CS10.2015 Prepare a discharge or transfer plan with children and young people and those involved in their care

Overview

This standard covers working with children and young people, and those involved in their care, to plan discharge and transfer of care. It covers planning and preparations for discharge/transfer and ensuring all necessary arrangements are in place. The standard covers discharge and transfer of care of children and young people to other services within the same organisation, to services provided by other organisations, and to care provided by parents, family and friends at home. 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:

1. legal, organisational and policy requirements relevant to your role and the activities being carried out
2. the nature, extent and boundaries of your work role and its relationship to others in your own and other organisations
3. the roles of other practitioners working with children, young people and families and how they relate between and across agencies
4. the importance of effective multi-agency working
5. the ethical issues, legal requirements and good practice guidelines on consent, including capacity issues and consent for children and young people
6. the principle of confidentiality and the implications for your practice
7. how to recognise and respond to the signs of injury, abuse or neglect and your responsibility in relation to raising concerns with the appropriate person or agency
8. local systems, procedures and protocols for safeguarding children, young people and vulnerable adults
9. the principles of equality, diversity and anti-discriminatory practice and how they are applied
10. the duty to report any acts or omissions in care that could be detrimental to the child or young person
11. the rights of children and young people to make decisions for themselves and to take risks in the context of their own lives, taking into account issues of capacity and your professional responsibility
12. how to engage with and communicate effectively with children and young people, and those involved in their care
13. the need for communication to be modified for different contexts and cultures, including the age, vulnerability, understanding, developmental capacity and communication needs and preferences of the child or young person and those involved in their care
14. the ways in which children and young people communicate non-verbally and through behaviour, as well as through language, and how different forms of behaviour can be interpreted
15. the importance of adopting a child/young person centred approach
16. the conditions and issues affecting children and young people in your area of practice and how they can inter-relate
17. child and young people's development, including emotional, physical, and social how they affect one another
18. how the behaviour needs of children and young people may affect others
19. the effect of parenting capacity, family, environment and cultural influences on the health and wellbeing of children and young people
20. the factors that contribute to the risk of harm to children and young people
21. local policies and protocols for discharge and transfer of care
22. the importance of planning discharge or transfer of care
23. procedures, protocols, and pathways for liaising with children, young people and their families, practitioners, departments, and agencies
24. the importance and methods of consulting the child or young person, and those involved in their care, from the beginning of the discharge planning process
25. the reasons why children and young people may be discharged/transferred from your area of practice
26. the reasons why children and young people and/or their parents may not wish for the transfer or discharge to take place
27. local protocols for managing disputes about discharge
28. the purpose of explaining the reasons for transfer of care or discharge to the child or young person and those involved in their care and giving them opportunity to discuss them
29. the eligibility criteria for discharge/transfers and continuing health and social care, including the processes for review and resolution of disputes
30. the services and resources available within your own organisation and from other agencies to support discharge and continuing health and well-being needs
31. the information that the child or young person and those involved in their care may require in relation to the discharge/transfer, and any concerns and particular needs they may have
32. the importance of knowing who will become responsible for the care of the child or young person after discharge/transfer
33. how to check that those who will be responsible for the child or young person after discharge/transfer are able to provide appropriate care for them
34. the ways of providing guidance and support to other practitioners to enable them to meet the needs of children and young people who transfer to their care
35. how to carry out or arrange parent/carer support in regard to discharge or transfer arrangements
36. the importance of agreeing a timed schedule for transfer of care or discharge with the child or young person and those involved in their care
37. how to prepare and educate children and young people to achieve an effective transfer into other services or care arrangements
38. the referral process within children's and young people's services
39. the importance of having a co-ordinated approach to transfer of care and discharge across all of the services involved and how to achieve this
40. how to complete and structure discharge/transfer plans so that they contain all of the essential information and are suitable for others to use
41. the importance of being certain that all necessary arrangements are in place prior to discharge/transfer
42. how to manage obstacles to or delay in the discharge and transfer process
43. the guidance that is available for your own practice and where to access this
44. current issues, research and evidence based practice relevant to your role
45. local sources of health and well-being information, advice and support for children and young people, and those involved in their care
46. 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:

1. ensure that discharge planning is initiated as early as possible
2. communicate with the child or young person and those involved in their care in a way that is appropriate to their age, understanding, developmental capacity and preferences
3. encourage the child or young person and those involved in their care to seek clarification of any procedures, information, and advice relevant to them
4. provide support to the child or young person to enable them to take an active part in decisions affecting them
5. involve the child or young person in a manner and at a level appropriate to their wishes, age and development stage, communication skills, and health status
6. obtain and review all relevant information on the child's or young person's health and care needs to inform discharge/transfer planning
7. discuss with the child or young person and those involved in their care the options for discharge/transfer, and identify the benefits and risks of each option
8. direct the child or young person and those involved in their care to further sources of information, advice or support as appropriate to their needs
9. agree the discharge/transfer arrangements with the child or young person and those involved in their care
10. make arrangements to ensure that discharge/transfer is not delayed and is as seamless as possible
11. identify, agree and document the aftercare needs of the child or young person following discharge/transfer
12. identify the person who will be legally responsible for the child or young person after discharge/transfer
13. check that there are adequate and appropriate arrangements and resources in place to support the child or young person after discharge/ transfer
14. confirm discharge/transfer arrangements with the child or young person and those involved in their care, including procedures for challenging decisions and making complaints
15. produce records and reports that are clear, comprehensive, and accurate and maintain the security and confidentiality of information

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 health and wellbeing needs