ContentsINTRODUCTION 1

1. Purpose and context 12. Assessment and identifying nursing needs: 2

a) Unified Assessment process 2b) NHS Funded Nursing Care and Continuing NHS health care 3

3. Summary of key points in introduction 4

UNDERTAKING THE ASSESSMENT 5

4. Setting the scene 55. Who will undertake the assessment? 66. Identifying the nursing care needs 67. Assessment of additional needs 88. Understanding care options 89. Making and recording the decision 1010. Next steps: 13

� Continuing NHS Health Care 13� Admission to care homes providing nursing care 13� Access to NHS services 14� Access to other services 14� Protection of Vulnerable Adults 14

11. Funding arrangements 1412. Review of care needs 1513. Appeals/Complaints/Disputes 1614. Summary of key points in Undertaking the Assessment 16

ANNEX A: The Unified Assessment Process 19ANNEX B: Nursing within the context of Unified Assessment 25ANNEX C: The policy context of NHS Funded Nursing Care in Wales 33ANNEX D: Glossary 37ANNEX E: Key documents 41ANNEX F: Illustrative case studies 43ANNEX G: Mapping the Unified Assessment and Care Management

Process Continuum 47ANNEX H: Nursing Needs Assessment Decision Record (NNADR) 49

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INTRODUCTION

1. Purpose and context

This document is intended to inform and advise nurses in Wales about theprocesses of assessment, decision-making, determination of eligibility for servicesand funding, and completion of the Nursing Needs Assessment Decision Record(NNADR). The policy context within which this document has been developed isdescribed in more detail in Annex C.

The document offers practical guidance to help nurses, following a nursingassessment, to make and record the decisions arising from that assessment,including, in particular the decisions that:

• the individual has health care needs which may give rise to eligibility forContinuing NHS Healthcare and requires further multi-disciplinaryassessment;

• the individual has nursing needs and is eligible for NHS Funded Nursing Carein a care home with nursing1;

• the individual has health care needs which, through accessing other careoptions, including intermediate care, rehabilitation or re-ablement schemes,will minimise the risk to independence;

• the individual has nursing needs, which may be managed in a communitysetting or a residential care home; and

• the individual has no nursing needs.

The Royal College of Nursing has identified some of the key features thatcharacterise professional nursing, including:

� the clinical judgement inherent in the processes of assessment, diagnosis,prescription and evaluation;

� the knowledge that is the basis of the assessment of need and thedetermination of action to meet the need;

� the personal accountability for all decisions and actions, including the decisionto delegate to others; and

� the structured relationship between the nurse and the patient whichincorporates professional regulation and a code of ethics within a statutoryframework.

It is within the wider context of these nursing activities and responsibilities that usingthe guidance in this document will equip nurses to undertake effective assessmentsand make and record consistent and well-informed decisions about the needs ofeach individual. The guidance should be used in conjunction with locally agreedarrangements for assessment, and supported by attending local training events.

1 or an independent hospital as defined by section 2(3)(b) of the 2000 Act where premises formerly registered as mentalnursing homes under the Registered Homes Act now have to register as independent hospitals under the 2000 Act by virtue oftheir providing residential accommodation to person or persons detained under the Mental Health Act. This note will apply asappropriate throughout this document.

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Nursing staff who are involved in assessing a patient's care needs are stronglyadvised to complete the Nursing Needs Assessment Decision Record at Annex H.The NNADR has been developed by nurses for use by nurses.

Completion of the record will ensure that a full, written justification for the nursingneeds assessment decision is readily accessible and is amongst the patient'srecords. This will be invaluable if, at a later date, any queries are made or acomplaint received in respect of the level or type of nursing care that a patient hasbeen assessed as requiring. Failure to complete such a record may result in a lack ofa clear audit trail justifying why such a decision was made in an individual case.

2. Assessment and Identifying nursing needs:

a) The Unified Assessment process

‘Improving Health in Wales – A Plan for the NHS with its partners’ (2001)identified the need to simplify and clarify assessment processes operating inlocal authority social services and in the health service. The lack ofcompatibility between systems has sometimes meant that people withcomplex needs find themselves undergoing multiple and uncoordinatedassessments. This is frustrating for the person who is often asked for thesame information over and over again; it is wasteful of resources to duplicateprocesses unnecessarily; it does not promote well integrated care planning,and it may leave gaps in service provision. The Welsh Assembly Governmentis now supporting the implementation of the Unified Assessment process inWales (UAP). The Unified Assessment Process takes a whole systemapproach to assessment with benefits for people who use services, foragencies and for professionals. The aim in developing UAP is to ensure moreeffective joint working and to prevent people being serially assessed andasked for the same information by different agencies. This is the contextwithin which nursing assessments will be carried out, and decisions onappropriate funding and placements made. Information from assessments willbe shared according to local information sharing protocols.

A brief outline of the Unified Assessment process is attached in Annex A, anda discussion of nursing in this context is contained in Annex B. Nursesinvolved in undertaking such assessments will need to ensure thatappropriate consent has been provided for the assessment to take place.Where the individual involved cannot give valid consent, the nurse shouldcarry out the assessment in the best interests of the individual beingassessed. The full guidance: ‘Creating a Unified and Fair System forAssessing and Managing Care’ (2002) provides further information on theprocess of assessment and the issue of consent.

Annex G provides a map of the Unified Assessment and Care ManagementProcess continuum.

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b) NHS Funded Nursing Care and Continuing NHS health care

‘NHS Funded Nursing Care’ refers to the funding provided to care homes(with nursing) by the NHS to support the provision of nursing care by aregistered nurse for those assessed as eligible. It is a standardised weeklypayment for nursing care costs, including those for continence care, paid tocare homes for all eligible residents. The resident (with local authority supportwhere appropriate) will continue to be responsible for the accommodation andpersonal care costs. ‘Continuing NHS health care’ describes a package ofhealth care arranged and funded solely by the NHS. It may be provided inhospital, in a person’s own home, or in a care home. Further explanation iscontained in Annex C.

A nursing assessment may stand alone, or it may be part of a comprehensivemulti-disciplinary assessment, one aspect of which will be to determineeligibility for continuing NHS health care. The Grogan judgment (The Queenon the application of Maureen Grogan v Bexley NHS Trust [2006] EWHC 44)indicates that a decision on eligibility for continuing NHS health care shouldcome before consideration of eligibility for NHS Funded Nursing Care. Such adecision is the product of a multi-disciplinary assessment. It cannot be madeby a nurse in isolation. The relevant guidance for continuing NHS health careand NHS Funded Nursing Care emphasises the importance of a multi-disciplinary, comprehensive assessment (in the context of the UnifiedAssessment Process) prior to any decision on a placement in a care home.This helps to ensure that residents are placed in the appropriate care settingto meet their needs, and that the appropriate funding arrangements are inplace.

There are circumstances, however, where a nurse may be undertaking anursing assessment where a full multi-disciplinary assessment has not beenundertaken e.g. for persons living in the community, or when undertaking anursing review in a care home. That is, the practice setting for nursingassessments do not make a prior decision on eligibility for continuing NHShealth care always appropriate or feasible. To meet the spirit of the Groganjudgment, the nurse undertaking an assessment should always ensure thattheir first consideration must be whether the patient has health care needswhich may give rise to eligibility to continuing NHS health care, and thatwhere this is the case, the patient should be referred for furthermulti-disciplinary assessment. This is discussed further later in this workbook,and in the section concerned with completing the NNADR.

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3. Summary of key points in Introduction

• This document will equip NHS nurses to make and record consistent andwell-informed decisions about the nursing needs of each individual.

• Identifying registered nursing input is approached on an individual basisfollowing a nursing assessment as part of the Unified Assessmentprocess.

• The key context for adults in which decisions relating to long term care(including NHS Funded Nursing Care) are made is the guidance ‘Creatinga Unified and Fair System for Assessing and Managing Care’ (2002).

• When undertaking a nursing assessment, the first consideration must bewhether or not the patient has health needs which may give rise toeligibility for continuing NHS health care. Where it appears that this maybe the case, the patient should be referred for further multi-disciplinaryassessment.

• Where this is not the case, the decision on the appropriateness ofplacement in a care home with nursing, and eligibility for NHS FundedNursing Care, will be made and recorded.

• Recording of assessments and decisions is essential in ensuring that thisinformation is available to the person assessed, to other professionals,and when required should there be any complaint about, or challenge to,decisions made or services provided.

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UNDERTAKING THE ASSESSMENT

4. Setting the scene

This section will explain how the assessment of an individual’s needs for registerednurse input will operate in practice.

The Royal College of Nursing defines nursing as “The use of clinical judgement inthe provision of care to enable people to improve, maintain, or recover health, tocope with health problems, and to achieve the best possible quality of life, whatevertheir disease or disability, until death”.

Undertaking an assessment occurs within this wider context and understanding ofnursing as a whole. However, decision-making following assessment has also totake into account the relevant case law and legislation, particularly where this affectssuch matters as eligibility for care or care funding.

In the specific context of NHS Funded Nursing Care, Section 49 of the Health andSocial Care Act 2001 states: "nursing care by a registered nurse" means anyservices provided by a registered nurse and involving-

(a) the provision of care, or

(b) the planning, supervision or delegation of the provision of care,

other than any services which, having regard to their nature and the circumstancesin which they are provided, do not need to be provided by a registered nurse.

This does not include:

• Time spent by non-nursing staff such as care assistants (although it doescover the nurse time spent in monitoring or supervising care that isdelegated to others); and

• Personal or social care or the accommodation provided to residents.

The implications of the Grogan judgement and the Primary Health Need Approachwill also need to be uppermost in the minds of nursing assessors when makingdecisions in relation to eligibility for NHS Funded Nursing Care. Relevant pointsarising from the Grogan judgement are included in Annex C. Guidance on how thejudgement is to be interpreted when making nursing care decisions is set out insection 6 below.

The guidance ‘Creating a Unified and Fair System for Assessing and ManagingCare’ (2002) provides the key context in which nursing assessments and decisionsare considered. This workbook builds on and reinforces, and does not replace,‘Creating a Unified and Fair System for Assessing and Managing Care’.

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The five options listed below are the main, but not the only, outcomes likely to resultfrom a nursing assessment:

• The individual has health care needs which may give rise to eligibility forContinuing NHS Health care and requires further multi-disciplinaryassessment;

• The individual has nursing needs and is eligible for NHS Funded NursingCare in a care home with nursing;

• The individual has health care needs which, through accessing other careoptions, including intermediate care (e.g. rehabilitation, re-ablementschemes), will minimise the risk to independence;

• The individual has nursing needs, which may be managed in a communitysetting or a residential care home; and

• The individual has no nursing needs.

These options are discussed further in section 8 below.

A key point at which a nursing assessment may be undertaken is when an individualis ready for discharge from hospital. Assessors need to ensure that they follow localprocedures for hospital discharge, which should follow the latest guidance issued bythe Welsh Assembly Government in 2005. Assessments may also take place in thecommunity, and in care homes as part of a review process, or when required forother reasons.

