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CHS233 Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care for individuals

Overview

This standard covers working as a member of an inter-disciplinary team through contributing to the assessment of service users' needs, contributing to the planning of individualised programmes of care, and contributing to evaluation and review. The assessment methods and approaches and the nature of interventions will be those which are agreed on a case-by-case basis with other members of the inter-disciplinary team. The term ‘inter-disciplinary team' has been used to mean teams formed of practitioners drawn from different professions (or different disciplines within a profession) who are working together as a co-ordinated team to achieve agreed objectives with service users. As you will be one of the main points of contact with individuals and will be undertaking specific individualised programmes of care, probably on a person-focused basis, there is a strong focus in this standard on promoting individual's rights. Due to the nature of the interventions, there will also be a number of issues related to confidentiality and consideration of who has access to certain information. The focus of the work is likely to be related to the services offered by an integrated service such as a rehabilitation standard, community team or in day care, or the service offered by a functional team, such as assertive outreach, crisis intervention. It is likely that the practitioner will specialise in working with one particular service user group or in one setting. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:
  1. the principles of inter-disciplinary working
  2. how inter-disciplinary working differs from other models of care provision
  3. the role of other workers who are contributing to the care programme and the particular benefits and strengths which each brings
  4. your role in the inter-disciplinary team and how it relates to the roles of the other team members
  5. the purpose of clarifying your own role and that of others when working with different individuals
  6. ways in which inter-agency and inter-disciplinary working can contribute to more effective delivery of care
  7. why effective communication is particularly important in an inter-disciplinary team
  8. the philosophy and approach of the inter-disciplinary team and its members
  9. your responsibility to keep records
  10. the purpose of involving individuals and significant others in the assessment process
  11. the purpose of keeping records of the assessment process
  12. the differing arrangements which may need to be put in place to make the assessment of needs effective
  13. the purpose of clarifying individuals' and significant others' understanding of the process and in clearing up any misunderstandings
  14. why it is important to recognise and support the rights of individuals and significant others and their role within the assessment process
  15. the type of background information which is necessary to undertake the assessment properly
  16. methods of supporting individuals and significant others in contributing to the assessment process
  17. methods of assessing individuals' health and wellbeing needs and the needs of the service user group with whom you work
  18. methods of interacting effectively with people
  19. methods of encouraging individuals and significant others to be actively involved in the process of assessment, and empowered to contribute
  20. how to present views and suggestions constructively and effectively
  21. why problems should be notified and what should happen if they are not
  22. the role of other agencies who are working in the planning process and the particular benefits and strengths which each brings
  23. the purpose of delivering staged goals within programmes of care and how these can be best developed to take account of different individuals' needs
  24. the purpose of planning specific aspects of care as part of an overall programme of care
  25. the range of services that are available to individuals and which members of the team lead on which services
  26. the potential difference between the individual's and significant others' views of the services they need and the views of people working in the team
  27. the disagreements which might arise between those involved in the planning and ways of negotiating with others so that a working agreement can be reached
  28. the functions and resources within the agency and the relationship of this to the needs of the individual and significant others
  29. how the services you are able to offer are affected by service contracts and resource limitations in the agency in which you are placed
  30. the range of needs that individuals may have and how these may conflict
  31. the different purposes which programmes of care may have for different individuals with health and wellbeing needs
  32. the particular requirements which different individuals may have and how these can be managed within the planning process
  33. the different type of activities and interventions which are commonly used with the individuals with health and wellbeing needs, the purpose of these and how they may differ from those used with other service user groups
  34. the range and purposes of interventions available and the relationship of these to individual needs, interests, preferences, age, gender
  35. the effects which cultural differences may have on the suitability of interventions for particular individuals
  36. the interventions which are to be made for the particular individuals concerned, their purposes and goals
  37. why final decisions should be recorded and disseminated to the appropriate people
  38. why evaluation is necessary and how it can be used to improve performance in the short and long term
  39. methods of involving individuals and significant others effectively in evaluation and the purpose of doing this
  40. methods of evaluating the process and outcomes of different interventions
  41. how to evaluate individual's progress towards agreed goals
  42. the purpose of modifying activities in the light of the evaluation with individuals, significant others and other members of the team
  43. methods of evaluation relevant to different interventions, how they work and how they need to be adapted according to the individual and their needs
  44. how to evaluate your own contribution constructively and make recommendations for improvement
  45. the different ways in which the way the team works with individuals and significant others might be improved
  46. how to communicate with individuals, significant others and other team members effectively
  47. how to explore differences of opinion and confusion constructively
  48. your role and responsibilities in recording the evaluation and review of programmes of care
  49. how you can determine when you are in need of further support and who to seek it from

Performance Criteria

You must be able to do the following:
  1. agree your role in assessing the individual's needs with other members of the care team
  2. offer clear and accurate information to individuals and significant others on the assessment and your role and the roles of other members of the care team within it
  3. obtain appropriate and necessary background information to allow the assessment to proceed effectively
  4. seek confirmation of the individual's and significant others' understanding of the assessment, any related interventions and the expectations they have of the team's services
  5. throughout the assessment, your interaction is appropriate to the individual and appropriate others and designed to emphasise their role as equal partners in the process
  6. carry out the assessment in the correct form and sequence and for the correct duration
  7. encourage individuals and significant others to contribute to the process, ask questions, seek advice and express any concerns
  8. seek support from an appropriate person as soon as is possible when any problems arise with the assessment
  9. pass relevant information to others in the care team who are involved in assessing the individual's needs in sufficient time for it to be of use
  10. ensure your records of the assessment are complete, legible, accurate and structured in a way which allows others to use them easily
  11. explain what will happen as a result of the assessment to individuals in an appropriate manner, level and pace
  12. accurately identify the purpose of the care programme and how this will meet the needs of the individual in discussion with relevant others
  13. clarify and confirm your role in the overall care programme with those concerned
  14. identify the particular requirements of the individual from their records and in discussion with other team members
  15. seek further advice, clarification and support from the other members of the team when you have any concerns about:
    1. the nature and purpose of the care programme
    2. the individual's needs
    3. your role in meeting these needs
    4. others' roles in meeting these needs
  16. explore the different activities and interventions which will form the care programme and how these will inter-relate, with other members of the team
  17. agree how the individual's needs may best be met, the different goals along the way and your role in this with other members of the team
  18. ensure that your contribution to the care programme is sufficient to enable effective interventions to take place whilst being an efficient use of resources
  19. ensure your records of the planning process and outcomes are accurate, legible and complete and consistent with your role and responsibility within the team
  20. identify the progress which individuals have made towards agreed goals and discuss this with individuals, significant others and any others involved
  21. assist individuals and significant others to evaluate the extent to which the sessions have met the agreed purposes and goals
  22. discuss and agree the reasons for activities not achieving their agreed aims with individuals and significant others
  23. clearly communicate your evaluation of the sessions and their effectiveness in meeting the individual's needs to the other members of the team
  24. discuss and agree ways in which the team could improve how it works with individuals and significant others with other team members
  25. explore any problems between different members of the team to allow a clearer understanding to be reached
  26. ensure your records of agreements reached are accurate, legible and complete
  27. modify your contribution to individualised programmes of care according to the agreements reached by the team

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard replaced MH25. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB2 Assessment and Care Planning to Meet Health and Wellbeing Needs
CHS233 Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care for individuals
Final version approved March 2013 © copyright Skills For Health,
For competence management tools visit tools.skillsforhealth.org.uk