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Key Stages

By Pedro Sullivan,2014-06-28 13:05
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Key Stages ...

    NHS No Date of Birth

    Family Name Forename

    With thanks to NHS South East Coast - Adapted from NHS London’s Health Needs Assessment and the

    Single Assessment Process of NHS South East Coast.

    Assessment Principles

? In line with the revised National Framework for NHS Continuing Healthcare, this Health Needs

    Assessment must accompany a social care assessment and other individual specialist

    assessments from Allied Health Professionals etc. to form a Comprehensive Multi-Disciplinary

    Assessment. This document indicates where additional specialist assessments may be required

    by use of this symbol *.

? Agencies should ensure that suitably qualified & competent staff are available to undertake

    assessments and that more qualified or specialist professionals can be readily accessed if more

    specialist assessment or investigation is needed. (Reference: National Service Framework for

    Older People Standard 2001)

? Those staff carrying out the assessment will need to be experienced and skilled in assessment

    practice and multidisciplinary working. They should be familiar with the needs of the individual.

    (Reference: National Service Framework for Older People Standard 2001)

? The person being assessed should always be treated as an individual. To ensure consistent

    access, assessments should be:

    o Culturally sensitive

    o User centred

    o Equitable

? The individual (and their carers/advocates reference Mental Capacity Act) should be consulted

    and fully involved in the assessment process.

? The timing and location of an assessment is important and due regard should be given to further

    rehabilitation potential and the outcome of any treatments or medications which may affect the

    on going needs of the individual.

? The assessment should accurately, clearly and comprehensively detail the individuals needs

    and risks.

? The multi-disciplinary assessment should be in a format such that it can also be used to assist

    PCT‟s and LA‟s to meet care needs regardless of the outcome of the eligibility consideration for

    continuing healthcare. The assessment process should include referral for specialist

    assessments and also make use of existing such assessments wherever it is appropriate in the

    light of the individual‟s care needs.

? As stated above, this is not a stand alone document. This Health Needs Assessment is just one

    part of the multi-disciplinary assessment required before a full consideration of Continuing

    Healthcare can take place and the DST can be completed. The minimum data set to be taken

    into account before the Decision Support Tool (DST) can be completed must include a social

    work assessment and a health needs assessment.

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 1/27

    NHS No Date of Birth Family Name Forename

Date of Commencement of Assessment:

Name: (title / first name(s) / last name)

    Date of birth : Permanent

    Address: Gender:

    Referrer: Phone No:

    Lead Health

    Co-ordinator Current Address (if not permanent Name: address):

    Contact Details Is English the If not what is the individual’s first Yes No first language? language?

    Has the individual, main carer or advocate been given written information about the Continuing Yes No Healthcare process?

    Has the Continuing Healthcare process been explained to the individual, main carer or advocate? Yes No Was the individual involved in the completion of the Health Needs Assessment? Yes No Was the individual offered the opportunity to have a representative such as a family member or Yes No other advocate present when the Health Needs Assessment was completed?

    If yes, did the representative attend the completion of the Health Needs Assessment? Yes No

    Name :

    Address:

     Please give the contact details of

    the representative Telephone No: Relationship to patient:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 2/27

    NHS No Date of Birth Family Name Forename

    Please provide us with some information about yourself. This will help us to understand whether everyone is receiving fair and equal access to NHS continuing healthcare. All the information you provide will be kept completely confidential. No identifiable information about you will be passed on to any other bodies, members of the public or press. (1) What is your sex? Male Female Transgender Tick one box only

     0-15 16-24 25-34 35-44 45-54 (2) Which age group applies to you? Tick one box only 55-64 65-74 75-84 85+

    (3) Do you have disability defined by the Disability Discrimination Act (DDA)?

    The Disability Discrimination Act (DDA) defines a person with a disability as someone who has Yes No a physical or mental impairment that has a substantial and long-term adverse on his or her

    ability to carry out normal day-to-day activities.

