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7/27/2019 Core Unit 4: Assessment and outcome planning
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Uned Graidd 4: Asesu a chynllunio gofal
Core Unit 4: Assessment and
outcome planning
7/27/2019 Core Unit 4: Assessment and outcome planning
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Digital ISBN 978 0 7504 7880 9
Hawlfraint y Goron/Crown copyright 2012
WG15036
2
Ysgriennwch eich nodiadau yma:
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Core Unit 4: Assessment and outcome planning
Write your notes here:
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Uned Graidd 4: Asesu a chynllunio gofal
Uned Graidd 4: Asesu a chynllunio goal
Oriau hyorddi yn gysylltiedig r uned hon = 3 awr
Nodaur uned
Nod yr uned astudio hon yw datblygu dealltwriaeth o asesu a chynllunio goal a thriniaeth ymmaes iechyd meddwl. Bydd ymarerwyr yn ystyried dulliau unigol o asesu a chynllunio goal a
thriniaeth syn canolbwyntio ar gyawnir canlyniadau goal y cytunwyd arnynt.
Rhoddir pwyslais ar yr angen i gynnwys denyddwyr gwasanaeth a goalwyr yn y broses hon.
Pri negeseuon i hwyluswyr
Yn yr uned hon dylair hwylusydd bwysleisio:
Nad yw Rhan 2 o Fesur Iechyd Meddwl (Cymru) 2010 yn pennu proses asesu benodol.
Dylid asesu mewn ordd syn helpu i gynllunio goal a thriniaeth yn holistaidd ar draws oleia un or wyth maes ym mywyd person.
Mae asesiad yn gyuniad o anghenion, cryderau a risgiau yn y meysydd uchod.
Dylair cynllun goal a thriniaeath adelwyrchu egwyddorion craidd y Cod Ymarer (2012).
Cywyniad
Pwrpas yr uned astudio hon yw edrych yn eirniadol ar yr ymarer presennol o sabwynt asesu
a chynllunio goal, ai gymhwyso i Fesur Iechyd Meddwl (Cymru) 2010. Mae cynllunio goal a
thriniaeth or radd aena, syn seiliedig ar gyranogiad ystyrlon y denyddiwr gwasanaeth ac
eraill, yn ganolog er mwyn sicrhau ymarer rhagorol. Maer uned astudio hon yn rhoi cye igyranogwyr ystyried eu hymarer presennol ac edrych pa mor gyson yw hynny goynion Mesur
Iechyd Meddwl (Cymru) 2010.
Canlyniadau dysgu
Ar l cwblhaur uned hon bydd y cyranogwyr yn:
1deall pwysigrwydd asesu cynhwysawr syn canolbwyntio ar yr unigolyn yn y broses o gynllunio goal
a thriniaeth
2 deall cyd-destun diwylliannol y broses asesu a chynllunio goal a thriniaeth
3dangos y gallu i weithio ar y cyd ag eraill er mwyn llunio cynlluniau goal a thriniaeth
ystyrlon
4 dangos y gallu i lunio canlyniadau priodol mewn cynlluniau goal a thriniaeth
5 nodi pri agweddau asesu risg a rheoli risg mewn cynlluniau goal a thriniaeth
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Core Unit 4: Assessment and outcome planning
Core Unit 4: Assessment and outcome planning
Training hours associated with this unit = 3 hours
Aims o the unit
The aim o the study unit is to develop an understanding o assessment and care and treatmentplanning within mental health. Participants will consider individualised approaches to assessment
and care and treatment planning that ocus on the delivery o agreed outcomes o care.
Emphasis will be placed on the need or the involvement o service users and carers in
this process.
Key messages or acilitators
In this unit, the acilitator should emphasise:
Part 2 o the Mental Health (Wales) Measure 2010 does not prescribe a particular
assessment process.
Sssessment should be collated in such a way as to aid the delivery o holistic care and
treatment planning across at least one o the eight areas in a persons lie.
Assessment is a combination o needs, strengths and risks in the above areas.
The care and treatment plan should reect the guiding principles o the Code o
Practice (2012).
Introduction
This unit o study is aimed at a critical reection on current assessment and planning practice
and its application to the Mental Health (Wales) Measure 2010. The issue o high quality care
and treatment planning, based on meaningul participation o service users and others iscentral to the pursuit o excellent practice. This unit o study provides participants with an
opportunity to reect on their current practice and explore how consistent it is with the
requirements o the Mental Health (Wales) Measure 2010.
Learning outcomes
On completing the unit participants will:
1
understand o the signifcance o comprehensive, person centred assessment in the care and
treatment planning process
2 understand the cultural context o assessment and care and treatment planning
3demonstrate the ability to work collaboratively with others to construct meaningul care
and treatment plans
4 demonstrate the ability to construct appropriate outcomes in care and treatment plans
5identiy the key aspects o risk assessment and risk management within care andtreatment plans
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Uned Graidd 4: Asesu a chynllunio gofal
Amser
(munudau)Focws
Canlyniadau
dysgu
cysylltiedig
Dull dysgu/
adnoddauCynnwys
10 munud Cywyniad - Traodaeth grwp Sleidiau 1 3
15 munudRhan 1:
Adolygur asesiad1
Sleid 4 5
Clip DVD
40 munudAsesu sgiliau
allweddol1, 2 a 3
Ymarer 1
Traodaeth grwp
Siart troi
Taen1 senariospersonol
Sleid 6
30 munud
Rhan 2:
Y cynllun goal athriniaeth integreiddio
diogelwch a risg.
2, 3 a 5 Ymarer 2Traodaeth grwp
Taen 2
Sleid 7
Clip DVD
60 munudRhan 3:
Cynllunio canlyniadau3,4 a 5
Ymarer 3
Tasg ysgrienedig a
thraodaeth grwp
Sleid 8
Taen 3
Taen 4
20 munud Crynhoi -
Traodaeth grwp,adborth anegeseuon addysgwyd
Cynllun y wers
Adnoddau dysgu angenrheidiol:
lle gwag a chyeoedd i wneud gwaith grwp a myyrio;
adnoddau ar gyer cywyniadau PowerPoint;
adnoddau i chwarae clipiau DVD syn dangos pri ganlyniadau dysgu;
siart ip a phinnau.
Cynllun gwers manwl
Sleidiau 1 3:
Cywynwch yr uned ddysgu, gan ddenyddior wybodaeth ar y sleidiau. Rhowch gye i gyranogwyr
oyn unrhyw gwestiynau am yr uned.
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Core Unit 4: Assessment and outcome planning
Time Focus
Related
learning
outcome
Teaching method/
resourcesContent
10 mins Introduction - Group discussion Slides 1 3
15 minsSection 1:
Reviewing assessment1
Slides 4 5
DVD Clip
40 mins Reviewing assessment 1, 2 & 3
Exercise 1 Group
discussion
ip chart
Handout 1 personalscenarios
Slide 6
30 mins
Section 2:
The care and treatmentplan saety and risk
integration
2, 3 & 5 Exercise 2Group discussion
Handout 2
Slide 7
DVD Clip
60 minsSection 3:
Outcome planning3,4 & 5
Exercise 3
Writing task and
group discussion
Slide 8
Handout 3
Handout 4
20 mins Conclusion -Group discussioneedback and takehome messages
Lesson plan
Detailed lesson plan
Slides 1 3:
Provide an introduction to the unit o learning, using the inormation on the slides.
Give participants the opportunity to ask any questions about the unit.
Required teaching resources:
space and opportunities or group work;
resources or PowerPoint presentations;
resources to play DVD clips illustrative o key learning outcomes;
ip chart and pens.
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Uned Graidd 4: Asesu a chynllunio gofal
Rhan 1: (60 munud)
Adolygur asesiad
Maer rhan hon or uned yn rhoi trosolwg byr o asesu mewn iechyd meddwl gan ganolbwyntio
ar asesiadau yr holl dm (hynny yw, y tm amlasiantaeth/amlddisgyblaethol) syn cynnwysdenyddwyr gwasanaeth a goalwyr el gwir bartneriaid yn y broses. Bydd yn rhoi sylw i
bwysigrwydd cydweithio amlddisgyblaethol rhwng un seydliad ar llall, ac yn edrych ar
broses asesu syn cynnwys yr holl anghenion, cryderau, gwendidau a gobeithion sydd gan
ddenyddwyr gwasanaeth, eu teulu au goalwr(wyr). Bydd y rhan hon yn adolygur prosesau
asesu cyn ystyried sut y bydd hynny yn dylanwadu ar gynllunio goal a thriniaeth.
