core unit 3: part 2 of the mental health (wales) measure 2010: the application of the measure

7/27/2019 Core Unit 3: Part 2 of the Mental Health (Wales) Measure 2010: the application of the Measure

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Uned Graidd 3: Rhan 2 o Fesur

Iechyd Meddwl (Cymru) 2010:

gweithredur Mesur

Core Unit 3: Part 2 of the Mental Health

(Wales) Measure 2010:

the application of the Measure


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Digital ISBN 978 0 7504 7878 6

Hawlfraint y Goron/Crown copyright 2012

WG15036

2

Ysgriennwch eich nodiadau yma:


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Core Unit 3: Part 2 o the Mental Health (Wales) Measure 2010: the application o the Measure

Write your notes here:


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Uned Graidd 3: Rhan 2 o Fesur Iechyd Meddwl (Cymru) 2010: gweithredur Mesur

Uned Graidd 3: Rhan 2 o Fesur Iechyd Meddwl (Cymru) 2010:

gweithredur Mesur

Oriau hyorddi yn gysylltiedig r uned hon = 3 awr

Nodaur uned:

Gwella dealltwriaeth cyranogwyr am Fesur Iechyd Meddwl (Cymru) 2010 ar dasg bwysig oi

weithredu.

Pri negeseuon i hwyluswyr:

Mae Mesur Iechyd Meddwl (Cymru) 2010 yn gosod dyletswydd ar gydlynwyr goal i ddarparu

cynlluniau goal a thriniaeth or radd aena gyda phwyslais ar wellhad.

Maer dyletswyddaun cynnwys datblygu a gweithredu cynlluniau goal a thriniaeth y cytunir

arnynt ar y cyd os ywn bosibl.

Mae ymgynghori, caniatd, cyrinachedd a nodi anghenion sydd heb eu bodloni ynagweddau pwysig o rl y cydlynydd goal.

Cywyniad

Mae Mesur Iechyd Meddwl (Cymru) 2010 yn cenogi cynllunio goal a thriniaeth mewn

gwasanaethau iechyd meddwl eilaidd. Maer cynllun hwn ar ddeddwriaeth ar Cod Ymarer

cysylltiedig yn gwreiddio cynllunio goal a thriniaeth o ewn ramwaith deddwriaeth a pholisi.

Maen amlinellu gweledigaeth glir ar gyer cydlynu goal yn eeithiol, a hynny ar sail

gwerthoedd y model gwellhad syn rhoi lle canolog i ddenyddwyr gwasanaeth yn eu cynlluniau

goal. Rl y cydlynydd goal yw gweithredur ddeddwriaeth a chenogi ei gwerthoedd allweddol.

Maer uned hon yn rhoi cye i gyranogwyr ystyried sut bydd y datblygiadau hyn yn newid y

yrdd y mae cydlynwyr yn gweithio gyda denyddwyr gwasanaeth, a gyda rhwydweithiau goal a

darparwyr gwasanaeth er mwyn sicrhau bod y goynion deddwriaethol a gwerthoedd gwellhad

yn cael eu hadlewyrchu yn eu gwaith. Maer uned yn canolbwyntio ar y materion ymarerol y

mae cydlynwyr goal yn debygol ou hwynebu wrth gydlynu gwasanaethau iechyd meddwl.

Canlyniadau dysgu

Ar l cwblhaur uned hon bydd y cyranogwyr yn:

1Deall y goynion y mae Mesur Iechyd Meddwl (Cymru) 2010 ar ddeddwriaeth ar polisi

cysylltiedig yn eu gosod ar weithwyr syn gweithio el cydlynwyr goal

2

Ystyried sut y gallwch gyawni gwerthoedd goal a thriniaeth yn eeithiol yn eich ymarer osabwynt:

a) Nodi angen heb ei odloni

b) Cydlynur gwasanaethau iechyd meddwl syn cael eu darparu

c) Ymgynghori phobl eraill syn gysylltiedig goal a thriniaeth y denyddiwr gwasanaeth

d) Cenogi proses sydd wedi ei chynllunio pan ydd denyddwyr gwasanaeth yn gadael ygwasanaethau iechyd meddwl


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Core Unit 3: Part 2 of the Mental Health (Wales) Measure 2010: the application of the Measure

Core Unit 3: Part 2 o the Mental Health (Wales) Measure 2010:

the application o the Measure

Training hours associated with this unit = 3 hours

Aim o the unit:

To increase participants understanding o the Mental Health (Wales) Measure 2010 and its

critical application.

Key messages or acilitators:

Mental Health (Wales) Measure 2010 places duties on care coordinators to deliver high

quality recovery orientated care and treatment plans.

Duties include the development and delivery o mutually agreed care and treatment plans

whenever possible.

Consultation, consent, confdentiality and identifcation o unmet needs are importantaspects o the care coordinator role.

Introduction

Mental Health (Wales) Measure 2010 supports care and treatment planning in secondary

mental health services. This initiative with the associated legislation and code o practice

enshrines coordinated care and treatment planning within a legislative and policy ramework.

This sets out a clear vision or eective care coordination ounded on the values o a recovery

model with service users placed at the centre o their care. The role o the care coordinator in

enacting the legislation and supporting its values is a vital one.

This unit provides an opportunity or participants to consider how these developments will

change the ways that coordinators work with service users, care networks and service provid-

ers to ensure that legislative requirements and recovery values are enacted within their prac-

tice. The unit ocuses on practical issues that care coordinators are likely to ace with regard

to coordinating the provision o mental health services.

Learning outcomes

On completion o this unit participants will:

1Understand the requirements that the Mental Health (Wales) Measure 2010 and

associated legislation and policy places on personnel who will unction as care coordinators

2

Consider how you might eectively enact the values o care and treatment within your workwith regard to:

a) Identifcation o unmet need

b) Coordinating provision o mental health services

c) Consulting with other persons involved in the service users care and treatment

d) Supporting planned discharge o service users rom secondary mental health services


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Amser

(munudau)Focws

Canlyniadau

dysgu

cysylltiedig

Dull dysgu/

adnoddauCynnwys

10 munud Gweithio trwyr unedau - Cywyniadau Sleid 1 3

30 munud

Rhan 1:

Cymhwysedd a

swyddogaethaur

cydlynydd goal

1PowerPoint a

thraodaethSleidiau 4 8

30 munud

Rhan 2:

Anghenion heb eu

bodloni cydlynydd goal

2(a) Ymarer 1Taen 1Taen 2

60 munud

Rhan 3:

Ymgynghori a darparu

cynlluniau goal a

thriniaeth

2(b a c)Traodaeth grwp

Ymarer 2

Sleidiau 9 11Taen 3Taenwybodaeth A

30 munud

Rhan 4:

Cenogi pan ydd y

denyddiwr yn gadael y

gwasanaeth

2(d) Ymarer 3Sleid 12Taen 4Taen 5

20 munud Crynhoi -

Cwestiynau

Negeseuon addysgwyd

Cynllun y wers

Cynllun gwers manwl

Gweithio trwyr uned

Gallech ddangos y sleid PowerPoint cynta wrth ir cyranogwyr gyrraedd.

