Detailed Guidance for Completion of Documentation:

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Detailed Guidance for Completion of Documentation: Powered By Docstoc
					                                    Brighton & Hove
                   Health and Social Care Community




                              Overarching Policy
                 for the Implementation of
                                              the
             Single Assessment Process




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                                                    Index

Section         Title                                                                    Page
                                                                                         number
1               Introduction                                                             4
1.1             What is the Single Assessment Process?                                   4

1.2             Why do we need a Single Assessment Process                               4

1.3             What is a person centred approach?                                       5

1.4             When does the Single Assessment Process apply?                           5

1.5             When the Single Assessment process does not apply                        5

2               Processes for enabling the information to be shared more effectively     6
2.1             The Person Held Record                                                   6

2.2             Purpose of the Person Held Record                                        6

2.3             When should a Person Held Record be set up?                              6

2.4             When a Person Held Record should not be set up?                          6

2.5             Contents of the Person Held Record                                       6/7

2.6             Issuing the Person Held Record                                           7
2.7             The Service Held Record                                                  7

2.8             The Visit Record Sheet                                                   7
3               How is agreement to share information obtained?                          8

4               What all assessors should check prior to any assessment                  8/9

5               Referrals within the Single Assessment Process                           9

6               Basic Personal Information                                               10
7               Contact Assessment                                                       10

7.1             Use of Contact Assessment                                                10

7.2             What happens following a Contact Assessment?                             10
8               Specialist Assessment                                                    11

8.1             The purpose of the Specialist Assessments                                11

8.2             When will a Specialist Assessment be undertaken?                         11

8.3             Sharing the Specialist Assessment                                        11


                                                                                         11

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9            The Overview Assessment
9.1          The purpose of the Overview Assessment                               11

9.2          When should an Overview Assessment be completed?                     11

9.3          Factors that should prompt an Overview Assessment                    12

9.4          Who should undertake an Overview Assessment                          12

9.5          Responsibilities of the Overview assessor                            12

9.6          Sharing the Rapid/Overview Assessment                                12

10           Comprehensive Assessment                                             12

11           Change in the service users circumstances                            13

11.1         Change of address, carer etc                                         13

11.2         Change of views on Consent to Share Personal Information             13

11.3         Change in condition- health or social care                           13

12           Interface with Mental Health – Single Assessment Process             13

13           Adult Protection                                                     13

14           Ending the assessment process                                        14

14.1         Outcome of Assessment /Review                                        14

14.2         Outcome of Assessment /Review & Non Complex Care Plan                14

14.3         Outcome of Assessment /Review & Complex Care Plan                    14

15           Unified care plan                                                    15
16           Care Co-ordinator                                                    15/16
17           Process Map- SAP/Documentation                                       17
18           Summary of all SAP Tools                                             18-21




                        Guidance on Single Assessment Process


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1.     Introduction

1.1.   What is the Single Assessment Process?

       The Single Assessment Process is one of the cornerstones of the National Service Framework
       for Older People and applies to both Health and Social Care. The Single Assessment Process
       recognises that many older people have health and social care needs and that agencies need to
       work together so that the assessment and subsequent care planning are:

          Person centred
          Effective
          Co-ordinated

       When fully implemented, the Single Assessment Process should lead to:

          A co-ordinated process of assessment and care planning which will address a person's
           health and social care needs.
          The scale and depth of an assessment will be in proportion to the persons` needs
          Agencies will not duplicate each other's assessments because there will be effective joint
           working between health and social care agencies within which professionals will contribute
           their expertise and knowledge in the most efficient way.
          Reduced repetition in providing information from the point of view of the person involved and
           experience of a more seamless service.
          Enabling & supporting a person to contribute as fully as possible to their care & related
           decisions
          Acknowledging & respecting that each person is different
          Principles of equality & anti-discriminatory practice are always central to the assessment &
           care planning process



1.2.   Why do we need a Single Assessment Process?
       Think about where you work-
          How many times do you ask the same questions to an individual that you know have been
           asked before?
          How many times have you copied information from another practitioner's referral form,
           assessment form or medical notes onto your form?
          Have you always received full and complete information?
          How often do you have to phone a number of different agencies to find out what care an
           individual is receiving or what their needs are?

       If you have replicated information or had difficulty finding out what service an individual receives
       you will understand why we need the Single Assessment Process.