Sleid 4: Asesu themu allweddol
Dylai pob cynllun goal a thriniaeth adlewyrchur wybodaeth a gasglwyd trwy wneud asesiad
cyredinol eang or denyddiwr gwasanaeth ac o unrhyw asesiadau manwl a phenodol eraill
(e.e. asesiadau risg) a gwblhawyd.
Maer egwyddorion a restrir isod yn bwysig os ydym am lunio asesiad cynhwysawr syn cenogi
gwellhad unigolyn ac yn datblygu sgiliau hunan reoli. Maer egwyddorion hyn yn
berthnasol i bob grwp o ddenyddwyr gwasanaeth, waeth beth o eu hoed. Gallai od o udd
i gyranogwyr ystyried yr egwyddorion hyn wrth gynllunio goal a thriniaeth i bobl hyn, pobl ag
Anableddau Dysgu a phlant a phobl ianc.
Cymryd rhan weithgar
Mae a wnelo hyn r graddau y maer denyddiwr gwasanaeth ar goalwr(wyr) yn teimlo eu bodyn rhan or broses asesu; i ba raddau y gwrandewir arnynt a aint o ddewis sydd ganddynt yn y
broses.
Dull amlasiantaeth
Mae dull amlasiantaeth yn dod gwahanol bersbecti a sgiliau ir broses asesu (yn cynnwys
y sector gwiroddol, os ywn briodol). Mae cynnwys y gwahanol sabwyntiau hynny yn helpu i
sicrhau proses gynhwysawr a chydlynol wrth gynllunio goal a thriniaeth. Wrth ystyried pobl
ianc, gallai rl y gwasanaethau addysg od yn bwysig. Maen bosibl y bydd angen cymorth ar
eraill gan y gwasanaethau praw, gwasanaethau cymdeithasol a nier o ddarparwyr gwiroddol
neu 3ydd sector.
Canolbwyntio ar gryderau a dymuniadau yn ogystal heriau ac anghenion
Mae canolbwyntio ar gryderau, strategaethau ymdopi, gobeithion a dyheadaun hanodol wrth
hybu gwellhad a helpu pobl i gymryd rheolaeth gynyddol ou bywydau eu hunain.
Mae cynnwys yr agweddau hyn yn arwain at asesiad cytbwys syn cydnabod potensial ar gallu
i sicrhau gwellhad. Mae pobl yn wy tebygol o gymryd rhan mewn cynllun goal a thriniaeth syn
cydnabod eu nodau eu hunain yn hytrach na nodaur gweithwyr proesiynol. Maer Cod Ymarer
yn cyeirion benodol at weithredun gadarnhaol ac ar sail cryderau, gan gymryd camau
graddol i gyawni nodau tymor hir (Rhan 1.15). Maer Cod heyd yn nodir angen i ymateb i
ddymuniadau denyddwyr gwasanaeth Cymraeg eu hiaith (Rhan 1.9 1.11).
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Uned Graidd 4: Asesu a chynllunio gofal
DVD
Clip DVD:
[Cysylltu r clip DVD syn edrych ar y broses asesu gydweithredol]
Nodiadau ir hwylusydd: Pwrpas y draodaeth hon yw cadarnhau bod asesun gam allweddol or
broses cynllunio goal a thriniaeth. Heb asesiad cynhwysawr byddai cynllun goal syn seiliedig
ar ganlyniadaun anodd ei lunio ai weithredu. Mae dull or ath yn gallu creu tensiynau rhwng
pobl (el rhieni a phobl ianc). Maen bwysig nodir posibilrwydd hwn ac ystyried rl y cydlynydd
goal i helpu i negydu llwybr syn ystyried y gwahanol sabwyntiau hynny.
Sleid 5: Wyth maes ym mywydau pobl
Maer wyth maes yman deillio or Mesur ac eu cywynir yma i atgoar cyranogwyr am y dull
holistaidd ar gyer cynllunio goal a thriniaeth.
Ymarer 1: Asesu sgiliau allweddol
Taen 1: Senarios personol
Rhannwch y cyranogwyr yn grwpiau a rhowch un neu wy or senarios personol a restrir yma ibob grwp [neu, treuliwch amser yn paratoi senarios syn wy addas ich cynulleida darged].
Goynnwch ir cyranogwyr adolygur senario ac ystyried y cwestiwn canlynol (ysgriennwch eu
sylwadau ar siart ip neu wrdd gwyn).
C: Yn eich barn chi, beth ywr materion allweddol wrth asesur bobl syn cael eu disgrifo yn y
senarios hyn?
Ar l ir cyranogwyr gwblhaur dasg hon:
rhoi adborth ir pri grwp a goyn i grwpiau eraill nodi unrhyw aterion asesu eraill a allai od
heb gael sylw;
goynnwch iddynt geisio blaenoriaethu eu rhestrau asesu, el eu bod yn rhestru 3 neu 4
mater asesu o bwys or senario a;
nodi pwy yn y tm cynllunio goal a allai gwblhaur gweithdrenau asesu hyn.
Nodiadau ir hwylusydd: Pwrpas yr ymarer uchod yw annog cyranogwyr i ystyried, traod a
chytunor materion allweddol syn eeithio ar ywydaur bobl hyn a pha rai a ddylai od yn rhan
or asesiad. Dylai heyd annog cyranogwyr i ystyried Mesur Iechyd Meddwl (Cymru) 2010 a
sut iw integreiddio. Mae asesu mewn ordd holistaidd ac amlasiantaeth wedi ei draod yn
Unedau Craidd 1, 2 a 3. Felly maen bwysig bod cyranogwyr yn ystyried y themu allweddol
hyn. Mae hynny yn cael ei bwysleisio heyd yn ymarer 2 isod.
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Core Unit 4: Assessment and outcome planning
DVD DVD clip:
(Link to DVD clip exploring the collaborative assessment process)
Notes or acilitator: The purpose o this discussion is to reinorce to participants that
assessment is a critical stage in the care and treatment planning process. Without a
comprehensive assessment an outcome based care plan will be difcult to construct and
difcult to implement. Such an approach can generate tensions between people (such as
parents and young people). It is important to identiy this potential and to consider the role o
the care coordinator in helping negotiate a path through these dierent views.
Slide 5: Eight areas in peoples lives
These eight areas are derived rom the Measure and are presented here as a reminder or
participants about holistic approach to care and treatment planning.
Exercise 1: Assessment key skills
Handout 1: Personal scenarios
Organise the participants into groups and provide them with either one or more o the
personal scenarios in the handout [alternatively, spend some time in preparing scenarios
which are more suited to your target audience].
Ask the participants to review the scenario and consider the ollowing questions (write their
reections on a ip chart or whiteboard).
Question: What do you consider are the issues in the assessment o the people who are
described in these scenarios?
When participants have completed this task:
feedbacktomaingroupandaskothergroupstoidentifyanyalternativeassessmentissues
that may have been missed;
ask them to try and prioritise their assessment lists, so as to list 3 or 4 signifcant
assessment issues rom the scenarios and;
identiy who in the care planning team, might complete these assessment procedures.
Notes or acilitator: The above exercise is designed to encourage participants to consider,
discuss and agree the critical issues which might be aecting these peoples lives and
which should be part o an assessment. It is also designed to encourage reection and
integration o the Mental Health (Wales) Measure 2010. The issue o holistic and multi-
agency perspectives on assessment has been raised in Core Units 1, 2 and 3. Thereore it isimportant that participants reect on this key theme. This is also emphasised in exercise
2 below.
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Uned Graidd 4: Asesu a chynllunio gofal
Sleid 6: Asesu Cwestiynau iw goyn
Cwestiynau iw goyn:
a wnaeth y cyranogwyr ystyried un (ond yn ddelrydol mwy nag un) or 8 maes a restrir ynadran 18 (1) (a) wrth asesur senarios personol yn ymarer 1?
a wnaeth y cyranogwyr ystyried dwyieithrwydd yn eu hasesiad?
a wnaeth y cyranogwyr ystyried cryderau a gobeithion yr unigolyn?
a wnaeth y cyranogwyr nodi risgiau ir unigolyn ac eraill (yn cynnwys amddiyn oedolion syn
agored i niwed ac amddiyn plant)?
Nodiadau ir hwylusydd: Maen bwysig bod cyranogwyr yn ystyried dwyieithrwydd yn eu
hasesiad. Maen bwysig ystyried sut gellir llunio asesiad llawn a chynllun goal a thriniaethcynhwysawr ar y cyd heb roi cye ir denyddiwr gwasanaeth ynegi ei hun yn Gymraeg neun
Saesneg yn l ei h/angen.
