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Assessment and Care Planning Process for Mental Health Patient


This assignment will focus on the assessment and care planning process of I think for a patient that is getting care in an assessment unit for mental health, for a severe and enduring mental illness. All patients have a nurse assigned to them who will coordinate with other teams, which is expected to address the issues of the most seriously services users with complex illness. The unit works with hard to draw in services users, proactively working towards keeping up their mental prosperity. I will give a short story and background that will include of the service user, medical findings, a concise history and any applicable social conditions.

All through the provision of care in my role as a student associate practitioner I use the 6Cs of nursing within my place of work. The use of the 6Cs of was developed to educate caring staff how to effectively demonstrate quality care. As part of compassion in practice (NHS England, 2012) the vision and methodology for all nursing staff, were employed to give benchmarks to the standard of care we endeavour to convey.

As a matter of first importance 6 are Care which is our primary business, this is the care we convey to an individual patient which thusly will enhance the care framework in general.  Being compassionate which can be portrayed as how the care is conveyed this can be shown through our relational connections, regarding our patients showing compassion. Competence is the third, this is to guarantee that all people utilised in a caring role have the appropriate level of skill to give the right care and to a high level. Communication is the fourth, although debatably the most vital, this does just empower us to discuss viably with our patients, building restorative connections. Good communication within a team is vital to conveying an elevated expectation of care.

The fifth of the 6Cs is courage, this attention on our quality as a professional person to speak up for the benefit of our patients or out against issues we cannot help contradicting.

The last 6c is commitment to our patients. We need to build on our commitment to improve the care and experience of our patients, to take action for all and meet the health, care and support challenges ahead.

To ceaselessly wish to enhance our aptitudes and thus enhance the models of care. (Hardicre, 2014)

I will demonstrate an understanding of The Care Programme Approach (CPA) by exploring how this is utilised to deliver patient centred care. I will also explain the key features of my chosen nursing model the tidal model (Barker and Buchanan-Barker, 2004) which is a model of care with a holistic approach which be evident throughout my assignment, incorporating the use of assessment tools. I will recognise the need for effective communication skills and ability to engage with a patient, building a rapport and enabling a therapeutic relationship to grow. I will also show an understanding of the care planning process by identifying the patient’s needs, and the agreed interventions. To conclude this assignment, I will summarise the care delivered and reflect upon my role in practice and my learning.

Throughout the assignment I will keep in mind the importance of respecting a patient’s right to confidentiality, following the Nursing and Midwifery Council (NMC) code of conduct. Therefore, any identifiable information such as names of patients, staff and places has been changed to protect their identity. (NMC, 2015). I will refer to my patient as ‘John’ throughout this assignment. This will ensure I follow guidelines set out by the Data Protection Act (1988) protecting my patient’s right to privacy. I gained consent from John, to use his information in this assignment and explained to his that I would protect his right to privacy throughout.


The Tidal Model

While breaking down administration client mind, it is basic to pick up from rehearses effectively demonstrated to work towards enhancing the prosperity of our patients. The should be possible by using nursing models made as of now. Remembering this when I have initiated with the evaluation and care arranging process, I used the Tidal Model and its out lined standards.

The Tidal Model (Barker and Buchanan-Barker, 2004) is a model of care which has an all-encompassing methodology rotating around recuperation that is individual for each patient. It accentuates being organised around the patients lived encounters, being understanding focused and engaging. The model urges the need to connect with a man in a period of emergency; it additionally considers the significance of hazard. Barker and Buchanan-Barker (2004) utilise the expression “spanning” to portray this basic demonstration in supporting a man. Barker Buchanan-Barker made an arrangement of ‘Ten duties’ regarding permit experts an enhanced information of the centred esteems the model concentrates on.

These duties can give nurture the pathway expected to review and convey the Tidal Model into their consistently conveyance of care. They Discuss the benefit of time and enabling the procedure to direct the length of the evaluation (Petersen, et al. 2014) Although perceives that the patient is the ace of their entire story and in addition the pioneer in the way their recuperation takes after (Copeland, 1997), the medical caretaker can work cooperatively to reveal the patients shrouded potential and forecast of recuperation. (Buchanan-Barker and Barker, 2008).

The Care Programme Approach

To do a full and definite appraisal of a patient alluded to the Assertive effort group (AOT) the evaluation paper work was finished (informative supplement 1). This evaluation is delivered in view of the Care Program approach, presented by the Department of wellbeing (DH) in 1991, giving an all-encompassing way to deal with survey the patient all in all. It looks to convey a methodical, broad and multi-disciplinary way to deal with patients persisting serious psychological well-being ailments and complex needs (Rethink, 2013). Amid a troublesome time in psychological well-being administrations, with the spotlight from the push on various occurrences, The Care Program approach was presented by administrations in 1990 (Sullivan, 1997). Comprising of 4 phases which incorporate evaluating the individual and their present circumstance, building up a care design cooperatively covering their requirements and objectives, allotting a care facilitator to encourage their movement through the care pathway giving a principle purpose of contact for the patient and different administrations included (Downing and Hatfield, 1999). A key factor is the customary audit of the care design and the care being conveyed, to find out whether this keeps on addressing the necessities of the individual (The Sainsbury Centre for Mental Health, 2005).

The part of the care facilitator is a perceived endeavour at joint working (Simpson, 2005) as a component of the MDT they will work intimately with the patient and their family (Callaghan, Playle and Cooper, 2009) to guarantee sufficient emergency arranging and hazard administration are set up to streamline the results for the patient.


