| |  | | | | Care Planning and Discharge | | | | | | | | | Care Planning
All our services follow the principles of Social Role Valorisation and positive behavioural support models. Each patient is allocated a Named Nurse and a CPA Keyworker who is responsible for co-ordinating the care plan for the patient. A preliminary planning meeting with clinical team members takes place every four months. Goals and achievements are discussed as well as future plans. The Risk Assessment is reviewed and revised at the same meeting.
A s117/CPA meeting (Clinical Review) takes place every 4 - 6 months where the patient, carer/family (if appropriate), purchaser, referrer and Social Services Keyworker are invited to attend.
Discharge Planning
Discharge planning begins before admission with the identification of the CPA Keyworker from Statutory Agencies. CPA Meetings (Clinical Reviews) will monitor progress and decide on a programme for discharge - this should be a joint decision between the clinical team and the purchasers/referrers and Social Services. A request is made for a joint assessment by Health Authority and Local Authorities to co-ordinate CPA, Care management and Section 117 into one process. Patients, relatives/carers (if appropriate) are actively involved throughout the planning process. We will plan appropriate visits and assess aftercare resources that are required.
Patients will be supported through the discharge process - this may include preparatory visits to the future placement and liaison between staff from both units. A final Section 117/CPA meeting is organised to complete the following:
 St Andrew's Discharge Plan including CPA and Care Management assessment.
Risk assessment.
Funding agreements.
Formalisation of statutory responsibilities.
Nominated RMO and CPA Keyworker.
Agree transition plan.
Appropriate follow up arrangements are agreed - our usual standard is a visit by Social Worker and Keyworker after six weeks.
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