core unit 4: assessment and outcome planning

7/27/2019 Core Unit 4: Assessment and outcome planning

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Uned Graidd 4: Asesu a chynllunio gofal

Core Unit 4: Assessment and

outcome planning


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Digital ISBN 978 0 7504 7880 9

Hawlfraint y Goron/Crown copyright 2012

WG15036

2

Ysgriennwch eich nodiadau yma:


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Core Unit 4: Assessment and outcome planning

Write your notes here:


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Uned Graidd 4: Asesu a chynllunio goal

Oriau hyorddi yn gysylltiedig r uned hon = 3 awr

Nodaur uned

Nod yr uned astudio hon yw datblygu dealltwriaeth o asesu a chynllunio goal a thriniaeth ymmaes iechyd meddwl. Bydd ymarerwyr yn ystyried dulliau unigol o asesu a chynllunio goal a

thriniaeth syn canolbwyntio ar gyawnir canlyniadau goal y cytunwyd arnynt.

Rhoddir pwyslais ar yr angen i gynnwys denyddwyr gwasanaeth a goalwyr yn y broses hon.

Pri negeseuon i hwyluswyr

Yn yr uned hon dylair hwylusydd bwysleisio:

Nad yw Rhan 2 o Fesur Iechyd Meddwl (Cymru) 2010 yn pennu proses asesu benodol.

Dylid asesu mewn ordd syn helpu i gynllunio goal a thriniaeth yn holistaidd ar draws oleia un or wyth maes ym mywyd person.

Mae asesiad yn gyuniad o anghenion, cryderau a risgiau yn y meysydd uchod.

Dylair cynllun goal a thriniaeath adelwyrchu egwyddorion craidd y Cod Ymarer (2012).

Cywyniad

Pwrpas yr uned astudio hon yw edrych yn eirniadol ar yr ymarer presennol o sabwynt asesu

a chynllunio goal, ai gymhwyso i Fesur Iechyd Meddwl (Cymru) 2010. Mae cynllunio goal a

thriniaeth or radd aena, syn seiliedig ar gyranogiad ystyrlon y denyddiwr gwasanaeth ac

eraill, yn ganolog er mwyn sicrhau ymarer rhagorol. Maer uned astudio hon yn rhoi cye igyranogwyr ystyried eu hymarer presennol ac edrych pa mor gyson yw hynny goynion Mesur

Iechyd Meddwl (Cymru) 2010.

Canlyniadau dysgu

Ar l cwblhaur uned hon bydd y cyranogwyr yn:

1deall pwysigrwydd asesu cynhwysawr syn canolbwyntio ar yr unigolyn yn y broses o gynllunio goal

a thriniaeth

2 deall cyd-destun diwylliannol y broses asesu a chynllunio goal a thriniaeth

3dangos y gallu i weithio ar y cyd ag eraill er mwyn llunio cynlluniau goal a thriniaeth

ystyrlon

4 dangos y gallu i lunio canlyniadau priodol mewn cynlluniau goal a thriniaeth

5 nodi pri agweddau asesu risg a rheoli risg mewn cynlluniau goal a thriniaeth


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Training hours associated with this unit = 3 hours

Aims o the unit

The aim o the study unit is to develop an understanding o assessment and care and treatmentplanning within mental health. Participants will consider individualised approaches to assessment

and care and treatment planning that ocus on the delivery o agreed outcomes o care.

Emphasis will be placed on the need or the involvement o service users and carers in

this process.

Key messages or acilitators

In this unit, the acilitator should emphasise:

Part 2 o the Mental Health (Wales) Measure 2010 does not prescribe a particular

assessment process.

Sssessment should be collated in such a way as to aid the delivery o holistic care and

treatment planning across at least one o the eight areas in a persons lie.

Assessment is a combination o needs, strengths and risks in the above areas.

The care and treatment plan should reect the guiding principles o the Code o

Practice (2012).

Introduction

This unit o study is aimed at a critical reection on current assessment and planning practice

and its application to the Mental Health (Wales) Measure 2010. The issue o high quality care

and treatment planning, based on meaningul participation o service users and others iscentral to the pursuit o excellent practice. This unit o study provides participants with an

opportunity to reect on their current practice and explore how consistent it is with the

requirements o the Mental Health (Wales) Measure 2010.

Learning outcomes

On completing the unit participants will:

1

understand o the signifcance o comprehensive, person centred assessment in the care and

treatment planning process

2 understand the cultural context o assessment and care and treatment planning

3demonstrate the ability to work collaboratively with others to construct meaningul care

and treatment plans

4 demonstrate the ability to construct appropriate outcomes in care and treatment plans

5identiy the key aspects o risk assessment and risk management within care andtreatment plans


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Amser

(munudau)Focws

Canlyniadau

dysgu

cysylltiedig

Dull dysgu/

adnoddauCynnwys

10 munud Cywyniad - Traodaeth grwp Sleidiau 1 3

15 munudRhan 1:

Adolygur asesiad1

Sleid 4 5

Clip DVD

40 munudAsesu sgiliau

allweddol1, 2 a 3

Ymarer 1

Traodaeth grwp

Siart troi

Taen1 senariospersonol

Sleid 6

30 munud

Rhan 2:

Y cynllun goal athriniaeth integreiddio

diogelwch a risg.

2, 3 a 5 Ymarer 2Traodaeth grwp

Taen 2

Sleid 7

Clip DVD

60 munudRhan 3:

Cynllunio canlyniadau3,4 a 5

Ymarer 3

Tasg ysgrienedig a

thraodaeth grwp

Sleid 8

Taen 3

Taen 4

20 munud Crynhoi -

Traodaeth grwp,adborth anegeseuon addysgwyd

Cynllun y wers

Adnoddau dysgu angenrheidiol:

lle gwag a chyeoedd i wneud gwaith grwp a myyrio;

adnoddau ar gyer cywyniadau PowerPoint;

adnoddau i chwarae clipiau DVD syn dangos pri ganlyniadau dysgu;

siart ip a phinnau.

Cynllun gwers manwl

Sleidiau 1 3:

Cywynwch yr uned ddysgu, gan ddenyddior wybodaeth ar y sleidiau. Rhowch gye i gyranogwyr

oyn unrhyw gwestiynau am yr uned.


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Time Focus

Related

learning

outcome

Teaching method/

resourcesContent

10 mins Introduction - Group discussion Slides 1 3

15 minsSection 1:

Reviewing assessment1

Slides 4 5

DVD Clip

40 mins Reviewing assessment 1, 2 & 3

Exercise 1 Group

discussion

ip chart

Handout 1 personalscenarios

Slide 6

30 mins

Section 2:

The care and treatmentplan saety and risk

integration

2, 3 & 5 Exercise 2Group discussion

Handout 2

Slide 7

DVD Clip

60 minsSection 3:

Outcome planning3,4 & 5

Exercise 3

Writing task and

group discussion

Slide 8

Handout 3

Handout 4

20 mins Conclusion -Group discussioneedback and takehome messages

Lesson plan

Detailed lesson plan

Slides 1 3:

Provide an introduction to the unit o learning, using the inormation on the slides.

Give participants the opportunity to ask any questions about the unit.

Required teaching resources:

space and opportunities or group work;

resources or PowerPoint presentations;

resources to play DVD clips illustrative o key learning outcomes;

ip chart and pens.


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Rhan 1: (60 munud)

Adolygur asesiad

Maer rhan hon or uned yn rhoi trosolwg byr o asesu mewn iechyd meddwl gan ganolbwyntio

ar asesiadau yr holl dm (hynny yw, y tm amlasiantaeth/amlddisgyblaethol) syn cynnwysdenyddwyr gwasanaeth a goalwyr el gwir bartneriaid yn y broses. Bydd yn rhoi sylw i

bwysigrwydd cydweithio amlddisgyblaethol rhwng un seydliad ar llall, ac yn edrych ar

broses asesu syn cynnwys yr holl anghenion, cryderau, gwendidau a gobeithion sydd gan

ddenyddwyr gwasanaeth, eu teulu au goalwr(wyr). Bydd y rhan hon yn adolygur prosesau

asesu cyn ystyried sut y bydd hynny yn dylanwadu ar gynllunio goal a thriniaeth.

