core unit 5: reviewing care and treatment plans

7/27/2019 Core Unit 5: Reviewing care and treatment plans

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Uned Graidd 5: Adolygu cynlluniau gofal

a thriniaeth

Core Unit 5: Reviewing care and

treatment plans


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Digital ISBN 978 0 7504 8173 1

Hawlfraint y goron/Crown copyright 2012

WG16600

2

Ysgriennwch eich nodiadau yma:


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Core Unit 5: Reviewing care and treatment plans

Write your notes here:


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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth

Uned Graidd 5: Adolygu cynlluniau goal a thriniaeth

Oriau hyorddi yn gysylltiedig r uned hon = 3 awr

Nodaur uned

Nod yr uned yw datblygu gwell dealltwriaeth o bwrpas a manteision cynnal adolygiadcynhwysawr a manwl o gynlluniau goal a thriniaeth. Bydd y grwp yn datblygu dealltwriaeth or

sgiliau angenrheidiol i drenu a chadeirio adolygiad urol o gynlluniau goal a thriniaeth.

Pri negeseuon i hwyluswyr

Yn yr uned hon dylair hwylusydd bwysleisio:

bod yn rhaid i gynlluniau goal a thriniaeth gael adolygiad gan y tm llawn o leia unwaith

bob 12 mis

bod gan gydlynwyr goal gyrioldebau sylweddol wrth benderynu ynghylch cynnwys

adolygiadau a pha mor aml y dylid eu cynnal

mae adolygur cynllun goal a thriniaeth yn broses hollbwysig wrth ddarparu goal ac maen

goyn am leelau uchel o sgiliau.

Cywyniad a chendir

Maer uned astudio hon yn adeiladu ar yr unedau craidd blaenorol. Y bwriad yw denyddior hyn

maent wedi ei ddysgu yn yr unedau blaenorol i gael golwg cynhwysawr ar y broses cynllunio

goal a thriniaeth. Mae cynnal adolygiad urol o gynlluniau goal a thriniaeth yn rhan bwysig

or broses o ddarparu goal iechyd. Maen gyfe i adolygu sut maer cynllun goal a thriniaeth yn

dod yn ei faen. Maen gyfe yn ogystal i gael adborth gan aelodau eraill y tm goal. Mae heydyn gyfe i ddenyddio dulliau urol y cytunwyd arnynt i esur sut mae amcanion y cynllun goal

yn symud yn eu blaen.

Mae yna agweddau pwysig syn rhan or broses adolygu wrth ymdrin chynlluniau goal a

thriniaeth plant a phobl ianc. Bydd yr uned hon yn nodi rhai or materion hyn ac yn annog y

grwp i ymateb iddynt.

Canlyniadau dysgu

Ar l cwblhaur uned hon bydd y cyranogwyr yn:

1edrych ar y sgiliau ar cymwyseddau angenrheidiol i drenu a chynnal cyarodydd eeithiol i

adolygu cynlluniau goal a thriniaeth.

2deall yn well y goynion ar gyer adolygu cynlluniau goal a thriniaeth ym Mesur Iechyd

Meddwl (Cymru) 2010 ar Rheoliadau.

3 deall materion yn ymwneud dwyieithrwydd wrth adolygu cynlluniau goal a thriniaeth.

4 deall swyddogaeth y cydlynydd goal wrth adolygu cynlluniau goal a thriniaeth, achynllunior broses gadael goal.


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Training hours associated with this unit = 3 Hours

Aims o the unit

The aim o the unit is to develop a greater understanding o the purpose and benetso comprehensive and detailed care and treatment plan review. Participants will develop

an understanding o the skills required to organise and chair a ormal review o care and

treatment plans.

Key messages or acilitators

In this unit, the acilitator should emphasise:

care and treatment plans must be the subject o a ull team review at least once every

12 calendar months

care coordinators have signicant responsibilities in decision making on content andrequency o reviews

care and treatment plan review is a critical process in care delivery and requires high

levels o skill.

Introduction

This unit o study builds on the previous core units. It is intended to bring the learning rom

these previous units to complete a comprehensive perspective on the care and treatment

planning process. The ormal review o care and treatment plans is an important element

in the healthcare delivery process. It is an opportunity to ormally monitor progress toward

agreed care and treatment planning outcomes. It provides an opportunity to receive eedbackrom all other members o the care team and also to consider the measurement o trends in

goal attainment using ormal and agreed measures.

There are important aspects o the review process when the care and treatment o children

and young people is concerned. This unit will identiy some o these issues and encourage

participants to respond to them.

Learning outcomes

On completing the unit participants will:

1examine the skills and competences required to organise and conduct eective care and

treatment plan review meetings.

2have a greater understanding o the requirements or care and treatment plan review in the

Mental Health (Wales) Measure 2010 and Regulations.

3 understand the issues o bilingualism when conducting care and treatment plan reviews.

4 understand the unction o the role o the care coordinator when reviewing treatment andcare and treatment plans and in discharge planning.


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Amser

(munudau)Focws

Canlyniadau

dysgu

cysylltiedig

Dull dysgu/

adnoddauCynnwys

10 munud Cyfwyniad - Traodaeth Sleidiau 1 3

40 munud

Rhan 1:

Proadau or broses

adolygu

1Ymarer 1

Traodaeth grwpSleid 4

50 munudRhan 2:

Trenu adolygiad1, 2, 3, 4

Siart troi

Traodaeth grwp

Ymarer 2

Clip DVD

Sleidiau 5-8,

Tafen 1

Tafen 2

60 munud

Rhan 3:

Cadeirio adolygiad

urol o gynllun goal

a thriniaeth: cael y

gorau or broses

1, 2, 3, 4

Siart troi

Traodaeth grwp

Ymarer 3

Clip DVD

Tafen 3

Tafen 4

20 munud Crynhoi -

Cwestiynau

Negeseuon a

ddysgwyd

Cynllun y wers

Adnoddau dysgu angenrheidiol ar gyer yr uned hon:

lle gwag a chyfeoedd i wneud gwaith grwp ac ystyried materion

adnoddau ar gyer cyfwyniadau PowerPoint

adnoddau i chwarae clipiau DVD syn dangos pri ganlyniadau dysgu

siart troi a phinnau

Cynllun gwers manwl

Gweithio trwyr uned

Gallech ddangos y sleid PowerPoint cynta wrth ir grwp gyrraedd.

