Current workstreams
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Workstream |
Description |
Lead |
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Care processes |
Embedding NHS England’s 10 essential care processes across community mental health services |
Andy Williams |
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Clinical pathways |
Standardising care for bipolar, psychosis, self harm, and more |
Claire Timmons |
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Older adults |
Redefining service models across six places |
Andy Williams/Rebecca Taylor |
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Clinical harm reviews |
Identifying and responding to harm from long waits |
Andy Williams |
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Lived Experience Charter |
Embedding lived experience in recruitment and culture |
Claire Newton/Ann Taylor |
Completed workstreams
Our journey
CERT was created to provide an enhanced community rehabilitation offer, reducing reliance on inpatient rehabilitation and supporting people with complex needs closer to home. The model is open dialogue informed, holistic and aligned with NHSE priorities and CQC quality standards.
CERT leaflet
Key milestones
May 2024
- Objectives set for Standard Operating Procedure (SOP), governance and workforce planning
- Band 7 roles initiated.
Summer 2024
- Recruitment began for occupational therapy (OT), nurses, support workers and peer support roles
- Clinical model and training strategy agreed.
Autumn 2024
- SOP drafts circulated - phased implementation agreed
- CERT launch day scheduled for 29 November 2024.
November 2024
- Team away day held to finalise SOP and implementation plan
- staff joined CERT on 1 November 2024.
Early 2025
- Oversight meetings started, performance dashboard integrated
- Communications strategy implemented.
Mid 2025
SOP signed off, CERT embedded into business as usual (BAU).
Community mental health services aim to embed lived experience at the heart of care by increasing representation in the workforce and strengthening knowledge and expertise. Mersey Care’s ambition is to build trusted, enduring relationships with individuals and communities to improve services and outcomes.
To achieve this, the service is developing a Lived Experience Charter focused on creating an inclusive, supportive and equitable environment. The charter will:
- Promote open and inclusive recruitment of people with lived experience
- Raise awareness of the benefits and address barriers to employment
- Provide tailored support from recruitment through to employment
- Establish clear progression pathways
- Foster a workplace culture free from discrimination and unconscious bias
- Share good practice and ensure co-production of services.
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Key milestones Early 2024
Summer 2024
Autumn 2024
October 2024
November 2024
February to April 2025
June 2025
October 2025
Follow the links for more: Care Programme Approach to Community Mental Health Framework Lived Experience Charter website Supported peer support worker colleagues with external training Purpose was to equip peer support workers (PSWs) with the skills, confidence and knowledge needed to deliver high quality, recovery focused support. Co-ordinating attendance at WithYou training ensures PSWs are prepared to embed lived experience principles into everyday practice and contribute effectively to community mental health transformation. WithYou training is a structured development programme designed to strengthen the role of PSWs within Mersey Care. About the training:
Key learning areas:
Why it’s valuable:
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The 5 Questions intervention has been developed within the Trust to provide a structured approach to service user engagement in settings with infrequent contact, such as depot clinics. By implementing 5 Questions, the Trust aims to enhance risk identification, communication and support planning, ensuring that service users receive the necessary oversight even in settings with limited direct contact. The purpose of the 5 Questions is to:
Feedback so far from colleagues and services users Service users reported that the questions asked during sessions are more specific, which encourages meaningful conversation. They did not perceive an increase in the number of questions or feel that the process was excessive. Regular attendees, who are generally well, noted some repetition in the questions but acknowledged their relevance and purpose. Service users expressed appreciation for the supportive environment and valued the consistency of staff at the clinic. Additionally, a student who attended the clinic provided positive feedback regarding its structure and organisation, describing the experience as a valuable learning opportunity. |
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The Communications, engagement and digital workstream was created to deliver the objectives set out in the Communications Strategy for 2023/24. It focused on:
Following a review with the Senior Leadership Team in January 2025, the workstream was formally closed as it successfully achieved its objectives. Communication processes are now business as usual, with teams working directly with the Communications Team for requests and sharing good news stories. We continue to communicate messages through Trust newsletters, the Clinical Excellence Meeting and by updating our YourSpace pages - which is the best place to come for updates regarding the transformation programme. You can view our animation explaining the community mental health transformation here. Key milestones Winter 2024
Spring 2024
Summer 2024
Autumn 2024
Winter 2025
Communications support embedded into BAU, teams liaise directly with Communications Team. |
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The Access and egress from service workstream focuses on the points where primary and secondary care services connect and the services that work within this space, such as Step Forward. The efficiency of this interface is vital to creating:
This workstream is about improving how patients access services and how they leave them safely and effectively. Our aim is to make the patient journey clear, timely and person centred, reducing delays and unnecessary complexity. Strong relationships with primary care networks (PCNs), GPs, local authorities (LA), integrated care board (ICB) and voluntary, community, faith and social enterprise (VCFSE) organisations are key to this workstream, helping us build place based support systems for our communities. Additional Role Reimbursement Scheme (ARRS) practitioners and Step Forward mental health leads work locally in this space, building relationships and understanding place based need to deliver the most effective patient journey possible. This ensures patients experience seamless transitions, quicker access to support and improved outcomes. Follow the links for more information: Step Forward Liverpool and Sefton and Kirkby Throughout this workstream, we looked at different areas, each with objectives to develop and improve transfers of care, did not attend (DNA) management, primary care referral pathways, VCFSE integration, renaming of services and the implementation of patient initiated follow up (PIFU). |
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Key milestones Spring 2024
Summer 2024
Autumn 2024
Winter 2024/25
Spring/summer 2025
Autumn 2025
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Waiting list management workstream was a key component of the Community Excellence Transformation Programme, aligned with the NHS Long Term Plan and the Community Mental Health Framework. Its purpose was to improve access and waiting times for community mental health services by introducing a flexible, responsive and personalised approach to care. This included:
The Transformation Team provided bespoke reporting templates aligned with NHSE requirements, step by step guidance for understanding and using dashboards and comprehensive support and training for staff and much more. This workstream has now successfully transitioned to business as usual, where waiting lists continue to be monitored and teams continue to adapt to new reporting requirements. This ensures that timely and effective care for service users remains the focus. Supporting information can be found here. Key milestones Winter 2024
Spring 2025
Summer 2025
Autumn 2025
Winter 2025
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Ongoing workstreams
The Framework makes clear that one of its purposes is to enable services to shift away from an inequitable, rigid and arbitrary Care Programme Approach (CPA) classification and bring up the standard of care towards a minimum universal standard of high quality care for everyone in need of community mental health care. A flexible, responsive and personalised approach following a high quality and comprehensive assessment means that the level of planning and co-ordination of care can be tailored and amended, depending on:
- Complexity of an individual’s needs and circumstances at any given time
- What matters to them and the choices they make
- Views of carers and family members
- Professional judgment.
To move away from CPA to the CMHF, a phased approach was introduced in April 2024. New service users entering secondary services were no longer placed under the rigid CPA but instead entered the CMHF model, which recommended personalised care based on need. Over the following 12 months, more service users transitioned to this individualised care based approach. By the end of this period, all community mental health teams were operating under the new CMHF.
Chart to show the progression of service users moved to the community mental health framework:
This work continues to be monitored via the new NHSE care processes workstream.
Further information on CPA to CMHF
Phase 1: Foundation (January 2024 to November 2024)
January 2024
- Start co-production of CPA to CMHF SOP
- Begin guidance development for keyworker role
- Launch holistic assessment review and care planning review.
April to August 2024
- Training for CMHTs on biopsychosocial assessment and PROMs
- Dashboard creation for BPS and care planning metrics.
October to November 2024
- Paper on personalised care planning options presented and signed off
- SOP versions circulated for feedback and amendments
- Awareness sessions with inpatient and urgent care teams.
Phase 2: Implementation and transition (January 2025 to March 2025)
January 2025
- Localised training sessions for CMHTs on SOP and key worker allocation
- Started early stages of moving service users from CPA to CMHF (initial cohorts after training).
February 2025
- Wider rollout of CPA to CMHF transition across CMHTs and recovery teams
- Engagement sessions completed across areas.
March 2025
- Dashboard updates (key worker allocation, carer identification)
- Monitoring of transition progress and feedback collection
- AMAT audit questions finalised and tested.
Phase 3: Integration and pathways (April 2025 onwards)
April 2025
- Moved personalised intervention based pathways into clinical pathway workplan
- Practitioner led care pilots (psychosis pathway) progress.
Ongoing
- Physical health checks SOP sign off
- VCFSE engagement for safe transitions back into secondary care
- Continuous Plan Do Study Act (PDSA) cycles for care planning, biopsychosocial assessment and risk formulation.
The older adults community mental health redesign aims to deliver a consistent, sustainable and accessible model of care for older people across Mersey Care. The transformation addresses historical disparities between North and Mid Mersey by standardising organic and functional pathways, improving access and timeliness of assessments and enhancing post diagnostic support. The model strengthens multidisciplinary team (MDT) working, integrates with primary care and care homes and prepares services for rising demand linked to ageing and dementia prevalence.
Key objectives include:
- Standardisation: align clinical pathways and documentation across all boroughs
- Improved access: reduce waiting times and ensure equitable service provision
- Enhanced support: deliver psychosocial interventions and care home liaison
- Integrated care: foster collaboration with physical health services and primary care networks
- Future proofing: build capacity for projected demographic changes.