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Core Unit 4: Assessment and outcome planning
Slide 6: Assessment Questions to ask
Questions to ask:
did the participants consider at least one (but ideally more) o the 8 lie areas in their assessments o the personal scenarios in exercise 1?
did the participants consider the issues o bilingualism in their assessment?
did the participants consider the strengths and resiliencies available to the person?
did the participants identiy potential risks to the individual and others (including protecting
vulnerable adults and the saeguarding o children?
Notes or acilitator: It is important that participants consider bilingualism in their assessment.
It is important to reect on how a ull assessment and a comprehensive and collaborativecare and treatment plan can be constructed without the opportunity or the service user to
express themselves in their language o need.
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Uned Graidd 4: Asesu a chynllunio gofal
Rhan 2: (30 munud)
Y cynllun goal a thriniaeth
Mae templed cenedlaethol ar gyer cynlluniau goal a thriniaeth el y nodir yn y Rheoliadau
ar Cod Ymarer. Cywynwch y cynllun goal a thriniaeth hwn ac eglurwch y bydd yr ymarerioncanlynol yn gwneud denydd helaeth or templed hwnnw (taen 2).
Taen 2: Y cynllun goal a thriniaeth
Ymarer 2: Integreiddio diogelwch a risg
Gan ddenyddio copi or cynllun goal a thriniaeth, goynnwch ir cyranogwyr sut bydden nhwn
integreiddio unrhyw aterion risg/diogelwch a nodwyd or senarios iw cynllun.
Sleid 7: Cynlluniau wrth gen ac argywng
Nodiadau ir hwylusydd: Maer Cod Ymarer yn nodi; Maer gwaith o asesu risg yn rhan or cam
cynta angenrheidiol i bennun canlyniadau a llunior cynllun goal a thriniaeth, el y nodir yn
adran 18 or Mesur. (rhan 2.18 - 22.1). Maer ymarer canlynol yn dechrau trwy ystyried y dull
hwn a sut iw integreiddio yn y cynllun goal a thriniaeth.
Clip DVD:
[Cysyllu r clip DVD syn traod cymryd risgiau cadarnhaol]
DVD
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Core Unit 4: Assessment and outcome planning
Section 2: (30 mins)
The care and treatment plan
There is a national template or care and treatment plans as identifed in the Regulations
and the Code o Practice. Introduce this care and treatment plan and explain that ollowingexercises will make extensive use o this template (handout 2).
Handout 2: The care and treatment plan
Exercise 2: Saety and risk integration
Using the copy o the care and treatment plan, asks the participants how they would integrate
any identifed risk/saety and security issues rom the scenarios completed above, intothe plan.
Slide 7: Crisis and contingency planning
Notes or acilitator: The Code o Practice states that; Assessment o risk orms a part o the
necessary frst step in setting outcomes and ormulating the care and treatment plan
(section 2.18 2.21). The ollowing exercise begins with a reection on this approach and
how it can be integrated into the care and treatment plan.
DVD Clip:
[Link to DVD clip discussing positive risk taking]
DVD
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Uned Graidd 4: Asesu a chynllunio gofal
Rhan 3: (60 munud)
Cynllunio canlyniadau
Bydd y rhan hon yn adeiladu ar y gwaith maer cyranogwyr wedi ei wneud ar asesu a chynllunio
wrth gen ac argywng. Maen canolbwyntion benodol ar sut y gellir difnio a chytunocanlyniadau gyda denyddwyr gwasanaeth a darparwyr gwasanaeth.
Clip DVD:
Cysylltu r clip DVD syn edrych ar ganlyniadau ar gyer iechyd meddwl
Ymarer 3: Rhoir canlyniadau ar waith
Sleid 8: Beth ywr canlyniadau?
Gydar ymareriad hwn, maen hollbwysig tybio bod eich asesiad wedi ei gwblhau. Goynnwch
ir cyranogwyr ddychmygu eu bod wedi casglur holl wybodaeth sydd ei hangen au bod bellach
mewn seylla i ysgriennu cynllun goal syn canolbwyntio ar ganlyniadau.
Taen 3: Gwellar ordd o ddisgrifo nodau a chanlyniadau
Denyddiwch daen 3 a goynnwch ir grwpiau adolygur senarios personol eto. Sut bydden nhw
yn cymryd y nodau iechyd meddwl a ynegir yn wael au haddasun ddisgrifadau o ganlyniadau
iechyd meddwl y byddai denyddiwr gwasanaeth yn dymuno eu cyawni.
Furfwch grwpiau bach a rhannwch syniadau ynglyn yrdd mwy ystyrlon o ynegi nodau/
canlyniadau. Goynnwch ir grwpiau am adborth a chymerwch un syniad da o gynlluniau goal
ei gilydd.
Gellir ysgriennur canlyniadau hyn wedi eu mireinio ynghyd r cynllun darparu ar y templed
cynllun goal a thriniaeth ar y tudalennau yn nhaen 2.
Nodiadau ir hwylusydd: Maen hanodol annog y cyranogwyr i ystyried y cysylltiadau rhwng yr
asesiad, nodi canlyniadau ar cynllun goal a thriniaeth. Goynnwch ir cyranogwyr ddenyddio
amcanion CAMPUS (Mae taen 4 ar gael iw helpu i wneud y dasg hon).
Crynhoi
Pwrpas yr uned hon yw rhoi trosolwg or broses asesu a chynllunio. Maen bwysig goyn
i gyranogwyr adeiladu ar yr hyn maent wedi ei ddysgu mewn unedau blaenorol a chynnig
strategaethau i oresgyn problemau a heriau posibl wrth ymarer. Rydym yn argymell eich bodyn rhoi sylw arbennig i sut mae cydlynwyr goal yn conodi cynlluniau goal a sut maen nhw yn
ystyried denyddio dulliau mesuradwy clir ar gyer canlyniadau.
DVD
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Core Unit 4: Assessment and outcome planning
Section 3: (60 mins.)
Outcome planning
This section will build on the work the participants have done on assessment and crisis and
contingency planning. The section ocuses specifcally on how outcomes can be defned andagreed with service users and service providers.
DVD clip:
Link to a DVD clip exploring outcomes or mental health
Exercise 3: Practising outcomes
Slide 8: What are outcomes?
For this exercise it is critical to assume that your assessment is complete. Ask participants
to imagine that have collected all the inormation they need and are now in a position to write
an outcome ocussed care plan.
Handout 3: Improving the way goals and outcomes are described
You can use handout 3 to ask the groups to review the personal scenarios again. How would
they translate the poorly expressed mental health goals into more helpul descriptions o the
mental health outcomes that a service user might want and be able to, achieve.
Form small groups and share ideas together about more purposeul expressions o goals/
outcomes. Ask groups to eedback and take one good idea rom each others care plan
These newly refned outcomes and delivery plan can be written on the care and treatment plan
template on the pages in handout 2.
Notes or acilitator: It is essential to encourage the participants to reect on the linkages
between the assessment, the identifcation o outcomes and the care and treatment plan.
Ask participants to integrate all they have reviewed about assessment and planning into this
exercise. Encourage participants to make use o SMART objectives (Handout 4 is provided to
support them in this task).
Conclusion
This unit is designed to provide an overview o the assessment and planning process.
Importantly participants are asked to build on previous unit learning and propose strategies
or overcoming potential problems and challenges in their practice. We recommend payingparticular attention to how care coordinators record care plans and how they think about using
clear measurable terms or outcomes.
DVD
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Uned Graidd 4: Asesu a chynllunio gofal
Cwestiynau Beth ydych chin mynd iw wneud yn wahanol nawr?
Mae hon yn rhan bwysig or uned ac ni ddylid ei hosgoi. Bwriad yr unedau dysgu yw herio pobl i
ymrwymo i newid a gwella eu gwaith wrth gynllunio goal a thriniaeth. Felly mae rhan or
ymrwymiad hwn yn gydnabyddiaeth gyhoeddus or hyn maen nhw wedi ei ddysgu, a pha gamau y
gallant eu cymryd yn syth i newid eu hymarer er gwell. Goynnwch ir cyranogwyr am o leia unpwynt dysgu pwysig a beth maen nhw yn bwriadu ei newid o ganlyniad iddo.
Negeseuon a ddysgwyd:
mae angen amser a goal i wneud asesiad holistaidd;
mae asesu a chynllunion dibynnu ar gyraniad pob un syn rhan or broses;
rhaid i unrhyw gyraniad at gynllunio goal od yn ystyrlon a rhaid rhoi sylw ir broses negydu
a thraod;
mae angen sgiliau a goal i ysgriennu cynlluniau goal syn seiliedig ar ganlyniadau, a phan o
hyn yn cael ei wneud yn dda maen gallu helpur broses draod a negydu i hybu gwellhad;
dylai canlyniadau od yn gyraeddadwy, amserol, mesuradwy, penodol, uchelgeisiol, synhwyrol.
