NATIONAL MINIMUM INFORMATION STANDARDS FOR ALL ADULTS IN SCOTLAND

Transcription

1 NATIONAL MINIMUM INFORMATION STANDARDS FOR ALL ADULTS IN SCOTLAND Assessment (including Single Shared Assessment) Shared Care and Support Plan Review Carers Assessment and Support Version 2.0 Formulated by the Assessment Review Co-ordinating Group Date 6 November November

2 Document control This document is an amalgamation of the following four documents: National Minimum s for Single Shared Assessment for All Adults version 1.1 National Minimum s for Shared Care and Support Plan (for use with all Adult Client Groups following Single Shared Assessment Version 0.6 (draft) National Minimum s for Review (for use with all Adult Client Groups following Single Shared Assessment) Version 0.1 (draft) National Minimum s for All Adults version 1.3 Document History Date Version Comments Status 28 June DRAFT STANDARDS FOR DRAFT ALL ADULTS-SSA, SHARED CARE AND SUPPORT PLAN AND MONITORING AND REVIEW August DRAFT STANDARDS FOR ALL ADULTS-SSA, SHARED CARE AND SUPPORT PLAN, MONITORING AND REVIEW AND CARERS ASSESSMENT DRAFT September /November DRAFT STANDARDS FOR ALL ADULTS-ASSESSMENT, SHARED CARE AND SUPPORT PLAN, REVIEW AND CARERS ASSESSMENT DRAFT 6 November

3 Changes from Previous Version Changes Forecast Amendments following ARCG consultation Amendments following wider consultation. Reviewed by Issue control: Authors: Kirsteen Cameron, s Branch, Transformational Technologies Division (TTD), Peter Knight, ISD NHS National Services Scotland Contributor(s): Owner and approver: Target Group: Distribution: Local Authorities NHSScotland Data Sharing Partnerships CHPs Scottish Government Relevant Groups Independent Sector Other stakeholders Assessment Review Co-ordinating Group members Assessment Review Co-ordinating Group Any agency or individual involved in the collection, processing or use of service user assessment information and any other relevant public sector bodies. 6 November

4 CONTENTS Overview of National Minimum s 5 Minimum s for Personal details for All Adults 11 Minimum s for Needs Assessment of All Adults 21 Indicator of Relative Need (IoRN) 32 Minimum s for Shared Care and Support Plan 36 Minimum s for Review 42 Minimum s for Carer s Assessment and Support 47 Carers Assessment Guidance for National s 55 Compliance Review 61 Appendix One: Membership of the Assessment Review Co-ordinating Group Appendix Two: Code Lists for Personal Details Data Items Appendix Three: Differences between s for Assessment for All Adults Version 1.1 August 2006 and current version 6 November

5 Overview of National Minimum s 6 November

6 Overview of National Minimum s Introduction isation of the content of the various stages of assessment and care management is a pre-requisite for the effective recording and appropriate sharing of information for the benefit of people receiving community care services and support. This compendium sets out the national minimum information standards for all adults, covering Assessment, Shared Care and Support Plans and Review. It also includes national minimum information standards for the identification of needs and support for Carers ( Carers Assessment ). These standards have evolved from the original SSA Guidance and complement the guidance on care management issued by the Scottish Executive in 2004 (Circular CCD8/2004) and, subsequently, the Care Management Framework published in 2006 (Circular CCD2/2006). Development of the standards, including those for carers, has been informed by the national work in early 2007 to develop Outcomes for Community Care and the standards will support both the objectives and the measurement of the Outcomes. The compendium builds on and supersedes the National Minimum s for Single Shared Assessment for All Adults issued in August 2006 ( CCD3/ 2006). The standards are the national minimum and should be adopted in all partnerships (as defined locally). They apply to all community care groups. Points to Note about the s There are two distinct types of standards used throughout this document: s which describe the subject matter that must be included without specifying exactly how it should be done or recorded. This leaves flexibility at local level into how information standards are incorporated into local tools and guidance in an appropriate manner to enable assessors to gain good insights of, and to accurately document, the needs of the people assessed. There is no intention that the question wording in the national standard has to be mirrored exactly in local tools for the tools to be compliant. Indeed compliance may be achieved through the provision of explicit guidance that ensures that the relevant practitioner considers the item. Thus in some cases there may be no requirement to include unique fields on a system to match every information standard. Data s which specify the content at a more prescriptive level and include details on the format and codes to be used for each of these standards. Data standards are particularly useful where there is a strong consensus on the exact content and where the data gathered are intended to be transferred across different systems. Compliance with the standards does require that local tools conform to the format and codes specified. Both forms of standards s and Data s are used in this document and are labelled accordingly. It is recognised that the standards do not contain all the information required to address a person s individualised care needs. They set out the minimum information which all professional groups within health, social care and housing would expect to record, a core of information to which specialist modules can be added. One underlying principle is that once this core information has been gathered it can be shared between the relevant professionals whenever appropriate, avoiding the need to gather the same information repeatedly with all the inconvenience and attendant risks. To meet the standards local assessment and care management tools, electronic systems or processes should have the capability to record every data item in the standards, but there is no presumption that every item will be recorded for every person. For example, it is possible that fewer items will be recorded for individuals with relatively simple needs, and items will not be recorded where they are clearly not applicable [e.g. Landlord Details are not applicable to a home owner]. 6 November