5. Who will undertake the assessment?

The assessment of an individual’s nursing needs will always be undertaken by aregistered nurse employed by the NHS (or, particularly where funding for NHSFunded Nursing Care is a likely outcome, a nurse otherwise acceptable to the LocalHealth Board), in conjunction with the care co-ordinator (where this is a differentperson), and/or (where appropriate) the multi-disciplinary team.

The nurses who are most likely to undertake the assessments will be appropriatelytrained. Nurses who assess the nursing needs of an individual should be familiarwith appropriate nursing assessment models, local arrangements for UAP, and therange of care available locally to meet the diverse needs which may be identified.

6. Identifying the nursing care needs

In order to identify the nursing care needs of an individual, a holistic assessmentneeds to be undertaken using recognised models of nursing within the context of theUAP. From the information gained from the overview assessment, and building onthat, the assessing nurse will need to identify all the nursing needs experienced bythe individual being assessed.

In evaluating all assessment information, the nursing judgement should take fullaccount of what is known about the person’s condition and their usual behaviourover the course of a week or a number of weeks, drawing on all relevant information.It must also consider the potential outcomes if help were not to be provided, or wasprovided in different ways. In making this evaluation, professionals should also focus

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on the impact of any decisions on the person’s independence, and risks involved forthe person, their family and others close to them.

In making their assessments, or re-assessments, the first consideration must alwaysbe the extent to which the identified needs of the individual indicate that the primaryneed may be a health need, and that they may meet the eligibility criteria forContinuing NHS Healthcare. This is the Primary Health Need Approach.

There will be a Primary Health Need if the nursing or other health services requiredby an individual are more than incidental or ancillary to the provision ofaccommodation which a local authority is under a duty to provide, and are of anature beyond that which an authority whose primary responsibility is for socialservices could be expected to provide but for section 49 of the 2001 Act as part of asocial services package2.

Therefore, the question for assessors will be whether all the nursing care or otherhealth care provided, or which needs to be provided, either by, or under thesupervision of, registered nurses or otherwise, is incidental or ancillary to theperson’s need for accommodation, in accordance with section 21 of the NationalAssistance Act 1948, and is of a nature which a Social Services authority could beexpected to provide (or could have been expected to provide before the coming intoforce of section 49 of the Health and Social Care Act 2001), or whether, alternatively,it is at a higher level in terms of quality or quantity.

If the latter applies, this will indicate that the person has a primary health need whichmay give rise to eligibility for NHS Continuing Care. This decision can only be takenafter a multi-disciplinary assessment and so where there is any possibility that aperson may have a Primary Health Need a multi-disciplinary assessment should bearranged.

The totality of the need for nursing – both by, or under the direction of, registerednurses and any other nursing care - will be taken into account as part of themulti-disciplinary assessment, and may in itself indicate potential eligibility forContinuing NHS Health Care fully funded by the NHS.

If the need for nursing and other services is merely incidental or ancillary to theprovision of accommodation by the local authority, eligibility for NHS Funded NursingCare needs to be addressed, and appropriate procedures followed. Nursesundertaking assessments have to decide whether or not each person needs nursingcare provided by a registered nurse, and what would be the appropriate outcome tomeet their needs. If the answer is that they do need care provided by a registerednurse, and this can only be provided in a care home providing nursing care, this willindicate eligibility for NHS Funded Nursing Care, and trigger the appropriate funding.At the same time, nurses will need to consider the alternative options for care, suchas those listed above and explained further below.

2 Section 49 prohibits local authorities from providing or arranging for the provision of nursing care by a registered nurse inconnection with the provision by them of community care services including nursing services provided under section 21 of theNational Assistance Act 1948

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7. Assessment of Additional Needs

The nursing assessment may indicate the need for further in-depth or specialistassessments, including the need for equipment, or further assessment of continenceproblems. The assessing nurse should ensure that appropriate referrals are made inthese circumstances. It is important to note that the individual in a care home has thesame access to NHS services as any other individual.

8. Understanding care options

Following an assessment of nursing needs, there will be a number of care optionsavailable that should be considered in the context of the Unified Assessment processand relevant eligibility criteria, to meet the identified needs while also minimising therisk to independence.

These care options include:

• The individual has care needs may give rise to eligibility for ContinuingNHS Health Care and require further multi-disciplinary assessment. Thisdescribes a package of health care arranged and funded solely by theNHS, which may be provided in a range of settings, including hospital,care home with nursing, or an individual’s own home. Decisions oneligibility for continuing NHS health care will be based on amulti-disciplinary comprehensive assessment; the nursing assessment willcontribute to this. The decision on eligibility cannot be based on thenursing assessment alone. In undertaking an assessment, or re-assessment, the Primary Health Need Approach should be followed andthe first consideration must always be the extent to which the identifiedneeds of the individual indicate that the primary need may be a healthneed, and that they may meet the eligibility criteria for Continuing NHSCare. In such circumstances, the matter must be referred to theappropriate person for multi-disciplinary assessment, according to localarrangements, and actions recorded.

• The individual has nursing needs and is eligible for NHS Funded NursingCare in a care home with nursing. It is important here to reiterate thedistinction between care homes providing nursing care and other carehomes (previously called residential homes). Not all care homes areregistered to provide nursing care. Those that are have a registered nurseon site at all times. They provide for people who require access to nursingcare greater than that available in the community from the usualcommunity nursing services. This could include direct nursing care of theindividual, as well as frequent supervision, monitoring, planning anddelegation of nursing care (provided by others), and regular review ofnursing needs. Some of these homes will also provide specialist nursingcare for the elderly mentally infirm (EMI); others will provide only forgeneral nursing care. Local Health Boards provide funding for the nursingelement of the care provided. The individual resident (supported by thelocal authority where appropriate) funds the remainder of the costs. Asexplained earlier, nursing care in these circumstances includes only

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nursing services which need to be provided by a registered nurse (asdefined in section 49 of the Health and Social Care Act 2001). It can onlycover nursing care which is within the limits set out in the Coughlanjudgement i.e. the quality and quantity of the nursing care must beincidental or ancillary to the provision of accommodation which a localauthority is under a duty to provide, and be of a nature which socialservices could have been expected to provide but for section 49 of theHealth and Social Care Act 2001.

• The individual has care needs which could be met in a range of settings,or through a range of care services (including intermediate care,re-enablement schemes, rapid response support etc.) which will minimisethe risk to independence. Intermediate care refers to a range of usuallytime-limited services, involving cross-professional and agency working,provided on the basis of a comprehensive assessment, which have aplanned outcome of maximising independence, targeting those who wouldotherwise face a prolonged hospital stay or inappropriate admission tohospital or care home.

• The individual has minimal nursing needs, which may be managed in acommunity setting or a residential care home. As noted above, not all carehomes have a nurse on site at all times. Individuals placed in a care homewithout a nurse on site will have lesser nursing needs which can besupported by the usual community nursing services.

• The individual has no nursing needs. They may, however, require socialcare services. These will be provided on the basis of an assessment oftheir social care needs - to which the nursing assessment may contribute -in the context of the local authority’s “Fair access to care” criteria.

Moving into a care home has enormous practical and emotional significance. Whilemost people want to remain in their own homes for as long as they can, andmaintaining independence should be promoted wherever possible, there comes atime for some people when such objectives are neither realistic nor fair. Somepeople welcome admission as it offers appropriate and round the clock care,security, and companionship. Other people approach such a move with someconcerns, and everything should be done to minimise distress and to providereassurance. It is especially important, therefore, to explain the purpose ofassessment to the person concerned and that they – and their carers or family whereappropriate – understand as far as possible what is happening. It is equally importantto ensure the involvement of the person and carers in the assessment process, andthe subsequent decision-making on future care, as the decision should be made bythe person concerned wherever possible.

The UAP and care planning processes should ensure that before the decision ismade to seek permanent admission to a care home a full, comprehensive,multi-disciplinary assessment has been carried out, as part of which:

• all other possible options have been explored,

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• that all opportunities have been taken to minimise the risk toindependence through rehabilitation objectives, such as throughintermediate care, and

• the possibility of supporting the continued independence of the person intheir community, if that is their preference, has been fully considered andexplored.

When assessing or reviewing a resident already admitted to, or living in, a carehome, nurses should have available the care plan and the full information generatedby the previous assessment processes (including risk assessments), and will usethese alongside their own professional knowledge and observations of the individualin reaching a decision. This is an essential stage of the assessment process which isintended to ensure that each individual’s nursing needs are properly addressedwithin the care home in which they will live. The assessment provides the opportunityto consider the appropriateness of continuing to live in a care home providingnursing care, and ongoing eligibility for NHS Funded Nursing Care payments. It willalso provide the opportunity to consider whether the care needs indicate that aperson should be referred for further assessment, including a consideration ofeligibility for continuing NHS health care. In any such assessment, this should be thefirst consideration.

9. Making and recording the decision

Following an in-depth nursing assessment, using the information presented by theassessment, and using your professional skill and judgement, write a summary ofthe registered nursing input required. This should form part of the nursingassessment summary record of the Unified Assessment records. Include all therelevant details to enable you to draw a conclusion on the best options for theindividual concerned, which should be recorded on the Summary Record and theNursing Needs Assessment Decision Record (NNADR).

Remember that care from a registered nurse includes time spent in direct contactwith the patient, but also that spent in planning, supervising and monitoring caredelivered by someone else – who may, or may not be a registered nurse.

In order to decide whether or not a person requires care in a care home providingnursing care (and is thus entitled to NHS Funded Nursing Care), the assessing nursewill need to address the key indicators of predictability, complexity, stability and risk(see also Annex C). This information should be used by the assessing NHS nursesalongside their professional skills, knowledge, and observations of the individualconcerned, to inform their decision.

The following indicators relate particularly to the need for nursing by a registerednurse in a care home providing nursing care (i.e. a care home where a nurse isavailable on-site). Nursing care in these circumstances includes only nursingservices which need to be provided by a registered nurse (as defined in section 49 ofthe Health and Social Care Act 2001). It only covers nursing care which is within thelimits set out in the Coughlan judgement i.e. the quality and quantity of the nursingcare must be incidental or ancillary to the provision of accommodation which a localauthority is under a duty to provide, and be of a nature which social services could

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have been expected to provide but for section 49 of the Health and Social CareAct 2001.

Research3 undertaken into the early development of a nursing needs decision recordindicated that indicators of stability, predictability, complexity and risk are reliable andvalid indicators for use in making nursing decisions, in particular for determining thedecision on the appropriate context for care. The decision record presented in thisdocument has built on that research. These indicators are still seen as thefundamental basis for the nursing decision, although the form has been developed toincorporate additional information.

These indicators provide the basis on which decisions on eligibility for NHS FundedNursing Care are made, and alternative options can be considered. The indicatorswill also be used to provide the rationale for the decision, documented on theNNADR.

1. Unpredictability: The unpredictability of the patient’s clinical condition,disease process or behaviour requires monitoring by a registered nurse. (Whenchanges to the patient’s condition cannot be anticipated with certainty, requiringongoing assessment or monitoring by a registered nurse).