Darllen pellach
Boardman, J., Currie, A., Killaspy, H. & Mezey, G. (gol) (2010) Social inclusion and mental health.
Llundain: Coleg Brenhinol y Seiciatryddion.
Care Services Improvement Partnership (2008) Three keys to a shared approach in mental
health. Coventry: Seydliad Cenedlaethol Iechyd Meddwl yn Lloegr (NIMHE)
Hughes, Meic. (2009) Maen nhwn siarad amdana i Gwasg Bwythyn Caernaron.
Woods, P. & Kettyes, A. (Gol) (2009) Risk assessment and management in mental health
nursing. Rhydychen: Blackwell.
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Core Unit 4: Assessment and outcome planning
Questions What are you going to do dierently now?
This is an important part o the unit and should not be avoided. The learning units are designed
to challenge people to make a commitment to change and improve their work or care and
treatment planning. Thereore part o this commitment is a public acknowledgement o what
they think they have learned and what immediate steps they can make to positively alter theirpractice. Ask the participants or at least one signifcant learning point and what they plan to
alter as a result.
Take home messages:
a holistic assessment takes time, care and attention;
assessment and planning relies on the contribution o all involved;
participation in care planning has to be meaningul and attention must be given to the
process o negotiation and discussion;
writing outcomes based care plans requires skill and attention, but when done well can help
on-going discussion and negotiation or recovery;
outcomes should be specifc, achievable and measurable, realistic and timely.
Further reading
Boardman, J., Currie, A., Killaspy, H. & Mezey, G. (eds) (2010) Social inclusion and mental health.
London: Royal College o Psychiatrists.
Care Services Improvement Partnership (2008) Three keys to a shared approach in mental
health. Coventry: NIMHE
Hughes, Meic. (2009) Maen nhwn siarad amdana i Gwasg Bwythyn Caernaron.
Woods, P. & Kettyes, A. (Eds) (2009) Risk assessment and management in mental health
nursing. Oxord: Blackwell.
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Uned Graidd 4: Asesu a chynllunio gofal
Ymarer 1:
Taen 1: Senario Personol Rhi 1 Joe
Mae Joe yn wr priod 42 oed gyda dau o blant yn eu harddegau. Yn ddiweddar collodd ei waith
mewn atri leol lle bun gweithio ers iddo adael yr ysgol yn 16 oed. Mae ei swydd wedi bod
yn ansicr ers mwy na blwyddyn, ond bellach mae wedi cael ei ddiswyddo ac mae hyn wedi
cael eaith awr ar Joe. Mae gwaith wedi bod yn bwysig iddo. Roedd ei rieni wedi dweud wrtho
erioed y dylech weithio er mwyn ennill bywoliaeth a darparu ar gyer eich teulu.
Tra bu yn y atri gweithiodd Joe ei ordd i yny i od yn oruchwyliwr ond ni chwblhaodd unrhyw
gymwysterau ychwanegol na gwneud hyorddiant cydnabyddedig urfol.
Maer diswyddiad wedi cael eaith andwyol ar Joe. Mae wedi mynd yn swrth, maen aros yn
y ty ac yn esgeuluso pethau. Nid ywn cysylltu bellach i deulu ai rindiau a phrin ei od yn
siarad gydai wraig ai blant. Mae pobl wedii glywed yn dweud na all weld unrhyw ddyodol yn
y dre hon. Yn ddiweddar mae Joe wedi cymryd gorddos gydag alcohol ac aethpwyd ag e ir
Adran Ddamweiniau ac Achosion Argywng. Dywedodd ei od yn diaru ei od yn dal yn yw, ac
maen gyndyn o draod y digwyddiad.
Mae Joe wedi bod dan oal ei eddyg teulu syn poeni nad ywn ymateb i gyuriau gwrth
iselder. Maer meddyg teulu wedi awgrymu ei od yn cael cymorth seicolegol ond nid oedd
Joe yn siwr beth oedd hyn yn ei eddwl, elly gwrthododd.
Yr hyn syn poeni Joe wya yw ei od yn teimlon ethiant. Mae bob amser wedi bod yn gen
iw deulu ac wedi goalu am holl anghenion materol y ty, gwaith addurno a thrwsio ac ati. Ynddiweddar mae wedi bod yn esgeulusor pethau hyn a heyd mae nier o fliau heb eu talu.
Nid yw Joe erioed wedi bod mewn dyled or blaen ond maen poeni bellach y bydd yn colli ei
gartre. Mae wedi cael sawl rhybudd o fliau heb eu talu. Mae gan Joe gymaint o gywilydd nad
yw wedi sn wrth neb od hyn yn boen iddo.
Maer meddyg teulu wedi cysylltu Dr Anne Jenkins y seiciatrydd ymgynghorol i gael ei barn.
Taen 1: Senario Personol Rhi 2 Olwen
Gwraig weddw 73 oed yw Olwen syn byw mewn ardal wledig lle siaredir Cymraeg yn benna.
Mae Olwen yn siarad Cymraeg yn benna i theulu, rindiau a chymdogion. Maen wraig
weddw ers sawl blwyddyn bellach ac maen annibynnol iawn. Yn ddiweddar mae ei chymdogion
wedi dechrau poeni am nad yw Olwen yn mynd allan mor aml ag or blaen, ac oherwydd bod yn
well ganddi dreulior rhan wya or diwrnod yn ei chadair. Dywed Olwen nad ywn dymuno gweld
neb a hyd yn oed pe byddain teimlo ychydig yn sl, dywed od popeth yn rhy bell iw cyrraedd.
Mae ei rindiau wedi sylwi bod Olwen yn yr o wynt wrth symud o gwmpas y ty ac nad yw mor
hapus i bywyd oi gymharu rhai misoedd yn l. Maen ymddangos yn wy anghous ac nid
ywn gallu goalu amdanii hun gystal. Mae ei meddyg teulu wedi goyn ir tm iechyd meddwl
oedolion hyn ymweld hi gan ei bod yn poeni bod Olwen yn dangos arwyddion o afechyd
organig, el dementia.
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Core Unit 4: Assessment and outcome planning
Exercise 1:
Handout 1: Personal Scenarios Number 1 Joe
Joe is a 42 year old married man with two teenage children. He has recently been made
redundant rom his job in local actory, a place he has worked in since leaving school at 16.
The prospect o redundancy has been around or a year or more, but now that it has happened
it has hit Joe hard. Work has been important or Joe. His parents had always told him that
you should work or your living and to provide or your amily.
While working at the actory Joe worked himsel into a supervisory position but he has avoided
completing any additional qualifcations or ormal recognised training.
The redundancy has had a devastating eect on Joe. He has become lethargic, housebound
and neglectul. He has withdrawn rom contact with amily and riends and talks rarely with hiswie and children. He has been heard to say that he can see no uture in this town.
Recently Joe has taken an overdose with alcohol and was taken to A&E. He stated he
regretted still being alive, but now he is reluctant to discuss the incident.
Joe has been under the care o his GP who is concerned that he is not responding to
anti-depressant medication. The GP made a suggestion about psychological approach but
Joe wasnt sure what he was on about so declined.
O greatest concern to Joe is his sense o ailure, he has always been a strong member o
his amily and took care o all the material needs in the house, decorating and repairs etc.
Recently he has been neglecting these things and also has not paid many bills. Joe has never
been in debt beore but is now worried that he will lose his home. He has received a number
o warnings about unpaid bills. Joe is so ashamed o this he has not previously told anyone
that this is a concern.
The GP has contacted Dr Anne Jenkins the consultant psychiatrist or an opinion.
Handout 1: Personal Scenarios Number 2 Olwen
Olwen is a 73 year old widow living in a predominantly Welsh speaking, rural community.
Olwen speaks mainly Welsh with her amily, riends and neighbours. She has been widowed ormany years and is fercely independent. Her neighbours have recently become concerned that
Olwen does not go out as much as she used to, preerring to spend much o her day in her
chair. Olwen says she does not want to see anyone and states that even i she did eel a little
better, everything is too ar away or her now.
Her riends have noticed that Olwen appears more breathless when moving around the house
and is nowhere as happy with her lie as she was some months ago. She appears more
orgetul and less able to look ater hersel.
Her GP has requested a visit rom the older adults mental health team as she is concerned
that Olwen may be showing signs o an organic illness, such as a dementia.