       It is unnecessary to duplicate information and this can be achieved by using one set of records.
       This record will hold all relevant information in one place making it easier for practitioners to
       know what care is being provided.




1.3.   What is a person centred approach?



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       A person centred approach is a way of working with people which recognises that individuals
       are best placed to discuss their own situation and should be worked with as active partners in
       identifying needs and how those needs will be met through the processes of assessment and
       care planning. Person centred approaches are ways of commissioning, providing and organising
       services based on what people want, and how to support people to live independently as they
       choose.

       The Single Assessment Process is under-pinned by the requirement for professionals to
       work in a person centred way. In practice this means:

          Placing a person at the centre of any assessment / care planning process & taking account
           of & respecting their views
          Acknowledging & using a persons strengths & abilities

       A person centred approach means the person seeking help from health, housing and
       social care services can expect:

          To give information about their needs once
          Professionals to work together in the best interests of the person, using evidence based
           practise
          Their views to be central to the assessment process and for their strengths and abilities to
           be taken into account
          The depth and detail of the assessment to be in proportion to their needs and to build a
           rounded picture of their needs and circumstances
          To receive confirmation of agreed key decisions in writing.
          To give permission for information being shared across agencies


1.4.   When does the Single Assessment Apply?

       In Brighton & Hove adults of 18 years and above will be eligible for inclusion within the Single
       Assessment Process except:

          People of working age with significant mental health needs whose needs will continue to be
           assessed under the Care Programme approach (CPA)

       Health and Social Care professionals should explore the wider health and social care needs of
       the person using the Single Assessment Process when:

          When needs are first described or suspected and where it is probable that an individual will
           /does require the involvement of another health, housing or social care professional or
           service in order to either assess or meet their needs adequately.


1.5.   When the Single Assessment Process does not apply:

       People would not need to proceed into the Single Assessment Process when:

          Minor ailments which can be treated or remedied quickly by one professional
          Requests for information about services
          Services under the Road Traffic Act 2000




2.     Processes for enabling information to be shared effectively

2.1    The Person Held Record (PHR)

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2.2.   Purpose of the Person held record

       The person-held record aims: -

             To be a means of involving people in their care – as part of the person-centred
              approach of single assessment

             To improve information flow and communication between different groups
              involved in a person’s care – including links between community and hospital



2.3    When Should a Person Held Record Be Set Up?
       Whenever:

             significant health and social needs likely to require multi-agency/
              multidisciplinary help are first described or suspected, or
             presenting needs are not clear cut (e.g. where the person’s medical or social
              needs indicate a more complicated problem), or
             other potential needs (either short- or in the longer-term) are identified likely to
              require the person to be referred on for multi-agency /multi-professional input or
              where people have chronic conditions that are likely to fluctuate/deteriorate), or
             requests for more intensive forms of support or treatment have been made (to
              enable people already receiving services to benefit from the SAP process).


2.4      A Person Held Record would not be set up:
             Where one already exists
             Where presenting needs or requests are straightforward and people have indicated there are
              no other needs or issues e.g.

             reversible and immediate needs specific minor ailments
             requests for information about services


2.5     Contents of the Person Held Record

       Indexes should always be put into the PHR to reflect the following sections.

       The person-held record should always contain:

          (1) SAP Contents Sheet
          (2) Visit record sheet
          (3) Agreement to share information form (updated six monthly) & copy of the ‘What you need
              to know leaflet’
          (4) Guidance for person - ‘ Person Held Record’
          (5) Care co-ordinator form
          (6) Any mandatory service specific leaflets
          (7) Basic Personal Information & Contact Assessment


          The person-held record should have a combination of the following documents in it:
          (8) Specialist Assessments

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             (9) Overview Assessment (excluding prompts) /Rapid Assessment
             (10) Care plans/Review documentation/treatment plans etc
             (11) Comprehensive Assessments
             (12) Additional Information

          There might also be additional records that would normally be left in the person’s home, e.g.
          nursing notes, Intermediate care records, which maybe removed when the service withdraws.


2.6       Issuing the Person Held Record

          The person held record belongs to the person and they should be advised to bring it with them
          to any appointments they may have with any health, housing or care professional.

          Health and social care staff will issue the person held record to all service users within the single
          assessment process, unless it would be detrimental to them (see section 13) or if they do not
          wish to have the record.

          Where possible the contact assessor will issue the person held record. When the contact
          assessment takes place over the phone, the person held record should be issued by the first
          professional to see the service user in person.