    A - White

     British Irish Any other White background, write below

    B - Mixed

     White and Black Caribbean White and Black African

     White and Asian Any other Mixed background, write below

    C Asian, or Asian British

     Indian Pakistani Bangladeshi Any other Asian background, write (4) What is your ethnic group? below Tick one box only

    D Black, or Black British

     Caribbean African Any other Black background, write below

    E Chinese, or other ethnic group

     Chinese Any other, write below

(5) What is your religion or belief?

    Tick one box only

    Christian includes Church of Wales, None Christian Buddhist Hindu Jewish Muslim Sikh Catholic, Protestant and all other

    Christian denominations

     Heterosexual/Straight Lesbian/Gay Woman Gay Man

     (6) Which of the following best Bisexual Prefer not to answer Other, write below describes your sexual orientation?

    Tick one box only

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 3/27

    NHS No Date of Birth Family Name Forename

    If there is a concern that the individual may not have capacity to give their consent, this should be determined in accordance with the Mental Capacity Act 2005 and the associated code of practice. Those completing assessments or the DST should

    particularly be aware of the five principles of the Act:

A presumption of capacity every adult has the right to make his or her own decisions and must be assumed to have capacity

    to do so unless it is proved otherwise;

    Individuals being supported to make their own decisions a person must be given all practicable help before anyone treats

    them as not being able to make their own decisions;

    Unwise decisions just because an individual makes what might be seen as an unwise decision, they should not be treated as

    lacking capacity to make that decision;

    Best interests an act done or decision made under the Act for or on behalf of a person who lacks capacity must be done in

    their best interests; and

    Least restrictive option anything done for or on behalf of a person who lacks capacity should be the least restrictive of their

    basic rights and freedoms.

Mindful of this who holds formal decision making responsibility?

    Self or Other? Self Other (as below) Date decision made:

     Health/welfare Lasting PoA: Level of power: Financial

     Health/welfare Deputy: Level of power: Financial Enduring PoA:

    Additional Info:

    Advanced decision to refuse treatment? Yes No Date decision made: Located where?

    Has this person got capacity? Yes No If Yes - has their consent been obtained for this assessment? Yes No Have they given consent to have information shared with their next of kin, main carer or Yes No advocate? Has their consent been obtained for sharing information contained within this assessment with Yes No potential care providers?

    If the person is deemed to not have capacity

    to consent, how was their capacity

    determined? How and by whom has it been

    decided that it is in the person’s best interests

    to complete this assessment?

    SIGNATURE OF ASSESSED PERSON:

    SIGNATURE OF ASSESSED PERSON’S REPRESENTATIVE:

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 4/27

    NHS No Date of Birth Family Name Forename

    This section should be completed by a registrar or above in a hospital setting or in a community setting it should be completed by a GP or advanced nurse practitioner. What are their current major diagnosis & problems (including management/treatment plan including the need for

    specialist review)?

Describe below - How stable is their condition?

Explain how the current health conditions impact on the individuals ability to undertake activities of daily living,

    include the individuals perspective:

     Where the assessed person is in hospital, please give

    the Consultants name and specialty:

     Allergies:

     Current Infection Control Status:

    Health History (please give dates). How was the person functioning prior to this assessment?

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 5/27

    NHS No Date of Birth Family Name Forename

    Has this individual reached their full potential for recovery? Please refer to members of the Multi-Disciplinary Team before completing this section. If the individual has NOT reached their full rehab potential do NOT continue with the CHC process.

Sources of information:

    What is the Individual’s view of their needs (or if the individual has no capacity then detail the carer’s or advocate’s views)

SIGNATURE OF ASSESSED PERSON:

    SIGNATURE OF ASSESSED PERSON’S REPRESENTATIVE:

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 6/27

NHS No Date of Birth

    Family Name Forename

    Hospital/ ward Reason for Admission Admission Date Discharge Date

Complete if applicable (particularly for individuals in the community)

    Date Reason for Visit Treatment/Plan/Outcome

ASSESSOR: DESIGNATION:

    SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 7/27

    NHS No Date of Birth Family Name Forename

All appropriate risk assessments, which document both potential impact and likelihood, should be carried out to consider

    relevant risks to the patient, carers or care workers and society. Evidence from these assessments should be attached to this

    document and considered when deciding the level of need appropriate in each domain. Please use this box to draw attention

    to any immediate risks pertaining to current care or health state. Indicate which, if any, of the risks are present and indicate if

    significant. Record the severity/frequency/whom it involves.