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Uned Graidd 4: Asesu a chynllunio gofal
Taen 1: Senario Personol Rhi 3 David
Ymhen 2 fs bydd David yn dathlu ei ben-blwydd yn 18 oed. Mae wedi bod yn derbyn goal gan
wasanaethau plant ers ei od yn 13 oed. Caodd David blentyndod anodd iawn ar l iw dadarw (wrth ymladd mewn taarn) pan oedd yn 3 oed. Roedd ei am yn dibynnu ar gyuriau ac
alcohol ac yn aml yn esgeuluso David. O ganlyniad roedd yn collir ysgol yn ysbeidiol yn ystod
ei ynyddoedd cynnar. Ers iddo dderbyn goal gan wasanaethau mae presenoldeb David wedi
gwella. Yn l yr athrawon mae David yn achgen deallus syn cael traerth awr canolbwyntio.
Mae David wedi cael traerth heyd urfo unrhyw berthynas arall o bwys yn yr ysgol neur tu
allan ac maen well ganddo od ar ei ben ei hun. Ers ei od yn 13 oed mae David wedi cael
cyarodydd rheolaidd gydar Gwasanaethau Iechyd Meddwl Plant a Phobl Ianc (CAMHS).
Mae wedi ymateb yn dda ac wedi urfo perthynas dda gydar gweithwyr yn y gwasanaeth.
Yn ddirybudd, darganur sta yn ei uned od David wedi dechrau anaui hun, gan honni bod
cyarwyddiadau yn ei ddillad syn dweud wrtho am wneud hynny. Mae wedi anaui hun yn
ddiriol weithiau, heb ddweud wrth aelod o sta.
Mae sta yn yr uned breswyl wedi sylwi bod David wedi bod yn syllu am gynodau ar y teledu
ac yn ymgolli mewn byd arall. Mae sta wedi sylwi heyd ei od yn osgoi gwisgo unrhyw
ddillad coch pan mae dan straen. Wrth draod ymddygiad David awgrymwyd bod angen ir
gwasanaethau i gleifon iechyd meddwl mewnol i oedolion ei asesu gan ei od bellach rhwng y
gwasanaeth i blant ac oedolion. Mae David yn anhapus iawn r syniad bod rhywun or tu allan
ir tm CAMHS yn cynnig help ac maen gwrthod cytuno i ynd ir uned cleifon mewnol.
Taen 1: Senario Personol Rhi 4 Mervyn
Gwr 50 oed yw Mervyn syn byw gydai rawd iau mewn bwthyn bach mewn cymuned wledig
ach. Mae wedi bod yn derbyn gwasanaethau iechyd meddwl am dros 30 mlynedd, ond nid
yw wedi bod mewn ysbyty yn y 12 mlynedd diwetha. Nid oes gwasanaethau urfol ar gael
wrth ymyl Mervyn a phrin od unrhyw gludiant cyhoeddus rheolaidd. Maen mynd i ore cof a
gynhelir yn y cae/siop leol ac maen mwynhau mynd ir llyrgell deithiol.
Yn achlysurol, mae Mervyn yn penderynu peidio chymryd ei eddyginiaeth. Credir bod
cysylltiad rhwng hyn r dirywiad yn ei hylendid personol, yr iaith ddirol maen ei denyddio ai
ymddygiad ymosodol. Pan mae hyn yn digwydd mae Mervyn yn cwyno bod y lleisiauntroin in.
Mae pawb yn y gymuned yn adnabod Mervyn ac yn ho ohono, ac yn cyeirio aton aml el
tipyn o gymeriad. Mae cyn cydlynydd goal Mervyn yn symud tramor i yw. Bydd yn cael
cydlynydd goal newydd syn nyrs seiciatrig cymunedol sydd heyd yn newydd ir ardal. Wrth
baratoi at ei swydd newydd, maer cyn gydlynydd goal wedi cywynor nyrs seiciatrig cymunedol
i nier o bobl allweddol yn y gymuned leol, yn cynnwys perchennog y siop gof, y bosteistres,
yr heddlu lleol ar llyrgellydd syn gyriol am y gwasanaeth teithiol.
Mae Mervyn wedi dweud ei od yn poeni am weithio gydag unigolyn newydd ac mae wedi
cytuno y gallai od yn amser da i wneud ailasesiad oi anghenion.
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Core Unit 4: Assessment and outcome planning
Handout 1: Personal Scenarios Number 3 David
David is 2 months o his 18th birthday and is a young man who has been in looked ater
childrens services since he was 13 years old. David had a very chaotic upbringing ollowingthe death o his ather (in a bar room fght) when he was 3. His mother had a drug and alcohol
dependency and was oten neglectul o Davids needs. Consequently his school attendance
was sporadic during his early years. While being in the care o services school attendance has
improved and teachers have ound David to be a bright boy who had a great deal o difculty
in concentrating. David also struggled to orm any signifcant relationships in or out o school
and is considered something o a loner. Since he was 13 David has been seen regularly
by the Child and Adolescent Mental Health Service (CAMHS). He has responded well and
ormed good relationships with the workers in the service. Quite suddenly, the sta at his unit
discovered that David has been harming himsel, claiming that there are instructions in his
clothing which tell him to do so. He has cut himsel, sometimes quite severely without ever
inorming a member o sta.
Sta at the residential unit have noted that David has periodically been staring intently at
the television and driting o into another world. He has also been noted to avoid any
red coloured clothing when under stress. It has been discussed that David requires the
assessment o an adult mental health in-patient services as he is now in a service transition
phase. David is very unhappy at the prospect o anyone other than the CAMHS team oering
help and is reusing to agree to enter the in-patient unit.
Handout 1: Personal Scenarios Number 4 Mervyn
Mervyn is a 50 year old man who lives with his younger brother in a small cottage in a small
rural community. He has been receiving mental health services or over 30 years, but has not
been in a hospital in the past 12 years. There are no ormal services near Mervyn and there is
little in the way o regular public transport. He attends a coee morning held in his local shop/
cae and enjoys using the mobile library.
Periodically, Mervyn decides to stop taking his medication and this has been seen to be
associated with a reduction in his personal hygiene, increased abusive language and
aggressive behaviour. Mervyn complains that the voices get nasty at this time.
Mervyn is a well known and liked individual in the community, oten reerred to as a bit o a
character. Mervyns previous care coordinator is leaving to move abroad. He is to have a new
care coordinator who is a community psychiatric nurse (CPN) who is also new to the area.
During the orientation phase to the new job, the previous care coordinator has introduced
the CPN to Mervyn and to a number o key people in the local community, including coee
shop owner; the post mistress; the local police ofcer and the librarian who runs the mobile
service.
Mervyn has stated that he is worried about working with a new person and has agreed that it
may be a good time to conduct a re-assessment o his needs.
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Uned Graidd 4: Asesu a chynllunio gofal
Taen 1: Senario Personol Rhi 5 Ken
Gwr oedrannus 83 oed yw Ken syn byw yn ei yngalo ei hun mewn tre archnad ach.
Symudodd e ai wraig i Gymru ar l ymddeol tua 20 mlynedd yn l. Mae ei ddwy erch yn byw
dros 100 milltir i wrdd ac nid ydynt yn dod iw weld yn aml. Collodd Ken ei wraig 3 blynedd yn
l. I ddechrau roedd yn ymddangos ei od yn addasun weddol dda. Ond yn raddol aeth braidd
yn anghous a diynegiant. Dechreuodd esgeuluso ei hylendid ar arer o wisgo amdano. Pan
ddaeth ei erch iw weld roedd yn bwyta a pob o dun, rhywbeth na yddai wedi ei wneud or
blaen.
I ddechrau roedd y meddyg teulun amau ei od yn diodde o iselder ac ei cyeiriodd eto
at y tm iechyd meddwl lleol i oedolion hyn. Ond mae ymddygiad a cho tymor byr Ken wedi
gwaethygu ymhellach a bellach maen mynd i glinig co. Heyd maen derbyn goal yn y cartre.
Mae gweithiwr yn galw heibio i baratoi prydau ai atgoa i gymryd ei eddyginiaeth at bwysedd
gwaed uchel. Weithiau mae Ken allan pan maen nhwn galw. Yn aml maen ymddangos yn
ddiynegiant ac yn crwydro or byngalo, a hynny weithiaun eitha cynnar yn y bore. Ar ddau
achlysur daeth gweithwyr lleol o hyd iddon seyll y tu allan ir siop bapur newydd tua phump
or gloch y bore yn disgwyl iddi agor am 6 or gloch. Nid oedd ganddo lawer o syniad or amser.
Ond mae bob amser yn llwyddo i ddod o hyd iw ordd adre heb oyn am gyarwyddiadau ac
maen oalus wrth groesir yrdd.
