Child and Adolescent Mental Health Services: regional Intensive Psychiatric Care Unit service specification

Indicators

1. Clinical Care Pathways

Children and young people experiencing mental health problems should be treated in the right place, at the right time, and as close to home as possible. Specialist mental health services for under-18-year-olds who present severe and/or persistent mental health conditions will be provided in accordance with the Child and Adolescent Mental Health Services (CAMHS) National Service Specification^[1].

Regions should ensure clear evidence-based pathways for community-based care. Intensive home treatment should be considered where appropriate, to avoid unnecessary admissions to inpatient care. However, there will always be some children and young people who require more intensive and specialised inpatient care.

The Mental Health and Wellbeing Strategy (2023)^[2] states that ‘All children should enjoy a life free from stigma and inequality and fulfil their right to achieve the best mental health and wellbeing possible’.

2. Regional and national inpatient CAMHS services in Scotland offer inpatient psychiatric care for children and young people:

• Three regional adolescent IPUs
• A national child IPU, and a national child learning disability IPU (co-located)
• In 2025, a medium secure national adolescent psychiatric inpatient unit

Young people may belong to one of two groups: those with ‘forensic’ presentations involving a significant risk of harm to others and those with ‘complex non-forensic’ presentations principally associated with behaviour that challenges, self-harm, and vulnerability.

There is currently no low secure unit for adolescents in Scotland. Two privately provided low secure units are licensed to admit young people aged 16 and over. The National Services Division (NSD) will continue to review ongoing needs and requirements for the commissioning of a low secure service. Low secure provision will be sought on a case-to-case basis and is available in NHS England. We will better understand this need following the opening of The National Medium Secure Adolescent Inpatient Service(NSAIS), Foxgrove.

The NSAIS, Foxgrove, will accommodate young people who are admitted for assessment and treatment of mental disorders under relevant sections of Mental Health Legislation. All patients admitted to the service will be considered to present a significant risk of harm to others and some patient may also pose a risk of harm to themselves.

This document refers to CAMHS Intensive Psychiatric Care Units.

3. Service requirements and functions

Adolescent IPCUs are designed to accommodate up to a maximum of 10 young people at any one time, in line with the National Minimum Standards for Psychiatric Intensive Care Units for Young People (NAPICU)^[3].

The national IPCU working group recommended at least two IPCU beds should be made available on each of the three regional sites within a total of six to eight nationally, based on the needs assessment information available at the time, and these would be for the use of a timely admission for an acute presentation in line with the criteria outlined above.

Each board will regularly review needs assessment information in the planning and commissioning process. Consideration should be given to the changing landscape of inpatient services and the potential that these changes may increase demand for IPCU beds. Routine reporting against the delivery of this specification and standards to the Scottish Government will also be a requirement from the hosting board.

Admissions should not last longer than six weeks with a maximum of eight weeks in exceptional circumstances. Any admission likely to last longer than six weeks must be subject to robust clinical review actively focused on identifying alternative options including, where appropriate, transfer to either low or medium security or step down back to an open ward if appropriate.

All young people admitted to IPCUs must be subject to detention under the Mental Health (Care and Treatment) (Scotland) Act 2003^[4] or Criminal Procedure (Scotland) Act 1995^[5] The predominant need for care and treatment in IPCU must be related to the assessed risk of harm to self and/or others in the context of the young person’s mental disorder.

Young people must be treated and managed utilising a robust multidisciplinary framework as a national standard, care programming approach (CPA) or a similar framework should be employed for all children and young people (CYP) admitted to an IPCU. Services should work collaboratively to ensure that admission and transfers within adolescent IPU and IPCU are achieved efficiently. The clinical pathway must be planned early in admission, with changes depending on developing needs and circumstances.

There are four recognised pathways into Adolescent IPCU, and all admissions must have had an access assessment prior to referral. The pathways are:

• stepping up from a general adolescent IPU
• direct admission from the community, including other residential establishments for young people with additional support needs (e.g., educational/residential social care). Prior to admission, an assessment must be completed by a CAMHS Consultant Psychiatrist or Specialist Trainee (ST4-6) in Child and Adolescent Psychiatry (in consultation with a CAMHS Consultant Psychiatrist) (NB: In some areas in Scotland CAMHS for 16 and 17-year-olds continue to be provided by adult services; in such circumstances adult psychiatrists (and their specialist trainees under supervision) would be responsible for making referrals. In the rare circumstance that care should be provided by adult services, local health boards must make provisions for the young person to be treated by CAMHS services as soon as possible
• admission from the National Medium Secure IPU
• direct referral from Scottish Courts.