          In cases where assessments/information is posted, it is very important that a cover letter/memo
          accompanies the documents explaining to the person that the information should be placed into
          their yellow folder. However, ideally assessments should be forwarded to the next professional
          who will be visiting the person, who should place the documents into the appropriate section.


2.7.      The Service Held Record

          This record holds all current and relevant information about the person receiving care and is
          updated by the Care Co-ordinator on receipt of updated information received from practitioners.
          It is the responsibility of each practitioner to ensure that the Care Co-ordinator receives
          updated information.

         A complete version of the SAP record will always be held by the named Care-Co-ordinator/the
          organisation/service to which the named care Co-ordinator belongs
         This file should contain copies of all the documentation plus copies of all other current
          documentation relevant to the persons` care.


2.8 .     The ‘ Visit Record Sheet’

          The Visit Record Sheet should be used by all professionals who visit the person/or when the
          person takes it to appointments with them, to record any assessments/interventions/actions
          undertaken or in progress.

          This record is held in the front of the Person Held Record and is available for the person, their
          carer (if appropriate), all the professionals involved in the persons care and the care co-
          ordinator to view with consent.




3.        How is agreement to share information obtained?

          Information obtained which relates to a person’s assessed needs or care arrangements cannot
          be shared with other agencies unless the person has given their permission for this to happen.


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       If an assessor recognises that the agreement to share information form has not been signed, it
       is the responsibility of the practitioner to ensure that the permission is sought at the time.

       The agreement to share information should be reviewed every six months.

       The professional conducting the Contact Assessment (see Point 7) will give the person the
       information leaflet about Agreement to Share Information (‘What you need to know’) and ask
       him or her to sign a standard agreement form (‘Agreement to share personal information’).

       *BSUH Documentation: The person’s ‘agreement to share information’ should be recorded on
       the Contact Assessment Form- where there is a specific place for this information.*

       Individual right to withhold information

       It is important to note the person has the right to withhold permission and this decision should
       be respected unless there would be a clear breach of a legal requirement such as a duty to
       care. Where a person does withhold permission, it should be explained that this could affect the
       outcome of the assessment and any services provided.

       It is important that the person’s request to withhold information is recorded.

       Verbal vs. Face-to –FACE agreement

       In situations where the assessment is not conducted face to face with the person, verbal
       permission will be sought initially and written permission obtained by the first professional to see
       the person.

       The following statement should be read to the person:

       "In order to ensure we provide you with the most efficient service it is important that we seek
       information concerning your care and when appropriate, share this will other professionals.
       Before I can do this, I need to ask your permission to do so. Do you give your permission?”

       Practitioner’s responsibilities

       NB. It is the responsibility of all practitioners to confirm with colleagues that this agreement is in
       place. Copies of the persons` signed agreement should be placed in their Person Held SAP
       record & in the Service Held SAP Record.


4.     What assessors check prior to assessment?

       Prior to assessment the following actions should ALWAYS be undertaken by all practitioners,
       other than where delay would present serious risk to the person.

       Check with the practitioners / their representative &/or through any available information
       systems:
        Obtain a copy of the Contact A & /or Basic Person Information (BPI) and any other relevant
           documents from the Care Co-ordinator or Service Held Record.
        Has the person got a named ‘Care Co-ordinator’?
        Does the person have a ‘Person Held SAP Record’?
        Has the person already received or is waiting to receive an assessment elsewhere by a
           health, housing or social care service or professional?
        Has the person given permission for information to be sought or shared from or with other
           relevant professionals in health, housing or social care agencies & other appropriate
           services required to meet their needs?
        The Basic Personal Information (BPI) should always be completed or checked / updated re
           any changes.


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5.   Referrals within the Single Assessment Process

       Referrals to other services, when Specialist Assessments are required may occur at any point in
       the process.

       The referral should be completed on the FACE referral form and a copy of the Basic Personal
       Information (BPI), the most recent assessments, care plans/reviews and the ‘Agreement to
       Share Information’ form should be shared at this stage.

       *BSUH Documentation: The BPI/Contact details and referral information are recorded on one
       document at BSUH (the Contact Assessment) and this information must be shared with any
       referral, alongside the appropriate supporting documents (as above).*


When fully implemented there will be four different types of assessment- these are not
necessarily undertaken in sequence and can be used in any combination:

             Basic Personal Information/ Contact Assessment (see Section 6/7)
             Specialist Assessment (see Section 8)
             Overview Assessment (see Section 9)
             Comprehensive Assessment (see Section 10)

The format for the Basic Person Information/Contact Assessment and Overview/Rapid assessment
documentation is common across a wide variety of health and social care services, and this makes
them familiar tools for sharing information across disciplines.