7 The order in which the standards are presented in this document is not intended to be prescriptive. sharing occurs in a variety of formats. The purpose of the National Minimum s is to support good practice in the recording of information that is gathered during and for the purposes of assessment and care management. Data required to share information electronically using the ecare Framework is contained within separate ecare specific documentation and can be accessed from the website: The purpose of the National Minimum s is to support standardisation of the practice of assessment and related activities and not to define the technical specification for data sharing. The latter is contained within specific ecare documentation. Where a standard requires that further details should be recorded this should be done in accordance with good practice for assessment and care management. The SSA IoRN is currently designed for use with people aged 65 and over. The SSA-IoRN questions and supporting guidance are listed at the end of the Assessment section. The questions are fixed and should be answered based on information drawn from the assessment process. General Principles underpinning the Minimum s In drawing up these standards, the Assessment Review Co-ordinating Group (ARCG) was guided by the following principles: The minimum standards need to make sense to practitioners and should reflect good professional practice The standards should support the development of local assessment and care management processes The standards should be a foundation for the development of supporting information systems Where possible, any mandatory information requirements should be supported by the standards. The National Minimum s issued by ARCG should complement not duplicate, other work on data standards for health and social care. Where relevant standards have already been the subject of a separate consultation these will be adopted by ARCG and viewed as part of the National Minimum. For example the Personal Details in Section 2 are a sub-set of the Generic Core Dataset produced by The Social Care Data s Programme. A positive approach at local level towards the benefits of compliance is crucial to the process of building standardisation of information. The National Minimum s cannot be considered in isolation from practice. For this reason this document should be read in conjunction with relevant national policies on assessment (including SSA), care management and carers assessment. Background to the ARCG and the development of minimum standards The ARCG The Assessment Review Co-ordinating Group (ARCG) was formed to meet the demands of local partnerships in Scotland for national minimum information standards that would standardise the recording of information about people receiving community care services and facilitate data sharing. It was formed following a national Integration Seminar hosted by the (then) Scottish Executive in March ARCG membership includes a representative cross-section of local partnerships, supported by staff from the Joint Future Unit, the central ecare Programme, s Branch, the and Statistics Division of NHS Scotland, and the SE s Community Care Statistics Branch. Membership of the Group as at 2007 is listed in Appendix One. 6 November

8 Context for the Minimum s The Scottish Executive issued general guidance for Single Shared Assessment in November 2001 in a circular entitled Guidance for Single Shared Assessment of Community Care Needs (circular CCD 8/2001). The SSA Guidance provided the initial reference point for the ARCG s work (see below). The work of the ARCG has also been informed by subsequent initiatives, including: Extensive work by local partnerships both on developing their own local assessment tools and procedures and on converting existing paper tools into an electronic form National work by the s Branch on the agreement of core data standards for ecare, and harmonisation with generic standards for health produced by the National Clinical Dataset Development Programme (NCDDP) The development and incremental roll-out of the SSA-Indicator of Relative Need (SSA-IoRN). This is a standardised tool (currently validated only for use with older people) which groups individuals according to their level of relative need, and is applied following a comprehensive Single Shared Assessment Early work to devise an agreed common core national dataset that will summarise the characteristics of older people (including the SSA-IoRN result) receiving community care services; this has a working title the Care Assessment Data Summary (CADS) Establishment of Performance Indicators for Single Shared Assessment within the Joint Performance and Assessment Framework (commonly referred to as the JPIAF 6 PIs) and, in 2007, the National Outcome Measures For Community Care. The Scottish Executive Circular CCD/2003 emphasised the importance of assessment of carers and noted, the fundamental principle underlying the new legislative provisions is at Local Authorities, the NHS and other support agencies should recognise and treat carers as key partners in providing care. Reflecting early priorities the ARCG initially devised, consulted on and issued, in December 2004, (SE Circular CCD 15/2004) a set of minimum standards for the assessment of older people. This was superseded by National Minimum s on Assessment covering All Adults issued in August 2006 (CCD3/ 2006). The diagram below indicates the key elements surrounding the process of assessment of need and care management. In health this is commonly referred to as the nursing process: within social care it is often referred to as the assessment and care management process. Review Assessment Implementation Care Planning 6 November

