Assessment Procedure [PDF]

Appropriate family members. • GP. • Care Providers to ascertain possible reasons for contact difficulties. • If th

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Idea Transcript


Newport City Council Occupational Therapy Service (COT)

Assessment Procedure

COT : Assessment Procedure Version 2:0 2011

Contents Contents ............................................................................................................... 1 Contact procedure for referrals prioritised as 1 & 2 Urgent ................................... 2 Contact procedure for referrals prioritised as 2 & 3............................................... 3 COT assessment .................................................................................................. 4 COT documentation storage on Persons Electronic file........................................ 5 COTOM database ................................................................................................. 5 Completion of Workflows ...................................................................................... 6 COT assessment authorisation ............................................................................. 6

COT : Assessment Procedure Version 2:0 2011

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COTs will only undertake an assessment if a referral has been received, prioritised and allocated to them by the COT Team Manager or SOT. COTs will aim to make contact with the person or named person within agreed time limit guidance and arrange an appropriate appointment to meet with the person and carers if appropriate e.g. informal carers, formal carers This will usually be arranged via telephone. Written confirmation can be sent if deemed appropriate or requested by the appointment confirmation letter. All the attempted contacts should be recorded on UAP. All UAP notes should be checked prior to contacting the SU. This should include:       



Any warnings re: visiting / contact advice All previous OT involvement should be looked at any other relevant recent case note history Any capacity issues noted What other workers / services are involved Any supported equipment insitu that needs reviewing. If there is supported equipment insitu then Cequip should be checked for last service date and any other information as to what else is insitu. If there is another referral in the OT service, the referrals should be combined and addressed in one visit. If the address search shows that the SUs carer / spouse is awaiting allocation as well for an COT assessment, this should be discussed with the SOT as in some instances it may be good practice to assess both people together. Violence at work database

Contact procedure for referrals prioritised as 1 & 2 Urgent If contact with the person or designated person is not achieved by telephone within 1 working day of allocation COTs should also consider taking the following measures:     

Contacting referrer Appropriate family members, GP Care Providers to ascertain possible reasons for contact difficulties. Appointment Request letter to be sent

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If the person is currently admitted to hospital and discharge is not expected within 7 days then COTs will liaise with the hospital OT. A discussion should take place to ascertain OT input required and if joint working is appropriate, COT to pass on any information necessary. This should be done by telephone and recorded on UAP. The referral should then be passed back to central admin with a completed workflow to cancel referral and update UAP. If there is no response from the person or designated contact person then the COT needs to contact the referrer and the SOT / TM and inform them of the issues found. If the case is deemed appropriate for closure then a workflow should be completed.

Contact procedure for referrals prioritised as 2 If contact with the person or designated person is not achieved by telephone call allocation then an Appointment Request letter should be sent requesting contact COTs should also consider taking the following measures:     

Contacting referrer Appropriate family members GP Care Providers to ascertain possible reasons for contact difficulties If there is no contact within 14 days then the referral can be closed

If the person is currently admitted to hospital and discharge is not expected within 7 days then COTs will liaise with the hospital OT to ascertain if joint working is appropriate and send any information necessary. This should be done by telephone and recorded on UAP. The referral should then be passed back to central admin with a completed workflow to cancel referral and update UAP if appropriate to close.

If the case is deemed appropriate for closure then a workflow should be completed.

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COT Assessment COT workers to undertake assessment according to the need of the person at time of assessment at the date and time agreed with person. If the COT worker is more than 15 minutes late, a phone call should be made to the person or appropriate person informing them of the delay and an estimated time of arrival. If the COT worker cannot get any response when visiting the person’s property they should leave a missed appointment letter whilst with all details necessary for the person to contact them and stating that if no contact has been received within 14 days then the case will be closed. COTs should complete COT Specialist Assessment or Unified Assessment (UA) with Specialist assessment if appropriate. All appropriate risk assessments and decision making tools should be completed. A Care plan must also be completed with all assessments when an outcome of Supported Equipment is going to be supplied. COT worker will review any supported equipment insitu. Appropriate Risk Assessments and review paperwork will be completed on visit and workflow should reflect this. All documentation must comply with guidelines issued by BAOT, HPC and the NCC assessment and care management guidance The person must be given the offer of Direct Payments for any equipment identified. The person must be asked if they want a copy of the assessment sent to them. The Community Occupational Therapy Outcome Measure (COTOM) must be completed for all COT assessments. If any other referrals or signposting to other agencies are identified as needed or requested then this should also be done within the timescales below. Eg Social Work Assessment, Carers Assessment, Safety at Home, Community Physiotherapists. UA / Specialist assessment and care plan to be completed within 1 working days from day assessment is completed if the needs fall into the critical eligibility category UA / Specialist assessment and care plan to be completed within 3 working days from day assessment is completed if the needs fall into the substantial eligibility category COT : Assessment Procedure Version 2:0 2011

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UA / Specialist assessment and care plan to be completed within 5 working days from day assessment is completed if the needs fall into the moderate or low eligibility category

COT documentation storage on Persons Electronic file All paperwork must be typed if the person has requested a copy, if not then a hand written can be scanned, and stored within the persons electronic file, stored on the “S Drive” in the “Client Files” folder in the DAT Folder:S:\CCAS\C\Duty & Assessment\CLIENT FILES All files should be saved in the following format: Swift number, SURNAME, Forename, Date, (Description of File) e.g. 245876 BLOGGS Joseph 09-02-2010 (DFG Form) Any other person related paperwork is to be stored within the persons paper file according to NCC guidelines

COTOM database The COTOM database start score needs to be filled in once the assessment paperwork has been completed, i.e. on return from the visit by the assessor. The end score needs to be completed on complete closure of the case, i.e. once all equipment and adaptations have been completed and checked by the reviewer. In order to ensure the database in completed in a timely manner, there is a prompt on the workflow sheet for both the start and end scores. Please refer to Guidance on completion of COTOM paperwork for correct completion and analysis of COTOM scoring

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Completion of Workflows Workflows must be completed in accurately and in a timely manner to ensure efficiency of the COT Service. Workflows are to be submitted to central admin following completion of interventions or pending major adaptations completion. Workflows must be submitted following the complete closure of all cases. Please refer to the Guidance on completion of workflows.

COT assessment authorisation If the worker hasn’t been signed off as being able to complete assessments independently by a SOT / TM,then the worker to forward copy of assessment, care plan and all appropriate risks assessments / decision making tools for the assessment outcome to OT Team manager / SOT for consideration and approval. If the Assessment, care plan and associated paperwork are not approved, then OT Team manger / SOT will discuss issues with COT and request amendments to be made and resubmitted or agree case to be progressed in an alternative way. This decision process should be recorded by the COT. If the person has asked for a copy of their assessment then the worker should send the appropriate letter plus x1 copy of assessment and care plan if appropriate with x2 signature slips with a SAE with the COT name on it to the person for consideration and possible amendment. COT : Specialist Assessment Letter including Care Plan COT : Specialist Assessment Letter without Care Plan COT : Review Letter COT : Manual Handling Letter COT : Bathlift Care Plan Review Letter COT : Bathlift Review Letter with Signature Slips

The person is to return x1 signature slip to the COT. It is the person’s responsibility to respond as they feel necessary and return the signature slip.

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If the slip if not returned within 28 days, then the letter indicates that the Assessment and care plan recommendations will be progressed. Once the slip is returned, any amendmends from the person’s perspective are to be addressed by COT. If there are no amendments, then the paperwork should be passed to central admin for filing.

DP 12/10/2011

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