Responsibility for the care of the young person normally remains with the referring agency/ service until the point of admission to the IPCU. ‘Getting it right for every child’ (GIRFEC) principles^[6] specify that practitioners and leaders should work together to ensure that any change to the lead professional is well planned and agreed with the young person.

Multi-disciplinary working and a co-ordinated multi-agency care pathway must underpin service delivery; the IPCU must provide:

• a rights-based approach, grounded in GIRFEC and UNCRC^[7] Act values and principles. The GIRFEC framework acknowledges the requirement for joined up working with services, young people and parents in a co-ordinated way
• young person-centred individualised multi-disciplinary evidence-based treatment packages, based upon assessment of need and risk
• proactive assessment and safe management of challenging behaviour
• physical and mental health care that meets the needs of and involves young people and, if appropriate, their families/carers from the beginning of the care pathway
• care for people with a learning disability and/or autism in line with the National Neurodevelopmental (ND) Specification: Principles and Standards^[8]
• a secure environment where young people can address their problems in safety and with dignity.
• an extensive range of therapeutic, educational and recreational opportunities including activity programmes during periods when education is not provided or for young people beyond school age who do not wish to continue in education. On-going assessment in collaboration with parents./carers, local authority education and social work services, or others who may be involved with the child and family, should support effective, safe, and timely discharge or indeed transfer to another inpatient or community setting
• provision of care in line with welfare principles from the Children’s Scotland Act (1995)(2020)^[9], Children and Young People (Scotland) Act (2014)^[10] and the Mental Health (Care and Treatment) (Scotland) Act (2003/13)^[4]
• age-appropriate advocacy services
• specialist professional and clinical advice to referrers and other agencies.
• appropriate educational services from an education authority and registered provider which is subject to HMI inspection
• consideration should be given to the needs of young people who are transgender or non-binary and take appropriate action to ensure comprehensive guidance is in place to appropriately support these young people as set out in the scoping review of intensive psychiatric inpatient care provision for young people in Scotland^[11].

4. Core competencies

The competencies that are required to meet the needs of young people with a range of complex behaviours are:

• a comprehensive Multi-Disciplinary Team (MDT) with a “core team” of psychiatry, clinical psychology, social work, occupational therapy, education, speech and language therapy, and nursing professionals. Services should ensure appropriate access to other necessary disciplines (family therapy and third sector organisations where applicable)
• a robust process of assessment able to formulate cognitive and behavioural paradigms and flexible enough to allow alternative formulations (psychodynamic, systemic, psychopharmacological etc.)
• expertise in the use of psychopharmacology in severe mental illness including local PRN and Rapid Tranquilization Policies
• a therapeutic regime that places primary importance on behavioural approaches, de-escalation, and the psychopharmacological treatment of mental illness and agitated behaviour in the context of psychiatric disorder. The therapeutic regime must also be able to effectively deliver a variety of other psychological interventions at an individual and group level and in particular deliver cognitive/behavioural interventions, interventions addressing interpersonal difficulties, family relationships, problem solving and affect regulation.
• occupational therapy interventions integrated into the care approach

The suitability of these interventions depends on the likely length of stay. The aim is to discharge young people from IPCU when it is safe to do so, which means that lengthier therapeutic interventions will not generally be appropriate, although they should still be available for example as brief interventions.

5. Environmental and Cultural values

We obtained the views of young people and carers prior to the commissioning and implementation of this service. We engaged young people across the three hosting regions with the support of local age-appropriate advocacy services. We have therefore considered the views of those with lived experience. An important piece of work around this development was the inclusion of carers/young people within the design process of intensive psychiatric inpatient facilities.

The United Nations Convention on the Rights of the Child (Incorporation) (Scotland) Bill was enacted in July 2024^[7]. The Scottish Government wants to give children's rights the highest possible protection in Scotland. This legislation will make it against the law for public authorities like the police, schools, hospitals, and Scottish Ministers to act in a way that is not allowed by the UNCRC. Legislation will apply to all children and young people under the age of 18. This will mean that public authorities must take steps to respect children's rights in their decisions and actions. The new law will mean that children and young people will have to be involved and listened to in decisions about their own lives and communities.

