Standard 10: A holistic assessment is undertaken with the service user.
Supporting material for standard 10:
People entering a mental health service who have complex needs requiring multidisciplinary input, should receive a holistic assessment, which includes an assessment of strengths and a self-rated assessment of needs.
The assessor should be appropriately skilled and qualified to deal with the type and level of assessment. The holistic assessment will guide staff in creating a person centred care plan which aims to meet identified needs.
The assessment will be shared with the service user and with their consent, with informal carers.
The assessment should be repeated and the care plan amended as the person progresses through the steps on their journey of care. When a referral is made, some assessments may have already happened. A record of these assessments must be included with the referral documentation.
For people from minority ethnic communities, it is important to consider unique aspects relevant to the specific community. This may necessitate access to independent input during assessment eg trained interpreters and/or independent advocates/advocacy agencies.
Examples of evidence required to meet standard 10:
- Assessment forms/templates that include:
- current and past mental health problems (including the informal carer's perspective)
- current and past interventions for these problems (including outcomes, adverse reactions and side-effects)
- personal, family and social circumstances
- strengths and aspirations
- physical health problems
- functioning (eg life skills assessment)
- service user needs assessment (eg Avon Mental Health Measure) and, where appropriate, informal carer needs assessment
- capacity to consent to care and treatment, and
- drug and alcohol use and misuse.
- The care record includes a space for entering target time to completion of holistic assessment, and the actual time.
Useful Resources:
- 1. Assessment Review Co-ordinating Group. National minimum information standards for single shared assessment for all adults: version 1.1. SEHD; 2006, pages 12-27
- 2. The Avon measure of needs
- 3. Joint Improvement Team: Multidisciplinary Assessment
- 4. World Health Organization. International Classification of Functioning, Disability and Health.
- 5. As a part of a holistic assessment, communication support needs should be considered. The Royal College of Speech and Language Therapists has prepared this evidence summary on how SLTs may be involved in your local ICPs