Sleid 4: Asesu themu allweddol

Dylai pob cynllun goal a thriniaeth adlewyrchur wybodaeth a gasglwyd trwy wneud asesiad

cyredinol eang or denyddiwr gwasanaeth ac o unrhyw asesiadau manwl a phenodol eraill

(e.e. asesiadau risg) a gwblhawyd.

Maer egwyddorion a restrir isod yn bwysig os ydym am lunio asesiad cynhwysawr syn cenogi

gwellhad unigolyn ac yn datblygu sgiliau hunan reoli. Maer egwyddorion hyn yn

berthnasol i bob grwp o ddenyddwyr gwasanaeth, waeth beth o eu hoed. Gallai od o udd

i gyranogwyr ystyried yr egwyddorion hyn wrth gynllunio goal a thriniaeth i bobl hyn, pobl ag

Anableddau Dysgu a phlant a phobl ianc.

Cymryd rhan weithgar

Mae a wnelo hyn r graddau y maer denyddiwr gwasanaeth ar goalwr(wyr) yn teimlo eu bodyn rhan or broses asesu; i ba raddau y gwrandewir arnynt a aint o ddewis sydd ganddynt yn y

broses.

Dull amlasiantaeth

Mae dull amlasiantaeth yn dod gwahanol bersbecti a sgiliau ir broses asesu (yn cynnwys

y sector gwiroddol, os ywn briodol). Mae cynnwys y gwahanol sabwyntiau hynny yn helpu i

sicrhau proses gynhwysawr a chydlynol wrth gynllunio goal a thriniaeth. Wrth ystyried pobl

ianc, gallai rl y gwasanaethau addysg od yn bwysig. Maen bosibl y bydd angen cymorth ar

eraill gan y gwasanaethau praw, gwasanaethau cymdeithasol a nier o ddarparwyr gwiroddol

neu 3ydd sector.

Canolbwyntio ar gryderau a dymuniadau yn ogystal heriau ac anghenion

Mae canolbwyntio ar gryderau, strategaethau ymdopi, gobeithion a dyheadaun hanodol wrth

hybu gwellhad a helpu pobl i gymryd rheolaeth gynyddol ou bywydau eu hunain.

Mae cynnwys yr agweddau hyn yn arwain at asesiad cytbwys syn cydnabod potensial ar gallu

i sicrhau gwellhad. Mae pobl yn wy tebygol o gymryd rhan mewn cynllun goal a thriniaeth syn

cydnabod eu nodau eu hunain yn hytrach na nodaur gweithwyr proesiynol. Maer Cod Ymarer

yn cyeirion benodol at weithredun gadarnhaol ac ar sail cryderau, gan gymryd camau

graddol i gyawni nodau tymor hir (Rhan 1.15). Maer Cod heyd yn nodir angen i ymateb i

ddymuniadau denyddwyr gwasanaeth Cymraeg eu hiaith (Rhan 1.9 1.11).


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DVD

Clip DVD:

[Cysylltu r clip DVD syn edrych ar y broses asesu gydweithredol]

Nodiadau ir hwylusydd: Pwrpas y draodaeth hon yw cadarnhau bod asesun gam allweddol or

broses cynllunio goal a thriniaeth. Heb asesiad cynhwysawr byddai cynllun goal syn seiliedig

ar ganlyniadaun anodd ei lunio ai weithredu. Mae dull or ath yn gallu creu tensiynau rhwng

pobl (el rhieni a phobl ianc). Maen bwysig nodir posibilrwydd hwn ac ystyried rl y cydlynydd

goal i helpu i negydu llwybr syn ystyried y gwahanol sabwyntiau hynny.

Sleid 5: Wyth maes ym mywydau pobl

Maer wyth maes yman deillio or Mesur ac eu cywynir yma i atgoar cyranogwyr am y dull

holistaidd ar gyer cynllunio goal a thriniaeth.

Ymarer 1: Asesu sgiliau allweddol

Taen 1: Senarios personol

Rhannwch y cyranogwyr yn grwpiau a rhowch un neu wy or senarios personol a restrir yma ibob grwp [neu, treuliwch amser yn paratoi senarios syn wy addas ich cynulleida darged].

Goynnwch ir cyranogwyr adolygur senario ac ystyried y cwestiwn canlynol (ysgriennwch eu

sylwadau ar siart ip neu wrdd gwyn).

C: Yn eich barn chi, beth ywr materion allweddol wrth asesur bobl syn cael eu disgrifo yn y

senarios hyn?

Ar l ir cyranogwyr gwblhaur dasg hon:

rhoi adborth ir pri grwp a goyn i grwpiau eraill nodi unrhyw aterion asesu eraill a allai od

heb gael sylw;

goynnwch iddynt geisio blaenoriaethu eu rhestrau asesu, el eu bod yn rhestru 3 neu 4

mater asesu o bwys or senario a;

nodi pwy yn y tm cynllunio goal a allai gwblhaur gweithdrenau asesu hyn.

Nodiadau ir hwylusydd: Pwrpas yr ymarer uchod yw annog cyranogwyr i ystyried, traod a

chytunor materion allweddol syn eeithio ar ywydaur bobl hyn a pha rai a ddylai od yn rhan

or asesiad. Dylai heyd annog cyranogwyr i ystyried Mesur Iechyd Meddwl (Cymru) 2010 a

sut iw integreiddio. Mae asesu mewn ordd holistaidd ac amlasiantaeth wedi ei draod yn

Unedau Craidd 1, 2 a 3. Felly maen bwysig bod cyranogwyr yn ystyried y themu allweddol

hyn. Mae hynny yn cael ei bwysleisio heyd yn ymarer 2 isod.


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DVD DVD clip:

(Link to DVD clip exploring the collaborative assessment process)

Notes or acilitator: The purpose o this discussion is to reinorce to participants that

assessment is a critical stage in the care and treatment planning process. Without a

comprehensive assessment an outcome based care plan will be difcult to construct and

difcult to implement. Such an approach can generate tensions between people (such as

parents and young people). It is important to identiy this potential and to consider the role o

the care coordinator in helping negotiate a path through these dierent views.

Slide 5: Eight areas in peoples lives

These eight areas are derived rom the Measure and are presented here as a reminder or

participants about holistic approach to care and treatment planning.

Exercise 1: Assessment key skills

Handout 1: Personal scenarios

Organise the participants into groups and provide them with either one or more o the

personal scenarios in the handout [alternatively, spend some time in preparing scenarios

which are more suited to your target audience].

Ask the participants to review the scenario and consider the ollowing questions (write their

reections on a ip chart or whiteboard).

Question: What do you consider are the issues in the assessment o the people who are

described in these scenarios?

When participants have completed this task:

feedbacktomaingroupandaskothergroupstoidentifyanyalternativeassessmentissues

that may have been missed;

ask them to try and prioritise their assessment lists, so as to list 3 or 4 signifcant

assessment issues rom the scenarios and;

identiy who in the care planning team, might complete these assessment procedures.

Notes or acilitator: The above exercise is designed to encourage participants to consider,

discuss and agree the critical issues which might be aecting these peoples lives and

which should be part o an assessment. It is also designed to encourage reection and

integration o the Mental Health (Wales) Measure 2010. The issue o holistic and multi-

agency perspectives on assessment has been raised in Core Units 1, 2 and 3. Thereore it isimportant that participants reect on this key theme. This is also emphasised in exercise

2 below.


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Sleid 6: Asesu Cwestiynau iw goyn

Cwestiynau iw goyn:

a wnaeth y cyranogwyr ystyried un (ond yn ddelrydol mwy nag un) or 8 maes a restrir ynadran 18 (1) (a) wrth asesur senarios personol yn ymarer 1?

a wnaeth y cyranogwyr ystyried dwyieithrwydd yn eu hasesiad?

a wnaeth y cyranogwyr ystyried cryderau a gobeithion yr unigolyn?

a wnaeth y cyranogwyr nodi risgiau ir unigolyn ac eraill (yn cynnwys amddiyn oedolion syn

agored i niwed ac amddiyn plant)?

Nodiadau ir hwylusydd: Maen bwysig bod cyranogwyr yn ystyried dwyieithrwydd yn eu

hasesiad. Maen bwysig ystyried sut gellir llunio asesiad llawn a chynllun goal a thriniaethcynhwysawr ar y cyd heb roi cye ir denyddiwr gwasanaeth ynegi ei hun yn Gymraeg neun

Saesneg yn l ei h/angen.