The therapeutic milieu must have the capacity and resilience to effectively deliver interventions in the face of acutely challenging behaviour. It must also be capable of demonstrating a robust safeguarding approach that is able to balance therapy delivery and the safety of staff and patients.

The service must provide an environment and culture that meets best practice for safety, welfare, and security and demonstrates a robust approach to risk assessment and management. Quality improvement methods (such as Plan, Do Study Act (PDSA) cycles) should be used with the objective of reducing restrictive and coercive practice and use of non-consensual measures such as physical intervention and rapid tranquilisation.

The Scottish Patient Safety Programme’s work on reducing restrictive and coercive practice may support teams in this approach and consideration should be given to safe wards protocols. Good practice should be employed at all times with up-to-date training and progressive practice around current drivers and legislation.

The service is required to complete regular audits throughout an annual cycle demonstrating the degree to which safety, welfare, and security within the unit are maintained and reviewed. The audit annual will report to NHS boards and NHS Scotland.

Equally, the individual services should review all significant adverse events by way of the current SAER process (Significant Adverse Event Review). Services should also conduct root cause analysis of serious incidents and near misses so that learning can be disseminated by following existing reporting procedures in keeping with internal and children’s services planning governance arrangements.

Robust governance arrangements must be in place regarding communication and information governance and all communication should aim to allow the young person access to information about their care in a way that is meaningful for them and enables the provision of feedback about their care.

Information should be given to the young person about the unit they are referred to prior to admission and all information and feedback from service users and their parents or carers should contribute towards future service development.

Services are expected to ensure that robust systems are put in place to gather patient, family, and stakeholder organisation feedback. A variety of means should be used to gather information including but not limited to:

• social groups in wards such as community meetings
• therapeutic intervention programmes
• discharge questionnaires
• patients’ self-reports on care and treatment
• advocacy support groups
• discussion with families
• consultation with referrers, and other key stakeholders

Age-appropriate independent advocacy (including independent mental health advocacy) services must be provided. Advocacy services are required to complete regular activity reports on service provision through service review meetings highlighting young people’s feedback and any areas requiring action.

The delivery of services in adolescent IPCUs must also include access to child welfare and educational services. The provision of clinical services must be made by a wide variety of professionals with a background in child and adolescent mental health and experience working with the serious psychiatric disturbance(s) that would necessitate intensive care.

The planning and design of any intensive psychiatric care facility should consider the importance of a specific environment that is designed to meet patients' sensory needs in a way that will support emotional regulation and self or supported de-escalation.

6. Governance and Procedural guidance

Each unit must have an identified child protection lead within the service who will be a senior point of contact in relation to any safeguarding concerns and who can liaise beyond the unit as necessary regarding such matters.

As stated within the National Guidance for Child Protection in Scotland 2021 - updated 2023^[11], everyone who works with children or young people has an important role in keeping them safe. Any individual could identify a concern that a child or young person may be at risk from abuse, neglect, exploitation or violence. The concern may arise from a disclosure by a child or young person or from other available information.

Where a young person is referred from an adolescent IPU, the unit must remain involved in review meetings and be committed to receiving the young person back into their care when the risk is manageable. In other circumstances, the referring clinician/service must continue to be involved until the young person leaves the unit and it is the unit’s responsibility to identify the relevant service for the young person’s future care.

The involvement throughout the admission and transfer by the local board CAMHS is essential and must be maintained through effective communication and involvement in clinical reviews. Particular attention and focus may be inclusive of going above and beyond the requirements of inclusion of the nearest relative, named person, and lead professional for the purposes of the Mental Health Care and Treatment Act (2003)^[4]. Should the family choose not to utilise a named person then this will be respected. The GIRFEC National Practice Model^[12] applies to all Children and Young people and therefore the IPCU should ensure that it is applied in practice, and of course, parents and carers may have a right to involvement in decision making. The local authority is the implementation authority should a child be subject to a Child supervision order. If a Parental Order has been obtained, the local authority may hold parental responsibility as defined under the terms of the Children’s (Scotland) Act 1995. Important local/catchment area services include health and social work professionals, youth justice teams, educational services, Community Mental Health, and Wellbeing Services, and Intensive Home Treatment Services and third sector organisations.

We developed a national steering group to allow economies of scale and consistency in service delivery if as regional services were commissioned, we wanted to develop and agree national standards to provide consistency across three units.