2. Complexity: The particular combination or complexity of the individual’sphysical and/or mental health needs require the clinical judgement of a registerednurse in the reassessment or adjustment of nursing interventions. (Clinicaljudgement - A registered nurse’s decision about a patient’s condition and therequired resulting action, based on their observation, knowledge and experience,and any relevant information or advice from others).

3. Stability: The individual’s unstable/fluctuating disease process (alternating orirregular) may require monitoring and/or prompt intervention or treatment from aregistered nurse. (Intervention by a registered nurse - The actions undertaken bya registered nurse based on their clinical judgement of patient’s needs).

4. Risk: The risk of harm to the individual or others may require the availabilityand prompt intervention of a registered nurse, or makes the placement in a carehome with nursing otherwise appropriate.

As noted earlier, in exploring nursing need in relation to these indicators, firstconsideration must always be given to whether the person has health care needswhich may give rise to eligibility for continuing NHS health care and require furthermulti-disciplinary assessment. Consideration will need to be given to the nature andextent of the nursing needs identified, as well as to other health care needs, indeciding whether or not the person should be referred for further assessment andconsideration of eligibility for continuing NHS health care. The document ContinuingNHS Health Care: Framework for Implementation in Wales 2004 (NAW 2004)provides further discussion of questions which may trigger such a referral.(NOTE: Circular WHC (2006) 046/NAFWC 32/2006 provides more recent advice onthe interpretation and application of this Framework).

3 See ‘Factors influencing the decision that an individual has nursing care needs’ in Annex E.

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These indicators will also inform the decision that the person’s needs can be met athome, or in a residential care home setting, or may benefit from alternative servicesto reduce the risk to independence.

You should use the NNADR attached as Annex H to this workbook as the record ofyour decision. You will ensure that the following are recorded:

1. Identifying information: Name, date of birth, normal address, current location,and unique identifiable number (e.g. NHS, hospital, NI), date ofassessment/review (The last two of these, plus the name, are repeated at thetop of each page of the form, to ensure identification when the normal A3 formis copied or faxed).

2. A clear decision as to eligibility for NHS Funded Nursing Care.

3. Justification for that decision, identifying whether or not each of the fourindicators is relevant, and why.

4. Whether or not the patient should be considered for further assessment todetermine eligibility for continuing NHS health care, and what action you willtake to progress this.

5. What other services may be appropriate, and what action you will take toprogress this.

6. The need to refer for any other specialist assessment, and what action is beingtaken to progress this.

7. Confirmation that the patient and/or their representative (where applicable)have been involved in and informed of the decision, and provided with relevantinformation.

8. Your signature, post and date.

9. The persons to whom copies of the NNADR are to be supplied.

It is important that you record how the indicator(s) lead to the eligibility decision, andyou must support your decision with a rationale based on the evidence andinformation available to you and drawing on your professional knowledge, skills andexperience. You should express this rationale as clearly as you can, making clearthe key aspects of need and indicators that informed your decision.

You should also record the decision on eligibility in the Unified AssessmentSummary Record. A copy of the completed NNADR should be appended to the UAPSummary Record, and distributed according to local arrangements, and with theagreement of the person assessed or their representative.

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10. Next Steps

A comprehensive assessment will involve a wide range of health and social careprofessionals working together, and undertaking their individual specialist or in-depthassessment. The nursing assessment may contribute to this as an in-depthassessment, where appropriate, or may be undertaken as a contact or overviewassessment. A range of possible outcomes may result from the nursing assessment.Five key outcomes have been outlined earlier. Consideration should be given to thefollowing when possible outcomes are being considered.

� Continuing NHS Health Care

In undertaking an assessment, or re-assessment, the first consideration must alwaysbe the extent to which the identified needs of the individual indicate that the primaryneed may be a health need, and that they may meet the eligibility criteria forContinuing NHS Health Care. In such circumstances, the matter must be referred tothe appropriate person for multi-disciplinary assessment, according to localarrangements, and actions recorded under ‘A’ on page 4 of the Nursing NeedsAssessment Decision Record.

� Admission to care homes providing nursing care

Once it has been agreed with the individual and/or their representative and theircarers (where appropriate) that a care home with nursing offers the best environmentin which their needs can be met, steps will need to be taken to plan the registerednursing that will be necessary and to set goals for that care. This is an integral part ofthe wider care planning process and is based on the comprehensive assessmentwhich has been undertaken. The NHS registered nurse who identified the careneeds to be provided by a registered nurse may have already co-ordinated theUnified Assessment process, or will have been closely involved. This process (withinthis episode of care) should usually be completed before an actual admission to acare home occurs. Where a local authority is involved in the admission the relevantprofessionals should be working closely together to identify the care required, whichin turn will inform the selection of a particular care home which will be most able toprovide the appropriate care. The guidance issued in 2004 on the NationalAssistance Act 1948 (Choice of Accommodation) Directions 1993 will be relevantwhere a local authority is involved. Arrangements for admission to care homes willbe made according to locally agreed protocols for the Unified Assessment process.

The individual concerned, and their carers (if appropriate) will need to be fullyinvolved in the decision as to an appropriate care home, as they will have views onwhat will meet their needs, and what they would prefer. These will need to be takeninto account as far as possible, alongside professional judgements, and the carehome’s views on whether they can accept and manage the patient. Discussions willneed to include identification of the individual’s specific requirements (includingequipment) and responsibility for the provision of these, based on the informationcontained in the summary assessment.

This nursing assessment will have identified the individual’s need for care from aregistered nurse and whether or not this is most appropriately provided in a care

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home with nursing. Where this is required under NHS Funded Nursing Carearrangements, the Nursing Needs Assessment Decision Record will be submitted tothe relevant (destination) LHB manager who is responsible for the implementation ofNHS Funded Nursing Care. This manager will be responsible for agreeing fundingfor registered nurse services in a suitable home and arranging payment.

� Access to NHS services

Whether or not the individual is to be placed in a care home with nursing, theassessment may have identified other health care needs. Residents of care homesshould have the same access to health services as those living in their own homes.The assessing nurse should ensure that referrals to appropriate services are madeas required.

� Access to other services

When placed in a care home with nursing, through NHS Funded Nursing Carearrangements, the funding responsibility for the accommodation and personal carewill remain with the local authority (or with the self-funding resident), andarrangements for both elements of the funding will need to be agreed before theplacement is made. Arrangements when individuals move between LHBs, or acrossborders, are contained in the guidance NHS Funded Nursing Care in Care Homes:Guidance 2004. Whichever option is chosen, all relevant authorities will need toco-ordinate their assessment and commissioning arrangements to ensure effectiveand smooth placement or alternative service provision.

� Protection of Vulnerable Adults

In undertaking the nursing assessment, the assessing nurse must be aware of thepossibility of abuse of all kinds, and be alert to any indicators of abuse. Where thereappears to be a possibility of such abuse, appropriate local procedures should befollowed.

11. Funding arrangements

Those who are assessed as eligible for continuing NHS health care will be providedwith a package of health care arranged and funded solely by the NHS. This may beprovided in a range of settings, including hospital, care home with nursing, or anindividual’s own home. Other agencies, such as Social Services or Housing, maycontinue to be involved, according to the assessed needs of the person and theircarers, and according to local eligibility criteria.

Those assessed as requiring care by a registered nurse in a care home are entitledto NHS Funded Nursing Care. This is a standard weekly payment made by LocalHealth Boards to care homes with nursing for eligible residents. Continence suppliesare funded as part of the standard payment for NHS funded nursing care. Furtherinformation is contained in the booklet: NHS Funded Nursing Care in Care Homes:What it means for you. Residents are still required to pay for, or contribute towards,their accommodation and personal care costs.

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Individuals not eligible for continuing NHS health care are required to fund, orcontribute towards, the cost of their care in a care home and at home. Currentlegislation requires local authorities to undertake a financial assessment of theindividual in order to determine whether or not they are entitled to financial support.Such assessments will include the income and capital available to the individual.One element of this is the capital limit, above which people are expected to pay fullyfor their care. Ownership of a house will normally count towards capital (although thiswould not normally be the case for as long as the assessed person’s partner remainsliving in the property). For some people paying for care may thus require the sale oftheir home at some stage. Local authorities may also put a charge on the property,so that it does not have to be sold immediately, with care costs being reclaimedwhen it is eventually sold (e.g. after the death of the resident). For the first 12 weeksof a placement in a care home, the value of a person’s home can be disregardedfrom the financial assessment carried out by local authorities for care in a carehome. This financially benefits residents, and provides a breathing space betweenadmission to a care home and the final decision on long term care, as well asproviding time for the decision on how to meet care costs.

Care options other than placement in a care home may be available in local areaswhich may be provided as part of mainstream services. Financial arrangements maybe put in place to fund the care required by an individual, either separately or jointlyby health and social services. Individuals may be required to contribute towards thecost of these services where they are not provided by the NHS.

12. Reviews of care needs

In general, arrangements should be made for health professionals to contribute toregular re-assessments or reviews of care needs to ensure that nursing and otherhealth care needs are identified and met. It is particularly important to considerwhether the individual’s potential for improving their level of independence is beingfacilitated within the care setting. In particular, for people living in care homes withnursing, the registered nurse employed by the statutory NHS body will need toconfirm the persons nursing care needs and whether they continue to qualify forNHS funded nursing care. It is important to recognise that individuals can move inand out of eligibility for NHS Funded Nursing Care. A prime consideration in any re-assessment or review should be whether or not the person’s changed needs triggerconsideration of eligibility for continuing NHS health care. As noted earlier, wherethis is the case the necessary procedures for multi-disciplinary assessment shouldbe initiated, and action recorded on the NNADR. Assessments need to take intoaccount the long term circumstances, and the potential effect of individuals beingrequired to move placements.

Anyone entering a care home providing nursing care on a permanent basis after1 April 2004 should have their nursing care needs reviewed within 3 months, or assoon as possible thereafter, in conjunction with the review by the local authoritywhere this is appropriate, and at least every 12 months thereafter, or as identified inthe initial care plan. Any significant change in the health status of a resident maytrigger a request for a review of the nursing needs, from the resident, theirrepresentative, the registered manager or other appropriate person.

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13. Appeals/Complaints/Disputes

If, following assessment, individuals, or their representatives, have concerns relatingto their assessment they can, initially, discuss it with staff involved in theassessment, to see if it can be resolved informally. If they remain dissatisfied, andwish to challenge the process or application of indicators they may ask the LocalHealth Board for a formal review of the decision.

Concerns about the care provided in the care home should normally be raisedthrough the care home’s own complaints procedure in the first instance, unless thereare good reasons not to. The person being assessed, or their representative, has theright to access the NHS complaints process where they are concerned about anyaspect of the nursing assessment process or its outcome, and about the nursingcare provided by a registered nurse under the NHS Funded Nursing Carearrangements. Local authorities and the Care Standards Inspectorate for Wales mayalso be approached with complaints or concerns about the care provided.

Disputes between health and social care agencies concerning assessmentprocesses, decisions, and subsequent funding arrangements, should be resolvedthrough their agreed disputes procedures. Such disputes should not have adetrimental effect on the timeliness or quality of the care provided.

