and/or care packages that may be required. Discharge planning should be considered at the earliest opportunity.

For both inpatient and community C(E)TRs, the panel will look for evidence of up to date, positive and proactive risk assessment and risk management plans that address the safety of the person and of others now and in the future.

For both inpatient and community C(E)TRs, the panel will ask about the person’s circle of support and how the person is being enabled to be part of their local community.