Yn dibynnu ar y seylla, gallech anteisio ar y cyfe i gyfwyno eich hun ar cyranogwyr iw gilydd.

Peidiwch threulio gormod o amser yn gwneud hyn.

Sleidiau 2 3:

Mae sleidiau 2 3 yn rhoi trosolwg o nodaur uned ar canlyniadau dysgu.Rhowch gyfe ir grwp

oyn unrhyw gwestiynau am yr uned.


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Time Focus

Related

learning

outcome

Teaching method/

resourcesContent

10 mins Introduction - Discussion Slides 1 3

40 mins

Section 1:

Experiences o the

review process

1Exercise 1

Group discussionSlide 4

50 minsSection 2:

Organising a review1, 2, 3, 4

Flip chart

Group discussion

Exercise 2

DVD clip

Slides 5 - 8,

Handout 1

Handout 2

60 mins

Section 3:

Chairing a ormal care

and treatment plan

review: getting the most

out o the process

1, 2, 3, 4

Flip chart

Group discussion

Exercise 3

DVD clip

Handout 3

Handout 4

20 mins Conclusion -

Questions

Take home

messages

Lesson plan

Detailed lesson plan

Orientation

You might like to have the rst title PowerPoint slide showing when participants arrive

Depending on the situation you might like to introduce yoursel and participants to each other.

This should be kept airly brie.

Slide 2 3:

Slides 2 3 provide an overview o the unit aims and learning outcomes. Provide opportunity or

participants to ask any questions about the unit.

Required teaching resources:

space and opportunities or group work and refection

resources or PowerPoint presentations

resources to play DVD clips illustrative o key learning outcomes

fip chart paper and pens


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Rhan 1: (40 munud)

Ymarer 1: Proadau or broses urol o gynllunio goal a thrinaeth

Y dasg yw goyn ir cyranogwyr ystyried eu proadau blaenorol o gynnal adolygiad urol o

gynlluniau goal a thriniaeth. Goynnwch iddynt ystyried eu barn eu hunain a heyd i ddeall

barn pobl eraill syn rhan or broses.

Sleid 4: Proadau or broses urol a gynllunio goal a thrinaeth

Nodiadau i hwyluswyr: Edrychwch ar y nodiadau rhagarweiniol ar ddysgu myyriol.

Ceisiwch oalu nad ywr dasg yn troin sesiwn o hel atgoon am broadau. Maen bwysig eich

bod yn dysgu or broses.

Traodwch eu proad o adolygiadau, gan ganolbwyntio ar bwyntiau da a meysydd y gellir eu

gwella. Goynnwch ir grwp ystyried sut y byddair bobl eraill oedd yn rhan or broses yn teimlo

yn ystod y proad hwn. Ar l cynnal traodaeth mewn grwpiau bach goynnwch ir cyranogwyr

roi adborth ir grwp mawr.

Dyma rai awgrymiadau i helpur draodaeth:

Sae ble mae lleoliad yr adolygiad?

Amseriad a gynhaliwyd yr adolygiad ar adeg briodol yng nghylch y cynllun goal?

Pwer a roddwyd sylw i ddylanwad gweithwyr proesiynol ar yr adolygiad?

Iaith oedd yr iaith yn briodol? (h.y. siaradwyr Cymraeg).

Mwy o weithwyr proesiynol Oedd mwy o weithwyr proesiynol nag o ddenyddwyr

gwasanaeth/goalwyr yn yr adolygiad, a hynnyn codi on arnynt?

Cynllun goal a thriniaeth heb ei draod a draodwyd y cynllun goal el blaenoriaeth?

Cynlluniau wedi eu gwneud cyn ir denyddiwr gael ei gynnwys oedd y denyddiwr gwasanaeth

yn gwybod bod adolygiad yn cael ei gynnal?Focws oedd y sgwrs wedi ei chyeirio at y denyddiwr gwasanaeth neur cydlynydd goal?

Cynnwys Oedd y bobl berthnasol i gyd wedi eu cynnwys yn y cyarod/draodaeth?

Diogelwch ai diogelwch a risgiau oedd yn cael y pri sylw yn yr adolygiad neu ni thraodwyd

nhw o gwbl?

Bydd yr uned hon yn goren gydag ymarer ar genogi neu annog ymarer da syn datblygu wrth

gynnal adolygiad urol o gynlluniau goal a thriniaeth.


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Section 1: (40 mins)

Exercise 1: Experiences o the ormal care and treatment planning process

The task is to ask participants or their refections on previous experiences o ormal care and

treatment plan reviews. They are asked to consider their own views and also try to understand

the views o others involved in the experience.

Slide 4: Experiences o ormal care and treatment plan reviews

Notes to acilitators: Please reer back to the introductory notes about refective learning.

Avoid the task becoming just a reminiscence o experiences. It is important to draw out the

learning rom the process.

Discus the experiences o reviews, ocus on some good points and areas where things can be

improved. Ask the participants to think how others involved may have elt during this

experience. Ater small group discussion ask participants to eed back to the larger group.

Some prompts that help the discussion are:

Premises the location o the review?

Frequency was the review conducted at an appropriate time in the care plan cycle?

Power were there issues o proessional dominance identied?

Language where there issues o appropriateness o language noted? (i.e. Welsh language

speakers).

Outnumbered Were service users/carers heavily outnumbered in the review and thus make it

potentially intimidating?

Care and treatment plan not discussed was the care plan discussed as a priority?

Plans made prior to user involved did the service user know there was a review?

Focus who was the conversation directed at - the service user or the care coordinator?

Involvement Were the right people not involved in meeting/discussion?

