Care Pathway

Care in Mind offers mental health support packages to young people and young adults with a range of severe and complex mental health difficulties. As such, their needs are different and various. However, we believe that there are a number of principles that apply to our work with these individuals irrespective of their presentation.

The information below shows the stages of our approach.

1. Assessment

Assessment of Mental Health & Residential Needs

Care in Mind clinicians and residential team (where appropriate) complete a comprehensive initial assessment.

Consent obtained re sharing of information.

Case Discussion

The team will discuss the case and consider placement and mental health needs, including the client and local teams where possible.

Specialist Assessments

Completion of any formal assessment measures required e.g. symptom measures, psychological assessments, mental capacity.

Identification of specific training needs for residential team to work effectively with service user.

Complete Initial Plan of Care

Written assessment summary provided to referrer. Draft Care Agreement outlining plan of care prepared to support funding processes and to prepare residential team for admission.

2. Therapeutic Intervention & Monitoring

Therapeutic Interventions

These include:

  • Risk Management Plans
  • Care co-ordination by one of our Clinical Nurse Specialists
  • Individual Therapy with a Clinical Psychologist
  • Family Therapy
  • Occupational Therapy
  • Input from Therapeutic Support Workers (where required)
  • 24/7 On-call Support to manage out of hours crises
  • Consultant Psychiatrist to take RC responsibility and oversee medication and risk management
  • All Care Plans outline clear objectives, are reviewed regularly and shared with the appropriate agencies.

Regular MDT Reviews

Involving residential teams and service users as well as other agencies such as college, police, etc.

Continual evaluation of effectiveness of interventions, diagnostic reformulation, monitoring and planning around identified risks.

Regular CPA Review Meetings involving local agencies and commissioners in order to review progress and plan future care.

Contribution to other statutory review processes such as Children Looked After reviews and Pathway Planning meetings.

Specialist Assessments

More specialist assessments may be required during the course of a placement in order to better identify and meet a client’s needs. These can be performed by the Care in Mind team as indicated and will then contribute to the care planning process.

3. Preparation for Discharge

Discharge Planning

Discharge planning should begin at admission. Identification of need in subsequent placement to be considered as early as possible. Plans will be developed with local agencies and funding sought where required to ensure smooth process of transition.

Discharge Transition Work

Assessments of independent skills will be carried out which will inform care plans to gradually increase independence and prepare for next placement. Interventions at this stage may include: Work around Therapeutic Endings, Contingency Planning and Relapse Prevention.


Client will be supported across transition into new placement. Discharge reports will be produced. Verbal handovers will be provided by all key team members to relevant professionals in new team.