John is an 84-year-old Man, who has a diagnosis of Alzheimer’s Dementia about 8 years ago he has been living with his wife for many years at his home address until his illness become too hard for John and his wife to cope with, John’s family agreed to give some background on John life while living at home before his diagnosis with Alzheimer’s Dementia. His wife, son and daughter-in law began with: John has always working till he retired, been a very active man, taking part in many sporting activates as a young man such as rugby and football, enjoyed family holidays in and out of the UK. As John got older he still walking to the local shop in the morning to get the local paper, taking their 11-year-old dog for walks in the local park area. His wife informed that over the last 15 years or so John appeared to her as getting slower/more forgetful and began to get worried about John walking on his own as he gotten lost from walking back from the local shops and local people brought him home, during the night John began to sleep lest was walking around the house during the night due to his wife would also be awake with him, his had negative effect on his wife health and she became unable to care for John, John was offered rest bite care from his local GP  for 4 weeks to help his wife recover and also give time for the family to think about what might be in John best interest for the future. During John’s time in rest bite he attacked another resident and also reports from staff working close with John there was many times that they had to intervein before to stop John from appearing to attack others. This was very unsettling for the family to hear and his son was concerned that would his mum be a risk when John returned to the family home. John’s GP referred him to the local community team who would come and see John at home one week after her had returned form rest bite care, to make an assessment on him, His wife inform me that when John returned home he appeared to have lost weight and also appeared not to recognise the layout of their home and would forget where the toilet was and other areas, John would wake up around 2-3 o’clock in the morning and attempt to open the front door due to John’s safety the family would lock the front door and remove the key, John on one occasion had attacked his wife when she attempted to interact with him while he was trying to open the front door, the police wasn’t called and no serious injury was coursed to his wife. A few days later his wife woke up to find John had a pillow over her face and attempted to suffocate her, John’s wife managed to roll off their bed onto the floor and left the room, she called their son who came over and later the police were called, on that day john was sectioned under the mental health act 1983 detained on a section 3 of the MHA.

Alzherimer’s Dementia

Alzheimer’s is a type of dementia that causes problems with memory, thinking and behaviour. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.

Alzheimer’s is the most common form of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life. Alzheimer’s disease accounts for 60 to 80 percent of dementia cases. (Alzheimer’s society)

The greatest known risk factor is increasing age, and the majority of people with Alzheimer’s are 65 and older. But Alzheimer’s is not just a disease of old age. Information from Alzherimer’s Society there are Approximately 850,00 people in the UK who are living with dementia, 42,00 younger people under the age of 65 have younger-onset Alzheimer’s disease (also known as early-onset Alzheimer’s).

Alzheimer’s is a progressive disease, where dementia symptoms gradually deuterate over a number of years. In its early stages, memory loss is mild, but with late-stage Alzheimer’s, individuals lose the ability to carry on a conversation and respond to their environment.

Dementia is the leading cause of death for women in the UK, heart disease remains the leading cause of death for men in the UK with dementia being the second by a report from the BBC 2015.  Those with Alzheimer’s live an average of eight years after their symptoms become noticeable to others, but survival can range from four to 20 years, depending on age and other health conditions.

Although current Alzheimer’s treatments cannot stop Alzheimer’s from progressing, they can temporarily slow the advancing of dementia symptoms and improve quality of life for those with Alzheimer’s and their cares. There is a worldwide effort under way to find better ways to treat the disease, delay its on-set, and prevent it from developing.

Just like the rest of our bodies, our brains change as we age . Most of us eventually notice some slowed thinking and occasional problems with remembering certain things. However, serious memory loss, confusion and other major changes in the way our minds work may be a sign that brain cells are failing.

The most common early symptom of Alzheimer’s is difficulty remembering newly learned information because Alzheimer’s changes typically begin in the part of the brain that affects learning. As Alzheimer’s advances through the brain it leads to increasingly severe symptoms, including disorientation, mood and behavior changes; deepening confusion about events, time and place; unfounded suspicions about family, friends and professional caregivers; more serious memory loss and behavior changes; and difficulty speaking, swallowing and walking.

People with memory loss or other possible signs of Alzheimer’s may find it hard to recognise they have a problem. Early diagnosis and intervention methods are improving dramatically, and treatment options and sources of support can improve quality of life.

Alzheimer’s and the effect it has on the brain, Ninety percent of what we know about Alzheimer’s has been discovered in the last 20 years according from the Alzheimer’s society. (Alzheimer’s society)

Some of the most remarkable progress has shed light on how Alzheimer’s affects the brain. The hope is this better understanding will lead to new treatments.

The brain has 100 billion nerve cells (neurons). Each nerve cell connects with many others to form communication networks. Groups of nerve cells have special jobs. Some are involved in thinking, learning and remembering. Others help us see, hear and smell. (live science)

To do their work, brain cells operate like tiny factories. They receive supplies, generate energy, construct equipment and get rid of waste. Cells also process and store information and communicate with other cells. Keeping everything running requires coordination as well as large amounts of fuel and oxygen.

Scientists believe Alzheimer’s disease prevents parts of a cell’s factory from running well. They are not sure where the trouble starts. But just like a real factory, backups and breakdowns in one system cause problems in other areas. As damage spreads, cells lose their ability to do their jobs and, eventually die, causing irreversible changes in the brain.

Researchers are working to uncover as many aspects of Alzheimer’s disease and related dementias as possible.  Ninety percent of what we know about Alzheimer’s has been discovered in the last 20 years. Some of the most remarkable progress has shed light on how Alzheimer’s affects the brain. The hope is this better understanding will lead to new treatments. Many potential approaches are currently under investigation worldwide.