    Areas to consider

    Risk To Self

    ? Suicide

    ? Deliberate self harm

    ? Accidental self harm

    ? Self neglect

    ? Addiction (alcohol /drugs)

    ? Wandering

    ? Falls

    Risk To Others

    ? Physically violent

    ? Threat of violence

    ? Verbally abusive

    ? Sexually inappropriate

    behaviour

    Vulnerability From Others

    ? Financial abuse

    ? Physical abuse

    ? Emotional abuse

    ? Sexual abuse

    ? Social isolation

    Unstable Mental State

    ? Mental health liable to

    deteriorate quickly or

    unpredictably

    Compliance Problems

    ? Refusing nursing/therapy

    intervention

    Other Risks

    (Please specify)

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 8/27

    NHS No Date of Birth Family Name Forename

    * Please attach current supporting mental health risk assessments/care plans/behaviour charts Please explain below in detail the types/ patterns/ triggers/ frequency of behaviours, required interventions and

    effectiveness of care plan:

CLINICAL PICTURE

    Does the person Sources of display: information: Disinhibition Daily At least weekly Less than weekly/infrequently Never Persistent noisiness Daily At least weekly Less than weekly/infrequently Never Persistent restlessness Daily At least weekly Less than weekly/infrequently Never Resistance to care Daily At least weekly Less than weekly/infrequently Never Interference with Daily At least weekly Less than weekly/infrequently Never others

    Inappropriate sexual Daily At least weekly Less than weekly/infrequently Never behaviour

    Inappropriate urination Daily At least weekly Less than weekly/infrequently Never Faecal Smearing Daily At least weekly Less than weekly/infrequently Never

At night, does the

    person display:

    Restlessness Daily At least weekly Less than weekly/infrequently Never Wandering Daily At least weekly Less than weekly/infrequently Never Need for sedation Daily At least weekly Less than weekly/infrequently Never

    Has the person been Daily At least weekly Less than weekly/infrequently Never physically violent?

    Do they threaten Daily At least weekly Less than weekly/infrequently Never violence?

    Are they verbally Daily At least weekly Less than weekly/infrequently Never abusive?

    Details :

     Is the individual subject to any Section of the Mental Health

    Act? If so which one?

If so please make sure you understand the guidance before you

    consider the individual for Continuing Healthcare Funding. Refer to

    National Framework for Continuing Healthcare , section 112 „Links

    to other policies‟

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 9/27

    NHS No Date of Birth Family Name Forename

Please comment on the individual’s ability to make decisions on a day-to-day basis (capacity); comprehension and

    ability to receive and understand information. Please comment if this individual requires an Independent Mental

    Capacity Advocate.

Are there other factors that make this difficult to assess? E.g. communication, psychological & emotional needs,

    behaviour etc.

    * Please attach any cognitive assessments e.g. mini mental state examination

CLINICAL PICTURE

    Is the person:

    Disorientated in time Always Mostly Occasionally Infrequently Never Disorientated in place Always Mostly Occasionally Infrequently Never Disorientated to person Always Mostly Occasionally Infrequently Never Confused Always Mostly Occasionally Infrequently Never

Has the individual been assessed and diagnosed by a GP or psychiatrist to indicate they are

    suffering from organic mental illness (e.g. dementia) which has affected their cognitive Yes No functioning

    Other sources of information:

Has an Abbreviated Mental Score:

    Test, Mini Mental State

    Examination or other Date test completed:

    validated test been carried

    out? Completed by?

If not please arrange for one to Name:

    be done before proceeding with

    this assessment Designation:

    ASSESSOR: DESIGNATION: SIGNATURE: DATE:

     London Health Needs Assessment V6 080909 to be reviewed by 31/03/10 10/27

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