7. Referrals

The decision to admit a young person to an IPCU must be based on a detailed risk assessment, consideration of how risks will be safely managed, and identify the measures required to resolve risk in the short term.

Referrals must be made using the national referral form (appendix 2) and or proforma. Children and young people who already have a completed national CAMHS referral form will only be required to complete the additional information required pertaining to an IPCU referral.

The processing of referrals must not be delayed because of issues relating to establishing commissioning responsibility or ordinary residence status as defined in the Responsible Commissioners Guidance (Scotland)^[10].

To prevent avoidable admissions, the assessment must demonstrate that the identified risk(s) cannot be effectively managed in an adolescent IPU and will not require longer-term management in a low/medium secure IPU.

8. Acceptance Criteria

All of the following must apply:

• the young person is under 18 years of age at the time of referral
• the young person will be subject to detention under Mental Health legislation
• young people may be accepted with pending criminal charges if subject to detention under Mental health legislation
• the young person suffers from acute behavioural disturbance, in the context of their mental illness, that cannot be safely managed in an adolescent IPU or community setting due to the nature and degree of risk of harm to others or themselves and requires intensive specialist risk management procedures and specialist treatment intervention.

9. Exclusion Criteria

Young people who present with longer term behavioural disturbance, either forensic or non-forensic, and require care in a low/medium secure or secure residential setting.

Young people who present a serious risk to the public (which may include some high-risk young people who may have no offending history, as well as those who have been charged with or convicted of specified violent or sexual offences under the Criminal Justice (Scotland) Act 2016^[13]. These young people may be more suitable for the national low or medium secure IPU.

Fire Setting not in the context of an acute mental illness.

10. Referral sources

Referrals are accepted from the following sources:

• community CAMHS, following assessment by a CAMHS Consultant (or Specialty Trainee 4-6 if waiting for a consultant assessment would result in a significant delay). Community CAMHS includes Intensive CAMHS, adolescent outreach services, early intervention in psychosis services, community adolescent forensic service (or an adult mental health service if they provide care for 16 - 18-year-olds)
• Tier 4 adolescent IPU (including low/medium secure IPU and National LD inpatient Service)
• specialist residential settings including Secure Children’s Units where the referral has been made by a CAMHS Consultant or Specialty Trainee 4-6 and only for children or young people subject to decisions of the Children’s Hearing System, and who are liable for detention under Mental Health legislation
• Scottish Courts

Referrals shall be considered by the IPCU team in consultation with the referrer. The IPCU response must be given within 24 hours of referral (including referrals made from hours of services and/or on bank holidays) and in line with local provider pathway arrangements.

All referrals must be supported by the CAMHS service responsible with agreement from the clinical team. Notification to the referrer of the decision to admit must be made no later than the next working day.

Responsibility for the clinical care of the young person remains with the referring agency/service until the point of admission to the IPCU.

11. Referral, initial assessment, and decision

The service will frequently take emergency admissions, however, the appropriateness and suitability of each referral still requires consideration by the IPCU and the referrer.

The decision to admit a young person should be made based on clinical need and the availability of a bed in the IPCU.

Emergency Referrals must be reviewed and responded to by a senior clinician within 2 hours. Emergency assessment must be offered within 12 hours followed by admission within a maximum 24 hours of the decision to accept.

Urgent referrals must be reviewed and responded to within 12 hours and assessment offered within 24 hours followed by admission within a maximum of 48 hours of the decision to admit.

There may be occasions when the referral may not be appropriate for that specific IPCU, because for example the patient mix at the time makes admission unsuitable due to vulnerability or an over-stimulated environment. The referral may also be inappropriate as individual treatment needs are long term and may be more suited to low/medium secure IPU.

Following admission, the initial assessment must be conducted by members of the multidisciplinary team (to include a consultant CAMHS psychiatrist) from the IPCU. Following the assessment, the service must give an opinion as to whether the young person requires an ongoing IPCU admission.

If it is found that the young person does not require ongoing intensive psychiatric care, then advice on alternative provision must be provided to the referring service where appropriate. In those cases when a young person’s care is transferred from IPCU to a different hospital site, the IPCU must provide a comprehensive assessment report.