Saety were saety and risks the sole ocus o the review or not discussed at all?

This unit will conclude with an exercise about supporting or encouraging emerging good

practice in ormal care and treatment plan reviews.


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DVD

Rhan 2: (50 munud)

Adolygur cynllun goal a thriniaeth

Clip DVD:

Clip o ddenyddiwr gwasanaeth yn adrodd ei broadau o adolygiadau urol o gynlluniau goal

a thriniaeth.

Ymarer 2: Trenu adolygiad

Sleid 5: Trenu adolygiad traodaeth mewn grwp bach

Maer rhan gynta hon or ymarer yn annog cyranogwyr i ystyried sut a phryd dylid trenu i

adolygu cynllun goal a thriniaeth. Gellir seilio hyn ar senario Anwen ond dylid ystyried materion

eraill heyd. Maen hysbys bod y broses adolygu urol yn gallu bod yn straen ar ddenyddwyr

gwasanaeth a chydlynwyr goal. Maer ymarer yn cyfwyno camau denyddiol y gallair cydlynydd

eu cymryd.

Rhannwch y cyranogwyr yn grwpiau bach a rhowch y cwestiynau canlynol iddynt; rhannwch

y cwestiynau rhwng y grwpiau. Goynnwch iddynt ysgriennu eu hatebion ar siart troi cyn rhoi

adborth ar yr atebion ir grwp cyan

Cwestiynau iw goyn:

A oes angen adolygiad neu a ddylid gwneud mn newidiadau mewn ymgynghoriad r

denyddiwr gwasanaeth?

Pa ath o adolygiad sydd ei angen urol/anurol? sut rydych yn penderynnu?

Pwy ddylai drenu adolygiad?

Pwy ddylid ei wahodd?

Beth ywr treniadau ar gyer denyddio eiriolwyr iechyd meddwl annibynnol?

Beth ywr problemau i siaradwyr Cymraeg a yddain dymuno cynnal adolygiad urol yn yr

iaith honno - a ddylid cynnal yr adolygiad yn Saesneg?

Sut gellir trenu adolygiad urol o gynllun goal a thriniaeth?

Pa gymorth a allai od ei angen ar bobl allweddol (el denyddwyr gwasanaeth/goalwyr) yn y

broses adolygu urol?

Pa waith paratoi cyn-adolygiad ydd ei angen ar gyer pobl allweddol?

Sut ydd canlyniadau cynlluniau goal a thriniaeth yn cael eu mesur ar gyer yr adolygiad?

Beth syn oynnol er mwyn sicrhau eu bod yn cael eu gweithredun eeithiol o dan Fesur

Iechyd Meddwl (Cymru) 2010?


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DVD

Section 2: (50 mins)

The care and treatment plan review

DVD Clip:

A clip o a service user recounting experiences o ormal care and treatment plan reviews.

Exercise 2: Organising a review

Slide 5: Organising a review small group work discussion

This rst part o the exercise encourages participants to consider how and when a care

and treatment plan review should be organised. It is well understood that the ormal review

process can be anxiety provoking or service users and care coordinators. The exercise

introduces useul steps that the care coordinator might take.

Form small work groups and provide participants with the ollowing questions; you can divide

the questions up so that each group takes a ew each. Ask them to write their answers on a

fip chart and then eedback the answers to the whole group.

Questions to ask:

Is a review required or are minor amendments to be made in consultation with theservice user?

What type o review is required ormal/inormal? how do you decide?

Who should organise a review?

Who should be invited?

What are the arrangements or use o independent mental health advocates?

What are the issues or Welsh speakers who would like ormal reviews to be conducted in

that language should the review take place in English?

How can a ormal care and treatment plan review be organised?

What support might key people (such as service users/carers) require in the ormal review

process?

What pre-review preparation will be required or key people?

How will care and treatment plan outcomes be evaluated or the review?

What is required to ensure eective discharge under the Mental Health (Wales) Measure

2010?


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Pwrpas y draodaeth grwp yw annog aelodaur grwp i ddenyddior holl wybodaeth y maent wedi

ei chasglu yn yr unedau dysgu blaenorol. Felly maen bwysig ystyried i ba raddau yr ydych yn

gweithio mewn partneriaeth gydar denyddiwr gwasanaeth ac i ba raddau maer ymarer yn

canolbwyntio ar ei wellhad wrth ichi draod sut i drenu adolygiad urol.

Heyd ceisiwch annog y grwp i ystyried pwy syn cymryd rhan mewn adolygiad urol a pham?Ydyn nhwn deall eu rl? Ydyn nhwn deall y broses gyathrebu sydd ei hangen er mwyn

sicrhau bod y cynllun goal a thriniaeth, y nodau a ddymunir ar canlyniadau goynnol yn eglur?

Meddyliwch am unrhyw gwestiynau ychwanegol a goynnwch ir grwpiau rannu gwybodaeth

gydai gilydd am eu dull o gynnal adolygiad urol o gynlluniau goal a thriniaeth.

Cynigiwch adborth adeiladol ar bob elen or dull, a goynnwch ydi hwn yn ddull syn rhoir

pwyslais ar wellhad yr unigolyn ac yn hybu perthynas gadarnhaol rhwng pobl?

Nodiadau ir hwylusydd:

1. Maer broses o benderynu pryd y dylid cynnal adolygiad yn rhan bwysig o Fesur IechydMeddwl (Cymru) 2010. Pwrpas yr ymarer hwn yw sicrhau bod y grwp yn deall beth

maer ddeddwriaeth ar rheoliadaun ei ddweud am adolygu cynlluniau goal a

thriniaeth. Byddain unddiol i chi gyarwyddo eich hunan eo Pennod 6 y Cod Ymarer.