Assessment Process

The Assertive Outreach Team give mind in the group to grown-ups 18 + with an extensive variety of emotional wellness needs, to perceive the objectives and meet the distinguihed needs the recuperation approach is used amid the appraisal and care arranging stages. The Assessment procedure can be depicted as having two phases, gathering of data and after that utilising the data properly to recognise the requirements of the customer (Norman and Ryrie, 2013). Care conveyed rotates around this progressing procedure, consistently evaluating whether the necessities continue as before, or if intercession is never again required. It is scratch that the medical caretaker and customer work firmly together amid the appraisal time frame to build up a successful care design. The Key standards of the Tidal model can be utilised amid the time of appraisal as this loan an all-encompassing methodology (Barker and Finlay, 2004), by using these standards it enables the assessor to pick up a more prominent comprehension of the customer’s needs from their view point. Aggleton and Chalmers (2000) examine that keeping a subjective approach and an individual medical caretaker’s perspectives being the concentration should be maintained a strategic distance from. To utilise a fitting model will guarantee that the evaluation procedure will be founded on the estimations of the model, thusly improving the nursing procedure. Amid the evaluation arrange medical attendants will either assemble verifiable data, which could be the customer’s appearance. Another being express data, when the customer’s needs, considerations or sentiments are plainly imparted by the individual (Norman and Ryrie, 2013).

An option evaluation show is that from a therapeutic point of view, which concentrates on signs and side effects at present introducing to the medical caretaker. This data can be important when endeavouring to analyse a patient and plan to cure their condition by offering treatment (Aggleton and Chalmers, 2000) conversely Barker and Buchanan-Barker (2003) prompted that supporting a patient with their perspectives and their reality can prompt recuperation without treatment.

John’s Assessment

John was at first hesitant to draw in with psychological wellness administrations, it was essential to make him open to amid the appraisal procedure. We completed this at an area of his picking, which was his folks’ home. The appraisal took after a casual meeting, to draw in John and ideally make Him feel calm. An Interview strategy offers a structure; significant inquiries should be asked by the medical caretaker and enables the customer to recount their anecdote about their life and encounters. In spite of the fact that Barker (2004) features the significance of medical caretaker’s not just picking up data with respect to the patient’s considerations and feeling, as this may just offer you the present issues and conclusion, it allows the attendant to pick up a knowledge into the patient’s life. (Manor and Gilbert, 2006; Norman and Ryrie, 2013).

The evaluation of John could stream as a discussion, enabling John to be open in he’s reactions. It is fundamental that the appraisal printed material was inside reach amid the meeting, this will have taken into consideration taking note of taking all through and provoked key talks. This takes into account recording to be precise as opposed to endeavouring reviewing data incorrectly (Barker, 2004).

The evaluating medical caretakers need to reliably be aware of their potential bias, because of their mentalities and convictions. Remembering this through John’s evaluation will confine any impact this may have on any judgements or decision (Hart, 2014; Walker, Carpenter and Middlewick, 2013).

It was critical that I at first familiar myself with John, making him feel esteemed and start fabricating a compatibility (Heron, 2001). Peplau (1991) stresses the significance of relational connections amongst patients and attendants. I was aware of my stance and how I could make John feel quiet, I kept up great eye to eye connection with him and a characteristic open stance (Wosket,2006; Boyd and Dare, 2014) I clarified that I would be doing an appraisal to investigate his needs and objectives (Barker, 2009).

I utilised a blend of open and finihed inquiry while stealing away John’s appraisal. Using the open inquiries this enabled John the chance to speak uninhibitedly about his on-going circumstance and how he carries on while encountering a hyper stage. It gave me a more prominent profundity to the discussions as he had a decent level of correspondence. It likewise considers the Tidal Models ten duties (Barker,2004) on occasion when John found a subject troublesome, for example, when discussing his association with his late stride father, I started to utilise shut inquiries as it enabled me to increase particular data while he was battling with conveying viably (Videbeck, 2013).

All through my cooperation’s with John I should esteem the significance of the 6 c’s of nursing, one of which is correspondence this being fundamental in building a compatibility with John. Likewise, in imparting adequately will help me in showing, empathy towards him. The other 4 c’s care, responsibility, capability and strength will be shown all through my cooperation’s and the shared procedure of surveying and care arranging. (Hardicre, 2014).

John started to talk openly and appeared to unwind after some time, while building a compatibility that lead John to feel bolstered and loose. Barker (2004) talk about the critical expertise of listening adequately to a patient amid the appraisal procedure, this thus enables the medical attendant to watch the patient’s non-verbal communication which can change all through the discussion, for example, while getting to be plainly upset. Watching viably and perceiving their non-verbal correspondence on occasion offer the attendant a more prominent knowledge into their emotions on the present theme (Hannagan, 2005).

To guarantee that I had comprehended what John had talked about, I summarised happen to he’s announcements (Barker, 2004). Thinking about what John had portrayed empowered me to demonstrate an enthusiasm for what he had let me know and show compassion concerning his circumstance; he would now and again at that point keep on elaborating on the data (Norman and Ryrie, 2003).

John talked about his association with his accomplice and the elements of he’s family, he prompted that he thinks that it’s hard to reliably taking he’s drug, he is right now endorsed Lithium, and accordingly he’s inclination to withdraw from administrations.

While evaluating John, it was critical that I considered the need of the Multi-Disciplinary Team (MDT) and their part inside he’s care. The mediations offered must be the most suitable for the individual and that all view focuses from the group considered (Norman and Ryrie, 2013) this must fixate on the most pertinent and breakthrough confirm accessible (Lloyd, 2012). To guarantee a comprehensive way to deal with John’s care it is basic that correspondence inside group between all expert is successful (Lloyd, 2012).