14. Summary of key points in Undertaking the Assessment

• Before undertaking an assessment, the assessing registered nurse shouldalways read carefully the guidance notes provided in this workbook.

• Where appropriate, the nursing assessment forms part of acomprehensive assessment of individual care needs, within the UnifiedAssessment Process, particularly where decisions on placement in a carehome are concerned.

• The assessment of an individual’s nursing needs will always beundertaken by a registered nurse employed by the NHS (or, particularlywhere funding for NHS Funded Nursing Care is a likely outcome, a nurseotherwise acceptable to the Local Health Board).

• Making a judgement on the most appropriate care options will require a fullanalysis of all assessment information, taking account of the prognosis ofpeople’s conditions and the likely outcomes if help was not provided, orwas provided in different ways. The assessment should use a wholesystem approach that addresses all physical and mental health care needsin the round, and considers all related needs and service options.

• Nurses must be aware of the range of care options that may be identifiedas possible outcomes of the assessment. Moving into a care home is amajor decision that should not be taken lightly. Before deciding on theneeds of anyone for registered nursing in a care home, nurses and otherprofessionals should satisfy themselves that all other care pathways andoptions have been fully explored, particularly in respect of intermediatecare and rehabilitation.

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Author: NNADR Task and Finish group

Date: December 2006

Review Date: June 2007

By whom: NNADR Task and Finish group

Date Review Completed:

• The identification of each person’s nursing needs is based on examinationof these needs, and any likely changes in nursing needs, in terms ofunpredictability, complexity, stability and risk.

• In undertaking an assessment, or re-assessment, the first considerationmust always be the extent to which the identified needs of the individualindicate that the primary need may be a health need, and that they maymeet the eligibility criteria for Continuing NHS Health Care. In suchcircumstances, the matter must be referred to the appropriate person formulti-disciplinary assessment.

• The standard paperwork should be completed for each decision about thenursing care needs. This should include the nursing assessment record,the Nursing Needs Assessment Decision Record and any additionalsheets summarising essential information that has informed the decision.Copies should be attached to the person’s Unified Assessment Summaryrecord documentation.

• Where it is proposed to place a person in a care home with nursing, theNHS Nursing Needs Assessment Decision Record paperwork should besent to the relevant lead manager for NHS funded registered nursing carein the relevant (destination) LHB.

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ANNEX A: THE UNIFIED ASSESSMENT PROCESS

There are real gains to be made through the Unified Assessment processinvolving all the health and social care agencies that are involved in the care ofthe individual. These include:

• helping to bring about ‘person-centred care’ and provide flexible andappropriate care irrespective of the administrative boundaries between healthand social care services;

• professionals work together in the best interests of the person beingassessed;

• the person’s (and carers’) views and wishes are central to the assessmentprocess;

• assessment builds a rounded picture of their problems and circumstances;

• the depth and detail of the assessment is proportionate to their needs;

• assessment is supported by an appropriate evidence base; and

• the process builds upon and supports existing good practice.

The Unified Assessment process enables professionals to see and recognise eachother’s contribution to care:

• it is useful to those practitioners responsible for its day to day operation;

• it enables professionals to see each others’ contributions to assessment,which are subsequently trusted and accepted;

• information about problems is given once, no matter that the assessment andsubsequent care planning and service delivery involves a number ofprofessionals and agencies;

• it can produce sets of agreed, evidence based standardised assessmentinformation and a single summary record on individual cases;

• it facilitates the sharing of case information between professionals and alsogenerates large scale information for strategic planning and performancemonitoring;

• it focuses on the outcomes of care for the individual and when it uses the fullrange of shared assessment information to develop appropriate and effectivecare plans and services; and

• it promotes the health, independence and quality of life of people seekinghelp.

Agencies are developing systems based on four broad types of assessment:

– Contact assessment– Overview assessment– Specialist/In-depth assessment– Comprehensive assessment

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These types vary in their breadth and depth. In practice, the four types ofassessment are likely to be undertaken within a Unified Assessment process, ratherthan in discrete stages.

The contact assessment refers to the initial contact with services – such as aconsultation with the GP, or initial discussions with other NHS or social servicesprofessionals. At contact assessment the nature of any presenting problem isdetermined, and whether or not there are wider health and social care needs isestablished. Basic personal information should also be collected at this stage(i.e. name, address, date of birth, gender, ethnicity, household composition etc). Formany people the contact assessment will be sufficient to determine and address theperson’s needs (where the presenting problem or request for assistance isstraightforward). However, if it is clear that there are complex or multiple problemsthat need to be examined, the decision to proceed to the other types of assessmentwill be made by the professionals concerned.

The overview assessment is the stage at which all or most of the domains of theassessment process are covered and further in depth assessment needs areidentified. These domains are listed in Box 2 below. This stage may be sufficient tofully describe the person’s needs; if not, it will trigger areas where furtherassessment is required. If the need for an overview assessment has beenimmediately apparent, this will have commenced as soon as basic personalinformation has been collected.

Specialist/In-depth assessment is the further exploration of specific domains thatmay have been indicated by the contact or overview assessment. In depthassessments require the involvement and judgement of appropriately qualified andexperienced professionals (such as occupational therapists, physiotherapists,qualified social workers, registered nurses and specialist nurses, geriatricians andold age psychiatrists). Overview assessment and some in-depth assessment maymake use of particular standardised assessment tools and scales to supportprofessional judgement (for example, the Geriatric Depression Scale might be usedto explore the extent of an older person’s depression, or the Mini-Mental StateExamination might be used to determine level of cognitive impairment or memoryloss in someone with early dementia).

A comprehensive assessment may arise in different ways. The completion ofin-depth assessment of all or most of the domains of the assessment processconstitutes a comprehensive assessment. A comprehensive assessment may alsobe instigated at first contact where it is apparent to the professional that the person’sneeds are complex and multiple. Comprehensive assessment should also becompleted for people when the level of support and treatment likely to be offered isintensive and complex (including permanent admission to a care home, intermediatecare services, or intensive packages of care at home). The assessment will alsoneed to consider what decisions may be required following the assessment,including eligibility for continuing NHS health care or NHS Funded Nursing Care. Nodecision about where people are best supported should be made prior to theevaluation of all information generated by the comprehensive assessment (includingconsideration of rehabilitation potential).

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Assessment is not just about the collection of information about a person’simmediate problems and circumstances. It is also about analysing those problems toidentify assessed need. Professionals should take account of the following issues:

• the risks to independence posed by problems in the past, present and future;• the stability, unpredictability and complexity of problems; and• the potential for rehabilitation.

Recording the process of assessment

The process depends for its effectiveness on good record keeping to ensurecontinuity of care, to prevent duplication of work and repeated questioning, to ensurethat the whole care team is informed about the needs to be met and render theprocess open and transparent to service users. Open communication with users andwithin their care team ensures that clinical governance requirements are met and thedecisions which are taken can be justified. Good record keeping is the best defenceof good practice if decisions are challenged or disputed.

The Domains of assessment

The following lists all the domains of assessment which will have been considered inthe overview assessment. Various other specialist assessments may have beentriggered, and where available can be used to inform the nursing specialistassessment.

Box 2: THE AREAS/DOMAINS OF ASSESSMENT

User's perspective• Problems and issues in the users' own words• Users' expectations, needs, strengths, abilities and motivation including cultural

and social expectations• Recent life events – including strengths and coping mechanisms• Personal and spiritual fulfilment and life style choices• Advocacy needs

Carers perspective and need for carer assessment• Physical difficulties in caring• Psychological difficulties and pressures arising from caring role, including shock,

grief, felt inadequacy• Life constraints arising from caring role e.g. clashes with employment, child care

responsibilities, leisure activity• Carer’s strengths, expectations, motivation and perception of her/his needs and

user’s needs

Clinical background• History of medical conditions and diagnoses• History of falls• Medication use and ability to self-medicate• Recent hospitalisation• Breathing difficulties

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Disease prevention

• History of blood pressure monitoring• Nutrition/current diet/swallowing ability/fluids• Vaccination history• Drinking and smoking history• Exercise pattern• History of screening

Personal care and physical well-being

• Pain• Oral health• Foot-care• Skin care including prevention of pressure areas• Mobility in and out of the home• Climbing stairs• Continence and other aspects of elimination• Sleeping patterns

Activities of Daily Living

• Washing• Bathing• Grooming, including hair care and shaving• Dressing• Accessing and using toilet• Transfer in/out of chair• Transfer from bed• Eating and drinking• Ability to make choices and have control over environment• Suitable equipment

Senses

• Sight• Hearing• Smell• Taste• Speech and communication, first/preferred language and understanding

Mental health

• Cognition and dementia, including orientation and memory• Mental health including confusional states, paranoid states, depression and

reactions to loss, and other emotional difficulties• Substance misuse (including tranquillisers or alcohol)

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Relationships

• Social support and network, personal relationships, and involvement in leisure,hobbies, religious groups

• Carer support and strength of caring arrangements• Ability to care for others where necessary e.g. partner

Safety

• Abuse and neglect (risk assessment)• Other aspects of personal safety (risk assessment)• Public safety/hazards (risk assessment)• Manual handling assessment (risk assessment)

Instrumental Activities of Daily Living

• Meal and snack preparation• Make hot drink• Heavy housework (cleaning)• Keeping warm• Shopping• Care of the home• Managing affairs (finances, paperwork)

Immediate environment and resources

• Accommodation (including noise), heating or physical hazards (risk assessment),location and access.

• Level and management of finances and need for benefit advice (riskassessment)

• Access to local facilities and services• Work, education, learning and participating in community activities• Transport needs

Summary of key points in the Unified Assessment Process

� Unified Assessment was implemented across health and social servicesfor older people in April 2005, and for all adult service users in April 2006.

� A more standardised approach will exist which addresses people’s needsin the round, and ensures that the scale and depth of assessment is keptin proportion to people’s needs; that agencies do not duplicateassessments; and that professionals contribute to assessments in themost effective way. Individual specialist assessments build on theinformation obtained in the enquiry, contact and overview assessment asappropriate.

� Assessment should not be used in a mechanistic or bureaucratic manner,but should reflect the principles that underpin the entire assessmentprocess, i.e. it focuses on the person as an individual, looks at their needsin the round, uses standardised tools where these are available, and isoutcome based.

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ANNEX B: ARTICLE: NURSING WITHIN THE CONTEXT OF UNIFIEDASSESSMENT

Nursing has for many years debated the role of nursing theory in relation to practice.The formulation of ideas around nursing in relation to the development of the UnifiedAssessment process (Creating a Unified and Fair System for Assessing andManaging Care - Welsh Assembly Government, 2002) gives nursing an opportunityto consider further the role of nursing as it focuses on helping the patient interpret hisor her own behaviours and experiences in relation to their individual journey alongthe health and social care continuum (Pearson et al, 2005). Therefore, it is importantthat nurses embrace the Unified Assessment process using a theoretical andevidenced-based approach in order to maximise the assessment experience. Inconsideration of the principles of Unified Assessment process it has been consideredbest practice for some years that nursing assessment should be both holistic andperson centred. This in addition to enhanced professional networks (across healthand social care) using a collaborative approach should lead to an improved patientexperience and professional gratification.

