Mental Health and Substance Abuse Accommodation-based Services
Support Plan Documentation
ContentsPage
Individual Support Plan / Assessment documentation 2 - 16
Support Action Plan Summary 18 - 19
Individual Support Plan Agreement 20
Risk Assessment Form 21 - 23
Risk Management Plan 24 – 25
Service Engagement Record 26
Review format 27 (to follow)
Notes – Support Planning in accommodation-based scheme for people with mental health needs and/or who abuse substances.
Support Plans should be based upon Threshold’s General Principles and Charter for Support Planning.
- The Support Plan Assessments should be generated from the Care Management/Assessment Plan or CPA provided by Social Services / Health Trust.
- An initial Support Plan should be completed within 48 hours of a service user’s entry to the service.
- The service monitoring record will be reviewed at least monthly - an indication of significant non-engagement in the support plan will require that a review of the support plan is convened as soon as possible.
Threshold Support is a charitable housing association
MH and SA Support Plan Documentation – Mar 06Page 1 of 26
INDIVIDUAL SUPPORT PLAN (No…….)
Name of Service User:
Address:
Date of Assessment / Plan:Keyworker / Staff Member
Dates of reviews:Attended by:
Date for Next Review:
1. AROUND THE SCHEME
Are you happy with/do you understand all the procedures that are in place around the scheme? Can you use the following or do you need help with any of them:
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateDoor entry system
Warden Alarm Call / Emergency On-call Procedure (If Applicable)
Reporting Repairs
Fire Safety Procedures
Others?
2. LIVING IN THE SCHEME
2.1 General
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateWhat do you like most about living here?
What do you not like about living here?
What would you like us to do to change the things you don’t like, if possible?
Do you understand the Complaints Procedure?Yes / No
Do you understand the Equal Opportunities Statement? Yes / No
Do you understand what Supporting People is all about? Yes/No
Are there any issues you would like to discuss today regarding the above?
2.2 Daily Living Skills
Can you think of anything that could be done to make daily living tasks easier for you?
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateIs the cooker/washing machine easy for you to use?
Do you use any aids or equipment to help you? (E.g. jar openers, high seats, trolleys, kettle tippers)
Do you use any aids or equipment to help you? (E.g. jar openers, high seats, trolleys, kettle tippers)
Other ?:
2.3 Personal Support
Can you think of anything that would help you to manage personal issues better?
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateCan you wash/bathe/dress yourself?
Can you get in and out of bed?
Do you use any aids to help you? (e.g. grab rails, walk in showers, bath/shower seats)
Other?:
2.4 Ethnic And Cultural Needs
Can you think of anything that would help us to provide support in line with your ethnic and cultural needs and beliefs ?
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateDo you see yourself as having specific ethnic, faith and cultural beliefs, background or inheritance?
Do you have views about the way things have been done here that conflict with your beliefs?
Are there specific social networks; clubs; church/mosque; language; diets or food; décor, books, pictures or music that are important to you?
Does this influence that way that you consider support should be provided?
Other?:
2.5 Your Health
Would you tell us if you had any health concerns? Yes/No
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateAre you currently receiving any medical treatment (list any medication) ?
For Physical / Substance Use / For Mental Health
Do you take the medication yourself?
Who collects your medication ?
Do you need support with your medication ?
Have you recently had a hearing and sight test?Yes No
If yes, date of last test for:
Hearing:______
Sight:______
Are you worried with your sight &/ or hearing?
Do you regularly see a chiropodist and dentist?
Is there anything that would help you to stay healthy? (e.g. advice about your diet, continence advice, making and attending appointments, giving up smoking etc.)
Have you had a ‘Life Check’ ?
Are there issues arising from your use of substances for your health?
If Yes, what are these?
Are there known ways of addressing these issues?
Other?:
2.6 Your Mobility
Can you think of anything that would help you to be more mobile?
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateCan you move around your flat easily?
Can you move around the scheme/use the stairs?
Can you go out by yourself?
Have you got a bus pass/dial-a-ride membership/cab card?
Other?:
2.7 Social Involvement
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateDo you belong to any outside clubs or organisations?
Would you like to be involved in any project activities?
If No, why not?
How do you feel you get on with the other service users?
Are there issues around personal relationships and sexuality that you would like to discuss or about which you feel the need for support?
Can you think of any way that socialising could be made easier for you?
Are there any activities that you would like to see run in this project?
Would you be willing to travel to other locations for activities?
Would you be willing to participate in the Supporting People Forum?