Risk Assessment

Hazard surveying is foremost to the way toward nursing (Hart, 2014). Hazard appraisal is a procedure by which you assess the potential results of different circumstances or conduct that may make hurt a man or individuals (Callaghan and Waldock, 2006). Investigating hazard considers a larger amount of care to be given, empowering positive hazard taking, and albeit failing to be ready to wipe out hazard the procedure empowers experts to lessen it (Woods and Kettles, 2009). While considering hazard evaluation, it is essential to remember that hazard is continually factor, it can’t be settled at any one time (Morgan, 2007). Various elements can impact the result, for example, the patient’s close to home conditions, changes in their condition, a lacking measure of assets, and a mind-boggling care facilitators case stack this is just to say a couple and is not comprehensive (Hart,2014). There are various different impacts that can influence a hazard evaluation; the setting of a movement can change the presumption of whether it is viewed as unsafe or not (Hart, 2014). Overseeing hazard while conveying consideration can now and again be viewed as prohibitive, and overprotective (Boardman and Roberts, 2014) this is in entire inconsistency to the recuperation focused way to deal with psychological wellness nursing that stresses the patient’s choice and seek after the future (Barker, 2012).

While evaluating John’s hazard amid he’s underlying appraisal (reference section 1) I expected to consider his past practices and episodes, for instance his medication utilises. Albeit taking medications bought on the bootleg market expands his hazard, he has not been known to have buy this with the end goal of over dosing. While talking about John’s accounted for danger of self-hurt this impacts the levels of hazard, in spite of the fact that John will normally do this unexpectedly and there is no expected danger of self-destructive ideations. John perceived various defensive factors throughout his life, for example, enhancing he’s association with he’s accomplice, keeping up concurred authority course of action with he’s little girl. John has additionally arranged an end of the week away with he’s family, including he’s little girl appearing forward arranging, John appears to be confident for what’s to come.

John required all through the underlying appraisal when chance was viewed as, I was unguarded with him in regards to the dangers we saw and he was given the chance to audit the result. This is in accordance with the rules set out by the Nursing and birthing assistance gathering (NMC) in regards to an attendant’s obligation of sincerity, guaranteeing straightforwardness with our patients and families all through the greater part of our practices (Hedges, 2015).

Care Planning

Following the consummation of the appraisal procedure is the definition of a care design, which is a relative blue print for the arranged intercessions. To empower medical caretakers to decide needs into particular, quantifiable, feasible, and sensible and time-bound (SMART) objectives (Tempest, 2012). The point of care arranging is to make sensible focuses on that are individual and vital to the patient (Hall, Wren and Kirby, 2013). This ought to be developed working intimately with the patient ensuring all parts of the individual are considered using a comprehensive approach, and a patient focused care design. To be close to home to the patient implies that a standard format can’t be utilised because of each individual having extremely one of a kind needs (Hall, wren and Kirby, 2013). The tidal Model proposes that the patient should lead the pack during the time spent care arranging and that the psychological well-being professional will encourage this incident, as the patient is the main master of their story (Buchanan-Barker and Barker, 2006). Including a patient in the arranging of their care has demonstrated to profit a man from numerous points of view, enhancing consistence, empowering autonomy and enhancing the nature of care (Anthony and Crawford, 2000). Higgins (1994) talks about that emotional well-being professionals can on occasion feel surplus to prerequisites with the cooperation and strengthening of the patient.

It is key to work together with the patient as well as the MDT when mind arranging, enveloping various distinctive ability which can help the conveyance of care guaranteeing the consistent approach from an assortment of administrations, evacuating any hindrances enhancing care (HM Government, 1999).

John’s Care Planning

Following the appraisal procedure John with urge could distinguish zones in which he felt that he required help. Working with myself and other emotional well-being experts he could consolidate these into particular objectives and arranged mediations. The Assertive effort collaboration with patient’s long haul, in this way John distinguihed shorter term needs that will prepare for he’s more extended term recuperation process.

The principal objective that John recognised was he’s fluctuating states of mind, because of his non-concordance of pharmaceutical. He disclosed that because of he’s expanded hyper stages it was winding up progressively hard to work once a day. Here and now consented to start on Lithium by and by, because of the conceivable poisonous quality of this drug John’s physical wellbeing should be observed intently all through the underlying beginning. John will be required to have an ECG, and blood tests to guarantee he is sufficiently sound to be endorsed Lithium. His renal capacity should be observed while taking this medication. As Lithium utilise is related with a scope of glomerular and tubular issue bringing about constant kidney sickness and all the more once in a while built up renal disappointment (Kripalani et al., 2009).

John wants to have the capacity to deal with he’s fluctuating states of mind, at first lessening this and in time understanding he’s ailment. I talked about with John’s the alternative of psychotherapy in the long haul particularly Cognitive Behavioural Therapy (CBT) which is an approach encompassing investigating emotions, musings and practices. It additionally considers a man’s responses and impression of specific encounters which may have caused a negative effect prompting mental misery (Norman and Ryrie, 2013).

The second objective that John distinguihed is the agony that he encounters every day because of physical afflictions. John discloses that because of low certainty he feels unfit to go to he’s GP surgery and dental specialist to take care of he’s physical wellbeing needs. With help from the Assertive effort group, John would like to go to these arrangements and address the on-going physical issues. John trusts that thus this will enhance he’s low disposition periods as constant torment is an impacting factor when he is feeling discouraged. Once more, CBT could be valuable as National Institute for Health Care and Excellence’s (NICE) rules (NICE, 2011) propose that a double approach is fitting for extreme wretchedness with unending physical medical issues. Which could comprise of 1:1 CBT treatment close by an upper drug, the contraindications with Lithium would should be considered by the expert specialist before recommending.

Care arranging needs should be consistently surveyed all through John’s pathway of recuperation, because of the idea of the Assertive effort group this will be a long-haul process until John no longer needs the help of the administrations. John was work in a joint effort with his care organizer as his principle purpose of contact, the MDT all in all will keep on playing an essential part in John’s recuperation.




All through the voyage of this task I have used the appraisal and care arranging procedure to convey John’s care. I have perceived the significance of following a supporting nursing model while working inside the Care Program Approach structure and conveying excellent care.

