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(1)For the purpose of improving the effectiveness of the mental health services provided to a relevant patient, a mental health service provider must take all reasonable steps to ensure that–
(a)different mental health services which it is responsible for providing for the patient are coordinated with each other;
(b)the mental health services which it is responsible for providing for the patient are coordinated with any other such services the provision of which is the responsibility of any other mental health service provider;
(c)the mental health services which it is responsible for providing are coordinated with any services related to mental health provided for the patient by a voluntary organisation.
(2)A mental health service provider may seek the advice of a patient's care coordinator as to how the provider should discharge its duty under subsection (1).
(3)A care coordinator may at any time give advice to a mental health service provider as to how the provider should discharge its duty under subsection (1).
(4)A mental health service provider must have regard to any advice given under subsections (2) and (3) in discharging its duty under subsection (1).
(5)In this section mental health services are–
(a)secondary mental health services;
(b)services under Part 1 of this Measure;
(c)things done in the exercise of a local authority's powers in section 8 of the Mental Health Act 1983 in respect of a person who is subject to the authority's guardianship.
(6)In this section “voluntary organisation” means a body whose activities are carried on otherwise than for profit.
(1)A relevant patient's care coordinator must work with the relevant patient and the patient's mental health service providers–
(a)with a view to agreeing the outcomes which the provision of mental health services for the patient are designed to achieve, including (but not limited to) achievements in one or more of the following areas–
(i)finance and money;
(iii)personal care and physical well-being;
(iv)education and training;
(v)work and occupation;
(vi)parenting or caring relationships;
(vii)social, cultural or spiritual;
(viii)medical and other forms of treatment including psychological interventions;
(b)with a view to agreeing a plan (“a care and treatment plan”) for achieving those outcomes;
(c)in connection with the review and revision of a care and treatment plan in accordance with provision in regulations made by the Welsh Ministers.
(2)Where a care and treatment plan has been agreed, the care coordinator must record the plan in writing.
(3)Subsections (4) and (5) apply if the outcomes referred to in subsection (1)(a) or the plan referred to in subsection (1)(b) cannot be agreed between the persons mentioned in subsection (1).
(4)If the relevant patient has a sole mental health service provider, the provider must, having regard to any views expressed by the relevant patient, determine the outcomes which the provision of mental health services for the patient are designed to achieve and determine a plan for achieving those outcomes.
(5)If the relevant patient has more than one mental health service provider, each provider must, having regard to any views expressed by the patient, determine the outcomes which the provision of mental health services by the provider are designed to achieve and determine a plan for achieving those outcomes.
(6)The care coordinator must–
(a)where a plan has been determined under subsection (4), record the plan in writing;
(b)where plans have been determined under subsection (5), record all of them in writing in a single document.
(7)The records made under subsection (6) are care and treatment plans for the purposes of subsection (1)(c) and (8) to (10).
(8)The Welsh Ministers may by regulations make provision as to–
(a)the form and content of care and treatment plans;
(b)any persons whom the care coordinator is to consult in connection with the exercise of the coordinator's functions under subsection (1)(a) or (b);
(c)the obligations of persons specified in the regulations in connection with the agreement or determination of care and treatment plans;
(d)the persons to whom written copies of a care and treatment plan are to be provided (including in specified cases the provision of copies without the consent of the relevant patient to whom the plan relates);
(e)the information to be provided by mental health service providers to an individual who has ceased to be a relevant patient.
(9)The provision that may be made by regulations under subsection (1)(c) includes (but is not limited to) provision–
(a)for care and treatment plans to be reviewed and revised in specified circumstances;
(b)conferring a discretion upon the care coordinator as to whether a review or revision is to be carried out;
(c)as to any persons whom the care coordinator is to consult in connection with a review or revision;
(d)imposing obligations upon persons specified in the regulations in connection with a review or revision;
(e)as to the provision of copies of revised plans to specified persons (including in specified cases the provision of copies without the consent of the relevant patient to whom the plan relates).
(10)So far as it is reasonably practicable to do so, a mental health service provider must ensure that mental health services for a relevant patient are provided in accordance with the patient's current care and treatment plan.
(11)In this section “mental health services” has the same meaning as in section 17(5).
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