Yn dibynnu ar y seylla, gallech anteisio ar y cye i gywyno eich hun ar cyranogwyr iw

gilydd. Peidiwch threulio gormod o amser yn gwneud hynny.

Sleidiau 2 a 3: Dangoswch nodau a chanlyniadau dysgur uned. Dylid dangos ac

esbonior rhain yn yr.

Adnoddau dysgu angenrheidiol:

cyrifadur a thaunydd LCD

siart ip neu wrdd gwyn, pinnau lliw

digon o gopau o lyrau gwaith yr uned

sisyrnau

peli o ruban neu linyn lliw.


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Time Focus

Related

learning

outcomes

Teaching method/

resourcesContent

10 mins Orientation - Introductions Slide 1 3

30 mins

Section 1:

Eligibility and unctions

o care coordinator

1PowerPoint and

discussionSlides 4 8

30 minsSection 2:

Unmet needs2(a) Exercise 1

Handout 1Handout 2

60 mins

Section 3:

Consultation andprovision o care and

treatment plans

2(b & c)

Group discussion

Exercise 2

Slides 9 11

Handout 3Inormationsheet A

30 minsSection 4:

Supporting discharge2(d) Exercise 3

Slide 12Handout 4Handout 5

20 mins Conclusion -QuestionsTake homemessages

Lesson plan

Detailed lesson plan

Orientation

You might like to have the frst PowerPoint slide showing when participants arrive.

Depending on the situation, you might like to introduce yoursel and participants to each other.

This should be kept airly brie.

Slides 2 & 3: Show the aims and learning outcomes or the unit. These should beshown and briey covered.

Required teaching resources:

computer and LCD projector

ipchart or whiteboard, coloured pens

sufcient copies o unit worksheets

scissors

balls o coloured string or ribbon.


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Rhan 1: (30 mins)

Cymhwysedd a swyddogaethaur cydlynydd goal

Er mai adolygu sleidiau a wneir yn y rhan hon or uned yn benna, maen bwysig rhoi cye ir

cyranogwyr oyn cwestiynau a chael eglurhad. Eallai y byddwch yn awyddus i dynnu sylwrcyranogwyr at y canllawiau polisi perthnasol.

Sleidiau 4 6: Y Cydlynydd Goal ar Mesur

Maer sleidiau hyn yn atgoa pawb am natur statudol cydlynu goal yn sgil y ocws yn y Mesur

ar Rheoliadau ar eini praw cymhwysedd allweddol.

Byddai o udd cael traodaeth ar hynny; dyma rai cwestiynau a allai godi:

pa gymorth a hyorddiant ydd eu hangen ar gydlynwyr goal?

beth yw profad a hyorddiant priodol?

beth ywr gwahaniaethau rhwng cymhwysedd a gallu?

Sleid 7 8: Cydlynu cynlluniau goal a thriniaeth

Mae Sleid 7 yn rhoi sylw i gynllunio goal a thriniaeth. Bydd UG4 ac UG5 yn edrych ar hyn

yn anylach.Maer sleidiau amllinelliad yn amlinellu pri swyddogaethaur cydlynydd goal. Maen werth

goyn ir cyranogwyr beth mae hyn yn ei olygu. Er enghrait:

sicrhau bod gwaith neu ymyriadau y cytunwyd arnynt yn digwydd

monitro cynnydd tuag at ganlyniadau.


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Section 1: (30 mins)

Eligibility and unctions o care coordinator

Whilst this part o the unit is mainly a review o slides, it is important that opportunity

or participants to ask questions or seek clarifcation is oered. You might wish to directparticipants to relevant policy guidance.

Slides 4 6: The care coordinator and the Measure

These slides provide a reminder about the statutory nature o care coordination in light o the

legislation and ocus on key eligibility criteria

It is useul to open this up to discussion some questions that may be asked are:

what support and training care coordinators might require?

what constitutes appropriate experience and training?

what might the dierences be between eligibility and capability?

Slide 7 8: Coordinating care & treatment plans

Slide 7 is related to care & treatment planning which will be covered in much more detail in

two subsequent units (CU4 & CU5).These slides outline the key unctions o care coordinators. It is worth asking participants

what this entails. For example:

ensuring agreed interventions happen

monitoring progress towards outcomes.


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Rhan 2: (30 munud)

Taen 1: Ymarer bodloni anghenion

Daen 1: Ymarer anghenion heb eu bodloni

Goynnwch ir cyranogwyr ddarllen y senario yn nhaen 1 cyn traod (gweler yr awgrymiadau yn

nhaen 1).

Goynnwch ir cyranogwyr draod sut bydden nhw, el cydlynwyr goal, yn ymateb ir seylla.

Yn dilyn y draodaeth grwp, rhannwch daen 2 i adolygur Cod Ymarer am y mater hwn.

Nodiadau ir hwylusydd: Mae a wnelor senario hon dyletswydd y cydlynydd goal i gydlynur

cynllun goal a thriniaeth. Eallai y byddwch yn awyddus i adolygur senario ac ystyried cwrdd ag

anghenion sydd heb eu bodloni yn achos siaradwyr Cymraeg.

Wrth ymateb, bydd angen ir cyranogwyr ystyried anghenion sydd heb eu bodloni a sut gellid

rhoi sylw i hynny. Dymar pri aterion iw hystyried:

cynghorir darparwr gwasanaeth iechyd meddwl. Gallai hynny gynnwys penderynu a ellir

prynur gwasanaeth gan y darparwr yn rhywle arall (yn breiat neu gan ddarparwr arall).

gallair seylla arwain at adolygiad. Byddai adolygiad yn odd ir rhwydwaith goal ystyried

yr opsiynau.

sgiliaur tm adolygu i roi sylw i anghenion Piotr. Gallai hynny gynnwys hyorddiant, datbly

giad a recriwtio.

conodi pa bethau a wnaed i odlonir angen.

rhoi sylw i Piotr a hawl ei bartner i gwyno am ei oal a cheisio eiriolaeth a chyngor.


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Exercise 1: Unmet need exercise

Handout 1: Unmet needs exercise

Ask participants to read the scenario in handout 1 and then open up to discussion.