9 Scope of the National Minimum s Broadly speaking, the shaded areas in the diagram below are the areas covered by this document. Consent and Service User Capabilities Basic information about the service user, their home, associated people, (including carers) and associated professionals. about the service user s needs Specialist Components of Assessment Shared Care and Support Plan Service Provision Review Carers Assessment Links/references The paper refers to a number of specific documents produced by various related work streams. These can be found at the following locations: Care Management: Original SSA Guidance Data s Manual (Core and Supplementary Person Datasets) SSA IoRN (relating to Older People) JPIAF National Training Framework for Care Management: Coordinated, Integrated and Fit for Purpose. A delivery framework for adult rehabilitation in Scotland. 6 November

10 CHP Toolkit: Management of Long Term Conditions Carers: The Community Care and Health (Scotland) Act (2002) The Elements of Nursing 4th edition. (Roper, Logan and Tierney) Churchill Livingstone, Edinburgh The Review of Nursing Voices from the Frontline 6 November

11 Minimum Data s for Personal Details 6 November

12 Minimum Data s for Personal Details Introduction The data standards documented in this section are the basic personal details that inform assessment, care and support planning, monitoring and review for anyone in contact with health, social work and housing in respect of their care needs. It may not be necessary to record all items for every person assessed, but the ability to record them is needed to comply with the standards. The minimum standards for personal details are all Data s and so the format and codes specified should be adopted to achieve compliance. Summary of Minimum s for Personal Details These data standards cover: Personal identification and key characteristics of the person concerned Person s GP Housing circumstances Basic needs (e.g. communication method) Crucial background information Some details of other important people (informal or professional) associated with the person receiving services and support. This section contains a listing of the data items. Full lists of values are given in Appendix Two. 6 November

13 Person Identification Data Item Description Field Structured Name Person Title e.g. Mr, Mrs, Miss, Ms, Dr, Rev, Sir, Lady, Lord, Dame, etc Person family name E.g. Gibson Format Length 35 Text 35 Text Data Data Person given name 35 Text Data E.g. Joan Unstructured Name Person Full Name This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. 70 Text Data E.g. Mrs Joan Hazel Gibson MSc Person Birth Date Age and age bands can be derived. E.g. 11/04/ CCYY MM DD Data Person Death Date 10 CCYY MM DD Data Person Identification The unique person identifier A number which can be used as a common reference number across information systems to identify an individual or an individual s records. CHI Number The Community Health Index is a population register used for healthcare purposes in which each person is uniquely identified by the CHI number. Variable max 50 characters Variable Data 10 Structured Data Gender/Sex Person Marital Status Person Current Gender E.g. female An indicator to identify the legal marital status of a person E.g. Married 1 Pick list Data 1 Pick list Data 6 November

14 Data Item Description Field Length Ethnicity Ethnic Group (Self Assigned) Up to 6 (2+4) There is a statutory, legal requirement for public authorities to collect data on ethnic group under the Race Relations (Amendment) Act 2000 in the interests of eliminating racial discrimination and promoting equality of opportunity and good race relations. Ethnic group and all the other Ethnicity items are also important for ensuring that appropriate, person-focused, needs-related care services are delivered sensitively to individuals. E.g. White Irish Format Pick list Data Religion E.g. Muslim Up to 6 (2+4) Pick list Data Interpretation assistance indicator E.g. no help needed 2 Pick list Data Preferred language A person's language of preference may differ from their identified first language. E.g. English Up to 6 Pick list Data 6 November

15 Data Item Description Field Length Address (BS7666) or Addresses conforming with BS7666 will be stored in and retrieved from an electronic gazetteer Address (note that several addresses may be held for an individual, each with its address type) UK Postal Address Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines). This number may be a mobile number UK Evening Telephone Number Format Gazetteer Data 5x35 Text Data Post Code 8 Ref File Data UK Daytime Telephone Number 35 Character Data string This number may be a mobile number Address Type Relates to the nature and status of the address, e.g. normal domicile address, alternative contact address. E.g. normal domicile address 35 Character string Data 2 Pick list Data Lives Alone Yes/No up to 3 Yes/No Data GP Person Family Name E.g. Linklater 35 Text Data Person Given Name E.g. Peter 35 Text Data Person full Name This alternative to recording structured name involves the whole name being recorded as a single character string with no separable identified elements. 70 Text Data Dr Peter Linklater MD 6 November

16 Data Item Description Field Format Length Registered GP Practice GP Practice Code Each GP practice in Scotland is identified by a unique GP practice code. 6 Reference file Data E.g (right justified) Address (BS7666) or Gazetteer Data UK Postal Address 5x35 Text Data UK telephone Number 35 Character string Data Housing details (part of Social, economic and physical situation) Data Item Description Field Length Accommodation type The type of accommodation in which the service user is normally resident. E.g. Mainstream housing Format Up to 6 Pick list Data Dwelling Type Tenure Type Landlord Details Is a description of the physical structure in which someone lives. E.g. Flat Indicates the basis on which an individual occupies the property in which they live. E.g. Owned Person Title E.g. Mr, Mrs, Miss, Ms, Dr, Rev, Sir, Lady, Lord, Dame, etc. e.g. Mr Person Family Name E.g. Thomson Person Given Name E.g. Gordon Person Full Name The alternative to recording structured name involves the whole name being recorded as a single character string with no separable identified elements. E.g. Mr Gordon Thomson 3 Pick list Data 3 Pick list Data 35 Text Data 35 Text Data 35 Text Data 70 Text Data 6 November