                                      Contact




          Overview/Ra                 Specialist                   Comprehensi
          pid                                                      ve



6.   Basic personal information (BPI)

       The BPI collects basic personal information and should always be completed/ checked to
       ensure it is up to date and shared on any referral.

       Basic personal information can be collected or verified by support staff e.g. GP receptionist,
       Social and Caring Services, Help Desk Support Staff




7.    Contact Assessment

       The Contact Assessment explores the presenting needs of the person from their perspective to
       enable a decision to be made about meeting the person’s needs when they first present to any
       health, housing or social care service. It is completed once only at the start of the Single
       Assessment Process and is never repeated when a person continues to receive health, housing
       and social care intervention.

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        A Contact Assessment is only ever filled in again, if the person is re-assessed as part of a new
        episode of care in future (at the beginning of the process).

        The exploration of the presenting and other needs can be undertaken by a trained and
        competent single practitioner, registered or not.

        The Contact can also be used to indicate if a person has given verbal consent (in an instance
        when for example, first contact was a telephone conversation). This should always be followed
        up by ensuring the person completes the standard ‘agreement to share information form’.


7.1      Use of the Contact Assessment

        The Contact Assessment form is used for all people requesting assistance; regardless of
        whether they proceed through the Single Assessment Process or non-SAP care management.
        A decision on whether they proceed into the Single Assessment Process should be made on the
        completion of the Contact Assessment. This decision making processes will be the same as that
        which you currently practise but if you are unclear about this please refer to your services
        guidance.


7.2     What happens following a Contact Assessment?

        Following the Contact Assessment the worker must decide:

            Is the person to continue in the Single Assessment Process or not?
            If yes, copies of the Contact Assessment Form/and or Consent Form (if obtained) and
             referral form must be sent to:

         -      The person her/himself for inclusion in the person held record
         -      Other professionals who will need to conduct further assessments
         -      The Care Co-ordinator.

            If no, the case will be closed after giving the person information and advice or continue in
             the agencies` non-Single Assessment Processes.

        N. B. In all cases where an immediate care need is identified without which the person
        would be likely to come to immediate harm, the appropriate service provision should be
        made.




8.     Specialist Assessment.

8.1.    The purpose of Specialist Assessments

        The Specialist Assessment should be carried out by specialist professionals e.g. therapists,
        nurses, social workers and care managers and it should be used when specific needs, need to
        be explored in more detail.


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8.2.     When will a Specialist Assessment be undertaken?

         A Specialist Assessment can be undertaken at any point with any other combination of
         assessments or when no other assessments have been undertaken.

         Individual services will have their own detailed guidance of when it would be appropriate
         to use a specialist assessment in their service.


8.3.    Sharing the Specialist Assessment

        Specialist Assessment should be included in the Person Held Record.

        See section 13 for exceptions.

         Details/outcomes of Specialist Assessments need to be forwarded to the Care Co-ordinator and
         discussed with other professionals involved in the person’s care. The assessments should be
         placed in the Service Held Record and the SAP Person Held Record.


9.     The Overview (rapid) Assessment


9.1.     The purpose of the Overview (rapid) Assessment

         An Overview (rapid) Assessment will be carried out when a person has a range of needs and a
         more rounded assessment is required using a set of domains and sub domains e.g. clinical
         background, personal care and physical well-being, relationships. It can also be used to help
         decide which areas (domains) need more in depth specialist assessment.

9.2.     When should Overview Assessment be completed?

         Professional judgement should be used to assess whether an Overview (rapid) or a Specialist is
         more relevant depending on the situation. It is the individual practitioner’s responsibility to
         decide which assessment format will best record the level and quality of the information they
         have gathered.

         Practitioners should check with team managers to see if there is any detailed guidance outlining
         in more detail, when it is appropriate to undertake an Overview (rapid) assessment in their
         service.




9.3.     Factors that should prompt an Overview (rapid) Assessment
            Problems and/ or difficulties have been identified that suggest the need for a broader
             assessment involving all or most of the domains.

            The service user has indicated that they would welcome a broader assessment.

            Presenting needs are not clear-cut.