Ask participants to discuss how, as care coordinators they might respond to the situation.

Following group discussion distribute handout 2 to oer a review o the Code o Practice

regarding this issue.

Facilitators note: This scenario relates to the duty o the care coordinator to coordinate the

care and treatment plan. You may wish to amend the scenario and consider meeting unmet

needs o Welsh speakers. Review chapter 5 o the Code o Practice (sections 5.1-5.5) to aid

discussion o duties relating to meeting needs.

In response participants will need to consider issues o unmet need and how this might be

addressed. Key issues are:

advising the mental health service provider. This might include determining whether the

service could be purchased by the provider elsewhere (privately or rom another provider).

that the situation could be a trigger or a review. A review would enable the care network to

consider options.

review team skills to help address Piotrs health needs. This might include training,

development and recruitment.

recording what eorts have been taken to meet the need.

addressing Piotr and his partners right to complain about his care and to seek advocacy

and advice.


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Rhan 3: (60 munud)

Ymgynghori ar gyer cynllunio goal a thriniaeth

Sleidiau 9: Gyda phwy y dylid ymgynghori

Maer sleidiau hyn yn dangos pwy ddylid a phwy y gellid ymgynghori hwy. Ni ddifnnir y gair

ymgynghori yn y rheoliadau nar Cod Ymarer. Felly maen agored iw ddehongli. Er enghrait,

a ywn golygu rhoi a/neu dderbyn gwybodaeth?

Wrth ddangos sleid 10 byddain help dechrau trwy draod pwy y byddair denyddiwr

gwasanaeth neur cydlynydd goal yn awyddus i ymgynghori nhw. Er enghrait, gallech oyn ir

cyranogwyr awgrymu pwy y bydden nhwn hof eu cynnwys. Dylair rhestr od yn eang a gallai

gynnwys:

rindiau

teulu (heb od yn gweithredu el goalwr)

cysylltiadau cymunedol el cymdogion, gweithwyr swyddar post, gweithwyr siop, taarnwyr a

chlerigwyr a allai gadw golwg neu genogi denyddwyr gwasanaeth

meddyg teulu a sta iechyd goal sylaenol

asiantaethau gwiroddol a dielw

gweithwyr proesiynol eraill syn gysylltiedig chynlluniau goal a thriniaeth.

Wrth ddangos sleid 9 eglurwch od amryw o gaeatau yn y Rheoliadau syn ymwneud rhannu

cynlluniau goal a thriniaeth. Maer rhain yn cynnwys materion syn gysylltiedig chapasiti,caniatd a budd penna. Felly maen bwysig atgoar cyranogwyr i wirior rhan berthnasol or

Rheoliadau neu gael cyngor priodol er mwyn rheoli amgylchiadau unigol.

Sleidiau 10 a 11: Copiau or cynllun goal a thriniaeth

Maer sleid hon yn nodi pwy ddylai dderbyn copi or cynllun goal a thriniaeth. Gallai od o udd

goyn ir cyranogwyr ystyried yn yr sut yddan nhwn sicrhau bod copaun cael eu dosbarthu

a sut gellid cael tystiolaeth o hyn. Er enghrait a ydd yna broorma lleol ar gyer conodir

cynlluniau a ddarperir yn y nodiadau?

Mae rheoliadau Rhan 2 yn rhoi cyarwyddiadau penodol ynglyn darparu copau o gynlluniau

goal a thriniaeth. Ystyrir bod cynllun goal a thriniaeth wedi ei ddarparu os yw:

wedi ei ddanon i unigolyn yn bersonol neu iw cyeiriad hysbys diwetha;

wedi ei bostio mewn amlen ragdaledig iw cyeiriad hysbys diwetha;

wedi ei anon trwy acs i ri a gawyd gan unigolyn, neu;

wedi ei ddanon neu ei anon trwy ddull arall y cytunwyd arno rhwng yr unigolyn sydd i od iw

dderbyn ar cydlynydd goal.

Maer Cod ymarer yn Argymell bod copiau or cynllun goal a thriniaeth ar gael cyn gynted agy bon ymarerol bosibl. Os nad ywn bosibl darparu copaun syth ar l cyarod cynllunio neu

adolygu yna dylair cydlynydd goal ddal i gynnig esboniad or cynllun goal a thriniaeth ir cla.


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Consultation or care & treatment planning

Slides 9: Who must be consulted

This slide identifes who must and could be consulted. The word consult is not defned

within the regulations or code o practice. It thereore can be subject to interpretation.

For example does it involve giving and/or receiving inormation?

When showing slide 9 it is useul to start to generate discussion about who the service user

or care coordinator might like to be consulted. For example you can ask participants to

suggest who they might involve. The list should be ar reaching and might include:

riends

amily (not acting as carer)

community contacts such as neighbours, post ofce workers, shop workers, publicans and

clergy who might keep an eye on or support service users

GP and primary health sta

voluntary and not or proft agencies

other proessionals involved in care & treatment plans.

When showing slide 9 explain that there are various caveats within the Regulations concerning

the sharing o care and treatment plans. These involve issues around capacity, consent and

best interests. It is thereore important to remind participants to check the relevant part othe Regulations or to seek appropriate advice to manage individual circumstances.

Slides 10 and 11: Copies o the care and treatment plan

This slide identifes who should be provided with a copy o the care and treatment plan. At this

stage it might be useul to ask participants to briey consider how they will ensure that copies

are distributed and how this might need to be evidenced. For example will there be a local

proorma or recording provision o plans in the notes?

The Part 2 regulations provide specifc instructions about the delivery o copies o care and

treatment plans. A care and treatment plan is considered to be provided when it has been:

delivered to a person by hand or to their last known address;

sent by prepaid post to their last known address;

sent by acsimile to a number specifed by a person, or;

delivered or sent by any other means agreed between the person or whom it is intended

and the care coordinator.

The Code o Practice recommends that copies o the care and treatment plan are made

available as soon as practicable. Where copies cannot be made available immediately ater aplanning or review meeting the care coordinator should still oer the patient an explanation o

the care and treatment plan.


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Ymarer 2: Cysylltu llinynnau

Oer angenrheidiol

Cardiau/bathodynnau neu sticeri mawr gwyn Pinnau lliw

Dau ath o linyn lliw

Sisyrnau

Cardiau gydar rolau canlynol wedi eu hysgriennu neu eu hargrau arnynt: Eleri; Daydd

(cydlynydd goal Eleri); Tomos (ewythr Eleri); Gwen (modryb Eleri); Rhys (Y Seiciatrydd Ymg

ynghorol); Sian (meddyg teulu Eleri); Caroline (rheolwr prosiect gwasanaeth elusennol);

Rosie (rind Eleri); eallai y bydd rolau ychwanegol el Therapydd Galwedigaethol;

Seicolegydd; Nyrs Iechyd Meddwl; Dietegydd; cymydog ac ati

Cardiau brifo ir cyranogwyr ar gyer y pri rolau.