How does nursing fit in?

Nursing assessment and its appropriate documentation should be developedthrough considering not only the Unified Assessment process but also nursingmodels and the individual patient and nursing context. A model typology such as thatsuggested by Wimpenny (2002, see diagram 1) offers an approach for nurses toengage with other professionals within this whole systems approach to genericassessment framework. It ensures that nurses are able to gain the information theyrequire to develop nursing diagnoses, acknowledge need, manage the risk toindependence, consider outcomes, decide interventions and prescribe nursingtreatment through planning, delivering, reviewing and evaluating individual patientcare.

The linked three-model typology (Wimpenny, 2002) considers a theoretical, asurrogate and a mental model. The relationship between these three models thenallows the nurse to develop the questions, gain the information that she/he needs toensure that assessment is holistic, patient centred, proportionate to need andevidenced based. Therefore nursing is demonstrated through assessment and clarityof action.

The surrogate model such as the Unified Assessment process, represents ‘astructure or a framework’ or a common system of organising work, around which allprofessionals are able to develop common language, collect common informationand share distinct information through local protocols. In this case it also providesthe process by which the theoretical and the mental models are driven. Its influenceis seen not only within the process structure but also in its principles of personcentred care and managing risks to independence.

The theoretical models such as Orem (Hartweg,1991) or Roper, Logan & Tierney(2000) comprise of beliefs, ideas and knowledge which should provide the tools bywhich nurses can think critically by developing the right questions and theories inorder to problem solve with or for the patient, carer and/or family. A single model or a

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combination of models may be adopted depending on your needs as a team and thepatients and families you nurse.

The mental model represents a combination of the personal knowledge andexperience of the nurse which influences his/her critical thinking and professionaljudgement. In addition to the patient’s personal situation that the nurse encountersand which will influence his/her assessment.

An extended Wimpenny (2002) typology (see diagram 1) is suggested through theinclusion of the influences of the environment and service model type. Both of whichare outside of the nurse’s influence, although they have a profound effect on theidentification of need and unmet need throughout the assessment process. Inparticular knowledge about service models available within the community followingpatient discharge will confirm whether or not the patients identified needs andoutcomes are likely to be met. Indeed if in the nurse’s opinion the most appropriateservice is not available to meet the patient’s need then an unmet need may then berecorded.

Diagram 1: The three model typology – extended version

So, nursing assessment is a multi-dimensional process which is not only essential todetermine problems needs and outcomes but also ensure that the correct nursingcare is prescribed. Using the typology in diagram 1 ensures that assessment isadequate and that patients are not put at risk.Adopting the Unified Assessment process as the surrogate model allows nursing toengage at the four levels of assessment as described in the Unified Assessmentguidance. The following information should help you to consider how to develop yourassessment and its appropriate documentation within a Unified Assessment context:

Surrogatemodel type

Mentalmodel type

Theoreticalmodel type

Environment &Service modeltype

Experience

UAPOrem

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Enquiry level

The Basic Personal Information (BPI) as defined within the Unified AssessmentNational Data Set is considered to be the universal minimum amount of informationrequired at this level. Nurses should only gather this information if the patient has notpreviously been known to the service such as a self-referral to a:

• community nursing team,• practice nurse• A&E department.

Whilst on most occasions nurses should not gather this information there will beoccasions within the implementation of the new process that it will be necessary todo so. Otherwise this information should be (in addition to further enquiryinformation) communicated to you as part of the referral information or summaryrecord. This should form the ‘front end’ of your documentation replacing any similarinformation such as found on page 1 of the All Wales documentation.

Consider that this may not be the only information that you require on the front endof your documentation. Further information that you will have need of will be ward orteam specific and can only be recognised by your team through assessing your owninformation needs, for example you may need to establish a record of previousadmissions, current medical or nursing diagnosis. A team working within an A&Edepartment, an acute medical area, a community nursing team or practice nurse willall have differing nursing information needs. These needs will be dependent uponthe team or individual role e.g. sustaining life or managing chronic illness and aproportion may be considered to be ‘in-depth’ in nature.

Consider also the patient’s ability to self assess. This should be considered withinthe Unified Assessment process as many patients and their families are embarkingupon common initiatives such as the ‘Expert Patient’ programmes.

Contact Assessment

Collating the 7 key issues through a patient’s (and carer if required) perspective is acommon approach adopted by most nurses to explore the presenting need andascertain the assessment approach to be adopted. You may also wish to includespecific trigger questions which may help to determine appropriate triggers forreferral e.g. using CAGE (Mayfield et al, 1974) with patients who have suspecteddrug or alcohol misuse may help to determine whether an overview or an in-depthassessment is the next best step.

Adopting the modular approach advocated within the Unified Assessment Guidance(2002) offers an opportunity to cater for the assessment in accordance with patientneeds, avoid duplication and develop collaboration. Adopting a nursing model at thisstage in accordance with your ward or team philosophy will serve to promotestandardisation, help to provide triggers for referrals to other professionals andagencies and determine the care to be agreed and delivered and the patientoutcomes desired e.g. using Roy’s model (Pearson et al, 2005) helping people toadapt to internal and external stimuli or using an adapted medical model to ascertain

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the immediate medical/nursing problems a patient may have when admitted to theMedical Assessment Unit.

The information required within this stage will be determined again by your

• Ward• Team• Unit or• Practice

This will be in relation to your information needs, relationships with otherprofessionals and agencies and in discussion with your local Unified Assessmentproject lead. For example, nursing teams working within A&E may be able to receivethis information from the Ambulance team transferring the patient to the department,from the GP, social services or the voluntary sector. The information gained willtrigger which type of in-depth assessment/ pathway is used e.g. trauma, drugoverdose at that time.

Overview assessment

The twelve domains (and their sub-domains) are modular and should only be usedproportionately. They act as a framework (surrogate) only for the initial collection ofbroad information required to support your nursing information needs. Here thedevelopment of information in accordance with the nursing (theoretical) model andthe nursing experience and knowledge (mental model) will determine further theappropriate questions to be asked in order to support the patient, manage risk toindependence and achieve clinical and individual outcomes. Developing theappropriate domains depends upon the patient’s needs, the proposed/expectedpatient outcomes and the patient’s length of stay within a department.

Should an overview assessment be developed following a contact assessment thenthe information content of a domain will determine the appropriate need for in-depthassessment (e.g. wound assessment, or continence assessment), planned care andpossible referral to other professionals for alternative or complementary in-depthassessment (e.g. medical, physiotherapy, occupational therapy, dietetics or tissueviability). Diagnostic tools used (e.g. blood pressure, blood results) here will be usedto aid professional judgement in respect of appropriate decision making.

However, there will be occasions when an in-depth assessment will occur prior to theoverview assessment. This is usually due to the need for fast track assessment ineither acute or community settings. The content of the in-depth assessment will thenprovide information for populating overview domains and may provide further triggersfor additional in-depth assessment(s).

In-depth assessment

An in-depth (or specialist) assessment should be provided when distinctive triggersfor assessment are recognised. This type of assessment offers an opportunity forspecific and critical investigation with analysis of a patient’s problem using arecognised model such as the change continuum advocated by Prochaska and

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DiClemente (1983) within the WIISMAT. The principles of Unified Assessmentincluding person centred assessment and risks to independence should beconsidered within the assessment. Needless to say patient’s needs, objectives,outcomes should be identified and incorporated within a prescribed nursing plan ofcare.

Any professional nurse with adequate education and experience may undertake thistype of assessment e.g. leg ulcer and continence assessments. Frequently these willbe interwoven into a care pathway. It is essential that these evidence basedassessments within the pathways adopt the Unified Assessment process principles,ensuring that the commonly shared items of information are not duplicated.

Occasionally the in-depth assessment may be integrated with other professionalassessments such as the WIISMAT (Wales Integrated In-depth Substance MisuseAssessment Tool), Care Programme Approach (Welsh Assembly Government, 2003)and Continuing NHS Health Care in order to provide an in-depth and allinclusive/complete assessment. The Nursing Needs Assessment Decision Record(NNADR) will be completed for recognised in-depth nursing assessments forContinuing NHS Health Care, NHS Funded Nursing Care and Intermediate Care,once the nursing assessment has been completed. This will provide clarity of nursingdecision making as to whether nursing care is required (and at what level) by thepatient.

Any specialist tools and scales such as MUST (Malnutrition Universal ScreeningTool; Bapen, 2003) and DAST-10 (Drug Abuse Screen Test -10; Skinner, 1982)should be standardised along the patient’s journey. This provides an opportunity tomeasure effectiveness of person centred outcomes and provides a baseline for anyfuture or further assessment.

Comprehensive assessment

This level of assessment provides an opportunity for the care co-ordinator to draw allassessments together and gain an overall picture as to what exactly is happeningwith the patient, in order to inform decision making. From this insight, thecare-co-ordinator will be able to develop a ‘service’ care plan from which nurses (andother professional groups and services) who are involved with delivering patient carewill have an understanding as to why they are being requested to do so and to whomthey should be communicating further information.

It is understood that the role of care co-ordinator is a flexible role which should bedetermined not only by the patient’s overwhelming and complex needs (i.e. whetherpredominantly health or social care) but also patient choice. Within the hospitalenvironment there should be a single care co-ordinator who has responsibility toensure that the patient’s complex needs in relation to care and discharge planningare complete. In the past this has been undertaken by the ‘Named Nurse’ prior tohanding over the role to the most appropriate professional within the community.This type of arrangement would now ensure continuity throughout the dischargeprocess and fulfil the needs of the Unified Assessment process.

Annex G provides a map of the Unified Assessment and Care Management Processcontinuum.

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Nursing Checklist

No. Detail Yes/No Comments/Actions1. Have you mapped your nursing

information needs across thepatient’s journey within your area?

2. Have you looked at where yourinformation comes from?

3. Can you use the informationpreviously collected to avoidreplication?

4. What information do you send toother professionals or agencies?Is it helpful?

5. Is this information helpful to them?6. Do you provide enough information to

inform them of what you and theservice user are expecting of them?

7. Have you adopted a nursing model(or a combination model) to help youask the right questions within yourassessment approach, process anddocumentation?

8. Have in-depth assessments (such astrauma, continence, wound care,nutrition, Continuing NHS HealthCare and NHS Funded Care) beenaltered to dovetail the UnifiedAssessment Process?

9. Have you standardised yourassessment tools and scales (sametype and version) along the patientjourney?

10. Have you integrated your carepathways within the UnifiedAssessment process?

11. Have you agreed what information toinclude within the Summary Record?

12. Have you decided how all nursingdecisions will be included within theSummary record?

13. Have you adopted the principles ofthe Unified Assessment processwithin your decision makingprocesses and relevantdocumentation?

14. Have you adopted the principles ofthe Unified Assessment processwithin your relevant documentation?

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No. Detail Yes/No Comments/Actions15. Have you incorporated the discharge

process within the UnifiedAssessment process?