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9.4     Who should undertake the Overview Assessment
        The service/practitioner who identifies the need for an Overview (rapid) Assessment should be
        the person to undertake the assessment. The service/practitioner most likely to identify the need
        for an Overview (rapid) will generally be the person who undertakes the Contact Assessment
        (where it is appropriate for this to be undertaken).



9.5.    Responsibilities of the Overview (rapid) Assessor

        The overview (rapid) assessor should:
           Undertake the assessment at an appropriate time and place for the person.
           Complete the assessment in one visit as far as possible. (There may be occasions when the
            assessor needs to obtain information from another source with the person’s consent or to
            clarify information with the individual)
           Contact any specialist services identified and following agreement make the referral(s).
           Ensure copies of the Overview (rapid) assessment are sent to the care co-ordinator and
            included in the SAP Service Held Record and Person Held Record.

           If the practitioner cannot find out who the care co-ordinator is, they should send information
            to the relevant professionals involved in the persons care (see Care Co-ordinator guidance-
            Point 16)


9.6    Sharing the Overview (rapid) Assessment

       A photocopy of the whole completed Overview (rapid) Assessment tool, excluding prompts,
       should be included in the person held record. Unless the assessor judges that part or all the
       assessment should be excluded, because inclusion would be detrimental to the service user, see
       section 13.

       A copy of the Overview (rapid) assessment tool should always be shared with any other
       professionals involved in the persons care (when appropriate).


10     Comprehensive Assessment

        The Comprehensive Assessment is the integration of the outcomes of a number of assessments
        and these are recorded onto a unified care plan.

        The role of the Care Coordinator is key in the completion of the Comprehensive Assessment.




11.     Change in the Service User’s Circumstances

11.1    Change of address, carer etc
        If a care professional becomes aware of a change in circumstance this must be noted on the
        BPI and should be included in the person held record and other professionals involved in the
        care delivery should be informed by telephone, secure fax etc as per current arrangements.




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11.2   Change of views on Agreement to Share Personal information
       If a care professional is informed by the service user of a change in their views on their Consent
       to Share Personal Information, then the Consent Guidance must be followed in respect of
       subsequent actions the need to be taken.

       The person’s agreement to share information should be reviewed, on a six monthly basis.

11.3   Change in condition – health or social care
       Changes in a service user’s condition will require re-assessment when the needs/issues
       significantly change from those set out in current documents.

       If a person’s needs change significantly this may be regarded as a new episode of care and a
       new assessment (overview) may be required.

       If there is a significant change complete the relevant assessment/review documentation.

       Any documentation that is generated should always be shared with the person, their carer (if
       appropriate), all the professionals involved in the persons care and the care co-ordinator; and
       should be held in Person Held Record and Service Held Record.

12.    Interface with Mental Health Services Single Assessment Process

       When a referral to Mental Health Services is required, the same process should be followed as
       outlined in Point 5.

       Mental Health services are currently using CPA forms for their assessments.


13.    Adult Protection

       If an adult protection issue arises at any stage during the Single Assessment Process, the care
       professional will need to ensure the person’s safety and instigate adult protection procedures.

       The practitioner should not continue to ask the person any further questions relating to the alert
       and should make an immediate referral to the Adult Protection Team.

       If appropriate, the practitioner should also continue their own assessments to ensure the
       person’s needs are met.




14.    Ending the assessment process

       All practitioners should refer to service specific guidance on the processes/documentation in
       place to record the outcomes and the care planning information in their service.


       Adult Social Care Services

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       Social Care staff following the end of any assessment should complete one of the following
       forms:

       14.1) Outcome of Assessment/Review
       14.2) Outcome of Assessment/Review & Non Complex Care Plan
       14.3) Outcome of Assessment/Review & Complex Care Plan

       Here is some guidance around what form would be appropriate:

       14.1) Outcome of Assessment

       The Outcome of Overview/Specialist/Comprehensive/Review summarises the presenting needs
       from persons` perspective; any presenting risks and immediate action taken to minimise these.
       It also performs the function of a non-complex care plan where appropriate.


       14.2) Outcome of Assessment/Review & Non Complex Care Plan

       A Non Complex Care Plan is used where a person has non-complex needs that can be met by
       simple services / interventions e.g.; Meals on Wheels, provision of basic ‘one off’ daily living or
       sensory equipment. It is used to record immediate actions agreed with the person to minimise
       risks’ e.g.; taking up loose mats / rugs, request for specialist housing, social care or health
       assessments or treatment plans etc and is used in conjunction with the Outcome of Assessment
       / Review Tool

       For ease & flexibility, all Assessment Tools have been designed to incorporate the Outcome of
       Assessment Form & Non Complex Care Plan as a continued section as well for use as a
       separate document.