17 Data Item Description Field Length Format Organisation Name 255 Text Data Address (BS7666) or Gazetteer Data UK Postal Address 5x35 Text Data UK Telephone Number 35 Character string Data Basic Needs Data Item Description Field Format Length Person Representative Required An adult who represents or communicates on behalf of the person. Up to 3 Yes No Data E.g. No Preferred Communication Method The method of communication preferred by the person to make themselves understood. E.g. Generally intelligible speech 3 Pick list Data Impairment E.g. Visual impairment 2 Pick list Data Background Data Item Description Field Length Crucial This covers any factors (other than background those indicated by other data items information in this dataset), which it is vital to know about in the early, pre-assessment stages of dealing with the person, including relevant medical factors and cultural issues. E.g. Recent Suicide Attempt Format Free text Data 6 November

18 Associated Person Data Item Description Field Format Length Person Role Associated people are the people who have a significant involvement or relationship with the person (e.g. main carer, next of kin, key holder, 3 Pick list Data emergency contact etc). The particular involvement(s)/relationship(s) of each associated person is/are indicated by the "Person Role" data item. Data should be entered for all people significantly associated with the subject, including all members of the person s household. E.g. Key holder Structured Name Unstructured Name Address Person Birth Date Person Title e.g. Mr, Mrs, Miss, Ms, Dr, Rev, Sir, Lady, Lord, Dame, etc e.g. Mrs Person Family Name E.g. O Reilly Person Given Name E.g. Christine Person Full Name This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. E.g. Mrs Chrissie O Reilly Address (BS7666) or UK Postal Address UK Daytime Telephone Number UK Evening Telephone Number E.g. 12/10/ Text Data 35 Text Data 35 Text Data 70 Text Data Gazetteer Data 5x35 Text Data 35 Character Data string 35 Character Data string 10 Date Data 6 November

19 Data Item Description Field Format Length Relationship to Relationship to Client/Patient 3 Pick list Data Client/Patient The relationship between an Associated Person and the data subject. E.g. Parent Gender/Sex Person Current Gender E.g. Female 1 Pick list Data Associated Professional Data Item Description Field Length Professional Person Role Professionals are the people who are already involved with the person in a professional capacity. (E.g. Social Worker, OT etc). The particular role(s) carried out by each professional is/are indicated by the Professional Person Role data item. Data for as many professionals as required can be entered. E.g. Social Worker Format 35 Text Data Structured Name Unstructured Name Person Title E.g. Mr, Mrs, Miss, Ms, Dr, Rev, Sir, Lady, Lord, Dame, etc. e.g. Ms Person Family Name E.g. McAteer Person Given Name E.g. Gill Person Full Name This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. E.g. Ms Gill McAteer 35 Text Data 35 Text Data 35 Text Data 70 Text 6 November

20 Data Item Description Field Length Employing Agency E.g. City of Edinburgh Social Work Department Format 255 Text Data Professional Contact Address Address (BS7666) or Gazetteer Data UK Postal/Simple Address 5x35 Text Data UK Daytime Telephone Number 35 Character Data string UK Evening Telephone Number 35 Character string Data 6 November

21 Minimum s for the Needs Assessment of All Adults 6 November

22 Minimum s for the Needs Assessment of All Adults Introduction Assessment is part of a wider process that includes care and support planning, resource access, monitoring and review. An assessment is undertaken to understand and document an individual's needs, to relate them to agency policies and priorities and to involve the person and/or their carer in identifying intended outcomes from any intervention. A well-documented assessment is a basis for ensuring a match between the needs of the individual and any interventions necessary to meet those needs. In preparing these minimum standards the ARCG took account of existing Single Shared Assessment tools, guidance and processes for a variety of community care groups including: Older People, Mental Health, Dementia, Physical Disability including sensory impairment and brain injury, Learning Disability, and Substance Misuse. The standards reflect core information (but not specialist components) and assume assessment appropriate to level of need. These standards focus on the information about the needs of the person being assessed and are intended to be sufficiently adaptable to fit with different local business processes, particularly since they are designed for use by partners within multiple agencies It may not be necessary to record all items for every person assessed, but the ability to record them is needed to comply with the standards. The content of a completed assessment will depend on the complexity of need. Where s are shown here the actual method used locally for incorporating the standard into local tools is flexible. Where Data s are shown the format and codes specified should be adopted to achieve compliance. Summary of minimum standards for Needs Assessment The standards for needs assessment are listed under the following headings: A. Person s perspective B. Carer s perspective C. Relationships D. Vision, Hearing and Communication E. Personal care and physical well-being F. Mental health G. Immediate environment and resources H. Social and Cultural Life I. Employment J. Education, Training and Life Long Learning K. Care and Protection I s denoted with the following symbol have related supplementary questions for completing an Indicator of Relative Need (IoRN).. These IoRN questions are detailed on pages November

