The Scottish Government

SCOTTISH RECOVERY INDICATOR ( SRI)

Version: April 18 ^th 2007

This draft version was adapted for Scotland from the Recovery Oriented Practices Index* and will be subject to further change and adaptation.

1. About this tool

A commitment to develop a tool to assess practice against expected values was outlined initially in the report of the Mental Health Nursing Review (Rights, Relationships and Recovery) and then later in Delivering for Mental Health. Initial work in Scotland suggested that the Recovery-Oriented Practices Index ( ROPI), developed at New York State Office of Mental Health following an extensive research, consultation and testing process, offered a good starting point for our needs. A stakeholder group was set up to consider how to adapt the tool and ensure relevance to Scotland. The group worked hard to ensure that the tool remained as faithful as possible to the original to ensure that the elements which are known to promote recovery are retained. The emerging SRI tool will be now be piloted in three Health Board areas and adapted and developed in the light of findings.

2. The context for using this tool

A recovery approach or recovery orientation is best described as applying individual level factors (the things which have been shown to help and hinder recovery on an individual basis) to system level change. In other words ensuring practice in mental health services relates to the factors which people have identified as helping or hindering recovery. The Scottish Recovery Network describes recovery as follows:

Recovery is being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Each individual's recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process. It is important to be clear that there is no right or wrong way to recover."

When using this tool it is important to take account of issues related to equality and diversity. The distribution of risk and resilience factors that can influence mental health and well-being is not random, some communities and people are exposed to greater risk than others. In particular:

1. The experience of poverty and economic inequality are associated with poorer mental health and well-being.
2. The experience of discrimination, prejudice and stigma on the basis of aspects of social identity, such as gender, race and culture, sexual orientation, age, disability or religion or belief can both be detrimental to mental health and well-being, and increase the risk of being in poverty or socially excluded.
3. For people with mental health problems the experience of discrimination, prejudice and stigma can have negative social and economic consequences.

In developing a recovery-orientated approach to mental health services, it is essential to recognise and respond appropriately to the individual needs and circumstances of people's lives. Services should be delivered in a person-centred way, fully respecting diversity and service user choice.

3. When using this tool

The item description and the five associated scale points serve as a guide for scoring services on the principle represented in each item. Where services or aspects of services do not fit the scale the following general instructions for scoring (adapted from Quality of Supported Employment Implementation Scale) should be applied:

5 = Full and complete adherence to all components of the principle and practice stated in the item narrative.
4 = A close approximation to the principle and practice, but falls short on 1 or more of the necessary components.
3 = A significant departure from the principle and practice, but nonetheless partially embodies the necessary components.
2 = Very little presence of the principle and practice.
1 = Absence of the principle and practice

Not all circumstances and characteristics of a service can be anticipated. If you feel that your service or team does not provide certain aspects which are expected then you should be sure that people who use your service are able to access that provision from elsewhere in the local service system. You should base your answer on the extent to which people are able to access that service.

*Mancini, A.D., and Finnerty, M.T. (2005). Recovery-Oriented Practices Index, unpublished manuscript, New York State Office of Mental Health

1. Meeting basic needs

Indicating that the assessment, planning and delivery of all services should first address basic needs. Services should include assistance in the following aspects:

1. Shelter - service has relationships with housing providers and has placed service users in housing through referrals. Housing services, including housing with support, are basic components of care and not merely addressed in isolated situations. (Respondent should discuss role of housing in care.)
2. Nutrition - service routinely provides service users with assistance to ensure access to good culturally appropriate quality food and a balanced diet. (Respondent will need to evidence how addressed)
3. Physical health - service assesses physical health care of service users, makes referrals to primary care when necessary, and has follow-up arrangements on service users with any physical health needs. (Ask about two service users with significant general health issues and how service facilitated care.)
4. Entitlements - service assists with entitlements, advocacy and general advice eg legal, financial, housing. (Where indirectly provided, respondents should evidence knowledge of local agencies and offer examples of individual referrals.)
5. Personal care - provides service users, as required, with help with personal care, including as necessary personal hygiene, attention to clothing , haircuts etc (Respondents to evidence attention to this area, with examples)
6. Religion and belief - records expression of religious or belief-based needs and enables access as required.

Assessments do not cover any basic needs, including shelter, nutrition, medical care, entitlements, and personal care

Assessments typically (>60%) address basic needs in a cursory fashion ( e.g. brief description of current housing or some assessment of medical issues)

Assessments typically (>60%) cover 1 or 2 basic needs in detail

Assessments typically (>60%) cover 3 or 4 basic needs in detail

Assessments typically (>60%) cover all 5 areas in detail

Service routinely provides 1 or no responses related to basic needs

Service routinely provides 2 responses related to basic needs

Service routinely provides 3 responses related to basic needs

Service routinely provides 4 responses related to basic needs

Service routinely provides all 5 responses related to basic needs

2. Personalisation and choice

Indicating that the planning and delivery of all services be designed to address the unique circumstances, history, needs, expressed preferences, and capabilities of each service user.

