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7/27/2019 Core Unit 5: Reviewing care and treatment plans
1/31
Uned Graidd 5: Adolygu cynlluniau gofal
a thriniaeth
Core Unit 5: Reviewing care and
treatment plans
7/27/2019 Core Unit 5: Reviewing care and treatment plans
2/31
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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Core Unit 5: Reviewing care and treatment plans
Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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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Core Unit 5: Reviewing care and treatment plans
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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Uned Graidd 5: Adolygu cynlluniau gofal a thriniaeth
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
and Service user10 mins
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
and Service user5 mins
v) alcohol use Care coordinatorand Service user
10 mins
vi) crisis and contingency plansCare coordinator
and Service user5 mins
4. Any other business 10 mins
5. Arrangements or next meeting 5 mins