23 INFORMATION ABOUT SERVICE USER S NEEDS A. Person s perspective 1. Was the person involved in the assessment process Yes/No 2. If No, provide details Type of If Yes, describe: 4. Problems and issues perceived and conveyed by the person 5. What is the person s understanding for the reason for this referral/assessment 6. Differences or disagreements B. Unpaid Carer/s (previously known as Informal ) 1. Is there an unpaid Carer (or Carers)? Yes/No If yes: 2. Was the unpaid carer involved in the assessment process? Yes/No 3. If No, provide details If Yes, describe 4. Problems and issues perceived and conveyed by the unpaid carer 5. What is the unpaid carers understanding of the reason for this referral/assessment 6. Is the unpaid carer happy to continue to support the person? 7. Differences or disagreements 8. Has the unpaid carer been offered assessment of needs? Yes/No 9. If No, provide details? 10. If Yes, was offer accepted? Yes/No 11. If main unpaid carer was not available would services (or additional services) be required? Yes/No 6 November

24 12. Level of Care provided by carer (or carers). Enter codes 0 4 against the period/s that apply Daytime Evening Overnight 0 None 1 Less frequently than daily. 2 Daily once or twice during period. 3 Daily more than twice during period. 4 Daily continuously during period. Type of 13. Are there any issues regarding current unpaid caring arrangements? Yes/No/Not Assessed 14. If Yes, describe specific issues. Arrangements for young carers 1. Has a referral been made to children services? Yes/no? 2. If No, provide details. C. Relationships Personal Relationships 1. Does the person have difficulty with key relationships? Yes/No/Not Assessed 2. If Yes, describe specific issues I Intimate Relationships 1. Has/does the person have difficulty with intimate relationships? Yes/No/Not Assessed 2. If Yes, describe specific issues including: Sexual health Sexual wellbeing Service Provision arrangements 1. Are there any issues regarding service provision (previously referred to as formal caring arrangements)? Yes/No/Not Assessed 2. If Yes, describe specific issues 6 November

25 D. Vision, Hearing and Communication Hearing and Vision 1. Are there any issues? Yes/No Type of 2. If Yes, describe specific concerns. Communication 1. Are there any issues? Yes/No 2. If Yes, describe specific issues Speech Language Understanding Reading / writing Numeracy Use of telephone Other equipment (specify) E. Personal care and physical well-being Relevant Medical Background including conditions that require ongoing care 1. Are there any relevant medical history/learning Disabilities/ Physical Disabilities that require ongoing care? Yes/No/Unknown/Not Assessed 2. If Yes, provide details/conditions and source of information e.g. Mental Health Dementia Learning Disability (as per SCDS definitions) Physical Disability Acquired Brain Injury History of falls 3. If No, provide details. 4. If Unknown or Not Assessed detail any action taken to identify medical/mental health history. 5. Has the person had any hospital admissions within the last 12 months? Yes /No / Unknown/ Not Assessed 6. If Yes, provide details/conditions and source of information. 7. If No, detail source of information. 8. If Unknown or Not Assessed detail any action taken to identify hospital admissions. 6 November

26 Type of 9. Has the person attended any clinic/outpatient or treatment centre in the last 12 months? Yes /No / Unknown/Not Assessed 10. If Yes, provide details/conditions and source of information. 11. If No, provide details. 12. If Unknown or Not Assessed detail any action taken to identify any attendance at a clinic/outpatient or treatment centre. Current physical health 1. Are there any current relevant health issues? Yes/No/Unknown/Not Assessed 2. If Yes, provide details and source of information including specific health issues. e.g. Skin care Allergies/Sensitivities Breathing difficulties 3. If Unknown or Not Assessed detail any action taken to identify current health issues. Medication 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Taking medication Obtaining medication Personal Care 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Managing personal appearance Washing Dressing I 6 November

27 Type of Eating, drinking and nutrition 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Does the person require the food to be placed in front of them to prompt them to eat? I Mobility 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Transferring from a position of lying down to sitting in a nearby chair Mobility on flat Mobility on stairs Mobility outdoors Falls I Substance Use 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Smoking Alcohol Drugs and solvents use (including prescribed drugs) Cognition F Mental health 1. Are there any issues? Yes/No/Not Assessed Type of 2. If Yes, describe specific issues e.g. Concentration Memory Orientation Wandering Awareness of danger 6 November