16. Have you considered whatinformation you need to share withother professionals and agencies?

17. Have you considered how you willshare information in the absence ofan electronic record?

18. Have you agreed (with colleaguesand/or partner agencies) how you willshare information in the absence ofan electronic record?

19. Have you agreed the terminologyaround the care plan and servicedelivery plan?

20. Have you agreed how these will linktogether?

21. Have you developed the link betweenclinical diagnosis, nursing diagnosisand the Unified Assessmentprocess?

22. Have you agreed the link betweenclinical diagnosis, nursing diagnosisand the Unified Assessmentprocess?

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References

Hartweg D (1991) Dorothea Orem Self-Care Deficit Theory. Notes on NursingTheories 4. Sage Publications.

Mayfield D, McLeod G and Hall, P. (1974). The CAGE questionnaire: validation of anew alcoholism instrument. American Journal of Psychiatry 131: 1121-3.(http://www.hda-online.org.uk/documents/manual_fastalcohol.pdf accessed on27th May 2005)

Pearson A Vaughan B & FitzGerald M (2005) Nursing Models for Practice 3rd

Edition. Butterworth Heinemann

Prochaska J & DiClemente C (1983) Stages and process of self change of smoking:towards an integrated model of change, Journal of Consulting and ClinicalPsychology 51:390-395

Roper N, Logan W & Tierney AJ (2000) The Roper-Logan-Tierney Model of Nursing:The Activities of Living Model. Churchill Livingstone.

Skinner HA (1982) The Drug Abuse Screening Test. Addictive Behaviour. 7; 363-371

National Assembly for Wales (2002) Creating a Unified and Fair System forAssessing and Managing Care.

National Assembly for Wales (2003) Mental Health Policy Guidance. The Careprogramme Approach for Mental Health Service Users.

Wimpenny P (2002) The meaning of models of nursing to practising nurses. Journalof Advanced Nursing 40(3) 346-353

Authors:

Carolyn Wallace, Senior Lecturer, School of Care Sciences, University ofGlamorgan.

Gill Haram, Office of the Chief Nursing Officer, Welsh Assembly Government.

Date: 7th November 2005Review date: 7th November 2006By Whom: Carolyn Wallace

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ANNEX C: THE POLICY CONTEXT OF NHS FUNDED NURSINGCARE IN WALES

‘Improving Health in Wales – A Plan for the NHS with its partners’ published inJuly 2001, set out the Welsh Assembly’s wide ranging plans for sustainedinvestment and modernisation of the health service. This included specific plans forthe funding of long term care, and provided the Welsh Assembly’s response to theproposals made by the Royal Commission on Long Term Care. Many of the RoyalCommission’s recommendations have been accepted by the UK Government andthe Welsh Assembly and acted upon. The subsequent publication of ‘Designed forLife’ (NAW 2005) builds upon this, reinforcing and developing the policy direction setin 2001.

Within this wider context the National Assembly for Wales is committed to a broadrange of actions to improve the care of older people including:

• implementing the Strategy for Older People and the National ServiceFramework for Older People;

• developing a Unified Assessment and care management system for peoplewith complex health and social care needs, in particular older people;

• promoting seamless services, independence and choice, and addressingwider issues affecting older people;

• implementing reforms to the funding of long term care;

• as part of the Strategy, reviewing the housing options available to promotecommunity support and reduce or avoid the risk of institutional care; and

• putting forward proposals and investment to develop and strengthenIntermediate Care Services as part of the Strategy and NSF for Older PeopleThese services, provided by health services in partnership with social careservices, are intended to:

� help people remain independent in their own homes where that is theirwish;

� avoid unnecessary hospital admissions; and� facilitate the transition from hospital to the community.

The continued development of such services should enable older people to be moreindependent, and help ensure that admissions to care homes can be delayed oravoided until or unless they are the most appropriate and preferred option.

NHS Funded Nursing Care by a Registered Nurse

‘Improving Health in Wales – A Plan for the NHS with its partners’ accepted thatregistered nursing care should be free of charge to the recipient, in all appropriatesettings. The situation which had evolved created unjustifiable anomalies whereby

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some people in care homes with nursing were responsible for some or all of thecosts of their nursing care. This does not occur when people receive registerednursing care in hospital or in the community. It was therefore announced that theNHS would meet the costs of registered nurse time spent on providing, delegating orsupervising care in a care home with nursing4.

Section 49 of the Health and Social Care Act 2001 made provision for the removal oflocal authorities’ responsibilities for providing nursing care by a registered nurse. TheAct defined nursing care in the following terms:

‘any services provided by a registered nurse and involving

(a) the provision of care or(b) the planning, supervision or delegation of the provision of care,

other than any services which, having regard to their nature and thecircumstances in which they are provided, do not need to be provided by aregistered nurse.’

This does not include:

• Time spent by non-nursing staff such as care assistants (although it doescover the nurse time spent in monitoring or supervising care that is delegatedto others).

• Personal or social care or the accommodation provided to residents.

Further, as clarified by the Grogan5 judgement, it includes only nursing serviceswhich need to be provided by a registered nurse (as defined in section 49 of theHealth and Social Care Act 2001). It only covers nursing care which is within thelimits set out in the Coughlan judgement i.e. the quality and quantity of the nursingcare must be incidental or ancillary to the provision of accommodation which a localauthority is under a duty to provide, and be of a nature which social services couldhave been expected to provide, but for section 49 of the Health and Social CareAct 2001, as part of a social services package.

In making the NHS responsible for the funding the nursing element of care homeswith nursing, no resident has to pay for the registered nursing provided. Identifyingregistered nursing input is approached on an individual basis, with funding beingtriggered when there is a need for care to be delivered by a registered nurse.

It is important to point out that all establishments providing accommodation withpersonal or nursing care are now described as care homes. Not all care homes areregistered to provide nursing care. Those which are (previously called nursinghomes) tend to be referred to now as ‘care homes with nursing’. They have aregistered nurse on site at all times. They are distinct from other care homes(previously residential homes) which provide for people who are dependent, needing

4 (and ,as noted earlier, appropriate, independent hospitals as defined by section 2(3)(b) of the CareStandards Act 2000 – see 2004 Directions)5 R v. Bexley NHS Care Trust & Ors [2006[ EWCH 44

35

social and personal care, but who do not require access to nursing care other thanthat available in the community from the usual community nursing services.

When did this take effect in Wales?

Extending the obligations of the NHS took effect at different times for different groupsof people, beginning on 3 December 2001 for people who were meeting the costs oftheir nursing care in a care home from their own resources. In April 2004 this wasextended to those care home residents supported by local authorities. From thatpoint, for all care home residents, arranging care from a registered nurse becamethe responsibility of the NHS.

How do the funding changes work in practice?

One of the things that have changed is who pays for the care by a registered nurse,and this has involved a transfer of costs from the individuals, and from localauthorities, to the National Health Service.

With the shift in funding responsibility, there needed to be a clear model foridentifying the NHS funded nursing needs, and the funding attached to this. TheWelsh Assembly considered various approaches to identifying the NHS contributionand this formed part of the consultation process on these changes. It was agreedthat the nursing contribution be presented as a standardised payment for nursingcare costs, including those for continence care. This is the funding that is theresponsibility of the NHS. It is different from the banding system adopted in England.The advantage of this standardised payment for care from a registered nurse is thatalthough the needs of the individual will change, they will not need to have frequentre-assessments unless there are major changes in their needs which may affect theireligibility.

Another change linked to who pays for the care is who contracts for, and monitors,the care provided. In relation to the nursing care, this becomes the responsibility ofthe Local Health Board for the area in which the care home is located. Theinformation obtained in the assessment and review process will help keep the LHBinformed of the care provided.

Each LHB is required to nominate nurses who will be responsible for managing thebudget for NHS funded nursing care. In addition, each LHB has a distinctresponsibility for monitoring the quality and consistency of nursing assessments anddecision making, and providing professional nursing advice on assessment and careplanning issues and service delivery plans.

Relationship with Continuing NHS Health Care

The NHS and local authorities both have responsibilities for arranging and fundingservices that meet the needs of their population. Long term care is a general termthat describes the care which people need over an extended period of time, as theresult of disability, accident or illness to address both physical and mental healthneeds. It may require services from the NHS and/or social care. It can be provided in

36

a range of settings, from a NHS hospital, to a nursing home, residential home orhospice, and people's own homes.

In addition, the NHS is responsible for what is known ‘Continuing NHS health care’which describes a package of health care arranged and funded solely by the NHS.These responsibilities remain unchanged; the requirement to fund theregistered nursing care of people in care homes will not reduce the need toalso make provision for continuing NHS health care. This has been discussedearlier in Section 6. Further advice on continuing NHS health care can befound in Circular WHC 2004 (54)/ NAFWC 41/2004: NHS Responsibilities forMeeting Continuing NHS Health Care Needs: Guidance 2004 which should beread in conjunction with Circular WHC (2006) 046/NAFWC 32/2006: Furtheradvice to the NHS and Local Authorities on Continuing NHS Health Care.

The Nursing Needs Assessment Decision Record

The 2003 report of the Health Service Ombudsman on Long Term Care emphasisedthe importance of clear recording of decisions on eligibility for continuing NHS healthcare. It is essential that all decisions on eligibility for care, including NHS FundedNursing Care and continuing NHS health care, are properly recorded and justified.This includes the decisions that people are not eligible, or that an assessment toexplore eligibility is not appropriate. The Nursing Needs Assessment DecisionRecord provides the basis for recording the decisions arising from nursingassessments.

37

ANNEX D: GLOSSARY

Assessment The process whereby the needs of and risks to/from anindividual are identified and their impact on independence,daily functioning and quality of life is evaluated, so thatappropriate action can be planned. Assessment involvesboth professionals and those with the needs thinking throughdifferent explanations for how the needs have arisen, andhow different needs interact with each other. Assessmentsshould cover the following three systems: the service usersystem, the informal care network system, and the formalcare network system. Assessment starts from the first ofthese and moves outward. Further information is obtainedwithin the Guidance WHC(2002)32/NAFWC 09/2002:Creating a Unified and Fair System for Assessing andManaging Care.

Care home The Care Standards Act (2000) established new terminologyfor care homes. For the purposes of this guidance a carehome is a home which has been registered to allow for theprovision of nursing care. Where a home is registered for theprovision of both residential and nursing care, the guidancerefers only to the provision of nursing care.

Care management A process whereby an individual's needs are identified andevaluated, eligibility for services is determined, PersonalPlans of Care are drafted and implemented, and needs aremonitored and re-assessed. ("Case management" is analternative term).

Care co-ordination This is undertaken by a named professional when a personhas needs that require the input of a number ofprofessionals. It ensures that assessment and subsequentaction is joined-up.

Care planning A process based on an assessment of an individual's needsthat involves determining the level and type of support tomeet assessed needs, and the objectives and potentialoutcomes that can be achieved.

Comprehensive This refers to assessments in which most or all of theassessment domains of the Unified Assessment process have been

triggered and explored through the use of specialist/in-depthassessments. All people entering care homes or in receipt ofintermediate care services should have received acomprehensive assessment. It will include medicalassessment.