Brochures/accessible information and documentation contain no mention of service user choice

Brochures/accessible information and documentation refer to service user choice but not as a cornerstone of expressed service philosophy

Brochures/accessible information and documentation make clear that service user choice is a fundamental principle guiding policies, procedures, and services

Care plans are standardised, with minimal to no variation

Care plans show minimal variation in goals, with 90% of plans having at least 1 similar or identical goal ( e.g. psychiatric stabilisation, medication compliance)

Care plans show moderate degree of variation in goals, with 50-89% of plans having at least 1 similar or identical goal

Care plans show high degree of variation in goals, with 20-49% of plans having at least 1 similar or identical goal

Care plans show substantial variation in treatment goals, with < 20% of plans having at least 1 similar or identical goal in most recent care plan

Minimal to no variation across service users

Some variation but response is substantially the same across service users

Moderate level of variation across service users ( e.g. substance abuse; some employment services)

Substantial variation ( e.g. participation in range of group and MH activities) but efforts to address unique needs of individual service users are minimal

Substantial variation and active efforts are made to address unique service user needs (Should be able to identify at least 50% service user's with services that are unique to them)

3. Strengths-based approach

Indicating that service delivery and planning should be focussed on service user's strengths.

Assessment does not address service user strengths

Assessment Includes one aspect relating to strengths

Assessment addresses strengths in multiple areas of functioning

Care plan format does not address role of service user strengths

Care plan format includes one generic section on strengths

Care plan format promotes integration of strengths into the achievement of goals

Service has no documented goal of promoting a strengths-based approach

Service documentation includes mention of promoting service user strengths but aspect is not basic to service philosophy

Service documentation evidences clear emphasis on service user strengths as a basic principle of care

4. Comprehensive service

Indicating that a range of treatment services (medication, vocational, family-based, substance abuse, wellness, counselling, trauma) using different approaches (individual, group, and peer) should be provided or support given to make accessible by the service, including the following:

1. Medication - service provides access to individually tailored advice on effects/side effects of medication, prescriptions, medications, delivery of medications, monitoring of medication compliance, blood testing etc as appropriate.
2. Vocational/ employment - service provides a range of proactive employment services, including job assessment, development, placement, coaching, and ongoing supports for those able and wishing to work. (If service only assesses job needs and provides some coaching, then it does not pass for this indicator. There should be evidence of active job assistance that has resulted in at least 5% annual open employment and 20% job or voluntary sector placements.)
3. Alcohol and drugmisuse - provides or can access both individual and group substance misuse counselling for service users.
4. Counselling - service provides, or is able to access, individual counselling and symptom management. (Should identify instances in which counselling or psychotherapeutic intervention was provided to address a specific service user's difficulty. For example, helping a service user suffering from panic symptoms overcome fears related to leaving the house.)
5. Family/Social system based treatment - provides assistance to partners, families, friends, named persons, faith communities and spiritual advisers to engage them in service user's treatment and/or care as appropriate- demonstrated by frequent joint visits with service user's partners, families and friends. (This should include frequent visits with partners, families and friends and family/friends-based groups run by the team. If one or the other is not available, no credit is given.)
6. Trauma services - service assesses and provides or accesses responses related to trauma, such as physical or sexual abuse, for service users in need. (Should include proactive efforts to identify service users suffering from trauma and targeted interventions to address it. Respondent should be able to identify a number of instances in which the team addressed an issue related to trauma...)
7. Wellness management - service provides or can access interventions designed to help service users manage their own symptoms, address relapse management and achieve valued personal goals. (Should include assistance designed to promote service users ability to manage their symptoms).
8. Health improvement - service provides access to a range of services such as diet, physical activity, smoking cessation, GP social prescribing.

Provides or can access at least 2 of the responses as part of routine care

Provides or can access 3 of the responses as part of routine care

Provides or can access 4-5 of the responses as part of routine care

Provides or can access 6 -7 of the responses as part of routine care

Provides or can access all 8 of the responses as part of routine care

5. Service user involvement/participation

Indicating service user involvement as integral to the planning and delivery of all services and to the determination of policies and procedures for service operations. Service should also actively recruit service users who are hired with equality in pay, benefits, and responsibilities to other employees.