Dywed Ken ei od yn colli ei wraig ai od yn teimlon unig. Ers iddi arw mae wedi cadw draw
or gweithgareddau yr arerai ynd iddynt el y cr lleol a chwarae dominos yn y clwb. Nid oes
ganddo lawer o ddiddordeb ail gydio yn y gweithgareddau hynny ac maen treulio amser yn
gwrando ar ei radio neun syllu ar y teledu heb dalu llawer o sylw.
Taen 1: Senario Personol Rhi 6 Mary
Mae Mary yn 36 oed; mae wedi cael diagnosis o Anhwylder Personoliaeth Ffniol (BPD).
Mae Mary wedi bod mewn cyswllt r gwasanaethau lleol ers yn 18 oed, ac mae wedi cael ei
derbyn droeon el cla mewnol, yn cynnwys i uned BPD arbenigol.
Tra oedd Mary yn gla mewnol gwnaeth sawl ymgais i niweidio ei hun ac ar adegau mae wedi
bod angen triniaeth eddygol rys. Mae Mary heyd wedi ymosod ar aelodau or sta yn y
gorennol.
Mae Mary wedi bod dan oal y Tm Iechyd Meddwl Cymunedol am saith mlynedd ac mae wedi
bod dan oal pump o wahanol gydlynwyr goal yn ystod yr amser hwnnw. Maer newidiadau
o ran y cydlynwyr goal wedi digwydd oherwydd bod sta wedi gadael neu oherwydd bod
y berthynas yn methu. Ar hyn o bryd maen derbyn gwasanaethau gan Nyrs Seiciatrig
Cymunedol, seiciatrydd, seicolegydd ac mae ganddi weithiwr cymdeithasol ar ei chyer.
Mae mam Mary yn byw gerllaw ac maen aml yn cwyno am y Tm Iechyd Meddwl Cymunedol;
maen ymddangos bod hyn yn digwydd pan o Mary leel uwch o angen neu pan mae mewn
argywng.
Yn aml mae Mary yn mynd ir ganolan iechyd oi gwirodd, ac mae hynny yn ei dron arwain at
lythyr atgyeirio ir Tm Iechyd Meddwl Cymunedol gan od Mary mewn seylla o argywng.
Yn aml, yr hyn syn ysgogi Mary i ynd ir ganolan iechyd neun peri iddi hunan niweidio ywr
aith ei bod yn credu bod gweithwyr proesiynol yn gwneud camgymeriadau e.e. yn methu
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Core Unit 4: Assessment and outcome planning
Handout 1: Personal Scenarios Number 5 Ken
Ken is an 83 year old man who lives in his own bungalow in a small market town. He and
his wie moved to Wales when he retired some 20 years previously. His two daughters both
live over 100 miles away and visit inrequently. Ken was widowed 3 years ago. Initially he
seemed to adjust reasonably well. However he gradually became a little vacant and orgetul.
He started to neglect his hygiene and dressing. He was visited by his daughter who ound him
eating baked beans rom a tin, something she said he would never have done previously.
At frst his GP suspected depression and reerred to the local mental health team or older
adults. However Kens behaviour and short term memory have deteriorated urther and Ken
now attends a memory clinic. Ken has also been allocated domiciliary care. A worker calls
to help him prepare meals and prompt him to administer his own medication or high blood
pressure. They report that Ken is sometimes out when they call. He will oten seem vacant
and he requently wanders o rom the bungalow, sometimes quite early in the morning.
On two occasions he was ound by local workmen standing outside the newsagents around 5am waiting or it to open at 6am. He seemed to have little idea o the time. However he always
seems to be able to fnd his way back home without needing to ask directions and to exercise
care when crossing the roads.
Ken says that he misses his wie and eels lonely. Since her death he has withdrawn rom
previous activities such as the local choir and playing dominoes at the club. He has little
interest in returning to these and now spends time listening to his wireless or gazing at the
television with apparently little attention.
Handout 1: Personal Scenarios Number 6 Mary
Mary is 36; she has a diagnosis o Borderline Personality Disorder. Mary has been in contact
with the local services since she was 18 years old and has had many inpatient admissions,
including to a specialist BPD unit.
Whilst an inpatient Mary has made numerous attempts to harm hersel which has on
occasions required emergency medical treatment. Mary has also assaulted sta members in
the past.
Mary has been under the care o this CMHT or seven years and has been under the care ofve dierent care co-ordinators during this time, the changes in care coordinator have been as
a result o sta leaving or the breakdown o the relationship. She currently receives services
rom a CPN, psychiatrist, psychology and has an allocated social worker. Marys mother lives
close by and oten makes complaints against the CMHT; this appears to be when Mary is
experiencing a higher level o need or crisis.
Mary requently attends the health centre o her own accord which consistently prompts a
reerral letter to the CMHT as Mary presents in crisis.
Marys attendance at the health centre or acts o sel harm is oten prompted by what she
believes are mistakes by proessionals such as not being able to meet her immediate needs,
or when in hospital having restrictions placed upon her care.
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Uned Graidd 4: Asesu a chynllunio gofal
bodloni ei hanghenion ar yrder, neu os yw yn yr ysbyty, am od cyyngiadau wedi eu gosod ar ei
goal. Weithiau mae Mary yn denyddio alcohol yn ormodol ac mae hynnyn gwaethygur
hunan niweidio.
Mae Mary wedi bod ar gyrsiau i adeiladu hyder a gynhelir gan wasanaethau dydd ond nid ywn
teimlo ei bod wedi elwa.
Dywed Mary yn aml nad yw eisiau, ac nad oes angen cynllun goal arni ac na ddylai od yn
derbyn gwasanaethau gan mai Ei bywyd hi ydyw.
Maer Tm Amlddisgyblaethol wedi trenu cyarod i adolygu ei chynllun goal a thriniaeth er
mwyn adolygu goal Mary gan od gweithwyr proesiynol unigol yn dweud nad ydynt yn gallu
bodloni anghenion Mary. Ond mae Clinigwr Cyriol Mary wedi dweud yn glir nad ywn credu bod
angen gwasanaethau arbenigol arni ac na ydd yn cau achos Mary eor gwasanaethau iechyd
meddwl eilaidd.
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Core Unit 4: Assessment and outcome planning
Occasionally Mary uses alcohol excessively which exacerbates her acts o sel harm.
Mary has attended courses on confdence building run by day services but doesnt eel that
she has benefted.
Mary oten states that she does not want or need a care plan and that she should not beinvolved with services as Its her lie.
The MDT have decided to arrange a care and treatment plan review meeting to discuss Marys
care as individual proessionals state that they eel unable to meet Marys needs, however
Marys Responsible Clinician has clearly stated that he does eel that specialist services are
required and that he will not discharge Mary rom secondary mental health services.
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Uned Graidd 4: Asesu a chynllunio gofal
Cynllun Goal a Thriniaeth
Gall y cynllun hwn gael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg
ac yn rhannol yn y Saesneg.
Mesur Iechyd Meddwl (Cymru) 2010 Adran 18 - Cynllun Goal a ThriniaethMaer cynllun goal a thriniaeth hwn wedii baratoi o dan adran 18 o Fesur Iechyd Meddwl (Cymru)
2010, ac yn unol r goynion yn Rheoliadau Iechyd Meddwl (Cydgysylltu Goal a Chynllunio Goal
a Thriniaeth) (Cymru) 2011.
Dyma gynllun goal a thriniaeth
Enwr cla
perthnasol
Cyeiriad arerol
llawn y cla
perthnasol
Enwr
cydgysylltydd goal
Rhi n, cyeiriad
post ac, os ywn
briodol, cyeiriad
e-bost y
cydgysylltydd
goal
Enwr BwrddIechyd Lleol neur
Awdurdod Lleol
a benododd y
cydgysylltydd
goal
Er hynny, cai
neur goalwr/goalwyr neur goalwr/goalwyr lleoliad oedolyn sydd ganddo/
ganddi oyn ir cynllun hwn gael ei adolygu unrhyw bryd.
Y dyddiad y caodd
y cynllun ei wneud Y
dyddiad y maen
rhaid adolygur cynllun
Caodd y cynllun hwn
ei wneud ar
ac mae iw adolygu erbyn
an bella.
syn byw yn
Y cydgysylltydd goal sydd wedi paratoir cynllun goal a thriniaeth hwn yw
Maer cydgysylltydd goal wedi cael ei benodi gan ac maen gweithredu ar
eu rhan
ac mae modd cysylltu r cydgysylltydd goal yn
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Uned Graidd 4: Asesu a chynllunio gofal
Maer rhan hon or cynllun goal a thriniaeth yn conodir canlyniadau y maer
ddarpariaeth gwasanaethau iechyd meddwl wedii bwriadu iw sicrhau, manylion y
gwasanaethau hynny sydd i gael eu darparu, ar camau sydd iw cymryd er mwyn
sicrhaur canlyniadau hynny.