Cam 1

Maer hwylusydd yn amlinellur seylla denyddiwch daen brifo 1 i roi crynodeb o Eleri ai

seylla. Ceisiwch osgoi darllen y dudalen byddain well cywynor seyllan wy anurfol trwy

sgwrsio.

Nodyn ir hwylusydd: Gallwch ychwanegu gwybodaeth am Eleri os dymunwch, e.e. bod ganddi

gleyd y siwgr (syn golygu bod y dietegydd yn aelod posibl or tm goal).

Cam 2

Gosodwch y cadeiriau mewn cylch mawr

Rhannwch y rolau ymysg y cyranogwyr gallwch gyuno rolau e.e. gallai un person gynrychiolir

rhieni os nad oes digon o gyranogwyr.

Rhowch y cardiau rl (Inormation sheet A) ir rhai syn chwaraer pri rolau.

Goynnwch ir cydlynydd goal ac Eleri seyll neu eistedd yng nghanol y cylch.

Cam 3

Eglurwch od adolygiad o gynllun goal a thriniaeth Elerin cael ei drenu.Goynnwch i Eleri ddenyddior llinyn i gysylltu r holl bobl y mae hin ystyried syn bwysig

iw goal.

Nodyn: Nid ywr sawl syn chwarae rl Eleri wedi ei chyyngu ir bobl a enwir yn y deunyddiau

ysgrienedig. Mae ganddi rwydd hynt i ddewis pwy y maen ystyried sydd rl bwysig iw chwarae

yn ei goal. Felly gellir cynnwys rolau ychwanegol el cymdogion, gweithwyr proesiynol eraill

ac ati yn y cylch. Gall rhai cyranogwyr wrthod derbyn rl yn y cynllun goal a thriniaeth (elly

gallant wrthod y llinyn) - gweler Adran 4.17 4.22 ymgynghori ag eraill ac adran 4.27 4.32

ymgysylltu goalwyr/rhieni yn y Cod Ymarer. Yn yr ymareriad maer rhai syn gallu gwrthod rl

yn golygu bod ganddynt rl ym mywyd Eleri ond nid o sabwynt ei chynllun goal.


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Exercise 2: Strings attached

Equipment required

Large white stickers or cards/badges Marker pens

Two types o coloured string.

Scissors

Cards with ollowing roles written/printed: Eleri; Daydd (Eleris care coordinator); Tomos

(Eleris uncle) Gwen (Eleris aunt); Rhys (The Consultant Psychiatrist); Sian (Eleris GP);

Caroline (charity service Project manager); Rosie (Eleris riend); Steven (Eleris dad) and Elin

(Eleris mum) there may be additional roles provided such as Occupational Therapist;

Psychologist; Mental Health Nurse, Dietician; neighbor etc Provide key participant briefng cards or key players (inormation sheet A).

Stage 1

The acilitator sets the scene use Handout 3 to give a synopsis o Eleri and her situation.

Try to avoid reading the page out it will sound better i you introduce the situation more

conversationally.

Note or acilitator: You can add inormation about Eleri i you wish, such as she has diabetes

(hence making a dietician a potential member o the care team).

Stage 2

Arrange chairs in a large circle

Allocate roles to participants roles can be combined e.g parents can be represented by one

person i there are insufcient participants.

Provide the role cards (Inormation sheet A) to the main players.

Ask the care coordinator and Eleri to stand or sit in the centre o the circle.

Stage 3

Explain that a review o Eleris care and treatment plan is being organised.

Ask Eleri to use string to connect with all those people who she considers important to her care.

Note: The person playing Eleri is not confned to the people named in the written materials.

He/she has ree rein to choose who they think may have an important role in their care.

So additional roles o neighbours, other proessionals etc can be included in the circle.

Some participants can reuse to accept a role in the care and treatment plan (so can reuse the

string) see section 4.17 4.22 consultation with others and section 4.27 4.32

engagement with carers/parents in Code o Practice. In the exercise those that can reuse a

role means they have a role in Eleris lie but not her care and treatment plan.


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Cam 4

Rhowch bl o linyn gwahanol liw ir cydlynydd goal a goynnwch iddo e neu hi gysylltu r holl

bobl y maen ystyried syn bwysig yng ngoal Eleri. Gallair rhain od yr un rhai, neun aelodau

gwahanol or cylch.

Nodyn ir hwylusydd: Edrychwch pwy sydd wedi ei gynnwys a phwy sydd heb ei gynnwys.

Ydir cydlynydd goal wedi methu chynnwys rhywun y maen ddyletswydd gyreithiol arnynt

ymgynghori ag e/hi? Os elly, denyddiwch y cye hwn i ddysgu a deall goynion y Mesur.

Dechreuwch draodaeth grwp am y bobl sydd wedi eu cynnwys ac sydd heb eu cynnwys;

Sut mae pobl yn teimlo ynglyn pheidio chael eu cynnwys mewn cynlluniau goal?

Edrychwch sut maer bobl wedi eu cysylltu

ydyn nhw wedi eu cysylltu ag Eleri yn unig?

rcydlynyddgofalynunig?

neurddau?

Chwiliwch am gyeoedd i ddeall y broses ymgynghori ar sail y cysylltiadau hyn.

Yn seiliedig ar y draodaeth a chydnabod teimladau neu bersbecti y cyranogwyr, gall y cydlynydd

goal a/neu Eleri adolygur cysylltiadau a ddewiswyd a gwneud rhai newydd.

Cam 5

Eglurwch sut maer ddeddwriaeth yn caniatu ymgynghori phobl neu seydliadau ychwanegol

(dangoswch sleid 9). Byddai hynny yn digwydd pe bair cydlynydd goal yn credu bod angen

ymgynghori nhw er mwyn cyawni ei swyddogaethau e neu hi a bod hynny er budd y denyddiwr

gwasanaeth. Yn yr un modd, eallai bydd y denyddiwr gwasanaeth yn awyddus bod y bobl eraill

hynny yn cael eu cynnwys. Byddair cydlynydd goal yn ymgynghori nhw pe bain credu y byddai

o udd ir cla.

Goynnwch ir grwp adolygur seylla eto mae angen eu hatgoa mair bobl hynny sydd

chyswllt r cydlynydd goal ywr unig rai yr ymgynghorir nhw.