2. Dylid annog peth traodaeth ar werth eiriolwyr iechyd meddwl annibynnol. Er bod yr hy

orddiant hwn yn canolbwyntio ar ran 2 or Mesur, mae angen i gyranogwyr od yn ymwy

bodol bod gan gleion syn deilwng o gael cymorth hawl i gael help gan eiriolwr iechyd

meddwl. Maen bwysig pwysleisio nad yw gweithwyr iechyd meddwl proesiynol yn gym

wys i weithredu el eiriolwyr.

Sleidiau 6 7: Adolygn cynllunio goal a thrinaeth

Taen 1: Rheoliadau adolygu cynlluniau goal a thriniaeth

Taen 2: Rheoliadau dod r cynllun goal i ben

Rhowch dafenni 1 a 2 ir cyranogwyr i ategur sleidiau. Dylid caniatu amser i oyn unrhywgwestiynau am y rheoliadau.


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The group discussion is to encourage participants to use all the inormation they have gained

in the previous learning units. Thereore it is important to consider the degree o partnership

working and recovery orientated practice in the discussion about organising a ormal review.

Additionally, encourage participants to refect on who is involved in a ormal review and why?

What will their role be in the review? Do they understand their role and the communicationprocess to ensure clarity o the care and treatment plan and desired goals and required

outcomes?

Think o any additional questions and ask the groups to share with each other their approach

to conducting a ormal care and treatment plan review. Subject each element o the approach

to constructive eedback and ask does this represent an approach which is recovery

orientated and promotes positive relationships between people?

Notes or acilitator:

1. The decision making process o deciding about when a review is required is animportant part o the Mental Health (Wales) Measure 2010. This exercise is designed

to ensure participants understand what the legislation and Code o Practice say about

care and treatment plan reviews. It would be benecial to amiliarise yoursel with

Chapter 6 o the Code o Practice.

2. Some discussion o the value o independent mental health advocates should be

encouraged. Although this training ocuses on Part 2 o the Measure, participants need

to be aware that Welsh qualiying patients who wish to become involved or more

involved in decisions made about their care or treatment are entitled to help rom a

mental health advocate (by way o representation or otherwise). It is important to

emphasise that mental health proessionals are ineligible to act as advocates.

Slides 6 7: Review o care and treatment plans

Handout 1: Regulations reviewing care and treatment plans

Handout 2: Regulations discharge

Provide handouts 1 and 2 to support the slides. Allow time to eld any questions about

the regulations.


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Rhan 3: (50 munud)

Cadeirio adolygiad urfol o gynllun goal a thriniaeth: cael y gorau or broses

Taen 3: Sut i gadeirio cyarod

Rhannwch dafen 3. Treuliwch amser yn traod hyn gydar grwp. Dylair draodaeth hon gyeirion l

at rai or materion a godwyd yn yr ymarerion blaenorol. Gallai od o udd cyfwynor syniad od rhai

denyddwyr gwasanaeth weithiaun awyddus i gadeirio neu gyd-gadeirio eu hadolygiadau eu hunain

ac y dylid cenogi hyn. Maen bosibl y bydd angen ystyried darparu cymorth a hyorddiant (os bydd

angen) i wneud hyn.

Clip DVD:

Ar l ir cyranogwyr edrych ar yr wybodaeth yn nhafen 3, chwaraewch glip DVDo ddenyddiwr gwasanaeth yn siarad am adolygiadau a chydlynydd goal yn siarad am ymarer

cadarnhaol yn y maes hwn.

Ymarer 3: Nodi sgiliau

Mae tafen 3 yn cynnig rhai syniadau ynglyn r camau y dylai cydlynwyr goal ac eraill eu cymryd i

drenu a chynnal adolygiad eeithiol o gynllun goal a thriniaeth. Maer dafen wedi ei rhannun dair

colon. (Camau, Cynnwys a Sgiliau) a sylwch od y golon sgiliau yn wag. Tasg y grwp yw ystyried pa

sgiliau sydd eu hangen i gwblhaur camau a sicrhaur cynnwys yn y colonau eraill.

Rhannwch y cyranogwyr yn grwpiau bach a goynnwch iddynt ynd trwyr tabl ac ysgriennu eu

syniadau yng ngholon 3 Sgiliau. Gallai heyd od yn uddiol ir grwp ystyried pa adnoddau bydd eu

hangen arnynt i wneud y broses adolygu urol hon.

Dewch r cyranogwyr at ei gilydd yn grwp mawr wedyn a goynnwch am adborth llawn.

Nodiadau ir hwylusydd: Dylid herior grwpiau i ystyried yr ystod lawn o sgiliau sydd eu hangen

i sicrhau adolygiadau pwrpasol o gynlluniau goal a thriniaeth. Eallai bydd angen ir cadeirydd

reoli gweithwyr proesiynol pwerus syn awyddus i ddylanwadu ar yr adolygiad. Mae angen sgiliau

rhyngbersonol a sgiliau trenu sylweddol, elly ceisiwch sicrhau bod y grwpiaun rhoi ystyriaeth

ir rhain.

Casgliad: Maer gweithgareddau yn yr uned hon wedi canolbwyntio ar sgiliau ymarerol trenu a

chynnal adolygiad urol o gynlluniau goal a thriniaeth. Maer uned wedi ceisio dangos y goynion

heriol syn ein hwynebu wrth geisio sicrhau canlyniadau llwyddiannus yn sgil adolygiadau urol.

Heyd,dylair uned helpu i ddangos y pri sgiliau cyathrebu syn oynnol a sut i greu perthynas syn

cenogi gwellhad yr unigolyn wrth adolygu cynllun goal a thriniaeth.

Cwestiynau Beth ydych chin mynd iw wneud nawr?

Maer rhan 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. Mae hyn yn golygu cydnabod

yr hyn maent wedi ei ddysgu, yn eu barn nhw, a pha gamau y gallant eu cymryd yn syth i newid eu

hymarer er gwell. Goynnwch ir gr wp am o leia un pwynt dysgu pwysig a beth maent yn bwriadu ei

newid o ganlyniad iddo.