Rhaid ir canlyniad(au) araethedig a gynhwysir yn y rhan ganlynol or cynllun ymwneud ag un neu
wy or meysydd sydd wediu rhestru, a chynnwys esboniad ar sut mae pob canlyniad yn ymwneud
phob maes. Gall canlyniadau gael eu sicrhau mewn meysydd eraill heyd, a rhaid iddynt gymryd
i ystyriaeth unrhyw risgiau sydd wediu nodi ar gyer y cla perthnasol. Maer rhan hon or cynllun
heyd yn nodi manylion y gwasanaethau sydd iw darparu, neur camau sydd iw cymryd, i sicrhaur
canlyniadau araethedig, gan gynnwys pa bryd a chan bwy y maer gwasanaethau hynny iw
darparu neu y maer camau hynny iw cymryd.
Rhaid
cytuno ar
ganlyniadauiw sicrhau ar
gyfer o leiaf
un or
meysydd a
ganlyn:
a)
llety
b)
addysg a
hyorddiant
c)
cyllid ac arian
ch) triniaeth
eddygol a
mathau eraill o
driniaeth, gan
gynnwysymyriadau
seicolegol
Y canlyniad sydd
iw sicrhau
Pa wasanaethau sydd iw darparu,
neu pa gamau sydd iw cymrydPa bryd Gan bwy
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Uned Graidd 4: Asesu a chynllunio gofal
d)
cyrioldebau
rhianta neu
oalu
dd)
goal personol
a llesiant
cororol
e)
cymdeithasol,diwylliannol neu
ysbrydol
)
gwaith a
galwedigaeth
Gall canlyniadau
iw sicrhau gael
eu cytuno heyd
ar gyer meysydd
eraill
Y canlyniad sydd
iw sicrhau
Pa wasanaethau sydd iw darparu,
neu pa gamau sydd iw cymrydPa bryd Gan bwy
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Uned Graidd 4: Asesu a chynllunio gofal
Gall y meddyliau, y teimladau neur ymddygiadau a ganlyn ddangos bod
yn mynd yn wy sl a bod angen cymorth ychwanegol oddi wrth y tm goal (maer rhain weithiaun
cael eu galwn arwyddion o bwl pellach):
Os bydd yn teimlo bod ei iechyd meddwl neu ei hiechyd
meddwl yn gwaethygu nes cyrraedd pwynt lle mae angen cymorth neu genogaeth ychwanegol, dylair
camau a ganlyn gael eu cymryd (mae hyn weithiaun cael ei alwn gynllun argywng a rhaid iddo
gynnwys manylion y gwasanaethau i gysylltu nhw):
Dylai unrhyw oynion neu ddymuniadau sydd gan
o ran iaith neu gyathrebu (gan gynnwys denyddior Gymraeg) gael eu conodi yma:
Enwr claf perthnasol
Enwr claf perthnasol
Enwr claf perthnasol
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Uned Graidd 4: Asesu a chynllunio gofal
Dyma arn am y cynllun goal a thriniaeth hwn, y
gwasanaethau iechyd meddwl sydd iw darparu, ac unrhyw dreniadau at y dyodol a ddylai gael eu
hystyried:
Cofnodwch unrhyw farn y
maer claf perthnasol yn
dymunoi chynnwys (gan
gynnwys dymuniadau a
theimladau yn y gorffennol
ar presennol ynghylch
y materion sydd wediu
cynnwys yn y cynllun)
gan gynnwys unrhywosodiadau am unrhyw
drefniadau at y dyfodol
a allai fod yn gymwys.
Os nad oes gan y claf
farn neu osodiadau ar y
materion hyn, neu os nad
oes modd sicrhau barn
y claf, dylai hynny gael ei
gofnodi hefyd.
* wedii gytuno gyda ac mae
wedii gonodi yn unol ag adran 18(2) o Fesur Iechyd
Meddwl (Cymru) 2010.
* heb gael ei gytuno gyda ond maer canlyniadau wediu
penderynu gan y darparydd/darparwyr gwasanaeth iechyd meddwl, ac maent wediu conodi yn unolag adran 18(6) o Fesur Iechyd Meddwl (Cymru) 2010.
* dileer fel y bon gymwys
(rhaid defnyddio un,
ond nid mwy nag un, or
gosodiadau)
Enwr claf perthnasol
Enwr claf perthnasol
Maer cynllun goal a thriniaeth hwn:
Enwr claf perthnasol
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Uned Graidd 4: Asesu a chynllunio gofal
Cyn belled ag y bon rhesymol ymarerol gwneud hynny, rhaid ir
darparydd/darparwyr gwasanaeth iechyd meddwl a ganlyn sicrhau bod
y gwasanaethau iechyd meddwl a nodwyd yn y cynllun goal a thriniaeth
hwn yn cael eu darparu:
Maer claf perthnasol yn
cael llofnodir cynllun
gofal a thriniaeth, os
ywn dymuno
Rhaid ir cydgysylltydd
gofal lofnodir cynllun
gofal a thiniaeth hwn
Rhowch y dyddiad y maer
cynllun gofal a thriniaeth
yn cael ei wneud
Rhowch enwr Bwrdd
Iechyd Lleol a/neur
Awdurdod Lleol syn
gyfrifol am ddarparu
gwasanaethau iechyd
meddwl eilaidd ir clafperthnasol
Llonod
Y cla perthnasol
Y Cydgysylltydd Goal
Llonod
Dyddiad
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Core Unit 4: Assessment and outcome planning
Care and Treatment Plan
This plan may be completed in either the Welsh or the English language, or partly in Welsh and
partly in English.
Mental Health (Wales) Measure 2010 Section 18 Care and Treatment PlanThis care and treatment plan has been prepared under section 18 o the Mental Health (Wales)
Measure 2010, and in accordance with the requirements o the Mental Health (Care Coordination
and Care and Treatment Planning) (Wales) Regulations 2011.
This is the care and treatment plan o
Name o
relevant patient
Full usual
address o
relevant patient
Name o care
coordinator
Telephone
number, postal
address, and
where
appropriate,
email address o
care coordinator
Name o Local
Health Board orLocal Authority
that appointed
the care
coordinator
However,
his or her carer(s), or adult placement carer(s), may request a review o this
care plan at any time.
Date plan was made
and date by which
the plan must be
reviewed
This plan was made on
and is to be reviewed
no later than
Who lives at
The care coordinator who has prepared this care and treatment plan is
The care coordinator has been appointed by, and is acting on behal o
who can be contacted at
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Core Unit 4: Assessment and outcome planning
This part o the care and treatment plan records the outcomes which the provision
o mental health services are designed to achieve, details o those services that
are to be provided, and the actions that are to be taken with a view to achieving
those outcomes.
The planned outcome(s) included in the ollowing part o the plan must relate to one or more o
the areas listed, and include an explanation o how each outcome relates to each area.
Outcomes also may be achieved in other areas, and are to take into account any risks identifed
in relation to the relevant patient. This part o the plan should also set out details o the services
that are to be provided, or actions taken, to achieve the planned outcomes, including when, and
by whom those services are to be provided or actions taken.
Outcomes to
be achieved
must be
agreed in
relation to
at least
one of the
following
areas:
a)
accommodation
b)
education and
training
c)
fnance and
money
d) medical and
other orms o
treatment,
includingpsychological
interventions
Outcome to be
achieved
What services are to be provided,
or actions takenWhen Who by
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Core Unit 4: Assessment and outcome planning
e)
parenting or
caring
responsibilities
)
personal care
and
physical
well-being
g)social, cultural
and spiritual
h)
work and
occupation
Outcomes to be
achieved may
also be agreed
in relation to
other areas
Outcome to be
achieved
What services are to be provided,
or actions takenWhen Who by
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Core Unit 4: Assessment and outcome planning
The ollowing thoughts, eelings or behaviours may indicate that
is becoming more unwell and may require extra help rom the care team (these are sometimes
called relapse signatures):
I eels that his or her mental health is deteriorating to the
point where he or she requires extra help or support, the ollowing actions ought to be taken (this is
sometimes known as a crisis plan and must include the details o services to be contacted):
Any language or communication requirements or wishes which
has (including in relation to the use o the Welsh Language) ought to be recorded here:
Name of relevant patient
Name of relevant patient
Name of relevant patient
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Core Unit 4: Assessment and outcome planning
The views o on this care and treatment plan, the mental
health services that are to be provided, and any uture arrangements that ought to be
considered, are:
Record any views that the
relevant patient wishes
to be included (including
past and present wishes
and feelings about the
matters covered by the
plan), and include any
statements about any
future arrangementswhich may apply. If the
patient does not have
any views or statements
on these matters, or the
patients views cannot be
ascertained, this ought to
be recorded also.