12. Pre-admission

The referring team must ensure that the staff at the IPCU receive all relevant documents and information about the case and include:

• the initial assessment and referral (including the referring team’s opinion on the reasons for seeking admission to IPCU) which will be completed by Tier 3 CAMHS Consultant Child and Adolescent Psychiatrist or Child and Adolescent Psychiatry Specialty Trainee ST4-6, in consultation with the Consultant Psychiatrist
• a comprehensive risk assessment
• completed Mental Health Act documents
• any further relevant information, for example from Youth Justice Teams, Police or Social Work, if available
• the individuals who hold parental responsibility should be established prior to admission and clarity obtained as to who is the nearest relative/named person for the purpose of the Mental Health (Care and Treatment) (Scotland) Act 2003^[4]
• where possible a discharge plan should be agreed before admission.

13. Admission

Admission to the adolescent IPCU must be facilitated in a timely way consistent with the urgency of referral, and it is recognised that admissions will frequently be urgent.

On admission, services must provide young people with information about the available treatments and facilities and ensure that they are informed of their rights under the Mental Health (Care and Treatment) (Scotland) Act 2003^[4] in a way that is meaningful to them. Written information about rights under the Mental Health Act must be sent to the nearest relative/named person unless the patient objects.

An admission planning meeting must be convened within five working days to plan a care pathway in the IPCU and to consider the length of stay and timeline for discharge (if this has not been agreed prior to admission). This should be in line with the care programming approach national guidance.

Services must comply with the requirements of the Mental Health (Care and Treatment) (Scotland) Act 2003^[4].

Prior to or within 72 hours into the admission of a young person to an adolescent IPCU, a named community case manager and community consultant child and adolescent psychiatrist in Tier 3 CAMHS must be identified and in place.

14. Care Planning

The Care Plan Approach must follow a recovery and outcome process, reflecting the need for inpatient care, treatment, and supervision and form the cornerstone of delivery of an effective care pathway through intensive care. As specified under the following:

• an initial care planning meeting must be convened within 5 working days
• further review meetings must take place at least every 3 weeks
• review meeting attendance should be encouraged by the use of teleconferencing and videoconferencing. Given the short timescales of IPCU care pathways, the involvement and responsibility of multiagency colleagues outside the unit is crucial and must be ensured
• for young people who are in the care of the local authority, looked After Children (LAC) reviews must be facilitated and should be undertaken jointly with inpatient reviews where possible
• for young people with a learning disability and /or neurodevelopmental conditions the unit must facilitate care planning that is inclusive of their needs and ensure that recommendations are acted on
• as mentioned above it is recommended that a robust multidisciplinary framework such as the care programming approach should be employed as a national standard

The treatment/care plan must incorporate routine outcomes monitoring such as those set out by Quality Network Inpatients CAMHS (QUNIC) standards^[14] to monitor progress and treatment on a week-to-week basis. Care planning should also incorporate the GIRFEC principles and the eight wellbeing SHANNARI indicators^[10].

The care plan must reflect the young person’s needs in the following domains:

• mental health
• developmental needs
• physical Health
• risk
• family support/functioning
• social functioning
• spiritual and cultural
• education, training, and meaningful activity
• where relevant includes a Carer’s Assessment
• where relevant includes accommodation / financial needs
• where relevant addresses substance / alcohol misuse
• where relevant addresses offending behaviour
• LGBTI

Considerations in intensive care pathway planning must always balance the relevant needs of an individual young person, including:

• the immediate risk posed by the young person to themselves and/or others
• specialist treatment needs which cannot be met in lower intensity settings
• the principle of least restrictive care
• the young person’s vulnerabilities, including potential destabilisation by multiple transitions
• placement stability and continuity of care.

15. Enhanced observations

Enhanced observations provide a level of supervision above routine observations. The frequency is determined by the needs of the young person, for example, regular 5-minute checks or continuous supervision.

Enhanced observations will in normal circumstances be considered to be part of the contracted level of general care.

All CAMHS IPCU must:

• develop and implement a policy for enhanced observation and therapeutic intervention (i.e., ‘From Observation to Intervention’- Healthcare Improvement Scotland (HIS)^[15] and Scottish Patient Safety Programme (SPSP)
• deliver enhanced observations in line with good clinical practice (for example but not limited to, when a young person exhibits overt physically aggressive behaviour towards others or is an active risk to themselves)
• review enhanced observations at least twice daily and reduce them to the minimum at the earliest opportunity undertake enhanced observations using staff members who are familiar with the care needs of the young person.