I have talked about the significance of successful relational abilities, enhancing the compatibility I have worked with John. Having the capacity to help him through a troublesome stage in his life, while monitoring non-judgemental mentalities keeping my convictions to affect the care I conveyed. Which thus urged John to express his considerations and sentiments straightforwardly, enabling me to construct a restorative relationship.

I have esteemed the MDT in offering community oriented care, guaranteeing an all-encompassing way to deal with the care arranging process, imperatively including John all through the procedure.

This task has enabled me to consider my work on, including my relational abilities and the impact this can have on my capacity to mind. Taking during the time spent evaluation and care arranging, has helped me to end up noticeably an important individual from the Assertive Outreach Team. The task has educated me of the significance of with respect to all viewpoints in somebody’s care including rules and enactment. This proof base has empowered me to build up my insight further, enhancing the care I have conveyed to John which I will bring forward through my vocation and consistent self-awareness.








Appendix 1:  Assessment


Examination on Referral
Source of Admission / Referral Legal Status
Date of Referral 


  Time of Referral  
Date of Assessment   Time of Assessment  
If A&E Triage Time      
Presenting Complaints as described by the Patient / Carer









Present stresses e.g. Social / circumstances (accommodation, household members, finances)  


Past Psychiatric History
Physical Health (including previously prescribed medication)
Present (describe whether stable or not)
Current Medication: 

  • Include a complete list of all medication being taken by the patient
  • Ask specifically about medication which may be omitted such as inhalers, eye drops, topical prescriptions (including patches), insulin, other injections, oral contraceptives, HRT, nebulas, oxygen, OTC medications., herbal remedies etc.
Allergy/ Intolerance (Please record none if none) none

(Including strength and form)


(including dose, route and frequency)


(use codes below)

Sources used to obtains information (minimum 2) (please tick)
1 2 3 4 5 6 7
Patient Medicine from Home GP Surgery Carer/Relative Repeat Prescription Care  Home Record Other (Specify)


Personal History
Birth and Early Development 




Normal Delivery at birth and met all normal childhood development stages.





John describes his childhood as ‘normal’, he was happy to go to school and had a good family dynamic.





John attended primary and secondary school, 

John later attended college

Occupation (Job Sequence and Dates, Reasons for Leaving, Current State) 



Mental State at Assessment
Appearance and Attitude 



Behaviour Appeared restless and at times agitated, he was unable to keep still for a long period of time.
Speech Pressure of speech evident,. Difficult to keep to one topic.
Mood (objective and subjective)
Sleep / Energy Levels 





John advises his appetite is poor no matter his mood, at times forgetting to eat and at others not having the motivation to eat.
Thought Content 

(Delusions, Obsessions, Preoccupation)


(Hallucination, Illusion)


Not observed responding to any hallucinations, although
Cognitive Function (including Attention and Concentration, Orientation, Memory) 


John reports a very poor concentration at present and states that he is unable to focus on even the simplest tasks. Orientated to time, place and person. Reports poor memory, although believes this to be due to his chaotic mood swings.



John displayed good awareness of his illness and the need for treatment.  he spoke about a wanting to try and improve his situation and could recognise that medication may be needed to do so. He is willing to work with services to devise a way forward.
Initial Management based on Formulation / Summary of Needs 

(include level of observations on admission, medication prescribed, psychosocial aspects of management)

Risk Assessment Identification of Risks Past and Present
John denied any thoughts of deliberate self-harm or suicidal ideations 

John is also at risk of causing himself unintentional harm. For example,

John describes himself as a calm and placid person,

John is at risk of neglect himself as he does not feel the need to eat, and at times will not attend to him personal hygiene or sleep regularly.


For each risk identified above please tick below 

Self-Harm  Suicide      Homicide       Self Neglect      Violence  Vulnerability 

Health / Medical Conditions  Risk to Children / Vulnerable dependents    Risk of offending behaviours 

Other 

Evaluation of Risks including Protective Factors and Patient / Carers Views 

For each identified risk include extent of the risk, which could be affected and what protective factors there are.  This should include the patient and carer views


At Present, it would appear that John is at risk of harming himself whether it is intentional or unintentional, although there seems to be no risk of intentional suicide.

John continues to neglect himself and this risk continues although he has a number of protective factors.

The first being his partner who he lives with and ensures John carries out basic self-care, his son also is a big support and will assist in keeping John safe as much as he can.



Information from Relatives / Carer
Mother and Partner will inform the team if John’s behaviour continues to escalate.




Appendix 2 John’s care plan

This Care Plan belongs to Mr John Doe
Inpatient Car Plan Summary
To be written and agreed with the patient- This plan outlines the ways in which we work together to reach and maintain your best possible level of wellbeing, by using your strengths and resources and describes and support and actions we have agreed. We will meet and discuss and update this plan and involved in your care and treatment.
Summary of identified need (s) following Assessments John was admitted to Meadowview ward on the 13th January 2017 detained under section 2 MHA 1983 due to deterioration of his mental health. John has a diagnosis of Alzheimer’s type dementia. John is confused and has presented as aggressive towards his wife and other residents in the ward controlled accommodation where he lives with his wife. 

10/02/2017 – John’s section 2 MHA had now expired and Multidisciplinary team agreed he no longer requires detention under mental health act and as a result ward had submitted application for DOLS.

10/03/2017 – John remains inpatient on Meadowview ward and is currently detained under DOLS. His assessment of needs had been completed and MDT is looking for 24 hour care facility where John’s needs can be met.