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Slide 6: Assessment Questions to ask

Questions to ask:

did the participants consider at least one (but ideally more) o the 8 lie areas in their assessments o the personal scenarios in exercise 1?

did the participants consider the issues o bilingualism in their assessment?

did the participants consider the strengths and resiliencies available to the person?

did the participants identiy potential risks to the individual and others (including protecting

vulnerable adults and the saeguarding o children?

Notes or acilitator: It is important that participants consider bilingualism in their assessment.

It is important to reect on how a ull assessment and a comprehensive and collaborativecare and treatment plan can be constructed without the opportunity or the service user to

express themselves in their language o need.


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Rhan 2: (30 munud)

Y cynllun goal a thriniaeth

Mae templed cenedlaethol ar gyer cynlluniau goal a thriniaeth el y nodir yn y Rheoliadau

ar Cod Ymarer. Cywynwch y cynllun goal a thriniaeth hwn ac eglurwch y bydd yr ymarerioncanlynol yn gwneud denydd helaeth or templed hwnnw (taen 2).

Taen 2: Y cynllun goal a thriniaeth

Ymarer 2: Integreiddio diogelwch a risg

Gan ddenyddio copi or cynllun goal a thriniaeth, goynnwch ir cyranogwyr sut bydden nhwn

integreiddio unrhyw aterion risg/diogelwch a nodwyd or senarios iw cynllun.

Sleid 7: Cynlluniau wrth gen ac argywng

Nodiadau ir hwylusydd: Maer Cod Ymarer yn nodi; Maer gwaith o asesu risg yn rhan or cam

cynta angenrheidiol i bennun canlyniadau a llunior cynllun goal a thriniaeth, el y nodir yn

adran 18 or Mesur. (rhan 2.18 - 22.1). Maer ymarer canlynol yn dechrau trwy ystyried y dull

hwn a sut iw integreiddio yn y cynllun goal a thriniaeth.

Clip DVD:

[Cysyllu r clip DVD syn traod cymryd risgiau cadarnhaol]

DVD


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Section 2: (30 mins)

The care and treatment plan

There is a national template or care and treatment plans as identifed in the Regulations

and the Code o Practice. Introduce this care and treatment plan and explain that ollowingexercises will make extensive use o this template (handout 2).

Handout 2: The care and treatment plan

Exercise 2: Saety and risk integration

Using the copy o the care and treatment plan, asks the participants how they would integrate

any identifed risk/saety and security issues rom the scenarios completed above, intothe plan.

Slide 7: Crisis and contingency planning

Notes or acilitator: The Code o Practice states that; Assessment o risk orms a part o the

necessary frst step in setting outcomes and ormulating the care and treatment plan

(section 2.18 2.21). The ollowing exercise begins with a reection on this approach and

how it can be integrated into the care and treatment plan.

DVD Clip:

[Link to DVD clip discussing positive risk taking]

DVD


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Rhan 3: (60 munud)

Cynllunio canlyniadau

Bydd y rhan hon yn adeiladu ar y gwaith maer cyranogwyr wedi ei wneud ar asesu a chynllunio

wrth gen ac argywng. Maen canolbwyntion benodol ar sut y gellir difnio a chytunocanlyniadau gyda denyddwyr gwasanaeth a darparwyr gwasanaeth.

Clip DVD:

Cysylltu r clip DVD syn edrych ar ganlyniadau ar gyer iechyd meddwl

Ymarer 3: Rhoir canlyniadau ar waith

Sleid 8: Beth ywr canlyniadau?

Gydar ymareriad hwn, maen hollbwysig tybio bod eich asesiad wedi ei gwblhau. Goynnwch

ir cyranogwyr ddychmygu eu bod wedi casglur holl wybodaeth sydd ei hangen au bod bellach

mewn seylla i ysgriennu cynllun goal syn canolbwyntio ar ganlyniadau.

Taen 3: Gwellar ordd o ddisgrifo nodau a chanlyniadau

Denyddiwch daen 3 a goynnwch ir grwpiau adolygur senarios personol eto. Sut bydden nhw

yn cymryd y nodau iechyd meddwl a ynegir yn wael au haddasun ddisgrifadau o ganlyniadau

iechyd meddwl y byddai denyddiwr gwasanaeth yn dymuno eu cyawni.

Furfwch grwpiau bach a rhannwch syniadau ynglyn yrdd mwy ystyrlon o ynegi nodau/

canlyniadau. Goynnwch ir grwpiau am adborth a chymerwch un syniad da o gynlluniau goal

ei gilydd.

Gellir ysgriennur canlyniadau hyn wedi eu mireinio ynghyd r cynllun darparu ar y templed

cynllun goal a thriniaeth ar y tudalennau yn nhaen 2.

Nodiadau ir hwylusydd: Maen hanodol annog y cyranogwyr i ystyried y cysylltiadau rhwng yr

asesiad, nodi canlyniadau ar cynllun goal a thriniaeth. Goynnwch ir cyranogwyr ddenyddio

amcanion CAMPUS (Mae taen 4 ar gael iw helpu i wneud y dasg hon).

Crynhoi

Pwrpas yr uned hon yw rhoi trosolwg or broses asesu a chynllunio. Maen bwysig goyn

i gyranogwyr adeiladu ar yr hyn maent wedi ei ddysgu mewn unedau blaenorol a chynnig

strategaethau i oresgyn problemau a heriau posibl wrth ymarer. Rydym yn argymell eich bodyn rhoi sylw arbennig i sut mae cydlynwyr goal yn conodi cynlluniau goal a sut maen nhw yn

ystyried denyddio dulliau mesuradwy clir ar gyer canlyniadau.

DVD


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Section 3: (60 mins.)

Outcome planning

This section will build on the work the participants have done on assessment and crisis and

contingency planning. The section ocuses specifcally on how outcomes can be defned andagreed with service users and service providers.

DVD clip:

Link to a DVD clip exploring outcomes or mental health

Exercise 3: Practising outcomes

Slide 8: What are outcomes?

For this exercise it is critical to assume that your assessment is complete. Ask participants

to imagine that have collected all the inormation they need and are now in a position to write

an outcome ocussed care plan.

Handout 3: Improving the way goals and outcomes are described

You can use handout 3 to ask the groups to review the personal scenarios again. How would

they translate the poorly expressed mental health goals into more helpul descriptions o the

mental health outcomes that a service user might want and be able to, achieve.

Form small groups and share ideas together about more purposeul expressions o goals/

outcomes. Ask groups to eedback and take one good idea rom each others care plan

These newly refned outcomes and delivery plan can be written on the care and treatment plan

template on the pages in handout 2.

Notes or acilitator: It is essential to encourage the participants to reect on the linkages

between the assessment, the identifcation o outcomes and the care and treatment plan.

Ask participants to integrate all they have reviewed about assessment and planning into this

exercise. Encourage participants to make use o SMART objectives (Handout 4 is provided to

support them in this task).

Conclusion

This unit is designed to provide an overview o the assessment and planning process.

Importantly participants are asked to build on previous unit learning and propose strategies

or overcoming potential problems and challenges in their practice. We recommend payingparticular attention to how care coordinators record care plans and how they think about using

clear measurable terms or outcomes.

DVD


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Cwestiynau Beth ydych chin mynd iw wneud yn wahanol nawr?

Mae hon yn rhan bwysig or uned ac ni ddylid ei hosgoi. Bwriad yr unedau dysgu yw herio pobl i

ymrwymo i newid a gwella eu gwaith wrth gynllunio goal a thriniaeth. Felly mae rhan or

ymrwymiad hwn yn gydnabyddiaeth gyhoeddus or hyn maen nhw wedi ei ddysgu, a pha gamau y

gallant eu cymryd yn syth i newid eu hymarer er gwell. Goynnwch ir cyranogwyr am o leia unpwynt dysgu pwysig a beth maen nhw yn bwriadu ei newid o ganlyniad iddo.

Negeseuon a ddysgwyd:

mae angen amser a goal i wneud asesiad holistaidd;

mae asesu a chynllunion dibynnu ar gyraniad pob un syn rhan or broses;

rhaid i unrhyw gyraniad at gynllunio goal od yn ystyrlon a rhaid rhoi sylw ir broses negydu

a thraod;

mae angen sgiliau a goal i ysgriennu cynlluniau goal syn seiliedig ar ganlyniadau, a phan o

hyn yn cael ei wneud yn dda maen gallu helpur broses draod a negydu i hybu gwellhad;

dylai canlyniadau od yn gyraeddadwy, amserol, mesuradwy, penodol, uchelgeisiol, synhwyrol.

