# data[].attributes.body
Being able to have a support worker that runs groups like art, who see the support user numerous times between appointments, if not even weeks, share concerns that they have noticed within the user, with the users consent.

Those concerns and observations need to be noted, as they may see situations that trigger negative responses in the user that they themselves are unaware of, and therefore never raised.

Not to replace the at risk protocols.

# data[].attributes.body
*Service user to have input into who should be the key worker

*Listen to the voice of the service user, ensure this is taken seriously, more than just saying we listen, actually listening

*Need to be people leading, ensuring information is shared & all staff / keyworkers are kept up to date with what is available either NHS or VCSE.  Ensuring it's all held together.

*Ensuring everyone involved in the care is in communication with each other.

*The individual needs direct access to the care plan and risk assessment - nothing about us without us principle should apply.

*Having a newsletter that is sent out updating people on events, input from service users and carers

*Progress needs to be updated regularly, care plan needs to keep being update, stop care plan stagnating, keep recovery focused.

# data[].attributes.body
Always being included and the care plan looks the same but the information is personalised
sharing would be easier and what is included etc.

# data[].attributes.headline
Ability to share care plan between services and with service users.

# data[].attributes.subject
Ability to share care plan between services and with service users.

# data[].attributes.headline
Care plan need to be robust and meaningful

# data[].attributes.subject
Care plan need to be robust and meaningful

# data[].attributes.body
Having right information at the right time

# data[].attributes.body
An opportunity that the service user can share their care plan with services like crisis team, police etc or even the GP

# data[].attributes.headline
Process driving the care under CPA - Important for care to drive the process

# data[].attributes.subject
Process driving the care under CPA - Important for care to drive the process

# data[].attributes.headline
We will have to put processes in place to ensure risks are managed

# data[].attributes.subject
We will have to put processes in place to ensure risks are managed

# data[].attributes.body
How do we have confidence that the careplans we are doing are fit for purpose and standards upheld

# data[].attributes.body
Variable from service to service but also from service user to service user

# data[].attributes.headline
Care plan shared between professionals & organisations

# data[].attributes.subject
Care plan shared between professionals & organisations

# data[].attributes.headline
care coordinator or first point of contact

# data[].attributes.subject
care coordinator or first point of contact

# data[].attributes.body
The most relevant person that has been involved in the primary intervention at that time
Person who devises the care plan possibly ?

# data[].attributes.headline
Keeping hold of key documents - care plan and crisis plan - but removing duplication, over-documenting.

# data[].attributes.subject
Keeping hold of key documents - care plan and crisis plan - but removing duplication, over-documenting.

# data[].attributes.headline
Meaningful relationship with key worker in order to build trust

# data[].attributes.subject
Meaningful relationship with key worker in order to build trust

# data[].attributes.body
Mechanism to make sure we have systems to remind and review to have a co-ordinated meeting - does this need a particular timescale or need based

# data[].attributes.body
How Voluntary Care organisations are included in care plan and have the right support to be able to deliver might not be trained equipped for care plan - if not the right time for someone on their journey

# data[].attributes.body
*Will existing care co be the named key worker?  Can there be a transition phase where people can keep current care co as keyworker? Some areas have been advised they may be divided up differently, meaning SU's may have to change care co & re tell their story.  Continuity of relationship would be important.

*Can there be some form of measurement of how you are feeling at the end of a visit to identify when you might next be seen- could be on a scale 1-10, in order to meet individual. Have a say in frequency of contacts based on needs.

*Coordinate so that new system comes in place in a planned way.

*Having some choice around who is the keyworker or care coordinator

*Match support workers to the interests of the individual

*more activity as part of the planning of care

*plans should be based on needs of the person

*Having one care plan, not multiple plans from multiple professionals

*physical health checks - duplication, needs to be addressed.  Need test results to be available to the individual

*Information needs to be more easily accessible to both service users and staff

*Keep easy read information, keep flexibility in our approach, still be able to be creative.

*How will section 117 entitlement be reviewed, can it be incorporated into the main care planning process - need joined up approach

*Regular reviews need to stay

*Post discharge visits need to be made in a timely way.  Also need information on voluntary sector services on discharge, needs to be kept up to date. Need to be updated with new services in the community

*Key worker to support to make connections with other services.

