Continuing Healthcare Team

Name: D.O.B:

Continuing Healthcare Team

NHS West Sussex

INDIVIDUAL NEEDS PORTRAYAL

The National Framework for NHS Continuing Healthcare (2012) cites that a Decision Support Tool (DST) must be used following a comprehensive multidisciplinary assessment of an individual’s health and social care needs and their desired outcomes. The purpose of this Individual Need Portrayal (INP) is to supportthe multidisciplinary assessment process.

All spaces/boxes within this INP must be completed so we know you have considered each point identified. The INP cannot be processed unless fully completed.

If the space provided in a particular area of the INP is inadequate to clearly detail the individuals needs please add extra pages as necessary and ensure this is clearly indicated on the relevant page.

Referrers/assessors are advised that the potential need for a “specialist assessment” is highlighted within this document by the use of this symbol *.

Name of individual being assessed:
Name of referrer:
Profession of referrer:
Contact details of referrer:
Date INP commenced
Date INP completed

Referrers are advised to contact WestSussexCounty Council and request a Social Worker to assist in completing this INP.

Did you attempt to secure Social Worker involvement? / Yes / No
If Yes, and a Social Worker was unavailable please give outcome of request:
Please record the date you contacted Adult Services/Locality Office Helpdesk
CHC Office Use Only / CHC Practitioner / Outcome Code / Estimated Provider / Review Date

Assessment Principles

• The person being assessed should always be treated as an individual. Assessments should be personalised, user centred and equitable.
• Referrers should ensure that suitably 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.
• Those staff leading 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.
• The individual (and their carers/advocates – reference Mental Capacity Act) should be consulted and fully involved in the assessment process.
• The assessment should accurately, clearly and comprehensively detail the individuals needs and risks.
• 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.

Structure of the INP

This INP follows the following format:-

• Consent to the assessment process and information sharing
• Detailsof the individual being assessed
• Health and social care needs assessment
• Informal carer’s details and circumstances
• Declaration / Agreement
• Checklist

Document Control

Version ID / Status / Published / Owner / Review Date
INP 0.9 / Final draft - Policy Group / 06-03-2013
INP 0.91 / Draft following CHC-Leads meeting / 27-03-2013
INP 1.1 / Go Live / Office Use Only added / 03-05-2013
INP1.2 / Consent V9 / 31-05-2013 / Andrew Holmes / 31-07-2013

CONSENT TO THE ASSESSMENT PROCESS & INFORMATION SHARING {v9}

Does the person have the mental capacity to consent to participating in the assessment process? / Yes [ ] / No [ ]
If the person is deemed to have mental capacity, has their consent been obtained for these assessments?
PLEASE TICK:Checklist( )INP ( ) Fast Track ( ) Decision Support Tool ( ) / Yes [ ] / No [ ]
Has the person being assessed given consent to have information shared with their representative or advocate? / Yes [ ] / No [ ]
Has the person being assessed given consent to have information shared with health social care agencies, third party support agencies?
If the person has been assessed as not having the mental capacity to consent to information being shared about them. Provide Contact details of the representative the MDT have identified information should be shared with in the best interest of the individual.
Name
Address
Telephone number / Yes [ ] / No [ ]
Does the person being assessed have Independent Mental Capacity Advocate (IMCA) service representation? / Yes [ ] / No [ ]
Has the person being assessed made a Lasting Power of Attorney Health and Welfare/Enduring Power of Attorney? / Yes [ ] / No [ ]
Has the LPA Deputyship Order been checked to confirm relevant authority?
If so please provide details including the name, address and telephone number of the persons representative: / Yes [ ] / No [ ]
If the person is deemed to not have the mental capacity to consent, how was their mental capacity determined and how and by whom has it been decided that is in the person’s best interests to complete this assessment?
Where the person is mentally incapacitated and unable to consent, information should only be disclosed in their best interests and then only as much information as is needed to support their care. For further guidance, see the Mental Capacity Act 2005 Code of Practice on and the guidance booklet ‘Making Decisions: a guide for people who work in health and social care’ on
MDT Staff Member:
Designation: / MDT Staff Member Signature:
Date:
Clients Name:
Date of birth: / Clients Signature:
Date:

Date of Completion:1INP1.2

Name: D.O.B:

DETAILS OF THE INDIVIDUAL BEING ASSESSED

Title: / Sex:
Forenames: / Date of Birth:
Surname: / NHS Number:
SS ID No:
Home Address: / Telephone
Number:
Postcode

Current Location:

Address: / GP Name:
GP Address:
Tel No: / GP Tel No:

Next of Kin / Significant other / Representative:

Name 1: / Name 2:
Address: / Address:
Tel No: / Tel No:
Mobile: / Mobile No:
Relationship: / Relationship:

HEALTH AND SOCIAL CARE NEEDS ASSESSMENT

Social Circumstances

Please give details of family history/social structure/previous issues.

Please give details of current social situation (e.g. social needs, domestic needs, interaction with others, personal preferences, see page 8 re accommodation).

What does the individual like to do socially but perhaps cannot fully participate in currently?