Darllen pellach

Boardman, J., Currie, A., Killaspy, H. & Mezey, G. (gol) (2010) Social inclusion and mental health.

Llundain: Coleg Brenhinol y Seiciatryddion.

Care Services Improvement Partnership (2008) Three keys to a shared approach in mental

health. Coventry: Seydliad Cenedlaethol Iechyd Meddwl yn Lloegr (NIMHE)

Hughes, Meic. (2009) Maen nhwn siarad amdana i Gwasg Bwythyn Caernaron.

Woods, P. & Kettyes, A. (Gol) (2009) Risk assessment and management in mental health

nursing. Rhydychen: Blackwell.


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Questions What are you going to do dierently now?

This is an important part o the unit and should not be avoided. The learning units are designed

to challenge people to make a commitment to change and improve their work or care and

treatment planning. Thereore part o this commitment is a public acknowledgement o what

they think they have learned and what immediate steps they can make to positively alter theirpractice. Ask the participants or at least one signifcant learning point and what they plan to

alter as a result.

Take home messages:

a holistic assessment takes time, care and attention;

assessment and planning relies on the contribution o all involved;

participation in care planning has to be meaningul and attention must be given to the

process o negotiation and discussion;

writing outcomes based care plans requires skill and attention, but when done well can help

on-going discussion and negotiation or recovery;

outcomes should be specifc, achievable and measurable, realistic and timely.

Further reading

Boardman, J., Currie, A., Killaspy, H. & Mezey, G. (eds) (2010) Social inclusion and mental health.

London: Royal College o Psychiatrists.

Care Services Improvement Partnership (2008) Three keys to a shared approach in mental

health. Coventry: NIMHE

Hughes, Meic. (2009) Maen nhwn siarad amdana i Gwasg Bwythyn Caernaron.

Woods, P. & Kettyes, A. (Eds) (2009) Risk assessment and management in mental health

nursing. Oxord: Blackwell.


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Ymarer 1:

Taen 1: Senario Personol Rhi 1 Joe

Mae Joe yn wr priod 42 oed gyda dau o blant yn eu harddegau. Yn ddiweddar collodd ei waith

mewn atri leol lle bun gweithio ers iddo adael yr ysgol yn 16 oed. Mae ei swydd wedi bod

yn ansicr ers mwy na blwyddyn, ond bellach mae wedi cael ei ddiswyddo ac mae hyn wedi

cael eaith awr ar Joe. Mae gwaith wedi bod yn bwysig iddo. Roedd ei rieni wedi dweud wrtho

erioed y dylech weithio er mwyn ennill bywoliaeth a darparu ar gyer eich teulu.

Tra bu yn y atri gweithiodd Joe ei ordd i yny i od yn oruchwyliwr ond ni chwblhaodd unrhyw

gymwysterau ychwanegol na gwneud hyorddiant cydnabyddedig urfol.

Maer diswyddiad wedi cael eaith andwyol ar Joe. Mae wedi mynd yn swrth, maen aros yn

y ty ac yn esgeuluso pethau. Nid ywn cysylltu bellach i deulu ai rindiau a phrin ei od yn

siarad gydai wraig ai blant. Mae pobl wedii glywed yn dweud na all weld unrhyw ddyodol yn

y dre hon. Yn ddiweddar mae Joe wedi cymryd gorddos gydag alcohol ac aethpwyd ag e ir

Adran Ddamweiniau ac Achosion Argywng. Dywedodd ei od yn diaru ei od yn dal yn yw, ac

maen gyndyn o draod y digwyddiad.

Mae Joe wedi bod dan oal ei eddyg teulu syn poeni nad ywn ymateb i gyuriau gwrth

iselder. Maer meddyg teulu wedi awgrymu ei od yn cael cymorth seicolegol ond nid oedd

Joe yn siwr beth oedd hyn yn ei eddwl, elly gwrthododd.

Yr hyn syn poeni Joe wya yw ei od yn teimlon ethiant. Mae bob amser wedi bod yn gen

iw deulu ac wedi goalu am holl anghenion materol y ty, gwaith addurno a thrwsio ac ati. Ynddiweddar mae wedi bod yn esgeulusor pethau hyn a heyd mae nier o fliau heb eu talu.

Nid yw Joe erioed wedi bod mewn dyled or blaen ond maen poeni bellach y bydd yn colli ei

gartre. Mae wedi cael sawl rhybudd o fliau heb eu talu. Mae gan Joe gymaint o gywilydd nad

yw wedi sn wrth neb od hyn yn boen iddo.

Maer meddyg teulu wedi cysylltu Dr Anne Jenkins y seiciatrydd ymgynghorol i gael ei barn.

Taen 1: Senario Personol Rhi 2 Olwen

Gwraig weddw 73 oed yw Olwen syn byw mewn ardal wledig lle siaredir Cymraeg yn benna.

Mae Olwen yn siarad Cymraeg yn benna i theulu, rindiau a chymdogion. Maen wraig

weddw ers sawl blwyddyn bellach ac maen annibynnol iawn. Yn ddiweddar mae ei chymdogion

wedi dechrau poeni am nad yw Olwen yn mynd allan mor aml ag or blaen, ac oherwydd bod yn

well ganddi dreulior rhan wya or diwrnod yn ei chadair. Dywed Olwen nad ywn dymuno gweld

neb a hyd yn oed pe byddain teimlo ychydig yn sl, dywed od popeth yn rhy bell iw cyrraedd.

Mae ei rindiau wedi sylwi bod Olwen yn yr o wynt wrth symud o gwmpas y ty ac nad yw mor

hapus i bywyd oi gymharu rhai misoedd yn l. Maen ymddangos yn wy anghous ac nid

ywn gallu goalu amdanii hun gystal. Mae ei meddyg teulu wedi goyn ir tm iechyd meddwl

oedolion hyn ymweld hi gan ei bod yn poeni bod Olwen yn dangos arwyddion o afechyd

organig, el dementia.


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Exercise 1:

Handout 1: Personal Scenarios Number 1 Joe

Joe is a 42 year old married man with two teenage children. He has recently been made

redundant rom his job in local actory, a place he has worked in since leaving school at 16.

The prospect o redundancy has been around or a year or more, but now that it has happened

it has hit Joe hard. Work has been important or Joe. His parents had always told him that

you should work or your living and to provide or your amily.

While working at the actory Joe worked himsel into a supervisory position but he has avoided

completing any additional qualifcations or ormal recognised training.

The redundancy has had a devastating eect on Joe. He has become lethargic, housebound

and neglectul. He has withdrawn rom contact with amily and riends and talks rarely with hiswie and children. He has been heard to say that he can see no uture in this town.

Recently Joe has taken an overdose with alcohol and was taken to A&E. He stated he

regretted still being alive, but now he is reluctant to discuss the incident.

Joe has been under the care o his GP who is concerned that he is not responding to

anti-depressant medication. The GP made a suggestion about psychological approach but

Joe wasnt sure what he was on about so declined.

O greatest concern to Joe is his sense o ailure, he has always been a strong member o

his amily and took care o all the material needs in the house, decorating and repairs etc.

Recently he has been neglecting these things and also has not paid many bills. Joe has never

been in debt beore but is now worried that he will lose his home. He has received a number

o warnings about unpaid bills. Joe is so ashamed o this he has not previously told anyone

that this is a concern.

The GP has contacted Dr Anne Jenkins the consultant psychiatrist or an opinion.

Handout 1: Personal Scenarios Number 2 Olwen

Olwen is a 73 year old widow living in a predominantly Welsh speaking, rural community.

Olwen speaks mainly Welsh with her amily, riends and neighbours. She has been widowed ormany years and is fercely independent. Her neighbours have recently become concerned that

Olwen does not go out as much as she used to, preerring to spend much o her day in her

chair. Olwen says she does not want to see anyone and states that even i she did eel a little

better, everything is too ar away or her now.

Her riends have noticed that Olwen appears more breathless when moving around the house

and is nowhere as happy with her lie as she was some months ago. She appears more

orgetul and less able to look ater hersel.

Her GP has requested a visit rom the older adults mental health team as she is concerned

that Olwen may be showing signs o an organic illness, such as a dementia.


