The Triangle Of Care - Carers Trust

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The Triangle of CareCarers Included: A Guide to Best Practicein Mental Health Care in EnglandSecond EditionSer viceuserProfessionalCarer

AcknowledgementsThe creation of the Triangle of Care has taken many years and involved many people.It celebrates a developing awareness of carers’ needs and demonstrates that in differentparts of the UK those people who work with and on behalf of carers are creating excellentresources and better outcomes.The original impetus to identify ways of ‘improving engagement between professionalsand carers’ grew from a training programme created by carers in Devon. Similarinitiatives grew in other places. The work of Lu Duhig in Avon and Wiltshire influenced thisresource in many ways.We acknowledge the thought and effort which has gone into creating the best practiceexamples and are grateful for the generosity of carer champions in responding torequests to make them widely available.The evolution of the Triangle of Care guide into the Triangle of Care project whichencompasses all areas of mental health service delivery across England is thanks tomany dedicated professionals, carers and services users who are involved in the CarersTrust’s Triangle of Care Steering Group and the eight regional Triangle of Care groups.Finally, thanks to Yvonne Stoddart and Malcolm Rae who, as always, provided invaluableencouragement and suggestions and to Bridget Lawless who helped with editing themany drafts.AuthorsAlan Worthington, Carer AdvisorPaul Rooney, National Acute Care ProgrammeRuth Hannan, Carers Trust (Second Edition amendments)Published byCarers Trust32–36 Loman StreetLondon SE1 0EHTel: 0844 800 4361Fax: 0844 800 4362Email: info@carers.orgWebsite: www.carers.orgCarers Trust is a registered charity in England and Wales (1145181) and in Scotland(SC042870). Registered as a company limited by guarantee in England and WalesNo. 7697170. Registered office: 32–36 Loman Street, London SE1 0EH. Carers Trust 2013The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care

ContentsForeword2Executive summary3Introduction4The rationale behind the key elements10Appendix 1: Triangle of Care self-assessment tool23References331

ForewordCarers are vital partners in the provision of mental healthand social care services. 1.5 million people care forsomeone with mental ill health in the UK.The original Triangle of Care guide was launched in July 2010 tobuild on existing developments and good practice to include andrecognise carers as partners in care. It offered key standards andresources to support mental health service providers to ensurecarers are fully included and supported when the person they carefor has an acute mental health episode; the inclusion of carersbenefits staff, carers and service users alike.Carers Trust is the largest independent provider of carers supportservices and we are delighted to be working in partnership with overthree quarters of mental health trusts in England as well as manyNetwork Partners and other leading mental health and carerorganisations to continue to drive forward the standards of theTriangle of Care. To this end, the second edition of this guide hasbeen revised to reflect the project development into all areas of themental health care pathway including specialist services.With the launch of the formal Triangle of Care membership schemewe hope to build on and develop this project further to ensure thatall carers of someone with a mental health issue receive theinformation, advice and support they require to continue in theirroles as expert partners in care.Thea Stein, Chief Executive, Carers TrustAbout Carers TrustCarers Trust is the UK’s largest charity for carers. With local Network Partners we work toimprove support, services and recognition for carers in communities across the UK. Weoffer practical help, both in and outside the home, desperately needed breaks, informationand advice. Together with Network Partners we work as one organisation united by a sharedvision for carers.Our vision is of a world where the role and contribution of unpaid carers is recognised andthey have access to the quality support and services they need to live their own lives.The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care2

Executive summaryThe Triangle of Care is a therapeutic alliance between service user, staff memberand carer that promotes safety, supports recovery and sustains wellbeing.The key elements toachieving a Triangle of CareThe essence of this guide is to clearly identifythe six key elements (standards) required toachieve better collaboration and partnershipwith carers in the service user and carer’sjourney through mental health services.For each element we suggest good practiceexamples and resources that may be helpful.The six key standards state that:1) Carers and the essential role theyplay are identified at first contact or assoon as possible thereafter.2) Staff are ‘carer aware’ and trainedin carer engagement strategies.3) Policy and practice protocols re:confidentiality and sharing information,are in place.4) Defined post(s) responsible for carersare in place.5) A carer introduction to the serviceand staff is available, with a relevantrange of information across thecare pathway.6) A range of carer support servicesis available.In addition to the above, there also needs tobe regular assessing and auditing to ensurethese six key standards of carer engagementexist and remain in place. A self-assessmentaudit tool for carer engagement can be foundin Appendix 1.Who is this document for?This guide is primarily addressed to mentalhealth services, directors, managers,commissioners and staff, and also to informcarers, service users and carer groups.Success in achieving change depends uponstaff becoming willing ‘champions’ for betterpartnership working and being able tochallenge practice that excludes carers.A more inclusive attitude for carers andfamilies should be promoted, where they arelistened to and really heard and consultedmore closely.Better recognition that carers are key partnersin the planning and provision of mental healthcare also makes sound economic sense.Both commissioners and providers of mentalhealth services need to recognise thatsupporting carers through initiatives such asthe Triangle of Care is a sound investment insafety, quality and continuity of care atrelatively little financial cost. That said,supporting carers should not be used as ameans, intentionally or otherwise, tosubstitute necessary statutory support andresponsibilities. Carers support should not beseen as a means to reduce support to serviceusers, or to legitimise inappropriateassumptions from services about how muchcarers can take on.Although the terminology and legislationreferred to in this guide applies to Englandthe standards and rationale are applicableacross the whole of the UK.3