       When a Non Complex Care Plan is required, or an Assessment Summary is required to be
       completed at the end of another assessment tool, in order to avoid duplication of work the
       relevant sections should be crossed through or marked.


       14.3) Outcome of Assessment/Review & Complex Care Plan

       A Complex Care Plan is completed in conjunction with the Outcome of Assessment / Review
       Tool. All sections of the Complex Care Plan should be completed. It is used when a person has
       a range of needs or more complex needs and is the main unified care plan that includes all
       interventions, services, & assistance the person receives.

       `Complex needs` may be indicated by:
        A high level of intensity of need / risk
        A range of needs
        Multi – agency / discipline involvement

       A Complex Care Plan indicates the existence of other Treatment Plans or Specialist Care Plans
       for the person e.g. physiotherapy programs, Adult Protection Plans, copies of which will be
       attached

       Comprehensive Assessments will always require the completion of a Complex Care plan.

       Where Treatment Plans or Specialist Care Plans also exist for the person these will be referred
       to in the Main Care Plan & attached to it.


15.    Unified Care Plans


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All services should be using a unified care plan. These care plans should record all the other agencies
involved in the persons care and reflect all the services interventions. This always should be shared
with the person, their carer (if appropriate), all the professionals involved in the persons care and the
care co-ordinator

Should be held in Person Held Record and Service Held Record.


16. Care Co-ordinator Role

A practitioner or a service will become the care co-ordinator for every person assessed in the Single
Assessment Process.

The care co-ordinator has two main functions:

i)        Admin Co-ordinator
ii)       Practice Co-ordinator

i)        Admin Co-ordinator

It is the responsibility of the Admin co-ordinator to:

         create, hold and maintain the service held record. Collating all the assessments they receive or
          undertake
         act as a focus for communication for the individual & different professionals involved

All services/practitioners should identify who the Admin Co-ordinator is and ensure that they send any
assessments or relevant information to the care co-ordinator.

It is essential to be able to identify and access contact details of the named Admin Co-ordinator so that
the unnecessary duplication of the collection of information is avoided and to ease the flow of the
information sharing process.

The best way to identify the Care Co-ordinator is by:

-     Looking on information systems i.e. - Care first/ PIMs
-     Talking to the service user to find out if any other services are involved, and if so contact those
      indicated.
-     Otherwise, this information should be recorded on the Care Co-ordinator Sheet, in the individuals
      Person Held Record.
-     Practitioners working in ASC and inputting who the name of the delegated Care Co-ordinator into
      Care First, must ensure they fill in the hard copy of the Care Co-ordinator sheet and put it into the
      Person Held Record and the Service Held Record, so their partners in health/housing have access
      to this information.


All Services need to ensure they have a robust assessment/admin process in place for receipt
of SAP documents sent to them from other practitioners.

All practitioners sending documents to Admin Co-ordinators need to be clear whether the
documents have been sent for information purposes and should be filed in the Person Held
Record or whether there is some intervention required – this should be clearly identified on the
accompanying referral form.


ii) Practice Co-ordinator




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This should be the practitioner best placed to co-ordinate the assessment and the care of the person.

Initially the first practitioner involved with a person new to health, housing or social care will become the
named care co-ordinator by ‘default’ until such time as, if appropriate, another named care co-ordinator
is agreed between practitioners / services as more appropriate

The following factors will influence identifying the care co-ordinator:

          The main presenting needs / support requirements of the person and the skills/services
           required to meet these most effectively
          The frequency of contact a person is likely to have with certain services or practitioners /
           professionals
          The setting in which the person is receiving this support:
           i.e.: acute or community
          Capacity available to undertake this role effectively with the person
          Long term care needs of the individual where the community nurses or social workers /
           social care practitioners are the main services

In very complex situations, in addition to the named Care Co-ordinator, organisations with a number of
their services or professionals involved with the person may wish to identify a ‘lead case manager’ for
their organisation to link with the named Care Co-ordinator.



