Care Coordination Workshop 1.7.22 by Moore Fiona (RRE) MPFT https://padlet.com/fionamoore2/az09o3rje3bf7sya Community Mental Health Transformation, Staffordshire, Shropshire, Telford & Wrekin en-us 2022-06-30 12:51:00 UTC 2025-12-25 07:01:14 UTC hello@padlet.com https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235151664 Retain co production as this is essential for working out the best way forward ]]> 2022-07-01 14:26:06 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235151664 Named contact - always pick the phone and speak to CC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235151968 2022-07-01 14:26:21 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235151968 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235152689 Timely response monitoring frequency time fly's ]]> 2022-07-01 14:27:33 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235152689 Knowing there's somebody who knows the person I care for. Knowing who to ask for. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235152832 2022-07-01 14:27:41 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235152832 Ability to build trust. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235153812 2022-07-01 14:29:12 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235153812 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235154605 Having a multi disciplinary approach ]]> 2022-07-01 14:30:12 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235154605 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235155396 Concerns if Care Co-Ordinator away back up person to support client - client to know who this is ]]> 2022-07-01 14:31:27 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235155396 Follow up on actions that have been agreed https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235155756 2022-07-01 14:31:57 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235155756 Risk of separation difficulties. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156028 2022-07-01 14:32:18 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156028 No having to repeat my story https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156469 2022-07-01 14:32:50 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156469 Named worker https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156581 2022-07-01 14:33:01 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156581 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156648 Care plans very rarely updated with fast changing care and shouldn't - good if dynamic updated without duplication ]]> 2022-07-01 14:33:08 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156648 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156768 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 

]]> 2022-07-01 14:33:21 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235156768 Carers involve throughout a service users journey https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157177 2022-07-01 14:33:58 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157177 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157292 Who owns the careplan format appropriate to person]]> 2022-07-01 14:34:09 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157292 Care plans co-produced with service users https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157950 2022-07-01 14:35:15 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235157950 Regular review of care plan and crisis plan. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158053 2022-07-01 14:35:26 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158053 Consistency https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158151 Build the relationship with one person means that there is less chance of something being missed ]]> 2022-07-01 14:35:37 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158151 Meaningful risk assessment https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158238 2022-07-01 14:35:44 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158238 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158557 How to make information accessible to a carer in times of a crisis ]]> 2022-07-01 14:36:19 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158557 Making sure only relevant individuals are involved https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158592 2022-07-01 14:36:22 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158592 Communication https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158623 consistency with this ]]> 2022-07-01 14:36:25 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235158623 Provides assurance that key documents inc. care plan and crisis plan are in place and reviewed regularly. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235159574 2022-07-01 14:38:07 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235159574 Different staff will be involved in a service users recovery journey to support with their specific needs https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235159865 2022-07-01 14:38:29 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235159865 Carers with power of attorney are included https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235160230 Retaining the need for all carers to still be involved with PoA and if wanted to by the service user ]]> 2022-07-01 14:39:05 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235160230 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235160808 All write together with patients and carers - careplan - timely reviewing if not going well to respond in a timely manner ]]> 2022-07-01 14:40:05 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235160808 Staff changes and pressures resulted in too frequent changes to care co https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161683 2022-07-01 14:40:59 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161683 Being a working document https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161757 Updated with the changing needs of the service user as and when these occur and arise ]]> 2022-07-01 14:41:07 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161757 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161822 Care should be dynamic - leaner approach to documentation]]> 2022-07-01 14:41:13 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235161822 Whilst a care co may change as part of a service users recovery journey but a core group need to have over sight https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235162466 2022-07-01 14:42:27 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235162466 Gives opportunity to know who is around somebody (support network). https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235162680 2022-07-01 14:42:35 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235162680 One care plan - often seen by various professions in one organisation and have 3 different care plans - that all look different fionamoore2 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235163196 2022-07-01 14:43:30 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235163196 Not being generalised https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235163832 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 ]]> 2022-07-01 14:44:31 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235163832 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235164442 Sometime care needs are more related to a wider group for being named person to met their needs and main priority - need with skill ]]> 2022-07-01 14:45:27 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235164442 Make sure there is somebody who can be an 'advocate' for the individual. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235164820 2022-07-01 14:46:03 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235164820 Most appropriate professional coordinates care other than just nurses/OT's https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235165060 2022-07-01 14:46:20 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235165060 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235165218 Service user on careplan has continuity of care may not necessarily be clinical - shared decision making with service user and carer]]> 2022-07-01 14:46:37 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235165218 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166286 Best placed person who is available and know the person well in a caring capacity - core training quality is really happening]]> 2022-07-01 14:48:24 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166286 Clear lines of responsibility. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166310 2022-07-01 14:48:26 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166310 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166907 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 ]]> 2022-07-01 14:49:32 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166907 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166980 Availability from service users perspective when conversations available to be had - not just a 9-5pm approach when is it best to talk]]> 2022-07-01 14:49:41 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235166980 Meaningful involvement in service users care other than compliance https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167289 2022-07-01 14:50:17 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167289 Need to have effective communication between agencies/organisations inc. IT systems. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167326 2022-07-01 14:50:21 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167326 Person centred https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167617 2022-07-01 14:50:53 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167617 Louisa's Group louisa_alderson https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167654 *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.

*







]]> 2022-07-01 14:50:58 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235167654 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235168259 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 ]]> 2022-07-01 14:51:56 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235168259 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235169427 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]]> 2022-07-01 14:53:40 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235169427 Triangle of care https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235170802 2022-07-01 14:55:55 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235170802 Meaningful relationship with key worker in order to build trust https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171208 2022-07-01 14:56:35 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171208 Keeping hold of key documents - care plan and crisis plan - but removing duplication, over-documenting. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171643 2022-07-01 14:57:16 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171643 care coordinator or first point of contact https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171968 The most relevant person that has been involved in the primary intervention at that time 
Person who devises the care plan possibly ? 

]]> 2022-07-01 14:57:42 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235171968 Care plan shared between professionals & organisations https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235172296 2022-07-01 14:58:14 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235172296 Currently are these being met https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235172958 Variable from service to service but also from service user to service user ]]> 2022-07-01 14:59:22 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235172958 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173309 How do we have confidence that the careplans we are doing are fit for purpose and standards upheld ]]> 2022-07-01 14:59:48 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173309 We will have to put processes in place to ensure risks are managed https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173644 2022-07-01 15:00:22 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173644 Process driving the care under CPA - Important for care to drive the process https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173895 2022-07-01 15:00:39 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235173895 Shared interface https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174311 An opportunity that the service user can share their care plan with services like crisis team, police etc or even the GP ]]> 2022-07-01 15:01:25 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174311 https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174350 Having right information at the right time ]]> 2022-07-01 15:01:28 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174350 Care plan need to be robust and meaningful https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174352 2022-07-01 15:01:29 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174352 Ability to share care plan between services and with service users. https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174572 2022-07-01 15:01:55 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174572 Shared framework https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174998 Always being included and the care plan looks the same but the information is personalised 
sharing would be easier and what is included etc. ]]> 2022-07-01 15:02:42 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235174998 How will we ensure carers are involved https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235175148 2022-07-01 15:03:00 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235175148 Louisa's Group louisa_alderson https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235175460 *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.]]> 2022-07-01 15:03:32 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235175460 support workers from community groups https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235190057 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. ]]> 2022-07-01 15:31:02 UTC https://padlet.com/fionamoore2/az09o3rje3bf7sya/wish/2235190057