Policies do not specifically address diverse service user involvement in activities or operations and there is no formal mechanism for promoting involvement

Policies exist regarding diverse service user involvement but no formal mechanism for promoting involvement

Policy and formal mechanism for promoting diverse service user involvement exist but mechanism is cursory ( e.g. yearly satisfaction survey) and has not significantly informed development

Policy and formal mechanism exist for promoting diverse service user involvement that has resulted in at least one significant change (must identify this change)

(In addition to 4) There is service user advisory board and/ or service user(s) on governing body. Service users also contribute to staff appointment process and training

No policy or protocol for service user- directed service planning

Policy but no protocol for service user -directed service planning

Policy and protocol for service user- directed service planning

No service users employed or service users not paid equally

Service users only employed in part-time positions or with limited responsibilities and/or no clear evidence of reasonable adjustments

Service users employed on permanent and temporary contracts(as appropriate) in part-time and full-time positions with equal pay and responsibilities and with clear evidence of reasonable adjustments

6. Involving support networks and promoting social inclusion and community integration

Indicating that there should be active efforts in the planning and delivery of services to involve service user's social support networks (families, partners, friends, named persons, work colleagues, spiritual advisers, community leaders etc) in care and treatment. Also indicating efforts to promote social inclusion and community integration.

Fewer than 10% of service users have some member of their support network involved in their care and treatment

11-20% of service users have a member of their support network involved in their care and treatment

21-30% of service users have a member of their support network involved in their care and treatment

31-40% of service users have a member of their support network involved in their care and treatment

> 41% of service users have a member of their support network involved in their care and treatment

Services to promote social inclusion and community integration include:

1. Self-help - service makes routine referrals to self-help and collective advocacy groups. (A list or detailed knowledge of self-help and collective advocacy groups in team's immediate area should be readily available).
2. Non-mental health activities - Service routinely facilitates service user's participation in non-mental health activities. (Should be able to identify significant instances in which service users were given assistance to participate in a desired activity, including educational, recreational, voluntary work or other pursuits. Group outings should not be counted toward this indicator).
3. Vocational/employment services - service provides or facilitates referral to a range of proactive employment services for those able and wishing to work, including job assessment, development, placement, coaching, and ongoing supports. (Assessing job needs and providing some coaching does not pass for this indicator; there should be evidence of active job assistance).

Service provides no responses related to community integration

Service provides 1 response related to community integration

Service provides 2 responses related to community integration

Service provides all 3 responses related to community integration

7. Service user in control and active participant even when subject to compulsion

Indicating that services takes steps to encourage service user's to:

1. Make decisions in advance of possible future incapacity. This includes information and encouragement to appoint powers of attorney for financial and welfare matters, nominating a named person and making an advance statement. A recovery-oriented service takes active steps to encourage these actions when the service user has capacity.
2. Participate in own care and treatment when subject to compulsion. Legislation requires that service user's under long-term compulsion have care plans. A recovery-oriented service promotes the involvement of service user's in the design and content of their care plans.

No evidence of information or active encouragement to make decisions in advance

Information on advance decision-making displayed but no policy or active encouragement

Service displays information and actively promotes advance decisions in its contacts with service user's

No evidence of involvement of service user's in their care plans

Service user's know that care plans exist and that they can access them

Service user's are given copies of their care plans

Service user's are consulted over the content of their care plans, have copies and are involved in reviews

Care plans demonstrate that service user's are actively involved in their design and content, and have copies

8. Recovery focus

Indicating that services should be oriented toward life roles, service user aspirations, and maximising independence, including techniques for self-management of mental health symptoms, development of meaningful activities and relationships, and, where relevant assistance with employment, parenthood etc.

<20% of care plans include one goal related to life roles, service user aspirations, or relationships

21-40% of care plans include one goal related to life roles, service user aspirations, or relationships

41-60% of care plans include one goal related to life roles, service user aspirations, or relationships

61-80% of care plans include one goal related to life roles, service user aspirations, or relationships

>80% of care plans include one goal related to life roles, service user aspirations, or relationships

Approximately <10% of total service provided is designed to address life roles, service user aspirations, self-management of illness, or improving relationships ( e.g. one group on goals or illness management)

10-20% of total service provided is designed to address life roles, service user aspirations, self-management of illness, or improving relationships

21-30% of total service provided is designed to address life roles, service user aspirations, self-management of illness, or improving relationships

31-40% of total service provided is designed to address life roles, service user aspirations, self-management of illness, or improving relationships

>50% of total service provided is designed to address life roles, service user aspirations, self-management of illness, or improving relationships (substantial focus on recovery is evident in range of interventions and all embrace recovery as guiding philosophy)

No training in the last year on a topic related to recovery

Training in recovery, empowerment, or person-centred planning within the last year

Training on a topic related to recovery, empowerment, or person-centred planning as a part of induction for each staff person

No supervision in last year

No supervision in last year focussed on recovery

Supervision occasionally focuses on recovery

Regular supervision with some focus on recovery

Regular supervision always focussed on recovery