Please give details of any assistance the individual requires in meeting their personal care needs.

How does the individual’s health condition impact on their ability to undertake daily living activities?

What outcomes would the individual like to achieve as a result of this assessment?

Occupation, Training, Leisure and Education

Please comment on the interests of the individual, current activities and needs for assistance with any of these.

Ethnicity issues/cultural sensitivity

Please provide information on needs relating to ethnic, cultural or religious background. Does this individual have specific needs in this domain?

Current Accommodation and Environment

Current Accommodation Circumstances (tick and give details as appropriate)
House / Bungalow / Sheltered Housing / Ground
Floor
Flat / Flat
Above
Ground Floor / Caravan
Owner
Occupier / Council
Tenant / Housing
Assn
Tenant / Private
Tenancy / Lodgings
Hospital / Care
Home / Type
Living
Alone / Living
with
spouse/partner / Living
with
offspring / Living
with
siblings / Living
with
other
relative / Living
with
friend
Suitability of Accommodation / No
Problems / Some
Difficulty
Due to
Disability / Confined
To one
Area
E.g. Sleeps
Downstairs
Heating / Central
Heating / Electric
Fires / Gas
Fires / Calor
Gas
fires / Coal
Fires
Cooking / Microwave
Oven / Electric
Cooker / Gas
Cooker / Calor
Gas
Cooker / Solid
Fuel
Toilet / Inside
Downstairs / Inside
Upstairs / Outside / Chemical
Commode / Commode
Bathroom / Downstairs
Shower / Downstairs
Bath / Upstairs
Shower / Upstairs
Bath / None
Access / Level
Front / Level
Back / Flight
Of stairs / Step
Or steps / Keysafe
Telecare
Lifeline
Comments/any other observations; Entry to property (e.g. Keys with neighbour/keysafe), animals, environmental issues, parking, lone worker issues, smoking, drugs, children etc.* Attach OT assessment as appropriate.

Date of Completion:1INP1.2

Name: D.O.B:

Medical Statement

Name of Doctor Completing Statement:
Title: (e.g. Consultant/ GP) / Address & Telephone Contact details:
Signature:
Date:
Individuals Diagnosis & Presenting Conditions:
What are the main presenting symptoms/difficulties as a result of medical condition?
Please comment on the individual’s potential for rehabilitation /recovery and or ongoing therapy needs?

Health Circumstances

History (include dates):

Current Health Condition(s):

Allergies:
Infection control status:

Current and Recent Hospital Admissions: -

Hospital/ ward / Reason for Admission / Admission Date / Discharge Date

Most Recent GP Interventions: -

Date / Reason for Visit / Treatment/Plan/Outcome

Other Healthcare Professionals interventions:-

Date / Professional (e.g. District Nurse, Therapist, Specialist Nurse, Care Co-ordinator) / Contact Name / Tel. No.

Aids and Equipment currently used by the individual or required:-

Type / Agency / Ordered / Date received / Date returned

Behaviour:

Please identify and explain in detail the types/patterns/triggers/frequency of behaviours, required interventions and effectiveness of care plan.

Is this individual subject to Care Programme Approach?Yes [ ]No [ ]

Care Coordinator / contact details:

* Please attach current supporting mental health risk assessments/care plans/ behaviour charts

Is this individual subject to Section 117?Yes [ ]No [ ]

Details:

List below any evidence you are including to support the needs you have identified above;

Cognition:

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

Please comment if this individual requires an Independent Mental Capacity Advocate.

List below any evidence you are including to support the needs you have identified above;

Psychological and Emotional Wellbeing:

Explain the individual’s mood, any periods of distress and anxiety symptoms, including identified trigger factors. Describe any interventions used and the individual’s ability to participate in their care plan.

List below any evidence you are including to support the needs you have identified above;

Communication:

Comment on the individual’s ability to express their needs, including verbal and non-verbal methods of communication and interventions/equipment required to support them.

*Include any assessments undertaken by the Speech and Language Therapist.

List below any evidence you are including to support the needs you have identified above;

Mobility:

Describe the actual needs of the individual.

How many people are needed to transfer/support the individual’s mobility? Explain what they need to do.

* Attach/reference current moving and handling, falls and risk assessments, including Physiotherapist and Occupational Therapist report.

List below any evidence you are including to support the needs you have identified above;

Nutrition:

Please comment on the individual’s ability to maintain their nutritional status.

Please detail Body Mass Index/weight history and any concerns regarding nutritional status.

* If this individual has dysphagia please attach a copy of the Speech & Language Therapy

assessment/care plan.

* If this individual has unintentional weight loss attach the Dieticians Assessment/care plan

List below any evidence you are including to support the needs you have identified above;

Continence:

Please describe the individual’s continence needs/management including any health related issues such as recurrent urinary tract infections/fluctuating bowel habits/risk factors/severe constipation.

* Consider if there is a need for a specialist continence assessment.

List below any evidence you are including to support the needs you have identified above;

Skin (including Tissue Viability):

Detail any evidence of broken/compromised skin conditions (whether pressure ulcers/ wounds/other). Explain how the wounds originated (e.g. pressure points, surgery).