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Taen 1: Senario Personol Rhi 3 David

Ymhen 2 fs bydd David yn dathlu ei ben-blwydd yn 18 oed. Mae wedi bod yn derbyn goal gan

wasanaethau plant ers ei od yn 13 oed. Caodd David blentyndod anodd iawn ar l iw dadarw (wrth ymladd mewn taarn) pan oedd yn 3 oed. Roedd ei am yn dibynnu ar gyuriau ac

alcohol ac yn aml yn esgeuluso David. O ganlyniad roedd yn collir ysgol yn ysbeidiol yn ystod

ei ynyddoedd cynnar. Ers iddo dderbyn goal gan wasanaethau mae presenoldeb David wedi

gwella. Yn l yr athrawon mae David yn achgen deallus syn cael traerth awr canolbwyntio.

Mae David wedi cael traerth heyd urfo unrhyw berthynas arall o bwys yn yr ysgol neur tu

allan ac maen well ganddo od ar ei ben ei hun. Ers ei od yn 13 oed mae David wedi cael

cyarodydd rheolaidd gydar Gwasanaethau Iechyd Meddwl Plant a Phobl Ianc (CAMHS).

Mae wedi ymateb yn dda ac wedi urfo perthynas dda gydar gweithwyr yn y gwasanaeth.

Yn ddirybudd, darganur sta yn ei uned od David wedi dechrau anaui hun, gan honni bod

cyarwyddiadau yn ei ddillad syn dweud wrtho am wneud hynny. Mae wedi anaui hun yn

ddiriol weithiau, heb ddweud wrth aelod o sta.

Mae sta yn yr uned breswyl wedi sylwi bod David wedi bod yn syllu am gynodau ar y teledu

ac yn ymgolli mewn byd arall. Mae sta wedi sylwi heyd ei od yn osgoi gwisgo unrhyw

ddillad coch pan mae dan straen. Wrth draod ymddygiad David awgrymwyd bod angen ir

gwasanaethau i gleifon iechyd meddwl mewnol i oedolion ei asesu gan ei od bellach rhwng y

gwasanaeth i blant ac oedolion. Mae David yn anhapus iawn r syniad bod rhywun or tu allan

ir tm CAMHS yn cynnig help ac maen gwrthod cytuno i ynd ir uned cleifon mewnol.

Taen 1: Senario Personol Rhi 4 Mervyn

Gwr 50 oed yw Mervyn syn byw gydai rawd iau mewn bwthyn bach mewn cymuned wledig

ach. Mae wedi bod yn derbyn gwasanaethau iechyd meddwl am dros 30 mlynedd, ond nid

yw wedi bod mewn ysbyty yn y 12 mlynedd diwetha. Nid oes gwasanaethau urfol ar gael

wrth ymyl Mervyn a phrin od unrhyw gludiant cyhoeddus rheolaidd. Maen mynd i ore cof a

gynhelir yn y cae/siop leol ac maen mwynhau mynd ir llyrgell deithiol.

Yn achlysurol, mae Mervyn yn penderynu peidio chymryd ei eddyginiaeth. Credir bod

cysylltiad rhwng hyn r dirywiad yn ei hylendid personol, yr iaith ddirol maen ei denyddio ai

ymddygiad ymosodol. Pan mae hyn yn digwydd mae Mervyn yn cwyno bod y lleisiauntroin in.

Mae pawb yn y gymuned yn adnabod Mervyn ac yn ho ohono, ac yn cyeirio aton aml el

tipyn o gymeriad. Mae cyn cydlynydd goal Mervyn yn symud tramor i yw. Bydd yn cael

cydlynydd goal newydd syn nyrs seiciatrig cymunedol sydd heyd yn newydd ir ardal. Wrth

baratoi at ei swydd newydd, maer cyn gydlynydd goal wedi cywynor nyrs seiciatrig cymunedol

i nier o bobl allweddol yn y gymuned leol, yn cynnwys perchennog y siop gof, y bosteistres,

yr heddlu lleol ar llyrgellydd syn gyriol am y gwasanaeth teithiol.

Mae Mervyn wedi dweud ei od yn poeni am weithio gydag unigolyn newydd ac mae wedi

cytuno y gallai od yn amser da i wneud ailasesiad oi anghenion.


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Handout 1: Personal Scenarios Number 3 David

David is 2 months o his 18th birthday and is a young man who has been in looked ater

childrens services since he was 13 years old. David had a very chaotic upbringing ollowingthe death o his ather (in a bar room fght) when he was 3. His mother had a drug and alcohol

dependency and was oten neglectul o Davids needs. Consequently his school attendance

was sporadic during his early years. While being in the care o services school attendance has

improved and teachers have ound David to be a bright boy who had a great deal o difculty

in concentrating. David also struggled to orm any signifcant relationships in or out o school

and is considered something o a loner. Since he was 13 David has been seen regularly

by the Child and Adolescent Mental Health Service (CAMHS). He has responded well and

ormed good relationships with the workers in the service. Quite suddenly, the sta at his unit

discovered that David has been harming himsel, claiming that there are instructions in his

clothing which tell him to do so. He has cut himsel, sometimes quite severely without ever

inorming a member o sta.

Sta at the residential unit have noted that David has periodically been staring intently at

the television and driting o into another world. He has also been noted to avoid any

red coloured clothing when under stress. It has been discussed that David requires the

assessment o an adult mental health in-patient services as he is now in a service transition

phase. David is very unhappy at the prospect o anyone other than the CAMHS team oering

help and is reusing to agree to enter the in-patient unit.

Handout 1: Personal Scenarios Number 4 Mervyn

Mervyn is a 50 year old man who lives with his younger brother in a small cottage in a small

rural community. He has been receiving mental health services or over 30 years, but has not

been in a hospital in the past 12 years. There are no ormal services near Mervyn and there is

little in the way o regular public transport. He attends a coee morning held in his local shop/

cae and enjoys using the mobile library.

Periodically, Mervyn decides to stop taking his medication and this has been seen to be

associated with a reduction in his personal hygiene, increased abusive language and

aggressive behaviour. Mervyn complains that the voices get nasty at this time.

Mervyn is a well known and liked individual in the community, oten reerred to as a bit o a

character. Mervyns previous care coordinator is leaving to move abroad. He is to have a new

care coordinator who is a community psychiatric nurse (CPN) who is also new to the area.

During the orientation phase to the new job, the previous care coordinator has introduced

the CPN to Mervyn and to a number o key people in the local community, including coee

shop owner; the post mistress; the local police ofcer and the librarian who runs the mobile

service.

Mervyn has stated that he is worried about working with a new person and has agreed that it

may be a good time to conduct a re-assessment o his needs.


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Taen 1: Senario Personol Rhi 5 Ken

Gwr oedrannus 83 oed yw Ken syn byw yn ei yngalo ei hun mewn tre archnad ach.

Symudodd e ai wraig i Gymru ar l ymddeol tua 20 mlynedd yn l. Mae ei ddwy erch yn byw

dros 100 milltir i wrdd ac nid ydynt yn dod iw weld yn aml. Collodd Ken ei wraig 3 blynedd yn

l. I ddechrau roedd yn ymddangos ei od yn addasun weddol dda. Ond yn raddol aeth braidd

yn anghous a diynegiant. Dechreuodd esgeuluso ei hylendid ar arer o wisgo amdano. Pan

ddaeth ei erch iw weld roedd yn bwyta a pob o dun, rhywbeth na yddai wedi ei wneud or

blaen.

I ddechrau roedd y meddyg teulun amau ei od yn diodde o iselder ac ei cyeiriodd eto

at y tm iechyd meddwl lleol i oedolion hyn. Ond mae ymddygiad a cho tymor byr Ken wedi

gwaethygu ymhellach a bellach maen mynd i glinig co. Heyd maen derbyn goal yn y cartre.

Mae gweithiwr yn galw heibio i baratoi prydau ai atgoa i gymryd ei eddyginiaeth at bwysedd

gwaed uchel. Weithiau mae Ken allan pan maen nhwn galw. Yn aml maen ymddangos yn

ddiynegiant ac yn crwydro or byngalo, a hynny weithiaun eitha cynnar yn y bore. Ar ddau

achlysur daeth gweithwyr lleol o hyd iddon seyll y tu allan ir siop bapur newydd tua phump

or gloch y bore yn disgwyl iddi agor am 6 or gloch. Nid oedd ganddo lawer o syniad or amser.