16. Seclusion facilities

IPCU must have appropriate facilities for the management of young people who require periods of care in seclusion away from the main patient group to appropriately manage the level of risk they pose to others.

All physical seclusion facilities and patient management practices must comply with the Mental Welfare Commission for Scotland’s Good Practice Guide^[16]on Use of Seclusion, ensuring due regard to the legal provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003 and Adults with Incapacity (Scotland) Act 2000.

17. Physical Healthcare

IPCU services must ensure that young people have access to routine and regular physical health needs assessment and treatments for emerging and ongoing physical health issues in a timely and effective manner.

Routine physical healthcare should be provided by junior medical staff under supervision and there must be access when necessary to paediatric and more specialist medical provision as required.

Services should have in place policies to support the visions laid out in the Mental health and wellbeing strategy (2023). Setting out to achieve improved overall mental wellbeing and reducing inequalities. An improved quality of life for CYP with mental health conditions, free from stigma and discrimination.

18. Education

Under the provisions of section 14 of the Education (Scotland) Act 1980^[17], education authorities have a statutory duty to make special arrangements for pupils to receive education at a place other than an educational establishment, where they are either satisfied the pupil would be unable to attend a suitable educational establishment as a result of their prolonged ill health, or if they feel it would be unreasonable to expect them to do so.

The Scottish Government has published guidance on education for CYP unable to attend school due to ill health^[18] which provides advice and information for education authorities in relation to this statutory duty.

Where a child or young person's illness is known, or reasonably thought to be likely to extend to or beyond 5 days, then education should proceed immediately, if medical assessment permits. Where there is less certainty over the possible length of any absence, education out with of school should commence at the earliest opportunity and certainly no more than 15 working days of continuous or 20 working days of intermittent absence. Young people are supported and encouraged to continue with their education or other learning opportunities when admitted to the hospital, even if for relatively short periods. The ambition is to enable education to continue wherever possible.

Acknowledgement is given that children and young people who require treatment in an IPCU facility may be too unwell to engage in an educational programme throughout their admission. Priority should be given to regular review of this in keeping with care and treatment.

Where the unit caters for young people over the age of 16, young people can continue with education.

If the young person is receiving education, educational staff at the unit should consult with the young person’s school to maintain continuity of education provision.

Where young people are returning to their local educational facility after discharge, education and unit staff support the young people with their reintegration.

The educational staff maintain communication with the young peoples’ parents/carers, e.g. by providing progress reports for each CPA review.

Educational outings are provided, as appropriate.

Teachers contribute to multi-disciplinary meetings.

Teachers and nursing staff have a handover at the beginning and end of each school day.

The unit is part of an education organisation that is a registered examination centre. The unit provides the core educational subjects: maths, English, and science.

The unit provides a broad and balanced curriculum that is suitable and flexible, appropriate to the students’ needs.

All in-patient services must ensure that educational sessions can be provided during the normal academic term. The education provided should be an integral part of the service provision. Whilst educational and recreational facilities should be available to young people in intensive care settings, these should be set up to reflect the shorter period of stay in these services.

Where children or young people were admitted to hospital, and subsequently discharged to go home to continue treatment or to recuperate, arrangements for their continued learning should be considered by the home education authority if the total period of absence is likely to extend beyond 15 days from that point.

Education provision should, as far as possible, be made in accordance with the child or young person’s education support plan (Individualised Educational Programmes or a statutory Coordinated Support Plan)^[19], Child’s Plan^[20] and account be taken of any additional support for learning needs as identified by the education authority under the Additional Support for Learning Act 2004. A review of a child or young person’s additional support needs should also be undertaken before they transition back to school.

Local authorities are funded to discharge this duty. The cost of education provision will not be included in the cost charged to the NHS.

Consequently, the quality and standard of education provided although integrated within the CAMHS provision, is subject to the local authority commissioning arrangements rather than subject to the NHS regional commissioning arrangements for the IPCU.

(i) Education is provided by local education authorities within which the hospital is based

(ii) Local Authorities commission the provider education authority based on the needs of individual young people

(iii) Education colleagues work closely with NHS hospital providers to ensure their input is integrated within the child and young people's plan.

The education must be full-time or as close to full-time as in the young person’s best interests taking account of their health needs. The full guidance can be found below.