Cwestiwn: A oes unrhyw anghytuno? A oes unrhyw un syn gysylltiedig ag Eleri sydd heb eu

cynnwys yn yr ymgynghoriad?

Nodyn ir hwylusydd: Beth ywr oblygiadau i unrhyw un syn dal heb ei gynnwys? Beth ywr

oblygiadau i Eleri ai chydlynydd goal?

Cam 6

Cywynwyd y senario ganlynol:

Maer hwylusydd yn darllen y wybodaeth ganlynol.

Tua blwyddyn yn ddiweddarach maer cydlynydd goal yn bwriadu adolygur cynllun goal a

thriniaeth. Mae Eleri wedi dechrau cymryd cyuriau eto ac nid ywn awyddus iw modryb ai

hewythr wybod hyn. Felly mae wedi goyn i chi beidio ag ymgynghori nhw o hyn ymlaen.


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Stage 4

Give the care coordinator a ball o dierent coloured string and ask them to connect to all the

people they consider to be important in Eleris care. This can be either the same or dierent

members o the circle. Participants can reuse to accept the string. This does not mean they

have no involvement in Eleris lie just a lack o desire to play a ormal role within the care and

treatment plan.

Note or acilitator: Examine who is included and let out. Has the care coordinator missed

anyone they are legally required to consult with? i so use this as a learning opportunity to

understand the requirements o the Measure. Explore who has or can reuse to accept a role

within the care and treatment plan.

Start a group discussion about the people who have been excluded and those that are included;

How do people eel about their exclusion rom care planning?

Look at how people are connected

aretheyconnectedtoElerionly?

tothecarecoordinatoronly?

ortoboth?

Look or opportunities to understand the consultation process based on these connections.

Based on the discussion and recognition o participants eelings or perspective, the care

coordinator and/or Eleri can review their connection choices and make new ones.

Stage 5

Explain how the legislation allows additional people or organisations to be consulted (display

slide 9). This would be i the care coordinator believes they need to be consulted in order to

carry out his or her unctions and it is in the service users best interests. Equally the service

user may want these other people to be consulted. The care coordinator would do so i they

believe it is in the patients best interests.

Ask the group to review situation again remind them that only those people connected to the

care coordinator will be consulted.

Question: Is there any disagreement? Is anyone connected to Eleri who is let out oconsultation?

Note or acilitator: What are the implications or anyone still let out? What are the implications

or Eleri and the care coordinator?

Stage 6

Introduce ollowing scenario:

The acilitator reads the ollowing inormation.

It is roughly a year later and the care coordinator is planning to review the care and treatment

plan. Eleri has started using drugs again and doesnt want her aunt and uncle to know this.

Thereore she has requested that you do not consult them rom now on.


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Yn y an hon, eallai y byddwch yn denyddior siswrn ac yn goyn i Eleri dorrir llinyn rhyngddi hi

ai hewythr ai modryb. Gallai Eleri heyd dorri unrhyw un arall oi thm goal os ywn dymuno.

Goynnwch sut maer ewythr ar odryb (ac unrhyw rai eraill) yn teimlo ynglyn chael eu torri

ymaith or tm goal.

Nodyn ir hwylusydd: Sylwch mai wedi torri ei hewythr ai modryb ymaith oi goal y mae Eleri ac

nid oi bywyd. Goynnwyd i Eleri ddenyddio llinyn i gysylltu phobl oedd yn bwysig yn ei

chynllun goal yn unig. Maen bwysig ceisio cael ymateb emosiynol gan y cyranogwyr yn y an

hon. Maen hanodol eu bod yn deall profad pobl sydd ar goll yn eu bywyd tra bod goal yn cael

ei ddarparu ou cwmpas.

Cwestiwn: Sut gallair cydlynydd goal reolir seylla? gallair draodaeth gynnwys:

Ystyr ymgynghori o dan y Mesur

Ydi ymgynghorin cynnwys rhoi neu dderbyn gwybodaeth, neur ddau?

Beth ywr materion iw hystyried o ran cyrinachedd a diogelu data?

Gallair cyranogwyr ystyried sut yddair ordd orau i weithredu o ewn y ddeddwriaeth ar Cod

Ymarer. Dylid eu hannog heyd i ystyried y dylair aith bod Eleri wedi gwrthod caniatd gael ei

draod gyda hi. Bydd hyn yn rhoi cye i Eleri ystyried yr oblygiadau o wrthod caniatd a rhoi

cye ir chydlynydd goal ystyried ei gallu.

A ellid rheoli pryderon Eleri ynglyn r aith bod gan ei modryb ai hewythr gopi oi chynllun

trwy roi rhan or cynllun iddynt? Maer Rheoliadaun datgan y gall cydlynydd goal gadwn l

neu ddarparu copi o ran o gynllun os ywn credu y byddai hynny er lles y cla.

Yn y pen draw, eallai bydd angen ir cyranogwyr ystyried a ddylair cydlynydd goal ynd yn groes

i gais Eleri. Nodwch od y berthynas rhwng y cydlynydd goal yn allweddol. Sut mae cynnal (a

gwella) perthynas os ywr cydlynydd goal yn gwneud penderyniad syn mynd yn groes i

ddymuniad y denyddiwr gwasanaeth?

Maer Cod Ymarer (4.20) heyd yn datgan Cyn ymgynghori ag unrhyw un or bobl hyn rhaid ir

cydgysylltydd goal ystyried sabwyntiaur cla perthnasol ynghylch pun a ddylid ymgynghori r

unigolion hyn ai peidio. Mae pwyntiau 4.17-4.22 or Cod Ymarer yn delio eor mater hwn.

Os bydd y cydlynydd goal yn penderynu mynd yn groes i ddymuniad Eleri, gellir ailgysylltur llinyn.

Cwestiwn Ola: Holwch i bawb am eu hymateb ir ymarer hwn ar hyn y maen nhw wedi ei ddysguam y Mesur a rl cydlynwyr goal, denyddwyr gwasanaeth ac eraill syn gysylltiedig r cynllun

goal a thriniaeth.

(Datblygwyd yr ymarer hwn o syniad gan Richard Birch Hyorddwr Cla Arbenigol o Haal yn

Wrecsam).


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At this point you may want to use the scissors and ask Eleri to cut the string between her and

her aunt and uncle. Eleri may also cut anyone else rom the care team i she is so minded to do.

Ask at this stage how the aunt and uncle (and any others) eel about being cut rom the

care team?