Ond mae bob amser yn llwyddo i ddod o hyd iw ordd adre heb oyn am gyarwyddiadau ac

maen oalus wrth groesir yrdd.

Dywed Ken ei od yn colli ei wraig ai od yn teimlon unig. Ers iddi arw mae wedi cadw draw

or gweithgareddau yr arerai ynd iddynt el y cr lleol a chwarae dominos yn y clwb. Nid oes

ganddo lawer o ddiddordeb ail gydio yn y gweithgareddau hynny ac maen treulio amser yn

gwrando ar ei radio neun syllu ar y teledu heb dalu llawer o sylw.

Taen 1: Senario Personol Rhi 6 Mary

Mae Mary yn 36 oed; mae wedi cael diagnosis o Anhwylder Personoliaeth Ffniol (BPD).

Mae Mary wedi bod mewn cyswllt r gwasanaethau lleol ers yn 18 oed, ac mae wedi cael ei

derbyn droeon el cla mewnol, yn cynnwys i uned BPD arbenigol.

Tra oedd Mary yn gla mewnol gwnaeth sawl ymgais i niweidio ei hun ac ar adegau mae wedi

bod angen triniaeth eddygol rys. Mae Mary heyd wedi ymosod ar aelodau or sta yn y

gorennol.

Mae Mary wedi bod dan oal y Tm Iechyd Meddwl Cymunedol am saith mlynedd ac mae wedi

bod dan oal pump o wahanol gydlynwyr goal yn ystod yr amser hwnnw. Maer newidiadau

o ran y cydlynwyr goal wedi digwydd oherwydd bod sta wedi gadael neu oherwydd bod

y berthynas yn methu. Ar hyn o bryd maen derbyn gwasanaethau gan Nyrs Seiciatrig

Cymunedol, seiciatrydd, seicolegydd ac mae ganddi weithiwr cymdeithasol ar ei chyer.

Mae mam Mary yn byw gerllaw ac maen aml yn cwyno am y Tm Iechyd Meddwl Cymunedol;

maen ymddangos bod hyn yn digwydd pan o Mary leel uwch o angen neu pan mae mewn

argywng.

Yn aml mae Mary yn mynd ir ganolan iechyd oi gwirodd, ac mae hynny yn ei dron arwain at

lythyr atgyeirio ir Tm Iechyd Meddwl Cymunedol gan od Mary mewn seylla o argywng.

Yn aml, yr hyn syn ysgogi Mary i ynd ir ganolan iechyd neun peri iddi hunan niweidio ywr

aith ei bod yn credu bod gweithwyr proesiynol yn gwneud camgymeriadau e.e. yn methu


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Handout 1: Personal Scenarios Number 5 Ken

Ken is an 83 year old man who lives in his own bungalow in a small market town. He and

his wie moved to Wales when he retired some 20 years previously. His two daughters both

live over 100 miles away and visit inrequently. Ken was widowed 3 years ago. Initially he

seemed to adjust reasonably well. However he gradually became a little vacant and orgetul.

He started to neglect his hygiene and dressing. He was visited by his daughter who ound him

eating baked beans rom a tin, something she said he would never have done previously.

At frst his GP suspected depression and reerred to the local mental health team or older

adults. However Kens behaviour and short term memory have deteriorated urther and Ken

now attends a memory clinic. Ken has also been allocated domiciliary care. A worker calls

to help him prepare meals and prompt him to administer his own medication or high blood

pressure. They report that Ken is sometimes out when they call. He will oten seem vacant

and he requently wanders o rom the bungalow, sometimes quite early in the morning.

On two occasions he was ound by local workmen standing outside the newsagents around 5am waiting or it to open at 6am. He seemed to have little idea o the time. However he always

seems to be able to fnd his way back home without needing to ask directions and to exercise

care when crossing the roads.

Ken says that he misses his wie and eels lonely. Since her death he has withdrawn rom

previous activities such as the local choir and playing dominoes at the club. He has little

interest in returning to these and now spends time listening to his wireless or gazing at the

television with apparently little attention.

Handout 1: Personal Scenarios Number 6 Mary

Mary is 36; she has a diagnosis o Borderline Personality Disorder. Mary has been in contact

with the local services since she was 18 years old and has had many inpatient admissions,

including to a specialist BPD unit.

Whilst an inpatient Mary has made numerous attempts to harm hersel which has on

occasions required emergency medical treatment. Mary has also assaulted sta members in

the past.

Mary has been under the care o this CMHT or seven years and has been under the care ofve dierent care co-ordinators during this time, the changes in care coordinator have been as

a result o sta leaving or the breakdown o the relationship. She currently receives services

rom a CPN, psychiatrist, psychology and has an allocated social worker. Marys mother lives

close by and oten makes complaints against the CMHT; this appears to be when Mary is

experiencing a higher level o need or crisis.

Mary requently attends the health centre o her own accord which consistently prompts a

reerral letter to the CMHT as Mary presents in crisis.

Marys attendance at the health centre or acts o sel harm is oten prompted by what she

believes are mistakes by proessionals such as not being able to meet her immediate needs,

or when in hospital having restrictions placed upon her care.


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bodloni ei hanghenion ar yrder, neu os yw yn yr ysbyty, am od cyyngiadau wedi eu gosod ar ei

goal. Weithiau mae Mary yn denyddio alcohol yn ormodol ac mae hynnyn gwaethygur

hunan niweidio.

Mae Mary wedi bod ar gyrsiau i adeiladu hyder a gynhelir gan wasanaethau dydd ond nid ywn

teimlo ei bod wedi elwa.

Dywed Mary yn aml nad yw eisiau, ac nad oes angen cynllun goal arni ac na ddylai od yn

derbyn gwasanaethau gan mai Ei bywyd hi ydyw.

Maer Tm Amlddisgyblaethol wedi trenu cyarod i adolygu ei chynllun goal a thriniaeth er

mwyn adolygu goal Mary gan od gweithwyr proesiynol unigol yn dweud nad ydynt yn gallu

bodloni anghenion Mary. Ond mae Clinigwr Cyriol Mary wedi dweud yn glir nad ywn credu bod

angen gwasanaethau arbenigol arni ac na ydd yn cau achos Mary eor gwasanaethau iechyd

meddwl eilaidd.


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Occasionally Mary uses alcohol excessively which exacerbates her acts o sel harm.

Mary has attended courses on confdence building run by day services but doesnt eel that

she has benefted.

Mary oten states that she does not want or need a care plan and that she should not beinvolved with services as Its her lie.

The MDT have decided to arrange a care and treatment plan review meeting to discuss Marys

care as individual proessionals state that they eel unable to meet Marys needs, however

Marys Responsible Clinician has clearly stated that he does eel that specialist services are

required and that he will not discharge Mary rom secondary mental health services.


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Cynllun Goal a Thriniaeth

Gall y cynllun hwn gael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg

ac yn rhannol yn y Saesneg.

Mesur Iechyd Meddwl (Cymru) 2010 Adran 18 - Cynllun Goal a ThriniaethMaer cynllun goal a thriniaeth hwn wedii baratoi o dan adran 18 o Fesur Iechyd Meddwl (Cymru)

2010, ac yn unol r goynion yn Rheoliadau Iechyd Meddwl (Cydgysylltu Goal a Chynllunio Goal

a Thriniaeth) (Cymru) 2011.

Dyma gynllun goal a thriniaeth

Enwr cla

perthnasol

Cyeiriad arerol

llawn y cla

perthnasol

Enwr

cydgysylltydd goal

Rhi n, cyeiriad

post ac, os ywn

briodol, cyeiriad

e-bost y

cydgysylltydd

goal

Enwr BwrddIechyd Lleol neur

Awdurdod Lleol

a benododd y

cydgysylltydd

goal

Er hynny, cai

neur goalwr/goalwyr neur goalwr/goalwyr lleoliad oedolyn sydd ganddo/

ganddi oyn ir cynllun hwn gael ei adolygu unrhyw bryd.