Describe/draw the size, grade and type of wounds (reference Stirling/NICE Guidance). Record the treatment regime in place and advise if the wound(s)/skin condition(s) are responding to treatment or continue to deteriorate.

*Attach any Tissue Viability Nurse Specialist assessment(s).

List below any evidence you are including to support the needs you have identified above;

Breathing:

Detail the individual’s needs in maintaining their airway.

Include vital signs; reference the individual’s normal respiration rates/oxygen saturation levels/pulse/BP and any equipment required to support respiratory function including BiPAP/CPAP/Nebulisers/Oxygen/Inhalers etc.

Are there any risk factors (e.g. Smoking/frequent chest infections)?

List below any evidence you are including to support the needs you have identified above;

Medication/Pain/Symptom Control:

Detail type/site/severity and frequency of pain/symptom. Is the pain/symptom chronic or acute in nature? How is pain or other symptom affecting the individual and their ability to carry out activities of daily living?Is pain or other symptom being managed effectively or is it difficult to manage? Is the prescription for medication regular/stable? Is PRN medication required? If so how frequently? How is the medication administered? How frequently does the prescription require reviewing? Are any alternative therapies used to manage symptoms?

* Consider attaching a Pain Scale Chart.

List below any evidence you are including to support the needs you have identified above;

Date of Completion:1INP1.2

Name: D.O.B:

Drug therapies and medications, including prescribed and non prescribed items. DATE:-

MEDICATION / DOSE / FREQUENCY / ROUTE OF
ADMINISTRATION / CONDITION PRESCRIBED FOR

Is this individual compliant with their medications?

If no, what actions are taken to ensure medication is given appropriately?
Does this individual self medicate? If not why not?

Date of Completion:1INP1.2

Name: D.O.B:

Altered States of Consciousness:

Describe any evidence of altered states of consciousness (this could include trans ischaemic attacks, seizures, alcohol/drug issues, coma etc).

Include frequency and duration of altered states of consciousness, identified risks to the individual and attach any seizure/coma scale charts as appropriate.

List below any evidence you are including to support the needs you have identified above;

Sleep:

Please indicate sleep pattern and comment on any deprivation experienced and interventions required.

List below any evidence you are including to support the needs you have identified above;

Current health and care support services

Does the individual have an existing personalised health care support plan?

Yes [ ]No [ ]

What health and care support services are currently provided to the individual?

(include type/time/frequency). What is and isn’t working well?

Informal support (friends/family), please also see page 26 re main carer:

Support services from the voluntary sector:

Support services from the private sector:

Social Services / other local authority service:

NHS funded services (e.g. community healthcare, outpatient care):

Direct Payment support services (e.g. employment support, payroll):

Have there been any gaps in service provision?

Advocacy, Legal and Financial:

Please identify any financial arrangements in place, whether voluntary or legal and detail the individual’s ability to manage their own affairs.

Please indicate where it is considered this individuals needs could be best supported:

Residential Home
Type: / Own home
Details:
Nursing Home
Type: / Personal (Health) Budget
Details:
Respite Care
Type: / Other
Details:

Please explain the rationale for this decision and how the individual’s needs could be best supported within this environment:

Date of Completion:1INP1.2

Name: D.O.B:

INFORMAL CARER’S DETAILS AND CIRCUMSTANCES

Only information that can be shared with the client should be included on this page, a separate carer’s assessment should be completed if requested by the carer.

Carer’s Name
Address
Tel No. / Signature
What kind of help does the carer provide?
Encourage the carer and the client not to underestimate the level of support provided and be as detailed as possible giving days and times if appropriate
Is the carer able and willing to continue to provide this level of support?
Reference where appropriate to the carers health and personal circumstances. Include any changes to the level of support that can be provided.
What services / support are provided to the carer?
Take into account physical, emotional, and financial support

DECLARATION and AGREEMENT

Do not type all the text in one row – press the tab key to create new rows. Adjust the size as required

All identified needs agreed between the individual and assessors (or their chosen representatives): -
Name / Role/Title / Base/Contact Number / Signature / Date
Individuals agree that they have been involved in and understand the content of this Individual Needs Portrayal. Please note that this must be completed or an explanation given if the individual’s agreement was not possible.
I have seen this form or have discussed its contents and understand that the information will not be changed without my being informed.
I am happy for this Individual Needs Portrayal to be shared with others who may be involved in my care.
Signed:
Name:
If signed by a Representative, please give name and relationship and reason why they have signed.
Relationship:
Date:
Reason:

Any further comments including service shortfalls/unmet need/assessment concerns: -

Date of Completion:1INP1.2

Name: D.O.B:

CHECKLIST

Name of patient / Date of completion
Please circle
statement A, B or C in each domain / C / B / A / Evidence in records to support this level
Behaviour* / No evidence of ‘challenging’ behaviour.
OR
Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or a barrier to intervention. The person is compliant with all aspects of their care. / ‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The person is nearly always compliant with care. / ‘Challenging’ behaviour that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.