11/04/2017 – John is detained under DOLS on Meadowview ward. His CHC checklist had been completed and it was agreed with MDT he would meet criteria for NHS continuing healthcare funding. Ward team is in process of completing necessary paperwork. John is mostly settled on the ward and spends his time wandering around the ward. He sometimes urinates inappropriately although if guided to the toilet is able to use it appropriately. His sleeping routine had been satisfactory with the prescribed regular Zopiclone. He usually sleeps in his bed and wakes up at night to urinate and once guided by staff he returns to bed. John continues to have good dietary and fluid intake. He usually accepts prescribed medication, although on few occasions staff had to facilitate covert medication care plan to administer prescribed medication in order his mental and physical health to be maintained as stable. John is usually cooperative with nursing interventions, like assistance with personal care, checking his vital signs and weight. John did not have fall since his admission to the ward.

09/05/2017 – John continues to be detained under DOL. DST application for has been completed and submitted to CC. MDT still waiting for their decision to process with the appropriate placement for John. John has been having good dietary and fluid intake but was observed to require more prompting during the mealtimes to remain seated by the table. He continues to accept prescribed medication although sometimes requires some prompting and encouragement from staff. John requires 1 – 2 members of staff to assist him with personal care needs.

John is mostly cooperative with nursing interventions, like checking his weight and vital signs. It was noted John has been regularly having low pulse (it is known to the ward he had history of low pulse prior to admission). MDT had discussed and team to liaise with Southend Cardiology department for follow up.

06/06/2017 – John continues to be inpatient on Meadowview ward and is currently detained under DOLS. His funding application had been declined and ward is awaiting further action plan from social services regarding his placement. John continues to have an adequate dietary and fluid intake, his current weight is 79.8 kg, sometimes he requires prompting and encouragement to remain seated during the mealtimes. John spends most of his time wandering around the ward. He has poor sleeping pattern and despite being prescribed regular Zopiclone medication does not settle to sleep in his bed. John requires 1 – 2 members of nursing team to assist him with personal care. John had no falls in this period but is very unsteady on his feet most of the time. He sometimes is not aware of others personal space and walks into the fellow patients feet when wandering around. John requires a lot of prompting and encouragement to take his prescribed medication which most of the time are now administered covertly as agreed with MDT.

John sometimes can become resistive but no aggressive behaviour towards others was observed.

John is cooperative with nursing staff to check his vital signs and weight most of the time. John’s physical health had declined and his pulse had been regularly low, bellow 50. He was admitted to Basildon General Hospital but team agreed that there was nothing they could do for John. John’s son had expressed that he does not wish his father to be transferred to general hospital. John has DNAR in place.

Summary of Identified Risk (s) following 


Risk of aggression 

Risk of self-neglect

Risk of falls as he had a fall in the past.

Patient / Carer Views including how patient 

wishes to be supported, what’s important to


John unable to discuss his views due to confusion. 

John’s son is very caring and visits his father regularly

John’s son said he is happy with the care his dad receives on the ward. He said “thank you for all you do”.

Staff Views (Inc. all MDT) 

Including safety concerns, legal


Staffs believe that John needs to stay in a place of safety in order for further assessment to be carried out. 

10/02/2017 – John is mostly cooperative with nursing interventions although sometimes requires prompting. He accepts reassurance from staff.

10/03/2017 – John responds to staff reassurance and is mostly cooperative with nursing interventions.

11/04/2017 – John is mostly cooperative with nursing staff and responds well to staff reassurance.

PHYSIOTHERAPY: John has a history of AV block and fall in past. He has been observed pacing around the ward and remains confused. No aggression observed recently. He has a shuffling gait with his upper trunk and both knees mildly flexed. No fall reported.

Patient Strengths 

Include abilities, coping strategies/

protective factors

John is able to communicate with staff to some extent due to his confusion. He is able to follow instruction from staff during personal care. He is mobilising independently. He was observed eating and drinking well and independently. 

10/02/2017 – John responds to staff reassurance and is cooperative with nursing interventions. He has caring son and daughter who visit him regularly.

10/03/2017 – John has caring family

11/04/2017 – John’s family is supportive towards him and visits him regularly.

PHYSIOTHERAPY: He has functional range of movement and good muscle strength in both upper and lower limbs. He is independent with sit to stand, transfers and mobility. But he pace around the ward and lack of environmental awareness.

Patient Care Plan (Recovery) Goal (s) 

Both Long Term and Short Term. Specific,

Measurable, Achievable, Realistic and


Further assessment into John’s mental state and aggressive behaviour to be carried out. John to stay on the ward for assessment and treatment under a legal status of Section 2 MHA 1983. 

11/04/2017 – John to be nursed in safe environment which at the moment is provided by Meadowview ward.

His aggressive behaviour to lessen

Reduce the risk of falls

John to be assisted with nursing needs as and when required

John is detained under DOLS.

PHYSIOTHERAPY: To ensure john is safe with mobility and reduce risk of fall in four weeks’ time.

List of Care Plans added
Care Plan # Care Plan Name Date Added
1. Mental Health Needs 14/01/2017
2. Physical Health care plan 14/01/2017
3. Mental Health Needs OT Care Plan 16/01/2017
4. Physical Health Care Plan Physiotherapy 30/03/2017
Mental Health Needs Care Plan
Identified Need and Risk Actions/Interventions Agreed by patient Who (MDT Member/patient) Review Date Outcome Date of Next 




Assessment of Needs For further assessment of needs to be carried out while John is an inpatient on Meadowview ward. 

Identify strengths and weaknesses and provide assistance and support.

Nursing staff, MDT members, family. 14/01/2017 None 14/02/2017
John continues to be nursed on level 2 observations to enable staff to be aware of his whereabouts on the ward. He does ask to leave but responds well to reassurance. He requires assistance with his personal care and is mostly cooperative. He requires 1 member of staff to assist him. John had been eating and drinking well since his admission. Nursing staff to continue to assist John with the activities of daily living. 

Routine investigations to be carried out i.e. bloods, urinalysis and scans as requested by the doctor.

His behaviour continues to be monitored and recorded in appropriate charts.

Weekly reviews in ward round and MDT meetings.