Note to acilitator: Please note Eleri has cut her aunt and uncle rom her care not her lie.Eleri was asked to connect people with string who were important in her care plan only. It is

important to seek an emotional reaction rom participants at this stage. It is essential to seek

understanding o the experience o people who are adrit while care is provided around them.

Question: How might the care coordinator manage the situation? discussion here might

include:

The nature o what consultation means under the Measure

Does consultation involve giving or receiving inormation or both?

What are the issues concerning confdentiality and data protection?

Participants may consider how best to operate within the legislation and Code o Practice.

They should also be prompted to consider that Eleris reusal to give consent should

be discussed with her. This will enable Eleri to consider implications o withdrawing consent

and enable the care coordinator to consider her capacity.

Could Eleris concerns about her aunt and uncle having a copy o her plan be managed by

providing them with part o a plan? The Regulations state that a care coordinator may

withhold or provide a copy o part o a plan i they believe it to be in the patients

best interests to do so.

In the fnal analysis the participants might need to consider whether the care coordinator shouldoverride Eleris request. Please note that the relationship between the care coordinator is a

critical one. How is a relationship to be maintained (and enhanced) i an overrule decision is

made by the care coordinator?

The Code o Practice (4.20) also says Beore consulting with any o these persons the care

coordinator must take account o the views o the relevant patient about whether these persons

or individuals ought to be consulted. Sections 4.17-4.22 o the Code o Practice deal with

this issue.

I the care coordinator decides to override Eleris request, or to regain her consent, the string

may be reconnected.

Concluding Question: Seek inormation rom the participants on their reections rom this

exercise and what they have learned about the Measure and the role o care coordinators,

service users and others involved in the care and treatment plan.

(This exercise was developed rom an idea by Richard Birch Expert Patient Trainer rom Haal

in Wrexham).


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Rhan 4: (30 munud)

Gadael y gwasanaethau iechyd meddwl eilaidd

Sleidiau 12-13: Asseu denyddwyr blaenorol o wasnaethau Iechyd Meddwl Eilaidd

Maer sleidiaun egluro pri ddimensiynaur ddeddwriaeth. Yn benodol, y treniadau i

ailasesu cyn ddenyddwyr gwasanaethau iechyd meddwl eilaidd a darparu gwybodaeth ar yr

adeg pan ydd y denyddiwr yn gadael. Dylair cyranogwyr od yn ymwybodol nad ywr sleidiaun

cynrychiolir ddeddwriaeth yn llawn a bod angen iddynt gael cyngor perthnasol.

Ymarer 3: Cenogir denyddiwr syn gadael y gwasanaeth

Goynnwch ir cyranogwyr ddarllen y senario yn nhaen 4

Daen 4:

Nodiadau ir hwylusydd: Os ywr grwp yn meddwl bod mam Nigel yn goyn am ail asesiad,

nodwch od adran 8.20 or Cod Ymarer drat yn datgan na all unrhyw un, heblaw am yr

unigolyn syn derbyn y gwasanaeth, oyn am ail asesiad.

Sut byddair cyranogwyr yn cynnig cymorth a chyngor i helpu Nigel i oyn am ail asesiad?

A oes yna amgylchiadau pan na yddair cyranogwyr yn trenu ail asesiad?

Os ydynt wedi eu hail asesu or blaen ni ddylai hynny eu hatal rhag cael asesiad (Cod Ymarer

8.21). Eallai y bydd y cyranogwyr yn awyddus i ystyried eithrio cais am asesiad ar y sail ei od

yn inderus neun wacsaw; beth yw ystyr y termau hyn (Cod Ymarer 8.18)?

Rhannwch daen 5

Enghrait o ymarer cadarnhaol syn datblygu.

Dyma enghrait o lythr dod ag achos i ben syn bodloni Mesur Iechyd Meddwl (Cymru) 2010.

Ceisiwch annog y cyranogwyr iw adolygu ac ystyried sut y byddent yn gallu ei wella.

Crynhoi (20 munud)

Maer uned hon yn ceisio dadansoddin anwl sut i roir Mesur Iechyd Meddwl (Cymru) 2010 ar

waith yn ymarerol. Dylai gwellhad, gallu diwylliannol a chymhlethdod od yn amlwg trwy gydol yr

uned hon. Yn yr uned hon, mae rl cydlynwyr goal au perthynas denyddwyr gwasanaeth ac

eraill syn gysylltiedig chynlluniau goal a thriniaeth yn rhan allweddol or dysgu.

Dylair cyranogwyr edru gwneud cysylltiadau rhwng yr unedau craidd blaenorol ar uned hon.


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Discharge rom secondary mental health services

Slides 12-13: Assessment o ormer users o secondary mental health services

The slides explain key dimensions o the legislation. In particular the arrangements or the

reassessment o ormer users o secondary mental health services and the provision o

inormation at point o discharge. Participants should be made aware that the slides are not

an exhaustive representation o the law and that they need to seek relevant advice.

Exercise 3: Supporting discharge

Ask participants to read the scenario in handout 4

Handout 4:

Notes or acilitator: I participants think that Nigels mum is seeking a re-assessment, please

note that section 8.20 o drat Code o Practice states no one other than the individual person

who received the service, can ask or a re-assessment.

How would participants give support and advice to aid Nigel asking or a re-assessment?

Are there circumstances when the participants may not arrange a re-assessment?

I they have been assessed previously this should not preclude them rom assessment

(CoP 8.21). Participants may want to consider excluding a request or assessment on the

basis o it being rivolous or vexatious what do these terms mean (CoP 8.18)?

Distribute handout 5

Emerging positive practice example.

This is an example o a discharge letter which meets the requirements o the Mental Health(Wales) Measure 2010. Encourage participants to review this and consider how they can

improve upon it and/or incorporate similar initiatives into their practice.

Conclusion (20 mins)

This unit seeks to provide a detailed analysis on how the Mental Health (Wales) Measure

2010 is applied in practice. The issues o recovery, cultural capability and complexity should

be evident throughout this unit. The role o the care coordinator and their relationship with

service users and others involved in care and treatment plans is a critical element o learning

in their unit. The participants should be in the process o making connections between the

previous core units and this one.


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Cwestiynau a Beth ydych chin mynd iw wneud yn wahanol nawr?

Maer adran hon yn rhoi cye ir cyranogwyr egluro unrhyw bwyntiau a godwyd yn y sesiwn.

Mae heyd yn bwysig goyn ir cyranogwyr ystyried y camau ymarerol y gallan nhw eu cymryd i

helpu i weithredur Mesur a goal iechyd meddwl syn seiliedig ar wellhad.

