Referrals and Assessments Process

- Devising our Service users Care and Support Plans, Health Action Plans, Communication Passports, Risk Assessments, PBS and Guidelines, etc. -

The service manager and the staff team will be involved in the creation of these documents. In the process, the service manager will allocate a Keyworker with the overall responsibility for the service users on a day-to-day basis.

- Six (6) Weeks Review -

The service manager will liaise with the keyworker to arrange a six weeks review with the service user and relatives along with the other people involved with the service user’s care (e.g. Social Worker, Consultant Neurologist, Psychiatrist, GP, Nurse etc.). This process will provide us with the opportunity to review the service placement with the aim to identify what has worked well for the service user, progress and achievement and any other concerns/ needs that need to be resolved with an agreed action plan within a further three months’ timeframe or earlier. The review chair will share the records of the review to ensure that there is an involvement of all professionals in order to continue to provide holistic and person centred care and support services to the service user.

- Three (3) Months Review -

The service user’s care plan will be reviewed for the first three months with the staff team. The Key worker will take a leading role to ensure that the action plan agreed previously is discussed and analysed in-depth. Which will be followed by the creation of another new action plan to ensure continuity of effective and efficient care and support.

- Six (6) Months Review -

The service manager and the key worker will also arrange the six months review in order to follow up the action plan set from the previous meetings. Discussions will be around progress and concerns whilst implementing the action plans, and another new action plan will be created and shared amongst parties.

- Yearly/Annual Review -

Service users’ annual review will take place to reassess and evaluate the overall implementation of the care plan. The review team will look into the present needs/services, to identify achievements and unachieved goals with further discussions and analysis to verify areas of additional support services if required, follow by the creation of a new action plan for the following year.

- The Process -

• Referral
• Need Assessment
• Service Users and Relatives Service Visit
• Recommendations & Costs
• Agreed Costed Care for Placement
• Transition Plan
• Induction
• Creation of Care/Support Plans, Health Action Plans, Communication Passports, Risk Assessments, PBS and Guidelines, etc
• Six (6) Weeks Review
• Three (3) Months Review
• Six (6) Months Review
• Yearly/Annual Review