19. Discharge

All young people and their families/carers must be supported to take an active role in their discharge planning and would normally be discharged into the following settings:

• Tier 4 CAMHS inpatient care
• open residential settings, including family home and residential care
• secure forensic mental health services for young people
• secure non-NHS provision

Services must actively involve the catchment area services from the young person’s home area. If the young person is detained under the Mental Health legislation, the service must ensure that the organisations responsible for aftercare are involved in discharge planning and decision-making.

20. Discharge to Tier 4 CAMHS general adolescent units, in-patient units, other residential care, and community settings

The discharge of a young person from intensive in-patient care must be dictated by the nature of their presentation and needs. However, the aim should be to keep the length of stay as short as possible, in line with the principle of least restrictiveness.

Admissions should not last longer than six weeks. Any admission that may last longer than six weeks must be subject to robust clinical review which focuses actively on alternatives to continuing IPCU provision including, where criteria are met, transfer to either low or medium security or alternative secure provision including secure children’s homes.

Any risk of delayed discharges must also be clearly communicated to the responsible board who should become actively involved in the facilitation of discharge. National Services Division will monitor lengths of stay.

Several different mental health problems may lead young people to require intensive psychiatric care, including psychosis, bipolar disorder, self-harm, neurodevelopmental disorders, and learning disabilities. Typically, a young person placed within an IPCU would have been transferred in the first instance to an open adolescent ward although occasionally to either residential care, a low secure setting or directly to the community with either Tier 3 or alternative specialist CAMHS care.

Discharges to the community must comply with Mental Health (Care and Treatment) (Scotland) Act 2003^[4] and guidance from the Mental Welfare Commission for Scotland relating to suspension, variation or revocation of detention^[21].

21. Delayed Discharge

If a patient is delayed from being discharged from the service other than for clinical reasons, the service must inform the relevant Senior Health and Social Care managers and the referrer as soon as possible to identify how the delay can be overcome. This must involve liaison with other agencies and should also trigger local escalation procedures.

Good practice would be inclusive of a robust discharge co-ordination framework which is activated at the point of admission and is inclusive of a multidisciplinary and multiagency approach. The hosting board should ensure there is an agreement between health and local authority around timeframes and escalation procedures.

22. Young people and family/carer involvement

Scotland’s ‘Getting it right for every child’ framework is clear that services should develop collaborative approaches to care which enable professionals, young people and families or other carers to work together to meet a young person’s needs at each and every stage of treatment^[10].

Family/carer involvement should include, if appropriate rights to visits and phone calls with family/carers, as long as there are no wellbeing or legal reasons precluding this.)

The 2003 Act introduced the concept of “specified persons” in respect of authorising restrictions on individual’s correspondence, use of telephones and also in relation to safety and security in hospitals. This means that where the responsible medical officer (RMO) is considering applying such restrictions, the patient concerned must be designated as a specified person. This should be done by way of a reasoned opinion being provided by the RMO before any restrictive measures around the use of telephones, correspondence and safety and security may be applied on any individual within the IPCU.^[17]

Family/ carer involvement should include providing a history and involvement of family/carers in planning and evaluating treatment and discharge planning.

23. Safeguarding

Young people in Tier 4 CAMHS, especially those with a learning disability are often vulnerable, with high levels of dependence, but low levels of trust. This is also particularly true of some Looked-After Children (LAC). In addition to the statutory responsibilities of professionals, sensitivity to these young people’s potential vulnerabilities is needed.

The service must take all appropriate measures in relation to the safeguarding of young people under their care. They should ensure that there is a child protection policy in place that reflects the guidance and recommendations of the National Guidance for Child Protection in Scotland 2021^[22] and that the policy is implemented by all staff.

The NHS board has designated lead roles for child protection issues and that staff know who to contact for child protection advice and support.

There are clear policies in place for identifying, sharing, and acting upon concerns about the risk of harm to a child or children.

There are clear clinical and care governance processes and systems in place, to enable continuous improvement in practice, as well as learning from child protection reviews, including both significant and adverse case reviews.

Each practitioner remains accountable for their own practice and must adhere to their own professional guidelines, standards, and codes of professional conduct.

There is a contemporary learning and educational framework that supports practitioners to build confidence and competence in discharging their duty to safeguard and protect children.

24. Post-age 18 care pathway

To ensure good age transition planning it is essential to be aware of young people’s age and date of birth prior to admission. There must be a transition policy in each NHS board to transfer young people when they reach 18^th birthday.