Goynnwch ir cyranogwyr nodi yn eu llyrau gwaith o leia un cam y gallan nhw ei gymryd i

wella cynllunio goal a thriniaeth syn seiliedig ar wellhad.

Negeseuon a ddysgwyd:

Bydd y cymhwysedd i weithredu el cydlynydd goal ar dyletswyddau perthnasol wedi eu

gwreiddio yn y ddeddwriaeth.

Bydd dyletswyddau cyreithiol ar gydlynwyr goal i:

gydlynugofalathriniaeth;

ymgynghoriageraillwrthbaratoicynlluniaugofalathriniaeth;

sicrhaubodcopauogynlluniaugofalathriniaethyncaeleurhannugydar

rhwydwaith oal;

cefnogirbroseswrthiddefnyddwyrgwasanaethadaelygwasanaethiechyd

meddwl eilaidd.


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Questions and What are you going to do dierently now?

This section oers participants and opportunity to clariy any points raised in the session.

It is also an important juncture to ask participants to explore practical actions they can take to

support implementation o the Measure and recovery orientated mental health care.

Ask participants in their workbooks to note at least one action they eel they can take to

improve recovery orientated care and treatment planning.

Take home messages:

The eligibility to act as a care coordinator and the relevant duties will be enshrined in law.

Care coordinators will have legal duties to:

coordinatecareandtreatment;

consultothersinformulatingcareandtreatmentplans;

ensurecopiesofcareandtreatmentplansaresharedwiththecarenetwork;

supportthedischargeofserviceusersfromsecondarymentalhealthservice.


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Taen 1: Ymerer anghenion hebeu bodloni

Ganed Piotr Wojtowicz yng Ngwlad Pwyl ond mae wedi bod yn byw yn ardal Wrecsam am y

5 mlynedd diwetha gydai bartner ai ddau blentyn ianc. Arerai gael ei gyogi gan gwmni

cyenwi lleol ond collodd ei swydd ar l cael problemau iechyd meddwl o ganlyniad i ddamwain

ordd. Arweiniodd hynny at atgofon o od mewn damwain ordd y bu ynddi yng Ngwlad Pwyl

pan laddwyd dau o bobl oedd yn y car. Dechreuodd Piotr deimlon gynyddol bryderus wrth yrru

an y cwmni, caodd ei ddiswyddo ac yna dechreuodd ddiodde o l achiadau, iselder, pryder

ac roedd yn cael traerth denyddio cerbydau (el gyrrwr a theithiwr). Dechreuodd yed yn drwm

i ymdopi r profad hwn a denyddio iaith elyniaethus yn gynyddol tuag at ei bartner a bod yn

in gydai blant. O ganlyniad bu bron iddo llwyddo i gyawni hunanladdiad a threuliodd

gynod el cla mewnol.

Gan ei od yn dal i eddwl am hunanladdiad, caodd ei gyeirio at y gwasanaethau iechyd

meddwl ac rydych chin gweithredu el ei gydlynydd goal. Mae cynllun goal a thriniaeth Piotryn cynnwys rhoi sylw iw drawma. Maer cynllun yn nodi y bydd Piotr yn cael ei gyeirio at

Seicolegydd Clinigol syn arbenigo mewn anhwylder straen wedi trawma. Rydych wedi cael

gwybod bod rhestr aros 18 mis ar gyer seicolegydd.

Maer tm yn cadw golwg ar iechyd meddwl Piotr, ac yn ei onitro. Maen ymddangos bod

Piotr yn gwaethygu; nid ywn cysgu, maen dweud ei od yn cael l achiadau ac maen colli ei

dymer yn aml. Yn l ei bartner mae Piotr wedi dechrau yed eto ac maen in nad yw Piotr yn

cael y cymorth sydd ei angen arno. Mae hi wedi bod yn genogol iawn ond dywed os bydd Piotr

yn parhau i waethygu bydd yn ei adael, yn mynd r plant gyda hi ac yn dychwelyd i Wlad

Pwyl i yw.


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Handout 1: Unmet needs exercise

Piotr Wojtowicz was born in Poland but has lived in the Wrexham area or the past 5 years with

his partner and two young children. He was employed at a local delivery company but lost his

job ater experiencing mental health problems ollowing a minor road trafc accident.

This triggered memories o his involvement in an earlier road trafc accident in Poland in which

the other two occupants o the vehicle were killed. Piotr elt increasingly anxious when

driving a company van. He was sacked and subsequently experienced ashbacks, low mood,

anxiety and ound it difcult to use motor vehicles (as a driver and passenger). He started

drinking heavily to cope with this experience and became increasingly verbally hostile to his

partner and irritable with his children. This culminated in a near atal suicide attempt and a

period o inpatient care.

In view o his continued suicidal ideas he was reerred to secondary mental health services

and you are acting as his care coordinator. Piotrs care and treatment plan includesaddressing his trauma. The plan specifes that Piotr will be reerred to Clinical Psychologist

who specialises in post traumatic stress disorder. You have been inormed that there is an

18 month waiting list or psychology.

The team are holding and monitoring Piotrs mental health. Piotr appears to be deteriorating;

he is not sleeping, he reports he has been having ashbacks and is requently losing his

temper. His partner has inormed you that Piotr is starting to drink again and she is angry that

Piotr is not getting the help he needs. She has been supportive but says that i Piotr continues

to deteriorate she will leave him, take the children and return to live with her mother in Poland.


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Taen 2: Mae testun sydd wedi ei ddethol or Cod Ymarer yn datgan bod:

Dyletswyddau a swyddogaethaur cydlynydd goal

3.35. Maen ddyletswydd ar ddarparwyr gwasanaeth iechyd meddwl gymryd pob cam rhesymol

i gydlynur broses o ddarparu gwasanaethau iechyd meddwl i gla perthnasol. Nod cydlynu

yw gwella eeithiolrwydd y gwasanaethau hyn. Gallai darparwyr gwasanaeth iechyd meddwl

oyn am arn y cydlynydd goal ynglyn sut y gall y darparwr gyawnir ddyletswydd hon, a gall

y cydlynydd goal, ar unrhyw adeg, roi cyngor i ddarparwyr gwasanaeth ynglyn hyn. Gallair

cyngor hwn od ar ur adrodd ynghylch anghenion na ellir eu diwallu, neu nad ydynt yn cael eu

diwallun llawn, trwyr gwasanaethau sydd ar gael (gweler Pennod 5).

Dyletswydd i ddarparu gwasanaethau

5.2. Mae Adran 18(10) or Mesur yn ei gwneud yn oynnol i ddarparwr gwasanaethau iechyd

meddwl, ir graddau y bon rhesymol ymarerol, sicrhau bod gwasanaethau iechyd meddwl argyer cla perthnasol yn cael eu darparu yn unol i gynllun goal a thriniaeth cyredol.