Would you like to learn more about sitting on our Management Board?
Other?:
3 LIFE PLANS AND GOALS
We can work with you to understand your current skill levels and aspirations, and then work with you to help you gain the skills or make the next steps or goals that you will need. By listening, planning and following up actions, we can help you to get what you want out of life.
Goals and Plans Identified / Action Plan / By who / By when / Outcome Achievement / DateLonger Term Life Plans and Goals (2-5 years)
Medium Term Life Plans and Goals (1-2 years)
What would need to happen to help you reach these goals ?
Short Term Goals (3 – 12 months)
(E.g. self-help skills; health issues; specialist interventions; behaviour management skills; substance management; meaningful day-time activities; social networks)
Other?:
4 EDUCATION / TRAINING / EMPLOYMENT
All service users in supported housing are encouraged to think about what they might want to do long term. What would you like to pursue in relation to education, training and/or employment?
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateMore information about options; travel and time implications; lit. and num. Issues; specialist employment advice; timekeeping and travel skills;
Others ?
5. NETWORKS
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateDo you see a lot of your friends and family?
Do they visit you regularly?
Do you get to visit them often?
Are you happy with the amount of contact you have with other people?
Is there anything you can think of that would help to improve the contact you have with others? (e.g. maybe joining a club, assistance with correspondence, cultural concerns)
Others?
6. YOUR FINANCE
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateDo you understand what you are paying for in your rent and service charges?
How do you pay your rent?
Would you like further advice regarding;
-claiming benefits or allowances
-making a will
Others ?
7. COMMUNICATIONS
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateIs English your first language? If no, can you read and write in English?
What other languages do you use?
Do you use sign language, Makaton, Braille?
Can you use the telephone to call for assistance i.e. dial 999/call the doctor?
Are you able to write letters for yourself?
Others?
8. SUPPORT NEEDS IDENTIFIED IN REFERRAL / COMMUNITY CARE ASSESSMENT FORM OR CPA
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / Date9. MOVING ON
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / DateHow long do you see yourself living here?
What type of accommodation would you like to move on to:
- Your own place?
- Living with other people in a shared house?
- Accommodation that has some type of support?
What area would you like to live in and why?
How can we help you to prepare for the move? What are the steps to be taken in the next 3 months?
How do you see this linking to your life plans or goals in the short and longer term?
Others ?
10. FURTHER CONCERNS / NEEDS EXPRESSED BY SERVICE USER
Issues/Needs Identified / Action Plan / By who / By when / Goal or Outcome / Achievement / Date11. OTHER AGENCIES INVOLVED IN PROVIDING SUPPORT
Nature of Support / Organisation / Contact name / Contact numberThreshold Support is a charitable housing association
MH and SA Support Plan Documentation - Individual Support Plan Mar 06Page 1 of 26
SUPPORT ACTION PLAN AGREEMENT FOR:Date:
Summary of Support Actions to be provided by Support Team
Summary of Action Plans / Support To Be Provided / By whom / Where / By when / How Often / Goal or Outcome / Achievement / Date1 Around the scheme
2 Living in the scheme
3 Life Plans and Goals
4 Education, Training and Employment
5 Networks
6 Finance
7 Communications
8 Support Needs identified in Referral/CCA/CPA
9 Moving On
10 Issues Raised by Service User
Action Plans Arising from Risk Assessment
Copies sent to
(Service User)(Date: …………… )
(Care Co-ordinator) (Date: …………… )
(Care Manager)(Date: …………… )
(Date: …………… )
(Date: …………… )
Signed by Service User: ______Date:
Signed by Support Worker: ______Date :
Signed by Service Manager: ______Date :
Date of Next Review:
YOUR INDIVIDUAL SUPPORT PLAN AGREEMENT
The Support Plan details are what I consider to be my main support needs at the present time. I am signing to say that I agree with its contents. I also agree that the keyworker can exchange confidential information about me on a need to know basis, i.e. doctors, or hospital staff and benefit agencies.
NAME:
Signature (service User)…………………………………Date……………………
Any other comments from the supported housing worker. Include any needs that cannot be addressed at this time and the reason why.
Signature (supported housing worker)………………………………………….
Date……………………………………
Name (Manager)………………………………………………………………….
Signature (manager)…………………………………………………………….
Date…………………………………….
Risk Assessment Form
This form asks sensitive questions. We would ask you to be as honest as you can so that we can assist you to plan for and manage any risks you may encounter.