DVD


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Section 3 (50 mins)

Chairing a ormal care and treatment plan review: getting the most out o the process

Hand out 3: How to chair a meeting

Distribute handout 3. Spend time discussing this with the group. This discussion should relate back

to some o the issues raised in the previous exercises. It can be worthwhile introducing the idea

that some service users might want to chair or co-chair their own reviews and that this should be

supported. Consideration may need to be given to providing the support and training (i required) to

do this.

DVD Clip:

Ater the participants have looked at the inormation on handout 3 play a DVD clip o a service usertalking about reviews and a care coordinator talking about positive practice in this area.

Exercise 3: Skills identication

Handout 3 provides some ideas on the actions required by care coordinators and others in

organising and conducting a productive care and treatment plan review. The handout is split into

three columns (Actions, Content and Skills) and note that the skills column is empty. The task o

the group is to identiy the skills required in completing the actions and delivering the content in the

preceding columns?

Split the participants into small groups and ask them to go through the table and add their thoughts

into column 3 Skills. It may also be helpul or participants to consider resources they will require

to deliver this ormal review process.

Bring the participants back into a large group or ull eedback.

Notes or acilitator: The groups should be challenged to think about the ull range o skills required

to deliver purposeul reviews or care and treatment planning. The chair person may need to

manage powerul proessionals who may wish to dominate proceedings. There are considerable

interpersonal and organisational skills required, so please ensure the groups examine these.

Conclusion: This unit has concentrated activity on the practical skills o organising and conducting a

ormal care and treatment plan review. The unit has sought to illustrate the challenging demands in

achieving successul outcomes rom ormal reviews. Additionally, the unit should help illustrate the

key skills o communication and relationships built on a recovery approach in care and treatment

plan review.

Questions What are you going to do 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 their practice. Ask the

participants or at least one signicant learning point and what they plan to alter as a result.

DVD


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16


Negeseuon a ddysgwyd:

mae materion pwysig iw hystyried wrth geisio dod o hyd ir dull gorau o drenu adolygiad o

gynllun goal a thriniaeth;

mae paratoi a threnu priodol yn helpu i sicrhau bod y rhai syn ymwneud r cynllun goal a

thriniaeth yn gallu cyrannu at yr adolygiad;

bydd angen sgiliau cadeirio cadarn ar y cydlynydd goal, yn arbennig i draod a chytuno ar

ganlyniadau ar camau angenrheidiol sydd iw cyfawni;

dylid cydbwyso hyn ag annog denyddwyr gwasanaeth i berchnogi a chyrannu at eu cynllun

goal a thriniaeth eu hunain a chymryd rhan weithgar yn yr adolygiad.


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Take home messages:

there are signicant issues in identiying the best approach to organising a review o a care

and treatment plan;

careul preparation and organisation pays dividends in helping to ensure that those involved

in the care and treatment plan can contribute to the review;

the care coordinator will require robust chairing skills particularly to negotiate and agree

outcomes and the planned actions required to help achieve them;

balance this with encouraging the service user to contribute and own their care and

treatment plan and to being an active participant in the reviews.


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Taen 1: Y Rheoliadau Adolygu a diwygio cynlluniau goal a thriniaeth

Maer Rheoliadau yn datgan bod yn:

(1) Rhaid i gydlynydd goal adolygu, ac os oes angen, addasu cynllun goal a thriniaeth os

(a) Oes cynod o 12 mis calendar wedi mynd heibio ers paratoir cynllun yn y lle cynta neu

ers adolygiad diwetha y cynllun;

(b) Os ywr cla perthnasol yn gwneud cais i adolygu ei gynllun e neu hi cyn ir cynod 12

mis calendr ynd heibio; neu

(c) Os yw darparwr gwasanaethau iechyd meddwl perthnasol yn gwneud cais i adolygur

cynllun perthnasol.

(2) Ond nid oes angen i gydlynydd goal adolygu cynllun goal a thriniaeth ar gais y claperthnasol os, yn ei arn e neu hi:

(a) ywr cais am adolygiad yn un di-sail a wnaed mewn ysbryd blin neu ar chwarae bach;

neu

(b) na u unrhyw newid sylweddol mewn amgylchiadau ers yr adolygiad diwetha syn

teilyngu cynnal adolygiad arall cyn ir cynod 12 mis ym mharagra 1 (a) ynd heibio.

(3) Cai cynllun goal a thriniaeth ei adolygu neu ei addasu o unrhyw bryd gyda chaniatd y

cydlynydd goal.

(4) Ar wahn ir goyniad i gynnal adolygiad ac addasur cynllun el a nodir dan bwynt (1)(a)

uchod, nid oes raid i gydlynydd goal adolygu cynllun goal a thriniaeth os mai mn

newidiadau yn unig sydd eu hangen ir cynllun, se newidiadau maen briodol eu gwneud

heb gynnal adolygiad, yn ei arn e /hi.


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Handout 1: The Regulations Review and revision o care and treatment plans

The Regulations state:

(1) A care coordinator must review, and, i necessary revise a care and treatment plan when

(a) A period o 12 calendar months has elapsed since the initial preparation or last review

o the plan;

(b) The relevant patient requests a review o his or her plan beore the 12 calendar month

period has elapsed; or

(c) A relevant mental health service provider requests a review o the relevant plan.

(2) But a care coordinator need not review a care and treatment plan at the request o therelevant patient i, in his or her opinion:

(a) The request or a review is rivolous or vexatious; or

(b) Since the last review there has been no major change o circumstances which merit the

holding o another review beore the 12 month period in paragraph 1 (a) has elapsed.

(3) A care and treatment plan may be reviewed or revised at any time with the agreement o

the care coordinator.

(4) With the exception o the requirement to have a review and, i necessary, a revision o thecare and treatment plan as provided in paragraph (1)(a), a care coordinator need not review

a care and treatment plan under any provision o this regulation i minor amendments are

required to the plan which, in the care coordinators opinion, it is appropriate to make with

out a review being carried out.