Y dyddiad y caodd

y cynllun ei wneud Y

dyddiad y maen

rhaid adolygur cynllun

Caodd y cynllun hwn

ei wneud ar

ac mae iw adolygu erbyn

an bella.

syn byw yn

Y cydgysylltydd goal sydd wedi paratoir cynllun goal a thriniaeth hwn yw

Maer cydgysylltydd goal wedi cael ei benodi gan ac maen gweithredu ar

eu rhan

ac mae modd cysylltu r cydgysylltydd goal yn


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Maer rhan hon or cynllun goal a thriniaeth yn conodir canlyniadau y maer

ddarpariaeth gwasanaethau iechyd meddwl wedii bwriadu iw sicrhau, manylion y

gwasanaethau hynny sydd i gael eu darparu, ar camau sydd iw cymryd er mwyn

sicrhaur canlyniadau hynny.

Rhaid ir canlyniad(au) araethedig a gynhwysir yn y rhan ganlynol or cynllun ymwneud ag un neu

wy or meysydd sydd wediu rhestru, a chynnwys esboniad ar sut mae pob canlyniad yn ymwneud

phob maes. Gall canlyniadau gael eu sicrhau mewn meysydd eraill heyd, a rhaid iddynt gymryd

i ystyriaeth unrhyw risgiau sydd wediu nodi ar gyer y cla perthnasol. Maer rhan hon or cynllun

heyd yn nodi manylion y gwasanaethau sydd iw darparu, neur camau sydd iw cymryd, i sicrhaur

canlyniadau araethedig, gan gynnwys pa bryd a chan bwy y maer gwasanaethau hynny iw

darparu neu y maer camau hynny iw cymryd.

Rhaid

cytuno ar

ganlyniadauiw sicrhau ar

gyfer o leiaf

un or

meysydd a

ganlyn:

a)

llety

b)

addysg a

hyorddiant

c)

cyllid ac arian

ch) triniaeth

eddygol a

mathau eraill o

driniaeth, gan

gynnwysymyriadau

seicolegol

Y canlyniad sydd

iw sicrhau

Pa wasanaethau sydd iw darparu,

neu pa gamau sydd iw cymrydPa bryd Gan bwy


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d)

cyrioldebau

rhianta neu

oalu

dd)

goal personol

a llesiant

cororol

e)

cymdeithasol,diwylliannol neu

ysbrydol

)

gwaith a

galwedigaeth

Gall canlyniadau

iw sicrhau gael

eu cytuno heyd

ar gyer meysydd

eraill

Y canlyniad sydd

iw sicrhau

Pa wasanaethau sydd iw darparu,

neu pa gamau sydd iw cymrydPa bryd Gan bwy


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Gall y meddyliau, y teimladau neur ymddygiadau a ganlyn ddangos bod

yn mynd yn wy sl a bod angen cymorth ychwanegol oddi wrth y tm goal (maer rhain weithiaun

cael eu galwn arwyddion o bwl pellach):

Os bydd yn teimlo bod ei iechyd meddwl neu ei hiechyd

meddwl yn gwaethygu nes cyrraedd pwynt lle mae angen cymorth neu genogaeth ychwanegol, dylair

camau a ganlyn gael eu cymryd (mae hyn weithiaun cael ei alwn gynllun argywng a rhaid iddo

gynnwys manylion y gwasanaethau i gysylltu nhw):

Dylai unrhyw oynion neu ddymuniadau sydd gan

o ran iaith neu gyathrebu (gan gynnwys denyddior Gymraeg) gael eu conodi yma:

Enwr claf perthnasol




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Dyma arn am y cynllun goal a thriniaeth hwn, y

gwasanaethau iechyd meddwl sydd iw darparu, ac unrhyw dreniadau at y dyodol a ddylai gael eu

hystyried:

Cofnodwch unrhyw farn y

maer claf perthnasol yn

dymunoi chynnwys (gan

gynnwys dymuniadau a

theimladau yn y gorffennol

ar presennol ynghylch

y materion sydd wediu

cynnwys yn y cynllun)

gan gynnwys unrhywosodiadau am unrhyw

drefniadau at y dyfodol

a allai fod yn gymwys.

Os nad oes gan y claf

farn neu osodiadau ar y

materion hyn, neu os nad

oes modd sicrhau barn

y claf, dylai hynny gael ei

gofnodi hefyd.

* wedii gytuno gyda ac mae

wedii gonodi yn unol ag adran 18(2) o Fesur Iechyd

Meddwl (Cymru) 2010.

* heb gael ei gytuno gyda ond maer canlyniadau wediu

penderynu gan y darparydd/darparwyr gwasanaeth iechyd meddwl, ac maent wediu conodi yn unolag adran 18(6) o Fesur Iechyd Meddwl (Cymru) 2010.

* dileer fel y bon gymwys

(rhaid defnyddio un,

ond nid mwy nag un, or

gosodiadau)



Maer cynllun goal a thriniaeth hwn:



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Cyn belled ag y bon rhesymol ymarerol gwneud hynny, rhaid ir

darparydd/darparwyr gwasanaeth iechyd meddwl a ganlyn sicrhau bod

y gwasanaethau iechyd meddwl a nodwyd yn y cynllun goal a thriniaeth

hwn yn cael eu darparu:

Maer claf perthnasol yn

cael llofnodir cynllun

gofal a thriniaeth, os

ywn dymuno

Rhaid ir cydgysylltydd

gofal lofnodir cynllun

gofal a thiniaeth hwn

Rhowch y dyddiad y maer

cynllun gofal a thriniaeth

yn cael ei wneud

Rhowch enwr Bwrdd

Iechyd Lleol a/neur

Awdurdod Lleol syn

gyfrifol am ddarparu

gwasanaethau iechyd

meddwl eilaidd ir clafperthnasol

Llonod

Y cla perthnasol

Y Cydgysylltydd Goal

Llonod

Dyddiad


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Care and Treatment Plan

This plan may be completed in either the Welsh or the English language, or partly in Welsh and

partly in English.

Mental Health (Wales) Measure 2010 Section 18 Care and Treatment PlanThis care and treatment plan has been prepared under section 18 o the Mental Health (Wales)

Measure 2010, and in accordance with the requirements o the Mental Health (Care Coordination

and Care and Treatment Planning) (Wales) Regulations 2011.

This is the care and treatment plan o

Name o

relevant patient

Full usual

address o

relevant patient

Name o care

coordinator

Telephone

number, postal

address, and

where

appropriate,

email address o

care coordinator

Name o Local

Health Board orLocal Authority

that appointed

the care

coordinator

However,

his or her carer(s), or adult placement carer(s), may request a review o this

care plan at any time.

Date plan was made

and date by which

the plan must be

reviewed

This plan was made on

and is to be reviewed

no later than

Who lives at

The care coordinator who has prepared this care and treatment plan is

The care coordinator has been appointed by, and is acting on behal o

who can be contacted at


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This part o the care and treatment plan records the outcomes which the provision

o mental health services are designed to achieve, details o those services that

are to be provided, and the actions that are to be taken with a view to achieving

those outcomes.

The planned outcome(s) included in the ollowing part o the plan must relate to one or more o

the areas listed, and include an explanation o how each outcome relates to each area.

Outcomes also may be achieved in other areas, and are to take into account any risks identifed

in relation to the relevant patient. This part o the plan should also set out details o the services

that are to be provided, or actions taken, to achieve the planned outcomes, including when, and

by whom those services are to be provided or actions taken.

Outcomes to

be achieved

must be

agreed in

relation to

at least

one of the

following

areas:

a)

accommodation

b)

education and

training

c)

fnance and

money

d) medical and

other orms o

treatment,

includingpsychological

interventions

Outcome to be

achieved

What services are to be provided,

or actions takenWhen Who by


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e)

parenting or

caring

responsibilities

)

personal care

and

physical

well-being

g)social, cultural

and spiritual

h)

work and

occupation

Outcomes to be

achieved may

also be agreed

in relation to

other areas

Outcome to be

achieved

What services are to be provided,

or actions takenWhen Who by


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The ollowing thoughts, eelings or behaviours may indicate that

is becoming more unwell and may require extra help rom the care team (these are sometimes

called relapse signatures):

I eels that his or her mental health is deteriorating to the

point where he or she requires extra help or support, the ollowing actions ought to be taken (this is

sometimes known as a crisis plan and must include the details o services to be contacted):

Any language or communication requirements or wishes which

has (including in relation to the use o the Welsh Language) ought to be recorded here:

Name of relevant patient




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The views o on this care and treatment plan, the mental

health services that are to be provided, and any uture arrangements that ought to be

considered, are:

Record any views that the

relevant patient wishes

to be included (including

past and present wishes

and feelings about the

matters covered by the

plan), and include any

statements about any

future arrangementswhich may apply. If the

patient does not have

any views or statements

on these matters, or the

patients views cannot be

ascertained, this ought to

be recorded also.