28 Type of Emotional well-being 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Bereavement Emotional difficulties arising from life events General Mood Anxiety Motivation Behaviour 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Agitation/Restlessness Disturbance/Disruption towards others Verbal Aggression Resistiveness or lack of co-operation Risk of harm to self or others G Immediate environment and resources Domestic tasks/care of the home 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Food & drink preparation Use of heating Use of appliances or gas I Type of I Level and management of finances 1. Are there any issues? Yes/No/Refused to disclose/not Assessed 2. If Yes, describe specific issues Data Item Description Field Length Format Has the person Yes been offered an income No. maximisation assessment? 1 Character Data 6 November

29 Type of 3. If the person has not been offered an income maximisation, provide details. Accommodation 1. Are there any issues? Yes/No/ /Not Assessed 2. If Yes, describe specific issues e.g. Concerns regarding fabric of the building Physical security Safety hazards Equipment and adaptations Heating Summoning help Housing support H Social and Cultural Life Social life and leisure activities 1. Are there any issues? Yes/No/Not Assessed Type of 2. If Yes, describe specific issues Spiritual, religious, cultural matters 1. Are there any issues that are relevant to the provision of care? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Requirements for worship or other religious observation Special dietary needs Arrangements for provision of care (e.g. gender of carer I Employment 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues Type of 6 November

30 J Education, Training and Life Long Learning 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues Type of K Care and Protection Abuse and neglect of person 1. Are there any concerns / relevant history? Yes/No/Not Assessed Type of 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details Other aspects of personal safety 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details Public safety / harm to others 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details Health and Safety at Work Issues relating to anyone in direct contact 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No 4. If Yes, provide details 6 November

31 L Contact Data Item Description Field Length Format Person Has the person been verbally 1 Character Data informed who is single point of contact informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments? Yes /No 1. If the person has not been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments, provide details Data Item Description Field Length Format Carer Has the carer been verbally 1 Character Data informed who is single point of contact informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments? Yes /No 1. If the carer has not been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments, provide details Data Item Description Field Length Start Date of Assessment The date on which an assessment of need commences. It is recognised that the process of assessment may be undertaken over a period of time. Data Item Description Field Length End Date of Assessment The date on which an assessment of need concludes and needs are recorded. This should be the actual end date of assessment and not the proposed end date. Format 10 CCYY-MM- DD Format 10 CCYY-MM- DD Data Data 6 November

32 IoRN Questionnaire The Single Shared Assessment - Indicator of Relative Need (SSA-IoRN) (previously known as the RUM) has been developed by ISD Scotland in partnership with the Scottish Government, Local Authorities, NHSScotland and other organisations. It is a standardised tool that uses information gathered from the SSA to place individuals over the age of 65 into groups according to their relative need. The main aim of the SSA-IoRN is to support the provision of better services for Scotland s older people through providing summary insights into the characteristics of people being assessed. The IoRN is a standardised tool, which classifies people into one of 9 groups (A to I). It consists of a specific set of questions covering 5 characteristics i.e. activities of daily living, personal care, food and drink preparation, mental well being and behaviour and bowel management. More detail on the use of the questions and the algorithm are available at Data Item Description Field Length Format When eating a Eats without assistance. meal, the Eats without assistance using 1 Character person equipment. Eats with help, e.g. cutting up or pureeing food. Eats with encouragement, prompting or supervision. Requires complete assistance Receives nutrition by tube or Infusion. When transferring from bed to chair or wheelchair the person Transfers independently Transfers independently using equipment or adaptations Needs the assistance of one person Requires the encouragement, prompting or supervision of one person Needs the assistance of more than one person (with or without equipment) Does not transfer from bed to chair (e.g. confined to bed) 1 Character When using the toilet, the person Is independent Is independent with catheter or colostomy and equipment or adaptations Needs assistance Requires encouragement, prompting or supervision Requires complete assistance Does not use the toilet 1 Character 6 November

33 Data Item Description Field Length Format Is the person Without difficulty able to wash Without difficulty using equipment 1 Character his/her hands or an adaptation and face? Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Is the person able to give himself/herself a complete wash, a bath or a shower? Is the person able to wash his/her hair? Is the person able to dress /undress himself /herself? Is the person able to prepare, cook and serve himself/herself a main meal? Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others 1 Character 1 Character 1 Character 1 Character 6 November

34 Data Item Description Field Length Format Is the person Without difficulty able to prepare, Without difficulty using equipment 1 Character himself/herself or an adaptation a light snack Has difficulty even if using (e.g. equipment or adaptation sandwich)? Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Is the person able to prepare, himself/herself a hot drink (e.g. a cup of tea)? Is the person agitated or restless? Has the person disturbed or disrupted other people? Is the person verbally aggressive? Is the person unco-operative or resistant to help with their care? Has the person had difficulty with key relationships? Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others Never, or less than three times in the last four weeks Three times or more in the last four weeks Never, or less than three times in the last four weeks Three times or more in the last four weeks Never, or less than three times in the last four weeks Three times or more in the last four weeks No Yes No Yes 1 Character 1 Character 1 Character 1 Character 1 Character 1 Character Has the person s behaviour constituted a risk of harm to themselves or to others? No Yes 1 Character 6 November