17. Process map of Single Assessment Process / documentation (page 16)

18. Single Assessment Process -Summary of documentation (page 17-20)




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                   Process Map of Single Assessment Process
                               (Documentation)


                              Person Present themselves to
                                 the service/Request for
                                       intervention




         (If First Contact)                               (If person known by
       Contact Assessment                                        service)
                & BPI                                    Check BPI on Contact
                                                               Assessment




                                      Decision




 Overview/Rapid                      Specialist                    Other intervention/
  Assessment                        Assessment                         Referral




                              Outcome of Assessment/
                                 Action/Care Plan




                                Appropriate referrals




                              Comprehensive & Unified
                                    Care Plan




                                  Co-coordinated
                                     reviews




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                                           SUMMARY- SINGLE ASSESSMENT PROCESS- DOCUMENTATION

SAP Assessment                         Purpose- What is it?                     When is it completed?                     When is it shared?
Tools/Documents
Basic Personal Information             Collects basic personal information      Completed when a person first             Always should be shared with the
                                       (BPI). This includes name, address,      presents to a health, housing or social   person, their carer (if appropriate), all
                                       household details, ethnicity, religion   care service. Should be checked to        the professionals involved in the
                                       etc                                      ensure it is up to date.                  persons care and the care co-
                                                                                                                          ordinator with any referral.

                                                                                                                          Should be held in the Person Held
                                                                                                                          Record and the Service Held Record.
Contact Assessment                     Explores the presenting needs of the     Completed only once, when the             Always should be shared with the
                                       person from their perspective when       person first presents himself or          person, their carer (if appropriate), all
                                       they first present to any health,        herself to a health, housing and social   the professionals involved in the
                                       housing and social care service.         care service.                             persons care and the care co-
                                                                                                                          ordinator with any initial referral or as
                                                                                                                          long as this information remains
                                                                                                                          relevant. However, often this
                                                                                                                          information becomes outdated and
                                                                                                                          would not need to be shared at a later
                                                                                                                          stage in the process.


Agreement to Share Information Form Records the individual’s permission         Completed at the initial Contact stage    This standard agreement should be
                                    for information which relates to their      in the assessment process, and            held in the Person Held Record and
                                    assessed       needs      or     care       should be reviewed every six months.      the Service Held Record.
                                    arrangements to be shared with other
                                    agencies when appropriate.                  If an assessor recognises that the
                                                                                agreement to share information form
                                                                                has not been signed, it is the
                                                                                responsibility of the practitioner to
                                                                                ensure that the permission is sought
                                                                                at the time.
Referral form                          To request intervention from another     This form is used when making a           With a copy of the last assessment
                                       service                                  request to a health, housing or social    /review and care plan (and any other
                                                                                care agency an assessment or a            relevant information to service) & BPI
                                                                                specific action/intervention.             with all referrals.

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                                                                                 (Note* - do not duplicate BPI
                                                                                 information unnecessarily on the
                                                                                 referral form)

SAP Assessment                          Purpose- What is it?                     When is it completed?                 When is it shared?
Tools/Documents
Specialist Assessments                  For                             specific When specific needs, need to be       Most recent Specialist Assessments
                                        disciplines/professionals/services to explored in more detail.                 are always shared as part of relevant
                                        record their specialist assessments                                            current information & BPI.

                                                                                                                       Always should be shared with the
                                                                                                                       person, their carer (if appropriate), all
                                                                                                                       the professionals involved in the
                                                                                                                       persons care and the care co-
                                                                                                                       ordinator.

                                                                                                                       Should be held in Person Held
                                                                                                                       Record and Service Held Record.
Overview Assessments (can be            Rapid- To record a more rounded          Whenever there are a range of         Always should be shared with the
recorded on a Rapid)                    assessment covering a number of          needs/areas in a person’s life that   person, their carer (if appropriate), all
                                        domains.                                 need to explored.                     the professionals involved in the
                                                                                                                       persons care and the care co-
                                        Overview- To record a more in depth      Completed by any assessor on behalf   ordinator
                                        rounded assessment covering a            of health, housing and social care
                                        number of domains.                       services. Review when appropriate.    Should be held in Person Held
                                                                                                                       Record and Service Held Record.