* been agreed with and is
recorded in accordance with section 18(2) o the Mental
Health (Wales) Measure 2010.
* not been agreed with but the outcomes have been determined
by the mental health service provider(s) and are recorded in accordance with section 18(6) o theMental Health (Wales) Measure 2010.
* delete as applicable
(one, but not more than
one, statement must
apply)
Name of relevant patient
This care and treatment plan has:
Name of relevant patient
Name of relevant patient
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Core Unit 4: Assessment and outcome planning
So ar as it is reasonably practicable to do so, the ollowing mental
health service provider(s) must ensure that the mental health
services set out in this care and treatment plan are provided:
The relevant patient
may sign the care and
treatment plan, if
they wish
The care coordinator
must sign this care and
treatment plan
Enter the date the care
and treatment plan
is made
Enter the name of the
Local Health Board and/
or the Local Authority
who are responsible
for providing secondary
mental health services to
the relevant patient
Signed
Relevant patient
Care Coordinator
Signed
Date
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Uned Graidd 4: Asesu a chynllunio gofal
Taen 3: Gwellar ordd o ddisgrifo nodau a chanlyniadau
Maer problemau hyn yn seiliedig ar straeon personol Joe / Olwen / David / Mervyn / Ken a
Mary. Fe welwch od y rhain yn broblemau ac yn ganlyniadau sydd wedi eu difnion wael: aralleiriwch y termau yn gynlluniau goal syn seiliedig ar ganlyniadau mwy denyddiol, gan
roi gwell difniad or nod/canlyniad a sut gellid adolygur problemau
edrychwch ar y problemau lle mae angen help a meddyliwch sut gellid eu geirio mewn ordd
syn ategu ethos gwellhad (gweler Unedau Craidd 1 a 2) a denyddiwch y wybodaeth am
sgiliau asesu allweddol yn yr uned hon
rhannwch rhain gyda grwpiau eraill i weld a ydyn nhwn gallu cynnig unrhyw welliannau
pellach ich gwaith.
Nod/canlyniad wedi ei ddifnion wael i Joe:
Mae gan Joe iselder
Mae Joe yn ddi-waith
Nid yw Joe yn cydymurfo i driniaeth seicolegol
Nid yw Joe yn ymateb iw eddyginiaeth
Mae Joe mewn dyled ac mae eisiau datrys ei bryderon ariannol
Mae David yn ymateb i gyarwyddiadau gan eraill na rennir gan ei gylch cyoedion
Mae David chysylltiad rhy agos phobl yn ei wasanaeth blaenorol
Nid oes gan David unrhyw rindiau agos
Ni all David ganolbwyntio
Mae David yn risg iddoi hun
Mae gan Olwen iselder
Mae Olwen yn ynysig yn gymdeithasol
Mae gan Olwen anawsterau anadlu
Nid yw Olwen yn deall Saesneg yn dda iawn
Nod/canlyniad wedi ei ddifnion wael i Olwen
Nod/canlyniad wedi ei ddifnion wael i David
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Core Unit 4: Assessment and outcome planning
Handout 3: Improving the way goals & outcomes are described
These issues are based on the personal narratives o Joe/Olwen/David/Mervyn/Ken and
Mary. You will see these are poorly defned problems and outcomes. Your task in groups is to: rephrase the terms into better more useul outcomes based care plans, providing a better
defnition o the goal/outcome and identiying how the issues can be reviewed
think about how the issues requiring assistance can be phrased in such a way as to rein
orce an ethos o recovery (see Core Units 1 and 2) and use inormation o key
assessment skills contained n this unit.
share them with other groups to see i they can improve your work urther.
Poorly defned goal/outcome or Joe
Joe is depressed
Joe is out o work
Joe is compliant with psychological treatment
Joe is not responsive to medication
Joe is in debt and wants to solve his money worries
David is responding to instructions by others not shared by his peer group
David is too attached to people in his previous service
David has no signifcant riends
David cant concentrate
David is a risk to himsel
Olwen is depressed
Olwen is socially isolated
Olwen has breathing difculties
Olwen does not understand English very well
Poorly defned goal/outcome or Olwen
Poorly defned goal/outcome or David
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Uned Graidd 4: Asesu a chynllunio gofal
Nod/canlyniad wedi ei ddifnion wael i Mervyn
Mae Mervyn yn ynysig
Ni wnai Mervyn gymryd ei eddyginiaeth
Mae Mervyn yn gallu bod yn ymosodol
Mae gan Mervyn hylendid personol gwael
Dywed Mary od ganddi anhwylder personoliaeth
Mae gan Mary hanes o drais
Mae Mary yn niweidio ei hun pan mae dan straen
Mae Mary yn mynd i ddosbarthiadau hunan hyder
Mae Mary yn gallu gwrthod cydweithredu
Weithiau mae gan Ken hylendid personol gwael
Mae Ken yn anghous
Mae Ken yn mynd i glinig co
Ni all Ken baratoi ei brydau ei hun
Mae Ken yn unig
Nod/canlyniad wedi ei ddifnion wael i Ken
Nod/canlyniad wedi ei ddifnion wael i Mary
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Core Unit 4: Assessment and outcome planning
Poorly defned goal/outcome or Mervyn
Mervyn is isolated
Mervyn wont take his medication
Mervyn can be aggressive
Mervyn has poor personal hygiene
Mary states she has a personality disorder
Mary has a history o violence
Mary sel harms when under stress
Mary attends sel confdence classes
Mary can be uncooperative
Ken sometimes has poor hygiene skills
Ken is orgetul
Ken attends a memory clinic
Ken cannot prepare his own meals
Ken is lonely
Poorly defned goal/outcome or Ken
Poorly defned goal/outcome or Mary
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Uned Graidd 4: Asesu a chynllunio gofal
Taen 4: Cynllunio canlyniadau pethau iw cynnwys
Cynllunio canlyniadau ymddygiadol:
targedwch ymddygiad penodol
helpwch trwy osod nodau cyraeddadwy ar gyer newid ymddygiad
helpwch trwy gael y genogaeth sydd ei hangen ar yr unigolyn er mwyn newid a chynnal y
newid hwnnw mewn ymddygiad
helpwch yr unigolyn i dorrir newidiadau ymddygiadol hyn yn dargedau esul dipyn
helpwch yr unigolyn i gael hyd ir adnoddau ar bobl syn gallu ei helpu i gyawni ei nodau.
Dylid ysgriennur canlyniadau gan ddenyddio egwyddorion CAMPUS h.y. dylent od yn rhai
Cyraeddadwy, Amserol, Mesuradwy, Penodol, Uchelgeisiol, Synhwyrol.
C cyraeddadwy,
A amserol,
M mesuradwy,
P penodol,
U uchelgeisiol
S synhwyrol.
Maen bwysig pwysleisio y dylid cynnwys y denyddiwr gwasanaeth yn y broses o ysgriennu
pob cynllun goal a thriniaeth a dylid eu hysgriennu mewn iaith y byddant yn gallu ei deall.
Maen bwysig medru ysgriennur cynllun goal a thriniaeth yn Gymraeg neu Saesneg yn l
anghenion y denyddiwr gwasanaeth.
Os nad ywn bosibl cynnwys y denyddiwr gwasanaeth, dylid conodir rhesymau pam nad ywn
rhan or cynllun ar camau y dylid eu cymryd i hwyluso cydweithio. Mae heyd yn bwysig ystyried
y rl y mae eiriolwyr iechyd meddwl annibynnol yn ei chwarae gyda chleifon syn gallu hawlior
cymorth hwnnw er mwyn eu cynnwys wrth gynllunio goal a thriniaeth.
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Hand out 4: Outcome planning things to include
Behavioural outcome planning:
target specifc behaviours
help set achievable goals or behavioural change
help fnd support the person needs to initiate and maintain change in behaviour
help the person break down required behavioural changes into smaller staged and
achievable targets
help person fnd the resources and people who can help them achieve their goals.
Outcomes should be written using SMART principles i.e. they should be Specifc, Measurable,
Achievable, Realistic, Timely.
S specifc,
M measurable,
A achievable,
R realistic,
T time-based,
You can also add R to make SMARTR
R Recovery orientated
It is important to emphasise that all care and treatment plans should be written with the
involvement o the service user and written in language they will be able to understand.
This includes the writing o care and treatment plans in Welsh or English.
I it is not possible to involve the service user, a record should be made regarding reasons or
absence o involvement and actions to be taken to acilitate collaboration. It is also important
to consider the role that independent mental health advocates will play with Welsh qualiying
patients in supporting the patients involvement in care and treatment planning.