Mental Health Care

Residents Strengths & Needs Assessment

To be completed in the company of and with the resident.

Resident’s Name: Date of Assessment:

Residents view/opinion of main problem areas:
Psychiatric history and treatment
Acceptance/Insight into mental health problem
Current medication & compliance with treatment
Reason/events leading up to referral

Strengths & Needs Assessment - Psychological

EmotionalState(anxious/sad/depressed/elated/labile mood/inappropriate)
Hallucination/delusions/perceptions of self and others (visual / auditory / tactile / olfactory / grandiose / paranoia / ideas of reference / distorted thought processes)
Verbal communication(speech content / tone / rate / volume)
Non-verbal communication( eye contact / body posture)
Cognitive(intellect / memory / orientation / ability to understand)
Alcohol/drug/substance use(amount / frequency / method / pattern / ability to manage use / considered a problem?)

Strengths & Needs Assessment – Physical Health

Previous physical health problems
Present physical health problems (include relevant medication)
Diet (special diets / abnormal perceptions)
Sleep patterns(duration / when / difficulties / early morning waking / sedation)
Hygiene/appearance(general appearance, dishevelled / smart / dirty – clean, appropriateness to situation, motivation)
Other physical issues(bowels / bladder, smoking, mobility, side effects, menstrual cycle)

Strengths & Assessment - Social

Daily coping skills:
Friends & social support network:
Family Contact / Support:
Accommodation:
Daytime activity:
Legal issues:
Finances:
Hobbies / interest:

Strengths & Needs Assessment - Outcome

Carers’/ key worker views
Assessment outcome (highlight main needs / problem areas)
Main points of response to referrer(accepted/declined)
Date arranged for visit: ______

Signed: Date:

Introduction Visit to Placement

House visited: Date of visit:
Accompanied by:
Interaction with other residents:
Interaction with staff:
Opinion / views of prospective resident:
Opinion / views of house Manager:
Placement offered: yes/no / Accepted /declined

Risk History

Confidential
Date completed / Person completing form:
Residents Details: / Care co-ordinator details:
Name: / Name:
House / Telephone
Risk History
Childhood / adolescent history:
Family history:
Past psychiatric history:
Forensic history:

Risk History Continued

Self neglect:
Risk to other residents/staff:
Risk to significant others:
Risk to public:
Risk to property:
Risk to children:
Risk of sexually inappropriate behaviour:
Risk when outdoors:
Other (specify)

Risk Triggers & Assessment of Current Risk

Confidential
Date of completion / Completed by
Residents name / Care co-ordinator
House Name / Telephone number

Score on each category and item. If the resulting score in any category is 0-23, this is seen as low risk and it is not expected that aRisk Management,Areas of Concern Form will need to be completed. If the score is 24-50 this is seen as moderate risk and the assessor will need to discuss the result with other key professionals involved in the care of the resident.

If the score is 51-75 this is seen as severe risk and the assessor MUST discuss with senior management before any further decisions are made.

Past concern / Current
Concern
Indicators for Suicide Risk / No / Yes / Score / No / Yes / Score
1 / Has the person made a previous suicide attempt on their life? / 12 / 12
2 / Did they use a violent method i.e. hanging, fire, jumping shooting? / 12 / 12
3 / Do they use recreational drugs? / 9 / 9
4 / Do they use alcohol to excess? / 9 / 9
5 / Are they expressing suicidal ideation? / 5 / 5
6 / Have they considered and planned how they would kill themselves? / 5 / 5
7 / Do they believe they have little or no control over their lives? / 5 / 5
8 / Are they expressing a high level of distress, delusion/ guilt/ low self esteem? / 5 / 5
9 / Do they feel nothing has changed since their last suicide attempt? / 4 / 4
10 / Do they live alone? / 2 / 2
11 / Are they separated, divorced or widowed? / 2 / 2
12 / Are they unemployed or retired? / 2 / 2
13 / Are they male? / 1 / 1
14 / Are they over 45 years old? / 1 / 1
15 / Are they in poor physical health? / 1 / 1
Total Score
Past concern / Current
Concern
Indicators for Risk of violence / No / Yes / Score / No / Yes / Score
1 / Has the person identified specific individuals they wish to harm? / 12 / 12
2 / Has the person used a weapon in the assault of another person? / 12 / 12
3 / Previous admission to a high security unit? / 9 / 9
4 / Previous admission to a low security unit? / 9 / 9
5 / Evidence of being dangerously impulsive? / 5 / 5
6 / History of assault on others? / 5 / 5
7 / Threatened physical/psychological harm to others? / 5 / 5
8 / Expressed but not shown aggressive behaviour? / 5 / 5
9 / Expressed paranoid delusions to specific people? / 4 / 4
10 / Evidence of inappropriate sexual behaviour? / 2 / 2
11 / Convictions for violent/sexually inappropriate behaviour? / 2 / 2
12 / Are there known triggers to violent behaviour? / 2 / 2
13 / Do they use recreational drugs? / 1 / 1
14 / Do they use alcohol to excess? / 1 / 1
15 / Have they refused treatment for violent behaviour? / 1 / 1
Total Score
Past concern / Current
Concern
Indicators for Risk of Neglect / No / Yes / Score / No / Yes / Score
1 / Is the person failing to drink properly? / 12 / 12
2 / Is the person failing to eat properly? / 12 / 12
3 / Is the person without amenities? / 9 / 9
4 / Are they unable to manage physical health problems? / 9 / 9
5 / Do they have debts with significant effect? / 5 / 5
6 / Do they experience financial difficulties? / 5 / 5
7 / Are they deprived of social contact? / 5 / 5
8 / Do they live in inadequate accommodation? / 5 / 5
9 / Are they unable to shop for themselves? / 4 / 4
10 / Are they unable to communicate their needs? / 2 / 2
11 / Are they at risk of eviction? / 2 / 2
12 / Do they have lack of appropriate clothing? / 2 / 2
13 / Are they unable to manage their personal hygiene? / 1 / 1
14 / Are they culturally isolated? / 1 / 1
15 / Is their accommodation a risk to their health? / 1 / 1
Total Score

Assessment of Current Risk: Date of completion:

Risk of suicide / Low (0-23) / Moderate (24-50) / Severe (51-75)
Risk of violence/aggression / Low (0-23) / Moderate (24-50) / Severe (51-75)
Risk of self neglect / Low (0-23) / Moderate (24-50) / Severe (51-75)
Notified risk of abuse to children
Other

1

VAS 13