IntroductionIn July 2010 the Triangle of Care, Carers Included: A Guide to Best Practicein Acute Mental Health Care was launched in the Houses of Parliament. A jointproduction with The Princess Royal Trust for Carers and the National MentalHealth Development; the guide received a positive reception from professionals,carers and service users alike.Carers Trust is a new charity formed by themerger of The Princess Royal Trust for Carersand Crossroads Care. Carers Trust now leadson the Triangle of Care project across Englandand works with over three quarters of Englishtrusts offering mental health services, to engage,include and support carers in their services.assessing my relative, the worker(s) whentalked to me as well, so as to get a clearThe Triangle of Care approach is aimed atencouraging partnership working with carersat all levels of care from the individual tooverall service planning.When treatment is at home, what if .gave explanations and offered a staffchoice of optionsWhat would help carers andservice users?a carer I was given the same sort of asinformation, support and coping strategiesAt a presentationto The Acute CareProgramme (now closed)Alan Worthingtonasked the followingquestions:What if? – A carer’s journey throughacute care servicespicture of how to helpworker(s) tried to get a good picture of thewhat my son was like when he was welland aspired to help him to return to this.were explained and strategies treatmentsfor managing the medication were giventhat are now seen in many inpatientsettings and reassurance when my relativebecame a person I couldn’t recognise.When an admission was being planned,what if .service was close enough to easily thekeep up family support(With apologies to Rudyard Kipling.)service could offer alternatives to a thehospital bed.When asking for help, what if .On the ward, what if .my relative and I had a phone numberstaff gave time each day to have good both theto call if an acute situation was to developconversation and give supporta carer I could call the staff, tell them asthe need was urgent and I would get aquick responseward provided a warm friendly theatmosphere with things of interest to doThe Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care4

were groups to explore general life and theremental ill health, with opportunities to learnfrom others and develop companionshipI visited the ward I was welcomed whenas a friend and supporter of the work, andstaff accepted that I wished to contributefor my relative’s benefit and the benefitof otherswas offered information about the ward Iandservicesthe named nurse was not available, whenthere was someone else who was willingto talk to me.At leave or discharge, what if .involved in the planning and we Iallwasworked out what to do if, for exampleif there was a relapse or if the carerbecame illrelative was given practical help with mykeeping his medication sorted and helpwith remembering to take it.Afterwards, what if .the episode was over, the services whenasked for feedback and used it to improveWhat if your service was responsive enoughto be able to answer all of Alan’s questionswith a yes. Carers Trust and its partnersbelieves the best way to do this is bydeveloping and maintaining the Triangle ofCare: a carer engagement approach formental health services.The Triangle of Care: a carerengagement approach formental health servicesThe Triangle of Care approach was initiallydeveloped by carers and staff seeking toimprove carer engagement in acute inpatientservices. It has now been extended to coverall services within a mental health servicewhether they be an inpatient, communityteam or specialist service such as eatingdisorders or forensic. Carers frequently reportthat their involvement in care is notadequately recognised and their expertknowledge of the ‘well person’ is not takeninto account.A disconnected model of involvement likethis can lead to carers being excluded atimportant points.things in the futureI knew that my relative would be thatvisited within two days of discharge that I knew that his physical and mentalhealth would be reviewed at regularintervalsnecessary, we would be offered family ifinterventionsand talking therapies. then our caring duties would diminishto a point when we could look towards ourown recovery.ProfessionalServiceuserCarerThis leads to gaps in practice which can resultin the carer being left on the outside and infailures to share information that may be vitalto risk assessment, care planning, and toacting in the best interests of both serviceuser and carer.5

Some common problems“At the time, when my relative joined theservice I felt completely lost. Here was aset of new experiences I could not haveimagined. I needed to know the ropes,who was there to help and what was goingon. I especially needed to believe in theprofessionals – that they understood myconnection to this precious person now intheir care. I needed to have confidencethey knew how to help him recover andthat they saw me as part of that recovery.”Carer speaking about when the personthey care for had their first episode“At times I try to imagine how differentthings might have been if the staff hadrealised how close we had been untilthe breakdown. If only someone had metme and listened to my part of the events– asked me what help I needed. I dowish they had explained to me whatthey were doing and warned me whenshe was discharged. I could have beenbetter prepared and we might still beclose friends.”Carer speaking of a lost relationshipCarers say their wish to be effective iscommonly thwarted by failures incommunication. At critical points and inspecific ways they can be excluded bystaff, and requests for helpful information,support and advice are not heard.The Triangle of Care can be part of thesolution.Service userProfessionalCarerThe concept of a triangle has been proposedby many carers who wish to be thought of asactive partners within the care team. It isseen when there is collaboration between themental health professional, service user andcarer. The link between the professional andpatient often defines the service, but in mostcases the bond between patient and carerhas pre-existed.An effective Triangle of Care will only becomplete if there is a willingness by theprofessional and carer to engage. Most carersrecognise that this three-way partnershipbetween service user, carer and clinicians,with all the voices being heard and influencingcare treatment decisions, will produce thebest chance of recovery. This places an onuson professionals and services to activelyencourage this partnership.Carers wish to be trusted, involved andbecome more effective. Services may havetraditional ways of doing things which createobstacles for carer support. More effectivecarer engagement will grow from changingattitudes and adopting positive practice. Thisrelationship can be reinforced by putting inplace key components which invite carerparticipation, giving information, support andadvice in a considered manner. Thi

in Acute Mental Health Care was launched in the Houses of Parliament. A joint production with The Princess Royal Trust for Carers and the National Mental Health Development; the guide received a positive reception from professionals, carers and service users alike. Carers Trust is a new charity formed by the merger of The Princess Royal Trust for Carers and Crossroads Care. Carers Trust now .

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