A
AF3.2014 Carry out comprehensive assessment for alcohol and other substances
Overview
This standard is about assessing the needs of individuals who use alcohol and other substances who have complex requirements and/or those people who require more intensive and/or structured care programmes. It covers assessment that is on-going throughout the contact with the substance use service and the wider support system. It includes:
preparing for a comprehensive assessment for alcohol and other substances
assessing the individual's substance use, support network and related problems
assessing possible risks to the individual
assessing the individual's understanding of services available
This standard relates to substances which may include alcohol, prescription and over-the-counter medicines, controlled or currently legal drugs, and new psychoactive substances. Users of this standard will need to ensure that practice reflects up to date information and policies.
Version No 2
Knowledge and Understanding
You will need to know and understand:
- legal, organisational and policy requirements relevant to your role and the activities being carried out
- local systems, procedures and protocols for safeguarding children and young people
- how to obtain information from individuals and other agencies in line with protocols
- how to pass information obtained during an assessment to another agency in line with local protocols
- how to evaluate requests for assessment according to their priority in line with your organisation's criteria
- how to adapt communication styles in ways which meet the individual's needs, strengths and capabilities
- how to involve an individual in the assessment of their needs and options
- how to assess and manage complex needs and co-morbidities
- how to assess the individual's strengths and coping strategies
- how to assess an individual's understanding of services available and readiness to engage in a treatment programme
- how to use motivational interviewing techniques to assess the individual's motivation
- how to assess individuals who are under the influence of alcohol or other substances and the action to take if the assessment cannot be undertaken
- who can provide support when there are any problems with the assessment
- the importance of adhering to locally agreed criteria and documentation when carrying out assessments
- how to record the outcomes of assessments and use the assessment to inform the development of a comprehensive care plan
- how to review assessments at appropriate intervals once an individual has commenced a programme of care
- your responsibility and accountability for the wellbeing of individuals
- how to recognise the signs of injury, abuse or neglect in the individual and how to raise concerns with the appropriate person or agency
- how to support the choice and wellbeing of the individual which is appropriate to their needs and preferences
- how substance use of others can impact on the emotional, social, physical and psychological development of children, young people and significant others and how to respond appropriately
- how to take account of a child or young person's age and maturity when considering the impact of others' substance use on them
- the principle of confidentiality and the implications for your practice
- how to support individuals to complete documentation
- the importance of monitoring the situation regarding an individual's use of substances, and how to do so
- how to assess the risk to individuals, children, families and to others from their substance use and/or co-existent problems and the appropriate action to take
- the importance of regularly reviewing risk assessments
- the signs and implications of a range of substance use related problems
- the principles of equality, diversity and anti-discriminatory practice and how they are applied
- how age, gender, cultural and social background, including the choice of substance being used can affect the working relationship
- ways of keeping your knowledge about substances and indications of substance use up to date
- how to understand the language used by substance users in your locality
- sources of information on health and wellbeing services providing treatment intervention service for substance users
- the range of treatment interventions and assessment services available in your locality and the process for referring individuals to these services
- the eligibility criteria and protocols for accessing services in your locality
- national, local and organisational treatment priorities and resource constraints
- how to respond to individuals who do not want to be referred to other services
- the importance of keeping full and accurate records, and how to do so in line with organisational requirements
Performance Criteria
You must be able to do the following:
- evaluate requests for assessment to determine their priority consistent with your organisation's criteria
- obtain further information if the initial information is insufficient for effective assessment to take place
- establish any particular needs of the individual which will need to be taken into account during the assessment from the available information
- fully and accurately record arrangements for the assessment in line with the organisation's procedures
- confirm arrangements for the assessment with the individual
- explain clearly to the individual any delays between requests for assessment and assessment taking place
- give the individual any documentation which needs to be completed by them to allow them to consider it before the assessment
- offer appropriate support to individuals who need assistance to complete documentation
- explain to the individual of the nature and duration of the assessment, the type of information which will be entered in their records and who will have the right of access to this information
- conduct the assessment in line with locally agreed criteria and using the correct documentation
- involve the individual in the assessment as far as possible according to their capability
- review information obtained from previous assessments completed within your organisation or by others involved in the individual's care
- collect information from the individual, exploring historical factors as well as presenting factors
- assess the individual's understanding of services available and readiness to engage in a treatment and/or support programme
- respond to challenging, abusive, aggressive or chaotic behaviour
- assess any risk to the individual which may result from substance use according to locally agreed protocols
- encourage the individual to ask questions, seek advice and express any concerns
- assess the nature of the individual's substance use problems and any other problems they may have
- use the results of the assessment to inform the collaborative care plan
- ensure your assessment takes account of the individual's needs, strengths, views inherent risks, safeguarding, and the legal duty of care to the individual and others
- keep accurate, legible and complete records of the assessment to inform the development of a care plan and for evaluation purposes
- assess and review at appropriate intervals once the individual has commenced a care plan
- provide individuals with accurate and clear information on systems for making complaints about the assessment system and appealing on the decisions
- seek support from the appropriate person as soon as possible when there are any problems with the assessment
- discuss assessments with other members of the substance use service team in order to ensure consistency of approach
- ensure your assessment records are in a format and level of detail which can be audited against locally agreed standards
- record and report changes made and any effect this might have on the individual within confidentiality agreements and according to legal and organisational requirements
Additional Information
This National Occupational Standard was developed by Skills for Health.This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004):
Dimension: HWB2 Assessment and care planning to meet people's health and wellbeing needs