Transition Care Plans^[23] (TCP) are a resource which aim to improve transitions from children to adult mental health services. TCPs allow children and young people who are receiving treatment from CAMHS to outline their needs, wants, preferences and concerns ahead of their move over to adult services.

It is the responsibility of the Local Tier 3 CAMHS to have an organised transition plan six months prior to the young person’s 18^th birthday.

If a young person turns 18 during an admission to an adolescent IPCU and still requires intensive psychiatric care, agreement should be reached between the Adolescent IPCU and the local Adult Mental Health service on an appropriate timescale for transfer to an adult IPCU. The adolescent IPCU staff must organise the transition to Adult Mental Health Service together with the Tier 3 CAMHS service.

The principles of good transitions^[24] have laid out guidance and set out a standard that the framework will support practitioners from across a range of services. In particular, this framework is an excellent tool for supporting young people with additional support needs transitioning from school into adulthood and from children’s to adult services. The Principles of Good Transitions 3 has been endorsed by key organisations that have committed to putting these principles into practice.

In some cases, young people may stay in an adolescent IPCU for a short time beyond their 18th birthday if a brief period of illness is anticipated and it is considered that it would be unnecessarily disruptive to organise a transfer to adult services. The view of Tier 3 CAMHS service and the family/carers should be sought. If the young person does not require further IPCU admission but requires an adult acute bed this must be organised by adolescent IPCU staff with the support of the young person’s care co-ordinator in the community.

25. Interdependence with other Services

Tier 4 CAMHS IPCU must be a separately staffed unit but not an isolated or stand-alone facility. Adolescent IPCUs complement Tier 4 CAMHS in-patient provision for young people and must be co-located with such provision.

Adolescent IPCUs are part of a spectrum of services that meet the needs of young people with mental disorders (including neurodevelopmental disorders such as learning disability and autism) in need of specialist care and treatment in an intensive setting. These services also support young people in their recovery and enable transitions into less restrictive environments.

National Services Division (NSD) are looking to commission a national learning disability (LD CAMHS) Inpatient unit on two sites to accommodate children under 12 and adolescents. When operational, these facilities will provide specialist care and treatment for children and young people with severe and profound learning disabilities comorbid with mental health disorders and/or neurodevelopmental disorders. This specialist facility will also provide a low secure developmentally appropriate setting with the same fabric and environmental security to that of an IPCU and therefore careful consideration should be given to where care and treatment needs would be best met.

26. Governance and accountability

Individual IPCU services should form part of a regionally and nationally co-ordinated network to ensure parity of practice and flexibility in terms of availability of in-patient beds.

NHS Greater Glasgow and Clyde has been identified as the initial provider board and will be supported by the west of Scotland director of regional planning and regional planning support team to ensure the following:-

• progress reporting to the West of Scotland regional planning group
• attendance and updates at the CAMHS regional clinical network, led and chaired by the directors of regional planning from across all regions
• regular meetings established between director of regional planning (owner) and the CAMHS improvement team (commissioner) to report on progress and early indication of any risks to completion
• regular updates to NHS board routine engagement meetings led by my colleagues in the menta health performance unit

IPCUs must establish a networking arrangement with regional, general adolescent units and the NSAIS, Foxgrove, in order to support smooth facilitation of step up and step-down processes for children and young people referred to or within service. The establishment of such a network has been discussed and agreed with stakeholders.

We want these standards to support equitable and non-discriminatory access to mental health care and support as well as equity in the experiences and outcomes of people using services. As outlined within the Core Mental Health Standards^[25] services should be evaluated and continually improved based on feedback and service user experience.

IPCUs should therefore ensure that they have measures in place to capture and address such feedback to meet these standards.

• I will be asked about my experiences and this feedback will be used to improve services. With my agreement, my support network will also be able to offer feedback
• I will be able to easily find clear information on what actions I can take if these standards are not being met or I do not feel satisfied with my experience
• I will be signposted to independent advocacy services for support, given the opportunity to share my experience confidentially and be supported to make a formal complaint if I want to

As outlined above these standards and specification have been input and supported by the national stakeholder group and also had some service user involvement. It also set out to address the recommendations from the findings of the Scoping Review^[11] These standards should be used as a guide for all CAMHS IPCUs in Scotland in order to provide a consistent approach and also to set out local policies.