35 Data Item Description Field Format Length Does the Provision of assistance, guidance, 1 Character person require any of the prompting or supervision to maintain bowel function: following Never or less than once a week interventions or on average treatments More than once a week on relating to average bowel management? 6 November

36 Minimum s for Shared Care & Support Plan 6 November

37 Minimum s for Shared Care and Support Plan Introduction Care and support planning supports the transition from the identification of need by assessment to the timely and effective implementation of appropriate interventions. The assessment processes should identify the needs and then, in producing a Shared Care and Support Plan, the lead assessor/care manager should document any related interventions intended to address those needs. The minimum standards for the Shared Care and Support Plan reflect this relationship. The aim of planning care is to ensure that the person s needs are addressed in appropriate and acceptable ways. This should take into account the needs identified through assessment processes and should involve consideration of the person s wishes for their care and their aspirations for the future particularly from a reenablement perspective. Care and support planning allows the lead assessor/care manager the opportunity to consider all the options / opportunities available to address assessed needs and to document these in the Shared Care and Support Plan. The Shared Care and Support plan provides a mechanism to record multi-agency interventions in relation to a variety of needs and resources. It should be general in scope with the facility to be augmented with specialist care plans e.g. an individual requiring rehabilitation may have several specialist, specific, goal setting care plans which outline discrete stages in the process of addressing a particular need. The Shared Care and Support Plan should draw together the combined needs and agreed interventions into one cohesive document which can be shared with all the professionals involved and with the person (and where appropriate, paid and unpaid carers. An intervention/resource can be: a service e.g. meals on wheels, respite a piece of equipment e.g. handrail or a person based resource e.g. physiotherapy It is recognised that more than one intervention/resource might be required to address a need and not all needs will be able to be fully addressed; a shared plan of care and support should reflect the interventions/resources identified to best meet the need, either partially or fully. Whenever possible the emphasis should be on enablement, with a rehabilitation and anticipatory focus. The content of a completed shared care and support plan will reflect the complexity of need and interventions. Where s are shown here the actual method used locally for incorporating the standard into local tools is flexible. Where Data s are shown the format and codes specified should be adopted to achieve compliance. Summary of minimum standards for Shared Care and Support Plan The minimum standards for shared care and support plan cover: identification of the lead professional each identified need for each need: the interventions required the objective of the interventions a coded list of interventions (tba) the standards also include various start and end dates: date plan agreed and end date planned date for review start and end date of each intervention reasons for end of intervention and for end of Plan 6 November

38 Data Items At a minimum the following sub set of the Personal Details should be included in the Care and Support Plan. Person Details Structured Name or Unstructured Name Person Birth Date Person Identification Address Lead Professional Details taken from Associated Professional The data items above are detailed in the Minimum s for Personal Details Section (Pages 11 20) and are selected from the Social Care Data s Manual, version 2.0 (August 2005). Identified Need/s Type of A need, which has been identified during the assessment process. Dependent on local vocabulary, needs maybe related to issues/problems/concerns etc. Local definitions of need should also consider disability and personal requirement needs. During the compliance review for SSA for All Adult Client Groups, Partnerships should have identified preferred language in relation to need which will be non-service specific. E.g. Maintaining Personal Hygiene Intended Outcome/s of Intervention/s The desired outcome/s for the person by initiating an intervention. E.g. Rehabilitation / re-enablement / independence Care / support Independence maintaining personal hygiene 6 November

39 Data Item Description Field Length Intervention/s The intervention/activity/resource required (to address to address a need identified during the Identified Need) assessment process. An intervention might relate to a particular task, resource or behaviour. As well as describing the direct intervention, it might also relate to the requirement for further assessment. Therefore an intervention might be a referral for a specialist assessment. The identified intervention should reflect the assessor/care planner s ability to decide the resource which is best to address the need/s. Several interventions may meet one need or one intervention may address more than one need. Similarly there maybe instances where no suitable interventions can be identified to address needs Draft pick list Social Stimulation / Activity Prompting Supervision Physical Assistance or doing tasks for the person Equipment and Adaptations Specialist Assessment Counselling Behaviour Management Person Advice / Training Carer Advice / Training Other Format Type of Data 3 Pick list to be developed? Resources to address Interventions Identified resources such as services, professionals, equipment considered appropriate to address the identified needs. It should be recognised that there may be more than one resource required to address a need or, conversely, no resources to adequately address needs. E.g. Telecare Respite Care Occupational Therapy (This could be selected from a pre-determine d list such as CADS and presented as a Data standard) 6 November