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Taen 2: Gwybodaeth i bobl nad ydynt bellach yn gleion perthnasol

10. (1) Rhaid ir wybodaeth a ganlyn gael ei darparu mewn ysgrien i unigolyn wrth ddod

i achos i ben gyda gwasanaethau iechyd meddwl eilaidd

(a) y rheswm dros ryddhaur unigolyn hwnnw o wasanaethau iechyd meddwl

eilaidd; a

(b) y camau a all gael eu cymryd, a chan bwy, os ywr unigolyn hwnnw or arn bod angen

rhagor o gymorth a chyngor mewn perthynas i iechyd meddwl yn sgil dod i achos

i ben.

(2) Yn ychwanegol at yr wybodaeth ym mharagra (1), rhaid i oedolyn gael gwybodaeth mewn

ysgrien am ei hawl i gael asesiad o dan Ran 3 (asesiadau ar ddenyddwyr blaenorol o

wasanaethau iechyd meddwl eilaidd) or Mesur.

(3) Yn ychwanegol at yr wybodaeth ym mharagra (1), pan o achos unigolyn wedi dod i ben

gyda gwasanaethau iechyd meddwl eilaidd el plentyn ond ei od yn dod yn oedolyn yn

ystod y cynod rhyddhau perthnasol rhaid ir wybodaeth a ganlyn gael ei darparu mewn

ysgrien

(a) gwybodaeth am ei hawl wrth gyrraedd deunaw oed i gael asesiad o dan Ran 3

or Mesur;

(b) esboniad ar sut mae ei ben-blwydd yn ddeunaw oed yn berthnasol at ddibenion hawl

i gael asesiad or ath; ac

(c) aint or cynod rhyddhau perthnasol sydd heb ddirwyn i ben ar ben-blwydd yr

unigolyn yn ddeunaw oed.

(4) Caniateir i wybodaeth heblawr hyn y maen rhaid ei ddarparu yn unol pharagraau (1), (2)

a (3) gael ei darparu ir unigolyn wrth ddod i achos i ben gyda gwasanaethau iechyd

meddwl eilaidd

(5) Pan o Bwrdd Iechyd Lleol yn dod ag achos unigolyn i ben gyda gwasanaethau iechyd

meddwl eilaidd, rhaid ir Bwrdd ddarparu gwybodaeth ir unigolyn hwnnw yn unol

pharagraau (1), (2), (3) a (4) os nad oes awdurdod lleol, ar y dyddiad dod r achos i ben,

yn darparu gwasanaeth iechyd meddwl eilaidd ir unigolyn hwnnw.

(6) Pan o awdurdod lleol yn dod ag achos unigolyn i ben gyda gwasanaethau iechyd meddwl

eilaidd, rhaid ir awdurdod ddarparu gwybodaeth ir unigolyn hwnnw yn unol pharagraau

(1), (2), (3) a (4) os nad oes Bwrdd Iechyd Lleol, ar y dyddiad dod r achos i ben,

yn darparu gwasanaeth iechyd meddwl eilaidd ir unigolyn hwnnw.


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Handout 2: Inormation or persons ceasing to be relevant patients

10. (1) The ollowing inormation must be provided in writing to an individual on his or her

discharge rom secondary mental health services

(a) the reason or that individuals discharge rom secondary mental health services;

and

b) the action which may be taken, and by whom, i that individual considers that urther

support and advice in relation to his or her mental health is required

ollowing discharge.

(2) In addition to the inormation in paragraph (1), an adult must be provided with inormation

in writing regarding his or her entitlement to assessment under Part 3 (assessments o

ormer users o secondary mental health services) o the Measure.

(3) In addition to the inormation in paragraph (1), where an individual is discharged rom

secondary mental health services as a child but becomes an adult during the relevant

discharge period the ollowing inormation must be provided in writing

(a) inormation on his or her entitlement on reaching the age o eighteen years to

assessment under Part 3 o the Measure;

(b) an explanation o how his or her eighteenth birthday is relevant or the purposes

entitlement to such an assessment; and

(c) the length o the relevant discharge period which is unexpired at the individuals

eighteenth birthday.

(4) Inormation other than that which must be provided in accordance with paragraphs (1), (2)

and (3) may be given to the individual on his or her discharge rom secondary mental

health services.

(5) Where a Local Health Board discharges an individual rom secondary mental health

services, the Board must provide that individual with inormation in accordance with

paragraphs (1), (2), (3) and (4) i, at the date o discharge, no local authority is providing

that individual with a secondary mental health service.

(6) Where a local authority discharges an individual rom secondary mental health services,the authority must provide that individual with inormation in accordance with paragraphs

(1), (2), (3) and (4) i, at the date o discharge, no Local Health Board is providing that

individual with a secondary mental health service.


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Taen 3: Cadeirio adolygiad urol o gynllun goal a thriniaeth: cael y gorau or broses.

Camau Cynnwys Sgiliau

Cyn y cyarod:

Os na wnaed

hynnyn

faenorol, cytunwch

ar y lleoliad ac

amser dechrau a

goren y cyarod

Sicrhau bod

ylleoliadynhwylusahawdd

iw gyrraedd.

bodycyfarfodyncaeleigynnalynbrydlongan

od hynnyn sicrhau presenoldeb y denyddiwr

gwasanaeth ar rhai syn ymwneud r cynllun

goal a thriniaeth.

Bydd amseroedd dechrau a goren yn sicrhau

bod amser digonol yn cael ei ganiatu i gynnal y

cyarod heb deimlo bod unrhyw rys.

Trenwch gyarod

y denyddiwr

gwasanaeth i

draod y cyarod,

er mwyn nodi

canlyniadau a

sicrhawyd a chael

barn am

ganlyniadau neuweithredoedd

pellach

A oes gan y denyddiwr gwasanaeth unrhyw arn o

sabwynt:

sut maer cyarod yn cael ei gynnal

pwy syn cael ei wahodd

a ydden nhwn ho dod rhywun gyda

hwy iw cenogi.

Os ywr cla yn gymwys i gael eiriolaeth iechyd

meddwl darparwch yr wybodaeth ynglyn hyn.