Outcome of assessment                   Summarises the presenting needs;         On completion of any assessment.      Always should be shared with the
(Note*- not all services implementing   presenting risks associated with those                                         person, their carer (if appropriate), all
SAP will at this stage in rollout be    needs and immediate action taken to      Also pulls together the outcomes of   the professionals involved in the
utilising these forms)                  minimise these.                          all assessments when there is more    persons care and the care co-
                                        (social care professionals record        than one.                             ordinator.
                                        eligibility needs)
                                                                                                                       Should be held in Person Held
                                                                                                                       Record and Service Held Record.
Non- Complex Care Plan                  Records immediate actions agreed Following an assessment/review- that          Always should be shared with the
(Note*-not all services implementing    with the person to minimise risks’ identifies needs requiring a service or     person, their carer (if appropriate), all
SAP will at this stage in rollout be    e.g.; taking up loose mats / rugs, intervention.                               the professionals involved in the

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utilising these forms)                  request for specialist nursing & social                                             persons care and the care co-
                                        care assessments made etc and When a person has non-complex                         ordinator
                                        follows/links to the Outcome of needs that can be met by simple
                                        Assessment / Review Tool.               service / intervention e.g. Meals on        Should be held in Person Held
                                                                                Wheels, provision of basic ‘one off’        Record and Service Held Record.
                                                                                daily living or sensory equipment.

SAP Assessment                          Purpose- What is it?                      When is it completed?                     When is it shared?
Tools/Documents
Complex Care Plan                       It is the main unified ‘overarching’                                      Always should be shared with the
                                                                                  Following an assessment/review- that
(Note*- not all services implementing   care     plan   that    includes   all                                    person, their carer (if appropriate), all
                                                                                  identifies needs requiring a service or
SAP will at this stage in rollout be    interventions, services, & assistance     intervention.                   the professionals involved in the
utilising these forms)                  the person receives/and is always                                         persons care and the care co-
                                        follows/links   the    Outcome     of  When a person has a range of needs ordinator
                                        Assessment / Review Tool.              or more complex needs.
                                                                                                                  Should be held in Person Held
                                        Other Treatment Plans or Specialist                                       Record and Service Held Record.
                                        Care Plans for the person e.g.
                                        physiotherapy      programs,     Adult
                                        Protection Plans, will be attached to
                                        this general overarching care plan.

Treatment Plans                         Nursing, therapies etc will use these     Following a Specialist Assessment         Referred to in non-complex or
                                        plans to record the outcome of a                                                    complex care plan.
                                        planned treatment for that particular
                                        individual.
Comprehensive                           Pulling together the outcomes of a        To provide a basis for a unified care     Always should be shared with the
                                        number of assessments to ensure the       plan.                                     person, their carer (if appropriate), all
                                        all the individuals relevant needs and                                              the professionals involved in the
                                        risks are summarised in one place.                                                  persons care and the care co-
                                                                                                                            ordinator
                                        (The outcome of assessment form is
                                        used to record this assessment)                                                     Should be held in Person Held
                                                                                                                            Record and Service Held Record.
Person Held Record                      A yellow folder (held by the assessed     When possible the assessor issues         Shared with al professionals involved
                                        individual) containing relevant records   the person with their PHR when they       in the individuals care with consent.
                                        from health and social care               first see them.
                                        professionals involved in the care

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                                       team.                                       The person should be advised to take
                                                                                   this folder with them when attending
                                                                                   any appointments/hospital etc
Service Held Record                    To ensure one complete record of            All people who have received care        Shared with all professionals involved
                                       relevant assessments/ care plans            will have a record held by the named     in the individuals care with consent.
                                       exists and is accessible by all             care co-ordinator
                                       services. Its location is often linked to   /organisation/service which hosts all
                                       the Care co-ordinator.                      the assessments and information
                                                                                   relating to that individual.
SAP Assessment                         Purpose- What is it?                        When is it completed?                    When is it shared?
Tools/Documents
Care Co-ordinator Form                 This form provides a record of the It is completed when a person first   Copies should be held in both the
                                       current Care Co-ordinator details. present themselves to the service and Person Held Record and the Service
                                                                          should be updated when appropriate. Held Record.

                                                                                   Any change to who should take on
                                                                                   the role of Care Co-ordinator should
                                                                                   be agreed through multi- disciplinary
                                                                                   discussion.
Visit record sheet                     Record of all professionals that have       Following all visits from professionals. This record is held in the front of the
                                       visited the person and any                                                           Person Held Record and is available
                                       assessments/interventions/actions                                                    for the person, their carer (if
                                       undertaken or in progress.                                                           appropriate), all the professionals
                                                                                                                            involved in the persons care and the
                                                                                                                            care co-ordinator to view with
                                                                                                                            consent.




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