Name: / Date of Birth: / Assessment Date: / AssessmentPrepared By :
IDENTIFIED RISKS / YES / NO / DON’T KNOW / DETAILS / SYMPTOMS / INDICATORS / WHAT MAKES IT WORSE / STRESSORS / TRIGGERS / WHAT HELPS / COPING STRATEGIES / SUPPORT NEEDS
1) Do you have a history of or are you currently using drugs?
2) Are you currently drinking alcohol excessively?
3) Have you experienced mental ill health and have you ever been detained under the Mental Health Act?
4) Are you on any medication for physical/mental health problems?
5) Haveyou ever physically neglected yourself?
IDENTIFIED RISKS / YES / NO / DON’T KNOW / DETAILS / SYMPTOMS / INDICATORS / WHAT MAKES IT WORSE / STRESSORS / TRIGGERS / WHAT HELPS / COPING STRATEGIES / SUPPORT NEEDS
6) Have you ever harmed yourself?
7) Have you ever made a suicide attempt?
8) Do you currently have feelings of hopelessness or lack of control?
9) Have you ever experienced exploitation or harassment?
10) Have you ever experienced violence or abuse?
11) Have you ever destroyed property or committed arson?
12) Have you ever been threatening, sexually abusive or violent towards others?
IDENTIFIED RISKS / YES / NO / DON’T KNOW / DETAILS / SYMPTOMS / INDICATORS / WHAT MAKES IT WORSE / STRESSORS / TRIGGERS / WHAT HELPS / COPING STRATEGIES / SUPPORT NEEDS
13) Have you ever been involved in any incidents with the police or courts?
14) Have you recently disengaged from any support services?
15) Have you ever spent time in residential care?
16) Have you ever absconded from a residential service?
17) Other individual factors (e.g. stressors, relationships)
Information Sources Used: (CIRCLE)ApplicantCarers/FriendsReferrerOther Agencies
Is Further Information Needed? YES / NOFrom What Source?
PLEASE GO ON TO COMPLETE RISK MANAGEMENT PLAN
Threshold Support is a charitable housing association
MH and SA Support Plan Documentation – Support Action Plan Agreement Mar 06Page 1 of 26
CONFIDENTIAL
Risk Management Plan
Name: ______Date of Birth:______
Address/ Room / Flat Number:______
Possible Area of Risk / Details of risk identified by referrer. / Action to take (transfer to Support Agreement)1. Substance Misuse (Drugs, Alcohol, etc).
2. Aggression, Violence to others including Verbal abuse, threats or harassment.
3. Self harm (including suicide attempts, overdosing, physical and emotional self harm).
4. Victim or possible victim of violence, aggression or abuse.
5. Environment: please indicate overall safety of immediate area user lives/may live. (Identify risk to others users, visitors and workers).
6. Physical health risks: please indicate any particular medical problems and strategy to deal with it.
7. Fire and Health & Safety risks (please give specific details).
8. Problems with visitors: please indicate when it would not be appropriate for workers to stay/allow visitors to stay, highlight risks.
9. Compliance with medication/treatment as prescribed: please indicate users attitude towards this and co-operation with workers involved in their care and support package.
10. Risk of workers being alone with client. Identify when double visits/double cover shifts are necessary.
11. Risk to worker due to their race, gender etc.
12. Impact of contact by significant others on behaviour/mental health or drug use.
13. Other Risks:
Please highlight anything else believed to be a risk area. These may be – [Recent severe stress, concern expressed by others (relatives, carers), Recurrence of circumstances associated with risk behaviour, social isolation, Ruthlessness]
Staff Name: ______Date: ______
Staff Signature: ______Date: ______
Managers Name: ______Date: ______
Managers Signature: ______Date: ______
Threshold Support is a charitable housing association
MH and SA Support Plan Docs – Risk Management Plan Mar 06Page 1 of 26
CONFIDENTIAL
SUPPORT PLAN ENGAGEMENT RECORD
Name of Service User: ______
Period Covered (Week / Month): ______
Support Action / Date provided / Did Service User Respond to contact? ( / X) / Outcome: Did service user engage in support action? ( / X)Monitoring support outcomes is a part of implementation and runs alongside it so that the support plan can be adjusted and its effectiveness improved. Threshold Support policy requires that there is recording of both the frequency and the outcomes of support sessions for a weekly or monthly check of progress, in particular the level of engagement of the service user in the plan using the ‘SMART’ actions identified in the Support Plan.
Threshold Support is a charitable housing association
MH and SA Support Plan Docs – Risk Management Plan Mar 06Page 1 of 26