Staff to continue to encourage John to engage in ward based activities.

Qualified nurses to administer prescribed medication to John to ensure his physical and mental to health to be maintained stable.


Nursing staff

John and his family.

10/02.2017 10/03/2017
Care plan review 

John’s assessment of needs had been completed and he is waiting for the placement.

10/03/2017 10/04/2017
John now is nursed on general level of observations. His CHC checklist was completed and DST paperwork is completed by NDT 11/04/2017 11/05/2017
Care plan review John is nursed on general level of observations. His DET application form has been completed with MDT and family and was submitted to CCG for consideration. Team is waiting for outcome before making plans for the future placement for John. 09/05/2017 09/06/2017
Care plan review 

John continues to be nursed on general level of observations. Nursing needs assessment was submitted to social services. John remains under DOLS and is waiting for placement. He is on delayed discharge since 21/03.

04/07/2017 04/08/2017
Section 2 MHA 1983 For John to be kept in a place of safety under the legal status of Section 2 MHA 1983 while being assessed and supported on the ward. 

For John to be read his rights under this section.

14/01/2017 14/02/2017 10/02/2017
John’s section 2 MHA had no expired and Multidisciplinary team agreed to apply for DOLS. John will continue staying on the Meadowview ward until future care arrangements will be made. John has been found to lack capacity to make an informed decision to remain in hospital. As a response to this, staff has applied for John to be placed under the Deprivation of Liberty Safeguarding (DOLS). 

An urgent application for DOLS was completed and sent by staff.

John to be given the opportunity to express his thoughts and feelings to staff in 1:1 sessions with nursing staff.

John to be given his prescribed medication which can be reviewed on a weekly basis in Ward Round.

Nursing staff to explain the appeal process to John and assist him if he wishes to do so.

Named nurse to review care plan regularly or as a when required


Nursing staff

John and his family

10/02/2017 10/03/2017
Care plan review 

John remains inpatient on Meadowview ward and is detained under DOLS until his future care arrangements will be made.

10/03/2017 10/04/2017
Care plan review 

John continues to be detained under DOLS until appropriate placement will be found.

11/04/2017 11/05/2017
Care plan review 

John remains to be detained under DOLS. His DOLS were granted and is due to expire on 04/06/2017.

Would DOLS due to expire before appropriate placement is found for John. Ward team is to apply for DOLS extension 09/05/2017 09/06/2017
Care plan review 

John remains under DOLS and is waiting for placement. DOLS renewal was sent on 10/05/2017.

04/07/2017 04/08/2017
Aggressive behaviour 

On admission it was reported that John has become aggressive towards his wife and tried to suffocate her with a pillow. On the ward he was observed to be settled since admission.

For aggressive behaviour to be monitored and further assessed, John was cooperative and was able to follow instructions from staff during personal care. 

PRN medication to be given if John becomes too agitated and other methods of de-escalation have failed.

Nursing staff, MDT members, family. 14/01/2017 14/02/2017
John had been shown aggressive behaviour towards staff and fellow patients at the start of his admission. Although sometimes he becomes agitated and verbally abusive towards staff but responds to reassurance most of the time. MDT members, Nursing staff, John and his family. 10/02/2017 10/03/2017
Care plan review 

John had no aggressive behaviour towards others recently, but can be agitated and resistive during personal care. He usually responds well to staff reassurance.

10/03/2017 10/04/2017
Care plan review 

John had not shown aggressive behaviour towards staff or fellow patients in last month. Although he can sometimes get frustrated and agitated by others or noise on the ward. John usually accepts reassurance from staff.

11/04/2017 11/05/2017
Care plan review 

John can become frustrated sometimes due to inability to express his needs for others to understand but he did not show aggressive behaviour towards staff or fellow patients.

09/05/2017 09/06/2017
Care plan review 

John did not show aggressive behaviour towards staff or fellow patients.

04/07/2017 04/08/2017
Risk of falls 

John is mobilising well on the ward and appears steady on his feet. However, it was reported on admission that he had a fall in the past.

For staff to assess John’s mobility and assist on his feet. John to be referred to physiotherapist in case of concerns Nursing staff, MDT members 14/01/2017 14/02/2017
John had no falls since his admission to the ward. He is regularly reviewed by the physiotherapy. MDT, Nursing staff, John and his family. 10/02/2017 10/03/2017
Care plan review 

John had no falls since his admission to the Meadowview ward, he is currently nursed on general level of observations and regular Care plan review

John had no falls since his admission to the ward. Reviewed by physiotherapy.

10/03/2017 10/04/2017
Care plan review 

John had no falls since last care plan review

11/04/2017 11/05/2017
Care plan review 

John had 2 falls recently and is under regular review of physiotherapy department.

09/05/2017 09/06/2017
Mental Health Needs OT Care Plan        Date Added: 16/01/2017
Identified Need and Risks Actions/Interventions Agreed by patient Who (MDT Member/Patient Review Date Outcome Date of Next Review Date Resolved
For John to be levelled using the PAL (Pool Activity Levelling tool) over a period of 4 weeks (Admission date to +4 weeks). 

To enable Occupational Therapists to devise a care plan that reflects an appropriate level of activity for this person and includes their personal preferences

1. To complete OT & PALs  assessments by the Ward OTs 

2. To interview John to find out his likes and dislikes, and establish a therapeutic relationship.

3. To encourage John to attend the morning breakfast group to complete kitchen assessment and to observe his eating to establish if there are any difficulties in these areas

4. To encourage John to attend group activities to assess problems solving skills, task concept, sequencing, cognitive functioning and observe social interaction

5. To gather information on how John is able to wash and dress himself though observations and from reports from support/ nursing   staff.