Dylid diweddaru asesiadau perthnasol

Gwnewch yn siwr bod gan y denyddiwr

gwasanaeth gopi or cynllun goal a thriniaeth

Ceisiwch gael barn y denyddiwr gwasanaeth, (ac

os ywn briodol) y goalwr ar:

gynnydd tuag at gyfawni canlyniadau y

cytunwyd arnynt yn faenorol

a yw camau y cytunwyd arnynt yn faenorol

wedi helpu i sicrhau canlyniadau ai peidio

unrhyw newidiadau syn angenrheidiol, yn eu

barn hwy, i sicrhau camau a chanlyniadau.

Os cynhelir y cyarod yn Gymraeg, Saesneg neu

iaith arall maen debyg y bydd angen cyeithur

cyarod ir rhai nad ydynt yn siarad yr iaith hon.

Mae hyn yn golygu eallai y bydd angen mwy o

amser ar gyer y cyarod.


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Handout 3: Chairing a ormal care and treatment plan review: getting the most out o the process

Actions Content Skills

Beore the meeting:

I not previously

undertaken agree

the venue and a

start and nishing

time or the

meeting

Ensure

venueisaccessible

thatthemeetingisheldatatimetoensure

attendance o service user and those involved

in care and treatment

Start and nish times will ensure that adequate

time is allowed to conduct the meeting without it

eeling hurried.

Meet with the

service user to

discuss the

meeting, to

identiy

achievement o

outcomes and to

obtain views on

urther outcomes

or actions

Has the service user any views with regard to:

how the meeting is conducted

who is invited

whether they would like to bring someone to

support them

I patient qualies or independent mental health

advocacy provide the inormation on this.Update relevant assessments

Ensure service user still has a copy o the care

and treatment plan

Obtain service user (and where appropriate)

carer views on:

progress towards achievement o previously

agreed outcomes

whether previously agreed actions have

supported achievement o outcomes

any changes they think are necessary to

actions and outcomes.

I the meeting is to be conducted in Welsh,

English or another language it is likely that the

meeting will need to be translated or those who

do not speak this language. This may also mean

that a longer time needs to be allowed or the

meeting.


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Anonwch

wahoddiadau

Gwnewch yn siwr bod y rhai a wahoddir yn cael eu

hatgoa i ddod ir cyarod

Gwahodd: gallwch wahodd rhai i gyfwyno

adroddiad ar laar (ar y n) neu gytuno i dderbyn

adroddiadau ysgrienedig. Maer rhain ynarbennig o werthawr os nad ywr person yn

galludod ir cyarod. Dylid conodi adborth llaar

(e.e. dros y n) yn ysgrienedig ai wirio gydar

person.

Maen ddenyddiol gwahodd gweinyddwr ir

cyarod i gymryd conodion.

O leia un wythnos

cyn y cyarod

Gwnewch yn

siwr bod unrhyw

asesiadaun cael

eu diweddaru

ac yn ddelrydol

gwnewch yn siwr

bod y rhain ar gael

ir parton

perthnasol

Cysylltwch agunrhyw rai a

wahoddwyd sydd

heb ymateb na

darparu adroddiad

Paratowch y

rhaglenGweler taen 4

Yn union cyn y

cyarod

Gwnewch yn siwr

bod yr ystaell

wedi ei pharatoi

Trenwch sut i eistedd mewn cylch el arer.

Gallech ddarparu dwr neu luniaeth.

Gwnewch yn siwr bod copau or rhaglen, y

cynllun goal a thriniaeth ac unrhyw asesiadau

neu adroddiadau ysgrienedig ar gael i bawb syn

bresennol.


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Send outinvitations

Ensure that those invited are prompted to

conrm attendance

Invitation: can invite verbally (telephone) or agree

to receive written reports. These are particularly

valuable i the person is unable to attend.Verbal eedback (e.g. via telephone) should be

recorded in writing and checked with the person.

It is useul to invite an administrator to the

meeting in order to record minutes.

At least one week

beore meeting

Ensure that anyassessments are

updated and

ideally ensure

these are available

to relevant parties

Contact any

invitees that have

not responded or

provided reports

Prepare agenda See handout 4

Immediately prior

to meeting

Ensure that the

environment is

prepared

Arrange seating usually in a circle.

You may wish to provide water or rereshments.

Ensure there are copies o the agenda, care and

treatment plan and any assessments or writtenreports available to all those attending.


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Yn ystod y cyarod

Gwnewch yn

siwr od pawb yn

bresennol

Ceisiwch ddechrau

a goren ar amser

Cyfwynwch bwrpas

y cyarod

Gwnewch yn siwr

od gan bawb

gopau o bapurau

perthnasol

Cyfwynwch

aelodau ac unrhyw

ymddiheuriadau

Cyfwynwch bob

eitem yn unol r

rhaglen.

Caniatewch amser

iw traod

Gwnewch yn siwr

od pob barn yncael ei chlywed

Rhowch adborth

ac arweiniad ir

unigolion os ydynt

yn crwydro oddi

wrth y rhaglen

Crynhowch y

draodaeth

Gwnewch ynsiwr od y pri

bwyntiaun cael eu

conodi

Os oes angen,

trenwch od

cymorth seicolegol

ar gael

Nid yw gadael denyddwyr gwasanaeth neu

oalwyr y tu allan i gyarod tra bod eraill yn eu

traod o unrhyw udd. Yr unig gyawnhad dros

wneud hyn yw os ywr denyddiwr gwasanaeth

wedi dweud yn benodol nad ywn dymuno bod yn

bresennol.

Dyletswydd y cadeirydd yw gorodi pawb i gadw atreolaur cyarod, se:

Sicrhaubodpoblynsiaradhebinebdorriar

eu traws.

Canolbwyntioarydasgapheidiochrwydro.

Hwylusorbrosesowneudpenderfyniadau.

Maer cadeirydd yn gallu ymyrryd os ywr

cyranogwyr yn crwydro neun siarad ar draws ei

gilydd.