Contact This refers to a first assessment involving the personassessment and professional, and establishing the nature of the

presented problem and whether or not there are potential

38

wider health and social care needs. Basic personalinformation will also be collected, or verified if previouslycollected, at contact assessment.

Continuing NHS This describes a package of health care arranged andhealth care funded solely by the NHS.

CSIW Care Standards Inspectorate (Wales).

Diagnosis This is another term for assessment most usually associatedwith health care. It often implies a cause and /or prognosis.

Identified nursing Those needs for care by a registered nurse which areneeds identified during the assessment process.

LA Local Authority

LHB Local Health Board

Long-term care Long-term care is a general term which refers to the carewhich people need over an extended period of time, as theresult of disability, accident or illness, to address physicaland/or mental health needs. It may require services from theNHS, social care and other services.

NHS National Health Service

NHS Funded The funding provided to care homes by the NHS toNursing Care support the provision of nursing care by a registered nurse

for those assessed as eligible.

NHS Funded The part of an assessment carried out by an NHSNursing Care nurse (or otherwise acceptable to the funding LHB)assessment who has undergone appropriate training which will determine

whether the person assessed is eligible for NHS FundedNursing Care in a care home.

Nursing care The use of clinical judgement in the provision of care toenable people to improve, maintain, or recover health, tocope with health problems, and to achieve the best possiblequality of life, whatever their disease or disability, until death(RCN)

Section 49 of the Health and Social Care Act, 2001 definesnursing care by a registered nurse as meaning any servicesprovided by a registered nurse and involving-

(a) the provision of care, or(b) the planning, supervision or delegation of the

provision of care, other than any services which,having regard to their nature and the circumstances

39

in which they are provided, do not need to beprovided by a registered nurse.

It does not include any time spent by any other personnelsuch as care assistants, who may be involved in providingcare, although it would include any nurse time spent inmonitoring or supervising the care that is delegated toothers.

Overview This refers to situations where all or most of theassessment domains of the Unified Assessment process are explored.

Overview assessment may be able to fully identify anddescribe needs; if not, it should indicate or trigger wherespecialist assessment is required.

Personal Plan A record that sets out, for people who are to beOf Care provided with help, the objectives of that help,(also known as a preferred outcomes, services to be provided, a reviewCare Plan) date, and other details. All people who receive services

should receive an appropriate Personal Plan.

Primary Health In applying the “Primary Health Need Approach”, theNeed Approach elements of quality and degree (i.e. nature, complexity,

intensity etc. of the need) should be considered against thelimits of the lawful provision of social services by the localauthority, and not in isolation. There will be a primary healthneed if the nursing and/or other health services required bythe individual are more than incidental or ancillary to theprovision of accommodation which a local authority is undera duty to provide, and are of a nature beyond that which anauthority whose primary responsibility is for social servicescould be expected to provide, but for s.49 of the 2001 Act, aspart of a social services package.

Review This refers to re-assessment of people's needs and issues,and consideration of the extent to which services aremeeting the stated objectives and helping to achieve thedesired outcomes.

Specialist/in depth This refers to further exploration ofassessment assessment domains that have been triggered by contact or

overview assessment. Specialist assessment will usually becarried out by qualified professionals and may require theuse of scales. It will result in detailed knowledge and insightsabout particular needs.

Tool This is a collection of scales, questions and checklists thathave been brought together for assessment purposes. Analternative term for "tool" is "instrument".

40

41

ANNEX E: KEY DOCUMENTS

Building for the Future - Social Services White Paper 1999

Creating a Unified and Fair System for Assessing and Managing Care (NAW 2002)

Continuing NHS Health Care: Framework for Implementation in Wales 2004(NAW 2004)

Defining Nursing (Royal College of Nursing 2003)

Designed for Life: Creating world class Health and Social Care for Wales in the21st Century (NAW 2005)

Factors influencing the decision that an individual has nursing care needs(University of Wales College of Medicine et al 2002)

Flexibilities for Joint Working between Health and Local Government (NAW 2000)

Further advice to the NHS and Local Authorities on Continuing NHS Health Care(WHC (2006) 046/NAFWC 32/2006) (NAW 2006)

Guidance on Protocols for Sharing Information (NAW 2003)

Hospital Discharge Planning Guidance (NAW 2005)

Improving Health in Wales - A plan for the NHS with its Partners (NAW 2001)

Increased Flexibilities Partnership Framework: A User Guide (NAW 2002)

In Safe Hands: Protection of Vulnerable Adults in Wales (NAW 2000)

National Service Framework for Older People in Wales (NAW 2006)

NHS Bodies and Local Authorities Partnership Arrangements (Wales)Regulations 2000

NHS Funded Nursing Care in care homes Guidance 2004 (NAFWC 25/2004 –WHC (2004)024) (NAW 2004)

NHS Funded Nursing Care in Nursing Homes – What it means for you(Revised December 2003) (NAW 2004)

NHS Responsibilities for Meeting Continuing NHS Health Care Needs: Guidance2004 (WHC (2004) 54 – NAFWC 41/2004) (NAW 2004)

Planning and Commissioning Guidance WHC (2003)63 (NAW 2003)

Practitioners Guide to Carers Assessment (NAW 2001)

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Promoting Partnerships in Care: Commissioning across Health and Social Services(NAW 2003)

Provision of services to registered nursing and residential homes: Guidance for GPs(BMA, 1996)

The Framework for the Assessment of Children in Need and their Families(NAW 2000)

The Strategy for Older People in Wales (NAW 2003)

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ANNEX F: ILLUSTRATIVE CASE STUDIES

The following case studies provide some illustrative examples of the range of peoplewho may have their nursing needs assessed, and the outcomes that may result fromthat assessment. They are designed to assist practitioners in understanding theapplication of the Workbook, and the completion of the NNADR.

The cases as presented are fictitious, but are derived from assessments of actualcases. They provide brief assessment information, and illustrations of how theindicators and decisions may be recorded. They can be used as part of trainingprogrammes or individual study. They should always be read in conjunction with therelevant policy documents.

Case study 1

Mr. Jones is 79 years old and lives with his wife at home. He has mobility problemsresulting in frequent falls. He has poor nutritional intake and has occasional episodesof urinary incontinence. Following a recent fall Mr. Jones has taken to his bed,making it difficult for his wife to manage. The G.P. was called, but there was no boneinjury. The GP decided that he did not need hospital admission and referred to theDistrict Nurse for re-assessment. Currently the District nurse visits him twice weeklyto redress his grade 2 pressure sore on his sacrum, and to administer 3 monthlyNeo-Cytamen injections. He receives home care daily.

Unpredictability: Presently his mobility, incontinence and nutritional intake areunpredictable requiring monitoring from a registered nurse. These require referral forfurther assessment.

Complexity: Not complex.

Stability: Mr Jones’ pernicious anaemia is stable. The general deterioration in hisphysical wellbeing is unstable and requires further investigation.

Risk: The patient is at risk of injury due to frequent falls. His skin integrity is at risk offurther breakdown and infection due being bed fast, incontinent and nutritionallycompromised. His condition requires further investigation.

Outcome: The nurse completes the assessment and NNADR, deciding thatthere is scope for further improvement before any consideration of long termcare, and refers to the local intermediate care team (ticking option C on theNNADR).

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Case study 2

Mr. Davis is a 75 year old gentleman with generalised arthritis. He has lived alone forthe last 6 years since his wife died. He has some short term memory loss. He ishaving home care service twice daily to assist with personal care tasks.

He has two children, one living in Canada and the other living in a nearby town. Hisson visits him as often as he can, but has found that his father is deteriorating. He isconcerned about his father’s well-being and ability to cope at home.

One morning Mr. Davis was found collapsed but conscious on the floor by aneighbour. On admission to an acute hospital he was found to have had a stroke.Following medical intervention Mr Davis condition was stabilised. He was transferredto a community hospital for rehabilitation. He now has a dense right sided weakness,for which he requires the assistance of one person to assist with transfers from bedto chair and to walk. He has fallen on two occasions whilst in hospital, trying to getout of the chair himself. He has urinary and occasional faecal incontinence andrequires regular toileting to promote continence. He requires some assistance witheating and drinking, as he is unable to co-ordinate effectively with his left hand. Hehas some expressive dysphasia, but can indicate his basic needs. He has variablemoods and is often quite tearful.

Unpredictability: His mood swings affect his level of motivation.

Complexity: The combination of conditions, including dense right-sided hemiparesis, incontinence with risk to skin integrity, and the need for some painmanagement, requires regular reassessment of nursing interventions.

Stability: Following treatment and rehabilitation, existing medical conditions arecurrently stable.

Risk: The risks to Mr Davis, attached to potential falls from reduced mobility, risk toskin integrity from the effects of incontinence, immobility and nutrition, result in theneed for monitoring by a registered nurse.

Outcome: The nursing assessment decision is that Mr. Davis would be eligiblefor NHS Funded Nursing care, should he decide to move into a care home, asthere is a need for monitoring and reassessment by a nurse, but there are noidentified triggers indicating further assessment for eligibility for continuingNHS health care (option B). (This assessment would form part of a MDTdischarge assessment, which would also consider eligibility).

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Case study 3

Mrs Williams, a 73 year old female living with her son and his family, is suffering withsenile dementia, with poor concentration span and lack of insight; wandering fromhome; inability to instigate and complete tasks. She is confused and disorientated,has mood swings, and is occasionally both verbally and physically aggressive toother individuals. She has a history of TIAs, hypertension, and falls. She is alsoincontinent of urine at times.

She is admitted to a psychiatric assessment unit due to her family being unable tocope with her deteriorating condition.

Unpredictability: Combined with poor mobility and a general inability to care forherself, her care delivery must be assessed and monitored by a registered mentalhealth nurse in order that her advancing dementia is managed appropriately.

Complexity: Due to her long standing dementia Mrs Williams has a level ofpsychosis, with delusional and paranoid ideation, and has bouts of depression andsevere distress. Her wandering and concentration problems exacerbate the risk offalls.

Stability: Mrs Williams has unstable mental health problems, with behaviouraldisturbances and mood swings, which can fluctuate on a daily basis. She requiresclose supervision to facilitate effective care and treatment. Her cardiovascular statusis stable at present, but needs to be monitored.

Risk: Mrs Williams is at risk of falls and subsequent injury, due to her wandering andvariable mobility. She does not recognise or comprehend situations of danger thatshe exposes herself to. Other people are at risk from her aggression, and she is alsoat risk of retaliatory attacks from others due to her aggressive behaviour. She is atrisk of skin breakdown due to her falls and incontinence. Appropriate interventionsmust be devised and her overall care managed by registered mental health nurses inorder to provide a safe environment.

Outcome: Mrs Williams is referred to the MDT for further assessment andconsideration of eligibility for continuing NHS health care, because of the highlevel of her health and nursing care needs (Option A).In addition, if she did not meet the criteria, she is also assessed as eligible forNHS Funded Nursing Care (Option B).