6. To encourage John to attend current affairs/ reminiscence and craft sessions to establish literacy and comprehension levels

OTs, John and his family, 16/01/2017 1. To be assessed by the OT team 

2. To be levelled using PAL by the OT team

3 For a new appropriate Care plan to be written that reflects an appropriate level of activity for this person and includes their personal preferences

16/02/2017 02/03/2017
John has been levelled using the PAL (Pool Activity Levelling tool) and has been assessed to be on the Exploratory Level. 

Occupational Therapists have devised a care plan to reflect this level of activity and John’s personal preferences

03/03/2017 03/04/2017 03/04/2017
John has been observed pacing, but his gait sometimes shuffles, potentially a falls risk. To engage John in physical activities which promote positive movement and address his stability? OT, John 03/03/2017 To maintain/improve mobility and independence in movements 03/04/2017
Care plan reviewed – to continue as above As above 29/03/2017 As above 29/04/2017
Care plan reviewed – to continue as above As above 28/03/2017 As above 28/05/2017 26/05/2017
Care plan reviewed – John is more physically frail, but remains able to mobilise, to continue as above 26/05/2017 26/06/2017
Care plan reviewed – to continue as above As above 27/06/2017 As above 27/07/2017
Care plan reviewed – to continue as above
To maintain a level of optimal independence for John, it has been noted that he lacks of structure and routine, and is often seen pacing the ward with no planned destination or purpose. For John to engage in a range of daily activities to give purpose and meaning to his day and reduce pacing, when no destination is planned. (Breakfast & Orientation/ Current Affairs/ Reminiscence/ Physical Games/ Self Care/ 1:1) OT/John 03/03/2017 For John to retain his levels of PADL and ADL skills allowing him to remain as independent as is possible for him to be. 

For John to engage in alternatives to unplanned pacing.

Care plan reviewed – to continue as above As above 29/03/2017 As above 29/04/2017
Care plan reviewed – to continue as above As above 28/04/2017 As above 28/05/2017
Care plan reviewed – although more physically frail, John continues to independently mobilise, – To continue with above care plan 25/05/2017 26/06/2017
Care plan reviewed – to continue as above As above 27/06/2017 As above 27/07/2017
Periods of increased agitation, distress and aggression, potential to cause harm to self or others. For care givers to employ distraction techniques and relaxation methods with John when he is more distressed or agitated. (physical Games/ self-care/ 1:1 interventions/ Reminiscence. OT/John 03/03/2017 To reduce the level of agitation and distress John experiences, allowing him to remain calm and effectively manage these emotional responses without harm to himself or others, 30/04/2017 29/03/2017
Although there has been some reduction in John’s levels of agitation and distress, these still remain a concern therefore the care plan reviewed – to continue as above For care givers to employ distraction techniques and relaxation methods with John when he is more distressed or agitated. (physical Games/ self-care/ 1:1 interventions/ Reminiscence. 29/03/2017 To reduce the level of agitation and distress John experiences, allowing him to remain calm and effectively manage these emotional responses without harm to himself or others, 29/04/2017
Care plan reviewed – to continue as above As above 28/04/2017 As above 28/05/2017 26/05/2017
Although there has been some reduction in John’s levels of agitation and distress, these still remain a concern. John is  more physically frail, however, he continues to independently mobilise, therefore the care plan was reviewed – to continue as above For care givers to employ distraction techniques and relaxation methods with John when he is more distressed or agitated. (physical Games/ self-care/ 1:1 interventions/ Reminiscence. 26/05/2017 To reduce the level of agitation and distress John experiences, allowing him to remain calm and effectively manage these emotional responses without harm to himself or others, 26/06/2017
Care plan review John had a fall on 08/06/2017 but did not sustain any injuries. He was reviewed by the physiotherapy. As above 28/06/2017 28/07/2017
Care plan review John remains inpatient on Meadowview ward and is currently detained under DOLS. His DST application form was rejected and alternative arrangements are to be made for John’s future care 08/06/2017 08/07/2017
Physical Health Care Plan Physiotherapy         Date Added: 30/03/2017
Identified Need and Risk Actions/Interventions Agreed by patient Who (MDT Member/patient) Review Date Outcome Date of Next 




Risk of fall, confusion, cognitively impaired, fatigue, wandering John need distance supervision while mobilising and supported if his mobility and mental health deteriorated. Or refer to PT team. Offer rest in between while pacing around. Nursing. Support worker, PT/OT- weekly 30/03/2017 30/04/2017
Same as above Same as above Nursing. Support worker, PT/OT- weekly 30/05/2017 30/06/2017
Same as above Same as above Nursing. Support worker, PT/OT- weekly 20/07/2017 20/08/2017
Transfer and Mobility John is independent with transfer and mobility Nursing. Support worker, PT/OT- weekly 30/03/2017 30/04/2017
Same as above Same as above Nursing. Support worker, PT/OT- weekly 30/05/2017 30/06/2017
PT Recommendations: 


John is independent with transfers Nursing. Support worker, PT/OT- weekly 20/07/2017 20/08/2017
PT Recommendations 


John is independent with mobility and Zimmer frame is also provided under constant supervision at all time. 

Because he was observed to do wall furniture walking.

Nursing. Support worker, PT/OT- weekly 20/07/2017 20/08/2017
Physical Health Care Plan
Identified Need and Risk Actions/Interventions Agreed by patient Who (MDT Member/patient) Review Date Outcome Date of Next 




It was observed John has approx. 2cm moisture lesion under his left side bottom cheek John to be referred to district nurses for assessment and advice nursing staff. 

Staff to assist John regularly with his personal care before breakfast, lunch and dinner and bedtime at lest and more often if required. Qualified nurse to be informed and assess the moisture lesion. If any concerns discuss with the ward/duty/doctor.

Staff to clean the lesion with the proshield spray and apply proshield cram.

Staff to ensure John is waring M size incontinence pad to reduce friction.

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