Dylair cadeirydd hwyluso traodaeth ond ni

ddylai ei reoli. Maen bwysig eu bod yn negydu

ac yn sicrhau bod pobl yn cael mynegi eu barn

yn hytrach na cheisio dylanwadu ar y rhai syn

anghytuno hwy.

Mae cyarodydd yn gallu bod yn straen i

ddenyddwyr gwasanaeth, goalwyr a rhai

gweithwyr proesiynol. Maen bwysig sicrhau bod

y cyarod yn ddiogel a chyeillgar.


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During the meeting

Ensure that

everyone is

present

Aim to start and

nish on time

Introduce purpose

o meeting

Ensure everyone

has copies o

relevant papers

Introducemembers and give

any apologies

Introduce each

item in line with

the agenda.

Allow time or

discussion

Ensure all views

are heard

Give eedback and

prompts i

individuals stray

rom the agenda

Summarise

discussion

Ensure that

key points are

documented

I necessary

provide emotional

support

Leaving service users or carers outside a

meeting while they are discussed can be

unhelpul. This can only be justied where the

service user has expressly stated that they do

not want to be present.

It is the chairs role to enorce meeting rules

these are:

Ensuring people speak without interruption.

Staying on task.

Facilitating decision making.

The chair can intervene i participants digress or

talk over each other.

The chairperson should acilitate but not

dominate discussion. It is important that they

negotiate and ensure views are heard rather than

trying to win over those they disagree with.

Service users, carers and some proessionals

can nd meetings stressul. It is important to

keep the meeting sae and riendly.


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Ar ddiwedd y

cyarod

Dylid diolch i

unigolion am odyn bresennol

Os ywn briodol

cytunwch ar amser

a dyddiad y

cyarod nesa

Nodwch unrhyw

gamau y byddwch

chi neu eraill

yn eu cymryd ar

l y cyarod i

ddiweddarur

cynllun goal a

thriniaeth

Byddai o udd cytuno ar ddyddiad a lleoliad tra

bod pawb yn bresennol mae hyn yn sicrhau bod

yr amser ar lleoliad yn hwylus i bawb ac maen

sbario gorod trenu a chytuno ar ddyddiad yn

ddiweddarach dros y n/trwy lythyr.

Ar l y cyarod

Dylid diweddarur

cynllun goal a

thriniaeth

Dylid ysgriennur

conodion

Rhannwch y

cynllun goal a

thriniaeth

diwygiedig ar

conodion

Gwnewch yn siwr

od y denyddiwrgwasanaeth yn

gallu arwyddor

cynllun goal

a thriniaeth a

chonodi unrhyw

arn

Byddai o udd diweddarur cynllun ac ysgriennu

conodion yn uan ar l y cyarod.

Dylid gwneud hyn tra ei od yn dal yn yw yn y co


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At end o meeting

Thank individuals

or attending

I appropriate

agree time and

date o next review

State any actions

you or others will

be taking ater the

meeting in relation

to updating the

care and treatmentplan

It is useul to agree a date and venue whilst

people are present this ensures it is mutually

convenient and saves time trying to agree a date

by telephone/letter later

At end o meeting

Update care and

treatment plan

Document minutes

o meetingDistribute

amended care and

treatment plan and

minutes

Ensure service

user is able to sign

care and treatment

plan and record

any views

It is useul to update the plan and record any

minutes soon ater the meeting

This is whilst it is resh in peoples minds


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Taen 4: Ymarer cadarnhaol wrth adolygu cynlluniau goal a thriniaeth

Enghrait o raglen adolygu cynllun goal a thriniaeth

Manylion Denyddiwr Gwasanaeth:

Cyarod iw gynnal: 10.30 hanner dydd, 27 Mehefn

Eitem Unigolyn cyriol Amser a ganiateir

1. Cywyniadau

Cyfwyniad y Cadeirydd

Ymddiheuriadau

Cyfwyniadau

Cydlynydd goal a

denyddiwr

gwasanaethau

5 munud

2. Asesiadau diweddara

i) asesiad anghenion

ii) asesiad risg

Cydlynydd goal a

denyddiwr

gwasanaethau

10 munud

3. Adolygur cynllun goal a thriniaeth

i) gwaith a galwedigaeth

Gweithiwr cymorth

cymunedol10 munud

ii) addysg a hyorddiantTherapydd

galwedigaethol

10 munud

iii)

- triniaeth eddygol a thriniaeth arall

- seicoleg

Seiciatrydd

Ymgynghorol

Seicolegydd Clinigol

Ymgynghorol

10 munud

10 munud

iv) perthnasoedd goalu a rhianta

Cydlynydd goal a

denyddiwr

gwasanaethau

5 munud

v) denyddio alcohol

Cydlynydd goal a

denyddiwr

gwasanaethau

10 munud

vi) treniadau wrth gen ac mewn argywng

Cydlynydd goal a

denyddiwr

gwasanaethau

5 munud

4. Unrhyw ater arall 10 munud

5. Treniadaur cyarod nesa 5 munud


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Handout 4: Positive practice in care and treatment plan reviews

Sample care & treatment plan review agenda

Service user details:

Meeting to be held: 10.30 12 noon, 27th June at

Item Person responsible Time allowed

1. Introductions

Chairpersons introduction

Apologies

Introductions

Care coordinator

and Service user5 mins

2. Updated assessments

i) needs assessment

ii) risk assessment

Care coordinator


3. Care & treatment plan review

i) work and occupation

Community support

worker10 mins

ii) education and trainingOccupational

therapist

10 mins

iii) medical and other treatment

- medication

- psychology

Consultant

Psychiatrist

Consultant Clinical

Psychologist

10 mins

10 mins

iv) parenting or other relationshipsCare coordinator


v) alcohol use Care coordinatorand Service user

10 mins

vi) crisis and contingency plansCare coordinator


4. Any other business 10 mins

5. Arrangements or next meeting 5 mins

core unit 5: reviewing care and treatment plans

Documents