40 Data Item Description Field Length Date Shared Care and Support Plan Agreed The date on which all contributors to the plan have agreed its content. This is an overall, generic date and is not specific to individual components of the plan. It is the date that needs and interventions are agreed and the date from which interventions is measured against. E.g. 01/05/2007 Format 10 CCYY MM DD Data End Date of Shared Care and Support Plan The date on which it is decided the Shared Care and Support Plan is no longer required or has no current relevance. E.g. 01/10/ CCYY MM DD Data Reason Shared Plan of Care and Support Ended A record of why the Shared Care and Support Plan has been ended. This may be due to the fact that the person has moved away, is deceased, or the case has been closed for a particular reason such as all objectives have been met. E.g. All intended outcomes met Person moved away Person died Type of (This could be selected from a pre -determined list and presented as a Data standard) Data Item Description Field Length Anticipated / Planned Date of Shared Plan of Care and Support Review The date on which it is intended to review the overall identified needs and interventions (as outlined in the shared care and support plan). This date would be no more than a year from the date the 'Date Shared Care and Support Plan Agreed'. E.g. 29/07/2007 Format 10 CCYY MM DD Data Data Item Description Field Length Start Date of Intervention The date on which an intervention was initiated. This is different from the referred or the requested date as some resources / interventions will have a waiting time. Similarly the actual start sate might be agreed to coincide with other components of the care and support plan such as hospital discharge. Format 10 CCYY MM DD Data 6 November

41 Data Item Description Field Length Format E.g. 29/07/2007 Data Item Description Field Format Length End Date of Intervention/s The date on which an intervention or the need for that intervention ceased 10 CCYY MM DD Data E.g. 13/06/2007 Reason Intervention Ended An explanation of why a particular intervention ended. E.g. Person refusal Need Status Changed All intended outcomes met (This could be selected from a pre-determine d list and be presented as a Data Item) Data Item Description Field Length Format Has the person Has the person been verbally 1 Character Data been informed informed/given written advice as to who as to who is the single point of contact is the single point of contact for co ordinating the delivery of care and support? Yes/No 1. If the person has not been verbally informed/given written advice as to who is the single point of contact for co-ordinating the delivery of care and support provide details Has the unpaid carer been informed as to who is the single point of contact Has the unpaid carer been verbally informed/given written advice as to who is the single point of contact for co coordinating the delivery of care and support? Yes/No 1 Character Data 2. If the unpaid carer has not been verbally informed/given written advice as to who is the single point of contact for co-ordinating the delivery of care and support provide details 6 November

42 Minimum s for Review 6 November

43 Minimum s for Review Introduction Note: Review is also a term applied to the ongoing monitoring and evaluation of needs and care provision for individuals who have been assessed and are in receipt of resource intervention. Many practitioners will constantly review needs and care arrangements as part of their daily professional business; however for the purposes of the national minimum information standards for review, the term is used to refer to the task of undertaking a formal Review of a person s overall needs and care interventions. To avoid confusion, the constant activity of reviewing needs and interventions will be referred to as monitoring and evaluation. Carrying out a formal review of the person s needs is an important stage in the cycle of effective assessment, care planning, monitoring and review. The formal Review allows the lead assessor/care manager the opportunity to reconsider, in discussion with the person, relevant professionals and where appropriate the carer, options/opportunities available to address current and future needs. It is a further opportunity to consider how well current interventions are meeting the person s needs and how far the intended outcomes of the existing plan are being achieved e.g. in relation to re-enablement, rehabilitation and anticipation of changing needs. The Review provides the person and where appropriate their carer the opportunity to express their views, needs and preferences and have these documented and fully addressed. The presumption is that the person and carers will be active participants in the Review process. The way that a Review is conducted may vary depending on a number of factors. The content of a Review will depend upon the complexity of need and the level of invested resources. The form of the Review will be substantially governed by what is judged to be the most effective way of involving the person and unpaid carer(s) as partners. The frequency will be governed by how much the needs are subject to change. Agencies may have set guidelines for the minimum frequency: for example, not less than once a year. However, the interval of Reviews should be related to the pace of change in the person s needs as this determines the need to revise the care plans. This does not prevent an earlier Review, if circumstances dictate. As detailed in these minimum standards the date of the next planned Review should be agreed and recorded at the end of each Review. It may not be necessary to record all items for every Review, but the ability to record them is needed to comply with the standards. The content of a completed Review will depend on the complexity of needs and interventions. Where s are shown here the actual method used locally for incorporating the standard into local tools is flexible. Where Data s are shown the format and codes specified should be adopted to achieve compliance. Summary of minimum standards for Review The minimum standards to reflect the purpose of the Review outlined above include: basic details about the person details of contributors and method of engagement, the documented viewpoint of the person (and where appropriate their carer) documented views of other contributors re-consideration of needs, objectives, intended outcomes and interventions decisions and actions 6 November