* been agreed with and is

recorded in accordance with section 18(2) o the Mental

Health (Wales) Measure 2010.

* not been agreed with but the outcomes have been determined

by the mental health service provider(s) and are recorded in accordance with section 18(6) o theMental Health (Wales) Measure 2010.

* delete as applicable

(one, but not more than

one, statement must

apply)


This care and treatment plan has:




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So ar as it is reasonably practicable to do so, the ollowing mental

health service provider(s) must ensure that the mental health

services set out in this care and treatment plan are provided:

The relevant patient

may sign the care and

treatment plan, if

they wish

The care coordinator

must sign this care and

treatment plan

Enter the date the care

and treatment plan

is made

Enter the name of the

Local Health Board and/

or the Local Authority

who are responsible

for providing secondary

mental health services to

the relevant patient

Signed

Relevant patient

Care Coordinator

Signed

Date


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Taen 3: Gwellar ordd o ddisgrifo nodau a chanlyniadau

Maer problemau hyn yn seiliedig ar straeon personol Joe / Olwen / David / Mervyn / Ken a

Mary. Fe welwch od y rhain yn broblemau ac yn ganlyniadau sydd wedi eu difnion wael: aralleiriwch y termau yn gynlluniau goal syn seiliedig ar ganlyniadau mwy denyddiol, gan

roi gwell difniad or nod/canlyniad a sut gellid adolygur problemau

edrychwch ar y problemau lle mae angen help a meddyliwch sut gellid eu geirio mewn ordd

syn ategu ethos gwellhad (gweler Unedau Craidd 1 a 2) a denyddiwch y wybodaeth am

sgiliau asesu allweddol yn yr uned hon

rhannwch rhain gyda grwpiau eraill i weld a ydyn nhwn gallu cynnig unrhyw welliannau

pellach ich gwaith.

Nod/canlyniad wedi ei ddifnion wael i Joe:

Mae gan Joe iselder

Mae Joe yn ddi-waith

Nid yw Joe yn cydymurfo i driniaeth seicolegol

Nid yw Joe yn ymateb iw eddyginiaeth

Mae Joe mewn dyled ac mae eisiau datrys ei bryderon ariannol

Mae David yn ymateb i gyarwyddiadau gan eraill na rennir gan ei gylch cyoedion

Mae David chysylltiad rhy agos phobl yn ei wasanaeth blaenorol

Nid oes gan David unrhyw rindiau agos

Ni all David ganolbwyntio

Mae David yn risg iddoi hun

Mae gan Olwen iselder

Mae Olwen yn ynysig yn gymdeithasol

Mae gan Olwen anawsterau anadlu

Nid yw Olwen yn deall Saesneg yn dda iawn

Nod/canlyniad wedi ei ddifnion wael i Olwen

Nod/canlyniad wedi ei ddifnion wael i David


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Handout 3: Improving the way goals & outcomes are described

These issues are based on the personal narratives o Joe/Olwen/David/Mervyn/Ken and

Mary. You will see these are poorly defned problems and outcomes. Your task in groups is to: rephrase the terms into better more useul outcomes based care plans, providing a better

defnition o the goal/outcome and identiying how the issues can be reviewed

think about how the issues requiring assistance can be phrased in such a way as to rein

orce an ethos o recovery (see Core Units 1 and 2) and use inormation o key

assessment skills contained n this unit.

share them with other groups to see i they can improve your work urther.

Poorly defned goal/outcome or Joe

Joe is depressed

Joe is out o work

Joe is compliant with psychological treatment

Joe is not responsive to medication

Joe is in debt and wants to solve his money worries

David is responding to instructions by others not shared by his peer group

David is too attached to people in his previous service

David has no signifcant riends

David cant concentrate

David is a risk to himsel

Olwen is depressed

Olwen is socially isolated

Olwen has breathing difculties

Olwen does not understand English very well

Poorly defned goal/outcome or Olwen

Poorly defned goal/outcome or David


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Nod/canlyniad wedi ei ddifnion wael i Mervyn

Mae Mervyn yn ynysig

Ni wnai Mervyn gymryd ei eddyginiaeth

Mae Mervyn yn gallu bod yn ymosodol

Mae gan Mervyn hylendid personol gwael

Dywed Mary od ganddi anhwylder personoliaeth

Mae gan Mary hanes o drais

Mae Mary yn niweidio ei hun pan mae dan straen

Mae Mary yn mynd i ddosbarthiadau hunan hyder

Mae Mary yn gallu gwrthod cydweithredu

Weithiau mae gan Ken hylendid personol gwael

Mae Ken yn anghous

Mae Ken yn mynd i glinig co

Ni all Ken baratoi ei brydau ei hun

Mae Ken yn unig

Nod/canlyniad wedi ei ddifnion wael i Ken

Nod/canlyniad wedi ei ddifnion wael i Mary


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Poorly defned goal/outcome or Mervyn

Mervyn is isolated

Mervyn wont take his medication

Mervyn can be aggressive

Mervyn has poor personal hygiene

Mary states she has a personality disorder

Mary has a history o violence

Mary sel harms when under stress

Mary attends sel confdence classes

Mary can be uncooperative

Ken sometimes has poor hygiene skills

Ken is orgetul

Ken attends a memory clinic

Ken cannot prepare his own meals

Ken is lonely

Poorly defned goal/outcome or Ken

Poorly defned goal/outcome or Mary


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Taen 4: Cynllunio canlyniadau pethau iw cynnwys

Cynllunio canlyniadau ymddygiadol:

targedwch ymddygiad penodol

helpwch trwy osod nodau cyraeddadwy ar gyer newid ymddygiad

helpwch trwy gael y genogaeth sydd ei hangen ar yr unigolyn er mwyn newid a chynnal y

newid hwnnw mewn ymddygiad

helpwch yr unigolyn i dorrir newidiadau ymddygiadol hyn yn dargedau esul dipyn

helpwch yr unigolyn i gael hyd ir adnoddau ar bobl syn gallu ei helpu i gyawni ei nodau.

Dylid ysgriennur canlyniadau gan ddenyddio egwyddorion CAMPUS h.y. dylent od yn rhai

Cyraeddadwy, Amserol, Mesuradwy, Penodol, Uchelgeisiol, Synhwyrol.

C cyraeddadwy,

A amserol,

M mesuradwy,

P penodol,

U uchelgeisiol

S synhwyrol.

Maen bwysig pwysleisio y dylid cynnwys y denyddiwr gwasanaeth yn y broses o ysgriennu

pob cynllun goal a thriniaeth a dylid eu hysgriennu mewn iaith y byddant yn gallu ei deall.

Maen bwysig medru ysgriennur cynllun goal a thriniaeth yn Gymraeg neu Saesneg yn l

anghenion y denyddiwr gwasanaeth.

Os nad ywn bosibl cynnwys y denyddiwr gwasanaeth, dylid conodir rhesymau pam nad ywn

rhan or cynllun ar camau y dylid eu cymryd i hwyluso cydweithio. Mae heyd yn bwysig ystyried

y rl y mae eiriolwyr iechyd meddwl annibynnol yn ei chwarae gyda chleifon syn gallu hawlior

cymorth hwnnw er mwyn eu cynnwys wrth gynllunio goal a thriniaeth.


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Hand out 4: Outcome planning things to include

Behavioural outcome planning:

target specifc behaviours

help set achievable goals or behavioural change

help fnd support the person needs to initiate and maintain change in behaviour

help the person break down required behavioural changes into smaller staged and

achievable targets

help person fnd the resources and people who can help them achieve their goals.

Outcomes should be written using SMART principles i.e. they should be Specifc, Measurable,

Achievable, Realistic, Timely.

S specifc,

M measurable,

A achievable,

R realistic,

T time-based,

You can also add R to make SMARTR

R Recovery orientated

It is important to emphasise that all care and treatment plans should be written with the

involvement o the service user and written in language they will be able to understand.

This includes the writing o care and treatment plans in Welsh or English.

I it is not possible to involve the service user, a record should be made regarding reasons or

absence o involvement and actions to be taken to acilitate collaboration. It is also important

to consider the role that independent mental health advocates will play with Welsh qualiying

patients in supporting the patients involvement in care and treatment planning.

core unit 4: assessment and outcome planning

Documents