Planned Care & Support

Planned Care & Support

This care/support forms an active integral part of the multi-disciplinary team approach, which involves working with other professionals within the N.H.S and Social Services, and local community services and facilities (e.g. education, employment and client’s families).

a. Assessment

The initial stage is a full social and personal assessment, the purpose of which is: -

1. To clearly establish the client’s assets, needs and areas of difficulty
2. To establish a baseline for care/support, and at a later date, re-assessment for the purposes of evaluation, which is: -
        i. To assess the client’s progress.
        ii. To evaluate the effectiveness of approaches and care/support being provided.
3. The assessment process is carried out through specific tasks and structured observation within Sunny Bank PRS’s accommodation and the local community.

The following areas are covered: -

Social

1. Living Skills, e.g.
   - Personal health/hygiene and care.
   - Domestic skills.
   - Home management.
   - Financial management.
   - Community services and facilities.
2. Cognitive Skills, e.g. Orientation, memory, concentration, literacy, comprehension, numeracy, currency.
3. Social and Interactive Skills, e.g. (Non) verbal communication, conversational/listening skills, assertion, social initiative and manner.
4. Physical Aspects, e.g. General physical health, attitude to health and medication, diet, weight, smoking, drinking, allergies, sexual health, use of health care facilities.

Personal

1. Psychological Aspects, e.g. Behaviour, thought content and process, perception, mood and emotional stability, insight, tolerance, reliability, responsibility.
2. Sociological Aspects, e.g. Social behaviour, relationships and dynamics, roles, family/friendship network, work and leisure.

b. Planning Care and Support

Following the initial assessment, individual staff work with the client using a client centred approach to help them identify: -

• Long-term Goals.
• Short-term Goals.
• Situations / things to try and change / improve and things that are important to the individual (to achieve).
• Identification of personal resources i.e. personal qualities, assets, achievements, social network, use of community resources and financial resources.
• Lifestyle/Strategies/Activities, etc. to help achieve their identified goals.
• A how they can stay well plan.

It is important that this process is primarily client–centred and that staff use previous knowledge gained from assessment work in a constructive, positive manner, in helping (if necessary) the client to identify (possible) areas of difficulty/needs, likely solutions, assets and achievements. We also use the Recovery Star to help clients identify progress. The resulting care/support plan belongs to each client, and distribution is to themselves, and professionals concerned in their care/support. It is the client’s choice, whether they show family/friends their care/support plan and if they are involved in any review meetings.

Consistent liaison/ongoing review and subsequent modifications of a client’s care/support occur within Sunny Bank PRS. Often this will involve contacting/consulting, and thereby involving the client’s relatives and/or other professionals. Also the more formal setting of Care Management Reviews occur, which are held with the client, family and other professionals concerned in their care/support. The frequency of these reviews is determined by all concerned parties, but a sooner review can be requested by anyone.

Clients are also asked about their own individual personal wishes/needs with regards to: -

Privacy. Dignity. Independence. Choice. Rights. Fulfilment

These are all aspects that help to underpin the quality of life for our clients, and they may in themselves have therapeutic value. Within the care/support planning process, senior care/support staff identify staff’s strategies and approaches to be used in the clients’ care/support to ensure consistency and continuity of care/support. All of these care/support plans and working practices aim not to place any “restrictions” on a client. However, it is recognised that sometimes this may occur with regards to a client’s privacy, dignity, independence, choice, rights and fulfilment (e.g. a client requiring assistance with personal hygiene), for an identified, and regularly reviewed period of time.

This may be due to: -

1. The client’s: -
   - Mental state
   - Physical Health
   - Intellectual capabilities
   - Level of functional skills
2. The need to consider the interests/needs of others (e.g. family, other clients).
3. The client being considered to present a degree of considered risk to themselves and/or others.
4. To ensure good practices as identified in the documents referred to in our stated philosophy and principles of care/support.

c. Delivery of Care/Support Plan

It is also our philosophy of normalisation to use, wherever possible, facilities and services which are provided for the general public within the community, rather than those specifically related to the field of mental health (e.g. leisure facilities, community centres, voluntary work, community support and social groups, education centres, day and evening classes, work training and opportunities).

The client’s own home within Sunny Bank PRS’s facilities is the most appropriate place to provide a lot of independent skills training.

Sunny Bank itself is used as the location for certain activities (e.g. social events, therapeutic and skill based group work, teaching activities, exercise classes, art groups and classes etc.).

Within the framework of the client’s individual, agreed care/support plan, the staff’s role consists of the following characteristics: -

• Encouraging
• Supporting
• Prompting
• Accompanying
• Initiating
• Accessing
• Liaising
• Co-ordinating
• Planning
• Representing

Their therapeutic relationship consists of working with, and along-side the client. Each client is an individual, and as such will have different needs and personal interests which will have to be met.