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Case study 4

Ms. Smith is 67 years old and has mild learning disabilities. She has been living withher sister, who has died, and on whom she was very dependent. She has diet-controlled diabetes.

Unpredictability: No identified problems.

Complexity: No problems, except her previous dependency on others may affecther response to any other health condition.

Stability: Her diabetes is stable and can be managed through the primary careteam, but her diet will require appropriate monitoring.

Risk: The patient could be at risk of because she has been heavily dependent onher sister and needs support in all aspects of daily living, particularly managing herdiet. However, her health can be monitored by the primary care team.

Outcome: The nursing assessment indicates that her nursing needs can bemanaged in a residential or other community setting and did not indicateeligibility for NHS Funded Nursing Care (Option D). A multidisciplinary meetingarranged to consider Ms Smith’s future care requirements (having eliminatedeligibility for continuing NHS health care) agrees that Ms. Smith required 24hour care in a Care Home (residential), or alternative suitable communityplacement if available.

Case study 5

Mr. Lewis, aged 69, is living in a residential home. He was admitted to hospital in anemergency with a strangulated hernia. Following his operation he was discharged,with dissolvable sutures.

Unpredictability: Mr. Lewis condition is currently predictable.

Complexity: There are no complicating factors in Mr. Lewis care.

Stability: Once Mr. Lewis’ wound has fully healed, his condition should be quitestable.

Risk: No further risks identified.

Outcome: No ongoing nursing needs were identified (Option E).

Mapping the U

nified Assessment and C

are Managem

ent Process Continuum

Unified

Care Pathw

ay Integrated C

are Pathways

to include Health, H

ousing, Social C

are & Voluntary

Professionals or Services

BR

EADTH

DEPTH

Com

mon/Shared D

ocumentation

Specialist Assessment

Continuing C

are/NH

S

Incorporating all Dom

ains + Sub Dom

ainFN

C Assessm

ents

RISK

TO IN

DEPEN

DEN

CE

CO

NTIN

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CY PLAN

NIN

G

Patient/Carer

Contacts: G

PC

all: NH

S Direct

Others: 1 Stop

Shop

EnquiryC

ontactO

verviewSpecialist/ in D

epthC

omprehensive

Summ

aryR

ecord

WAG

Data

Set

Basic Personalinform

ation inD

emographics

Users perspective

Carers perspective

+2 further D

omains

NN

ADR

?

Users/carers

Perspective

3+ Dom

ain

NN

ADR

?

Nursing

PhysioO

cc TherapistPractitionerC

onsultantPodiatristEg: N

utritionSw

allowing

Mobility

Manual H

andlingC

PAN

NAD

R?

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ains & Subdom

ains + multi

agency -Specialistassessm

entsN

NAD

R?

Outcom

es

Outcom

es

• LTC/

Cont.C

are• N

HS FN

C-

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• Intermediate

Care

• Residential

Care

• Ongoing

Hospital

Care

• Hom

e +Independent

• Hom

e SSPackagePC

T DN

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V SpecN

urse• H

ome +

Respite

• Refer to

anotherhospitalC

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• Housing

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• shelteredaccom

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rossBorderServices

• O

ut of areareferrals

• C

ontactC

entre

• Patient/C

arem

ay alsopresent forassessm

ent

• H

ospital Services:C

hildren + Wom

enSurgeryM

edicineAcuteTertiary

• C

omm

unity:PN

– DN

– HV

Dental O

T - PhysioSW

+ SS :LABenefits/H

ousing etc

Com

-m

issioningand ServiceProvision

Social Care

Plan.ServiceD

elivery Plan.

Care plan.

ServiceD

elivery Plan.H

ealthServices.N

NAD

RFast Track toSim

ple Services,Eg: sm

all pieces ofequipm

ent, meals

on wheels etc.

ANNEX G

47

48

ANNEX H

49

Individual’s Name …………………………………. Unique Identifier No. ………………………

Date of Assessment / Review * (please delete as appropriate) ………………………

NURSING NEEDS ASSESSMENT

DECISION RECORDGuidance for using this Decision Record

This form is a decision record that records the outcome of a nursing needs assessment and doesnot replace any fully documented assessment that may be completed by members of themulti-disciplinary team. It is to be used within the context of the Unified Assessment process anddocumentation and with particular reference to the document ‘Assessment, Decision making,Eligibility and Completion of the Nursing Needs Assessment Decision Record’ (The Workbook),which sets out more fully advice for using this decision record (NNADR). A copy should beattached to the completed assessment and/or the Summary Record of the Unified Assessment.

This decision record must be used following a nursing assessment, to record the decision that anindividual:-

A. Has health care needs which may give rise to eligibility for Continuing NHS Healthcareand requires further multi-disciplinary assessment.

B. The individual has nursing needs and is eligible for NHS Funded Nursing Care.C. Has health care needs, which through accessing other assessments or care options

(e.g. intermediate care, rehabilitation, mental health) will minimise the risk toindependence (local provision will apply)

D. The individual has nursing needs, which may be managed in a community setting or aresidential care home.

E. The individual has no nursing needs

It should be completed and retained in the care record for all individuals who have received anursing assessment, and record which options for care are being considered. Also, it should beretained for those individuals who are found not to be eligible for NHS Funded Nursing Care inthe event of appeal.

In undertaking an assessment, or re-assessment, the first consideration must always be theextent to which the individual has health care needs which may give rise to eligibility forContinuing NHS Healthcare (for further advice on this, see the Workbook). In suchcircumstances, the matter must be referred to the appropriate persons for multi-disciplinaryassessment, according to local arrangements, and actions recorded under ‘A’ on page 4 of thisform.

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Individual’s Name …………………………………… Unique Identifier No. ……………………...

Date of Assessment / Review* (please delete as appropriate) ……………………………

Indicators for eligibility for NHS Funded Nursing Care:NHS Funded Nursing Care refers to the funding by the NHS of the element of care by aregistered nurse, in a care home providing nursing. Nursing care in these circumstancesincludes only nursing services which need to be provided either by, or under the supervision of,registered nurses or otherwise in accordance with section 49 of the Health and Social CareAct 2001, are incidental or ancillary to the person’s need for accommodation, in accordance withsection 21 of the National Assistance Act 1948, and are of a nature which a Social Servicesauthority could be expected to provide1. The nature and limits of this nursing care are explainedfurther in the Workbook.

The following indicators relate to the need for nursing by a registered nurse. They must beconsidered during the assessment process solely in relation to nursing needs only,particularly when part of a multi-disciplinary assessment, taking into account the intensityof need identified, in order to inform the decision-making process.

1. Unpredictability: The unpredictability of the individual’s clinical condition, diseaseprocess or behaviour requires monitoring by a registered nurse. (Monitoring - When changesto the individual’s condition cannot be anticipated with certainty, requiring ongoing assessment orreview by a registered nurse.)

2. Complexity: The particular combination or complexity of the individual’s physical and/ormental health needs require the clinical judgement of a registered nurse in the reassessment oradjustment of nursing interventions. (Clinical judgement - A registered nurse’s decision aboutan individual’s condition and the required resulting action, based on their observation, knowledgeand experience, and any relevant information or advice from others.)

3. Stability: The individual’s unstable/fluctuating disease process (alternating or irregular)may require monitoring and/or prompt intervention or treatment from a registered nurse.(Intervention by a registered nurse - The actions undertaken by a registered nurse based ontheir clinical judgement of an individual’s needs.)

4. Risk: The risk of harm to the individual or others may require the availability and promptintervention of a registered nurse or makes the placement in a care home with nursingotherwise appropriate.

The first consideration must be whether the individual has health care needs which maygive rise to eligibility for Continuing NHS Healthcare. If so, you will need to tick A onpage 4, and refer to the appropriate persons for multi-disciplinary assessment, accordingto local arrangements. If the indicators lead you to decide that an individual may beeligible for NHS Funded Nursing Care (e.g. at least one YES answer) you must tick B onpage 4, and (once eligibility for Continuing NHS Healthcare has been eliminated) forwardthe decision record to the relevant manager in the appropriate LHB. The form does nothave to be forwarded to the LHB if you tick either C, D, or E.

It may be appropriate to tick both A and B (i.e. the person is eligible for NHS FundedNursing Care, but also requires to be assessed for continuing NHS health care).

1 (or could have been expected to provide before the coming into force of section 49 of the Health and Social Care Act 2001)

51

Individual’s Name ……………………………………… Unique Identifier No. ……………………

Date of Assessment / Review* (please delete as appropriate) …………………………………..

DECISION PROCESSPlease complete the indicators below.

Please tick and comment on each indicator in all cases.

1. UnpredictabilityThe unpredictability of the individual’s clinical condition, disease process or behaviour requiresmonitoring by a registered nurse. YES NOExplanation

2. ComplexityThe particular combination or complexity of the individual’s physical and/or mental health needsrequire the clinical judgement of a registered nurse in the reassessment or adjustment ofnursing interventions. YES NOExplanation

3. StabilityThe individual’s unstable/fluctuating disease process may require monitoring and/or promptintervention or treatment from a registered nurse.

YES NOExplanation

4. RiskThe risk of harm to the individual or others may require the availability and prompt interventionof a registered nurse, or makes the placement in a care home with nursing otherwise appropriate.

YES NOExplanation

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Name of individual:………………………………………. Date of Birth .… / …. /….

Address…………………………………………………….

……………………………………………………………….

Current location (if different) Unique identifier number (at least one) e.g.: NHS / Hospital / NI Number / LHB Number

……………………………………… (Indicate which)………………………………..……. ………………………………..

On the basis of the judgement made on the previous page, please tick A, B, C, D, E asappropriate (tick both A and B where appropriate).

A. The individual has health care needs which may give rise to eligibility for ContinuingNHS Healthcare and requires further multi-disciplinary assessment.

(Referred to………………………………………………. on (date) …………………..)

B. The individual has nursing needs and is eligible for NHS Funded Nursing Care.C. The individual has health care needs which, through accessing other assessments or

care options (e.g. intermediate care, rehabilitation, mental health) will minimise the riskto independence.

D. The individual has nursing needs which may be managed in a community setting orresidential care home.

E. The individual has no nursing needs.

I confirm that the individual and / or (where applicable) their representative has beeninvolved in the assessment and will be informed of this decision, and also about thedecision / appeals process, if appropriate. (please tick) YES NO

ASSESSORName ………………………………………………… Signature …………………………………..

Post ………………………………………………….. Date …… / …… / ……

Should the individual be eligible for NHS Funded Nursing Care, this decision recordshould now be forwarded to the relevant manager in your LHB.

ASSESSMENT CERTIFIED BY (assessing LHB for NHS Funded Nursing Care):

Name………………………………… Signature……………………………...

Post………………………………….. Date …... / …... / …...

A copy of this completed form, and the assessment, will be passed to the individual (orrepresentative) and the care co-ordinator. Also, with the agreement of the individual (orrepresentative), those indicated below (where applicable) may receive a copy uponrequest (please tick)

Social worker Next of Kin Care Home Manager

Person with Registered Power of Attorney Public Guardianship

Person with Registered Enduring Power of Attorney