*

# data[].attributes.headline
Need to have effective communication between agencies/organisations inc. IT systems.

# data[].attributes.subject
Need to have effective communication between agencies/organisations inc. IT systems.

# data[].attributes.headline
Meaningful involvement in service users care other than compliance

# data[].attributes.subject
Meaningful involvement in service users care other than compliance

# data[].attributes.body
Availability from service users perspective when conversations available to be had - not just a 9-5pm approach when is it best to talk

# data[].attributes.body
Risk is monitored through and by everyone involved in the care not necessarily placed on one person
Over coming challenges times doc. is more current document to help manage risk is this better framework or relapse planning - should be incorporated into the care plan

# data[].attributes.body
Best placed person who is available and know the person well in a caring capacity - core training quality is really happening

# data[].attributes.body
Service user on careplan has continuity of care may not necessarily be clinical - shared decision making with service user and carer

# data[].attributes.headline
Most appropriate professional coordinates care other than just nurses/OT's

# data[].attributes.subject
Most appropriate professional coordinates care other than just nurses/OT's

# data[].attributes.headline
Make sure there is somebody who can be an 'advocate' for the individual.

# data[].attributes.subject
Make sure there is somebody who can be an 'advocate' for the individual.

# data[].attributes.body
Sometime care needs are more related to a wider group for being named person to met their needs and main priority - need with skill

# data[].attributes.body
Ensuring that it remains the personalised approach helping to set goals for the service user so that these can be evaluated and adjusted as part of the overall approach

# data[].attributes.headline
One care plan - often seen by various professions in one organisation and have 3 different care plans - that all look different

# data[].attributes.subject
One care plan - often seen by various professions in one organisation and have 3 different care plans - that all look different

# data[].attributes.headline
Gives opportunity to know who is around somebody (support network).

# data[].attributes.subject
Gives opportunity to know who is around somebody (support network).

# data[].attributes.headline
Whilst a care co may change as part of a service users recovery journey but a core group need to have over sight 

# data[].attributes.subject
Whilst a care co may change as part of a service users recovery journey but a core group need to have over sight 

# data[].attributes.body
Care should be dynamic - leaner approach to documentation

# data[].attributes.body
Updated with the changing needs of the service user as and when these occur and arise

# data[].attributes.headline
Staff changes and pressures resulted in too frequent changes to care co

# data[].attributes.subject
Staff changes and pressures resulted in too frequent changes to care co

# data[].attributes.body
All write together with patients and carers - careplan - timely reviewing if not going well to respond in a timely manner

# data[].attributes.headline
Carers with power of attorney are included 

# data[].attributes.subject
Carers with power of attorney are included 

# data[].attributes.body
Retaining the need for all carers to still be involved with PoA and if wanted to by the service user

# data[].attributes.headline
Different staff will be involved in a service users recovery journey to support with their specific needs 

# data[].attributes.subject
Different staff will be involved in a service users recovery journey to support with their specific needs 

# data[].attributes.headline
Provides assurance that key documents inc. care plan and crisis plan are in place and reviewed regularly. 

# data[].attributes.subject
Provides assurance that key documents inc. care plan and crisis plan are in place and reviewed regularly. 

# data[].attributes.body
consistency with this

# data[].attributes.headline
Making sure only relevant individuals are involved

# data[].attributes.subject
Making sure only relevant individuals are involved

# data[].attributes.body
How to make information accessible to a carer in times of a crisis

# data[].attributes.body
Build the relationship with one person means that there is less chance of something being missed

# data[].attributes.headline
Regular review of care plan and crisis plan. 

# data[].attributes.subject
Regular review of care plan and crisis plan. 

# data[].attributes.headline
Care plans co-produced with service users

# data[].attributes.subject
Care plans co-produced with service users

# data[].attributes.body
Who owns the careplan format appropriate to person

# data[].attributes.headline
Carers involve throughout a service users journey

# data[].attributes.subject
Carers involve throughout a service users journey

# data[].attributes.body
Having a voice and knowing that there will always be someone overlooking my case - without the need to keep repeating and not miss important info being missed

# data[].attributes.body
Care plans very rarely updated with fast changing care and shouldn't - good if dynamic updated without duplication

# data[].attributes.headline
Follow up on actions that have been agreed

# data[].attributes.subject
Follow up on actions that have been agreed

# data[].attributes.body
Concerns if Care Co-Ordinator away back up person to support client - client to know who this is

# data[].attributes.body
Having a multi disciplinary approach

# data[].attributes.headline
Knowing there's somebody who knows the person I care for. Knowing who to ask for.

# data[].attributes.subject
Knowing there's somebody who knows the person I care for. Knowing who to ask for.

# data[].attributes.body
Timely response monitoring frequency time fly's

# data[].attributes.headline
Named contact - always pick the phone and speak to CC

# data[].attributes.subject
Named contact - always pick the phone and speak to CC

# data[].attributes.body
Retain co production as this is essential for working out the best way forward