Pre-implementation work has taken place over the past couple of years to engage with key stakeholders, understand service differences and identify an effective service re-design. This groundwork allowed us to define a clear plan and three key phases for the project:
- Phase One – Referral to treatment time (RTT) and assessment
- Phase Two – Review, identify and develop
- Phase Three – Standardisation of interventions.
During the project launch, stakeholders asked a range of questions. These were recorded, considered and responded to by the project lead. You can read these here.
Key milestones
Early 2025
- Scoping exercise completed across six service areas: clinical pathways, triage and access, assessment, MDT working, crisis care, care homes
- Collected workforce details from older adult teams: current profiles and proposed structures for organic and functional pathways.
Spring to summer 2025
- Paper completed and presented at senior ops meeting, pathways agreed
- Implementation plan developed and agreed.
Autumn 2025
- 7 October: soft launch meeting with CMH Transformation Team and senior leadership
- Phases of project, objectives and timescales agreed
- 14 October: official launch meeting with full stakeholder group and request for feedback
- Questions and responses circulated with attendees, considerations for project collated and saved for task and finish groups
- All requests to engage in task and finish groups collated, membership finalised and invited to first meeting
- TOR for steering group and task and finish groups agreed and saved
- First meeting for RTT and assessment task and finish group took place.
Ongoing
- Phase One RTT and assessment.
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NHSE requires all teams to establish a clear process for identifying and responding to harm caused by excessive waiting times. This process ensures patient safety, supports prioritisation and promotes transparency through duty of candour. The guidance advises teams to use a standardised proforma to record harm assessment, engage clinicians and where appropriate, patients/carers and escalate serious harm in line with the serious incident policy. From this guidance we began a pilot in April 2025, where chosen pilot teams conduct clinical harm reviews with patients. The purpose of a clinical harm review is to:
Supporting information can be found here. Key milestones Spring 2025
Summer 2025
Autumn 2025
Winter 2025
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The care processes initiative is a strategic programme aligned with NHSE’s framework to standardise and improve mental health care delivery across community services. It focuses on embedding 10 essential care processes that ensure care is person centred, evidence based, co-ordinated and responsive.
Why? To improve consistency, clinical outcomes, patient experience and integrated working.
How? Through task and finish groups in each locality, supported by digital integration, structured oversight and reporting to the care process steering group.
What? The 10 care processes include communication of service offer, assessment and formulation, risk formulation, care planning, named person, review, outcome measurement, treatment options, following the patient and transitions/discharge.
Governance is structured around a steering group (bi-monthly) and task and finish groups (monthly), each with defined roles and reporting templates. The expectation is that groups identify members, set up meetings and provide monthly updates to feed into the overall project plan.
The initiative is not just compliance driven, it aims to transform patient journeys, ensuring safety, continuity and meaningful engagement.
Key milestones
September 2025 to November 2025
Focus: Named person (key worker allocation and processes).
November 2025 to April 2026
Focus: Patient journey.
Includes care planning, reviews, outcome measurement, treatment options, transitions and discharge.
January 2026 to March 2026
Focus: Assessment and risk.
Covers assessment and formulation, plus risk formulation.
March 2026 to June 2026
Focus: Communication of service offer.
Ensuring clear, timely communication for service users.
July 2026 to September 2026
Focus: Review, finalise, close down.
Consolidate work, finalise processes and prepare for full implementation.
The clinical pathways workstream aims to standardise mental health pathways across community mental health services to ensure interventions are consistent, evidence based and person centred. This initiative addresses variations in practice and ensures that service users receive care tailored to their needs.
Key objectives include:
- Reviewing existing pathways to align with best practice and NICE guidance with our urgent care and inpatient colleagues
- Developing new standardised pathways for priority areas:
- Psychosis
- Bipolar
- Self harm
- Additional pathways under review include depression, personality disorder, obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD), and 18 to 25 services.
Co-production is central, involving multidisciplinary teams and lived experience representatives.
Task and finish groups have been established for each pathway, with strong representation from clinical staff, psychology, medicines management, medics and peer support.
Draft pathways for psychosis, bipolar and self harm have been developed, incorporating neurodiversity considerations and allied health professional interventions.
Next steps include sign off, final refinements and implementation planning.
Key milestones
June 2025
Draft pathways for psychosis, bipolar and self harm prepared for clinical pathways meeting.
July to October 2025
Task and finish groups continue development, incorporating feedback and NICE guidance.
5 November 2025
Review and potential sign off of draft pathways at clinical pathways meeting.
November to December 2025
Final refinements based on feedback, prepare implementation plans.
January to March 2026
Begin phased implementation of approved pathways across service line.
April to June 2026
Monitor early adoption, gather feedback and adjust as needed.
July 2026 onwards
Full integration into business as usual (BAU), supported by training and digital tools.