Fodd bynnag, nid ywr cydlynydd goal yn gyriol am sicrhau bod y gwasanaethau ar gynllun

goal a thriniaeth cla perthnasol yn cael eu darparu. Y seydliadau r dyletswyddau statudol

i ddiwallur anghenion a aseswyd ar gyer y cla perthnasol, o dan ei gynllun goal a thriniaeth,

syn gyriol am ddarparu gwasanaethau.

5.3. Yn hytrach dylair cydlynydd goal oruchwylior modd y darperir y cynllun goal a thriniaeth.

Cyawnir hyn trwy onitror modd y darperir y cynllun goal a thriniaeth ac y cyawnir y

canlyniadau a gonodir trwy ddarparu gwasanaethau iechyd meddwl priodol.

5.4. Pan nad oes modd darparu gwasanaethau iechyd meddwl yn unol r cynllun goal a

thriniaeth, dylair cydlynydd goal hysbysur darparwr gwasanaeth iechyd meddwl perthnasol.

Rhaid ir darparwr gwasanaeth roi sylw i unrhyw gyngor gan y cydlynydd goal ac, ar y cyd

ag asiantaethau perthnasol eraill, dylai gymryd y camau angenrheidiol i sicrhau, pan on

ymarerol, od y gwasanaethau a nodir yn y cynllun goal a thriniaeth yn cael eu darparu.

Os, ar l cymryd y ath gamau, nad ywn rhesymol ymarerol darparu gwasanaethau iechyd

meddwl or ath o hyd, dylair cynllun goal a thriniaeth gael ei adolygu er mwyn ceisio dulliau

amgen o gyawnir canlyniadau a ddymunir. Dylid esbonio wrth y cla perthnasol os oes angen

adolygiad.

5.5. Ystyr anghenion nas diwallwyd (gan gynnwys anghenion syn cael eu diwallun rhannol)

yw anghenion na ellir eu diwallu or adnoddau sydd ar gael ir seydliad. Gallai conod or rhain

od yn allweddol i helpu i wellar broses o gynllunio gwasanaethau iechyd meddwl. Argymhellir

seydlu proses lle denyddir pwer y cydlynydd goal i gynghori darparwyr gwasanaethau iechyd

meddwl er mwyn rhoi gwybod am anghenion nas diwallwyd i grwpiau cydgynllunio strategol lleol

ym maes iechyd meddwl.

Cydlynur modd y darperir gwasanaethau

5.6. O dan Adran 17 or Mesur maen ddyletswydd ar ddarparwyr iechyd meddwl gymryd pob

cam rhesymol i sicrhau bod y gwasanaethau iechyd meddwl sydd angen eu darparu yn cael eu

cynnig mewn dull cydlynol. Mae heyd yn ddyletswydd ar y darparwr i gydlynu ei wasanaethau

iechyd meddwl gydar rhai a ddarperir gan ddarparwyr gwasanaeth iechyd meddwl eraill, neu

ddarparwyr, dielw, trydydd sector syn darparu gwasanaethau i gla perthnasol.


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Handout 2: Selected text rom the Code o Practice states that:

Duties and unctions o the care coordinator

3.35. Mental health service providers are under a duty to take all reasonable steps to

coordinate the provision o mental health services to a relevant patient. The aim o such

coordination is to improve the eectiveness o those services. Mental health service providers

may seek the views o the care coordinator as to how the provider can meet this duty, and the

care coordinator may, at any time, give advice to service providers on this. Such advice can

be in the orm o reporting where needs cannot be met, or are not ully being met, through the

services that are available (see Chapter 5).

Duty to provide services

5.2. Section 18(10) o the Measure requires that, so ar as it is reasonably practicable to do

so, a mental health service provider must ensure that mental health services or a relevantpatient are provided in accordance with their current care and treatment plan. However, the

care coordinator does not have responsibility or ensuring that the services on a relevant

patients care and treatment plan are provided. The responsibility or the provision o services

rests with the organisations with statutory duties or meeting a relevant patients assessed

needs under their care and treatment plan.

5.3. The care coordinator instead has oversight o the delivery o the care and treatment

plan. This is achieved by monitoring the delivery o the care and treatment plan and the

achievement o the recorded outcomes through the delivery o appropriate mental health

services.

5.4. Where it is not possible to provide mental health services in accordance with the careand treatment plan, the care coordinator should inorm the relevant mental health service

provider. The service provider must have regard to any advice given by the care coordinator

and, together with other relevant agencies, should take the necessary steps to ensure that,

where practicable, the services specifed in the care and treatment plan are provided.

I ater ollowing such steps it is still not reasonably practicable to provide such mental health

services, the care and treatment plan ought to be reviewed in order to seek alternative means

o delivering the desired outcomes. The need or a review should be explained to the relevant

patient.

5.5. Unmet needs (including those that are being partially met) are needs that cannot be

met by an organisations available resources and having a record o these can provide

crucial inormation that could assist in improving the planning o mental health services. It is

recommended that a process is put in place whereby the care coordinators power to advise

mental health service providers is utilised to inorm local strategic mental health joint planning

groups o unmet needs. This process may also include the inclusion o an annual report on

unmet needs identifed by local mental health service providers.

Coordination o the provision o services

5.6. Section 17 o the Measure places mental health service providers under a duty to take all

reasonable steps to ensure that the mental health services that it is required to provide are

delivered in a coordinated manner. The provider is also under a duty to coordinate its mentalhealth services with those provided by other mental health service providers, or not-or-proft,

third sector providers who are providing services to a relevant patient.


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Taen 3

Mae Eleri yn 22 oed ac mae wedi bod yn diodde o broblemau gyda seicosis a denyddio

cyuriau anghyreithlon. Mae wedi cael ei hanon ir ysbyty dair gwaith: a hynny ar l esgeulusoei goal, ymateb i rithweledigaethau/clywed lleisiau, gwrthdaro i rhieni ac o ganlyniad i gael

ei gorodi i adael eu cartre am nad oeddent yn gallu ymdopi i hymddygiad.

Ar l cael ei derbyn ir ysbyty y tro diwetha gwrthododd rhieni Eleri iddi ddychwelyd gartre.

Roedd nier o bobl yn rhwydwaith goal Elerin credu bod hyn yn beth da oherwydd roeddent yn

teimlo bod gan rieni Eleri ormod o reolaeth, eu bod yn eirniadol ac yn tueddu i

orsymleiddio atebion i anawsterau Eleri. O ganlyniad, aeth Eleri i yw at ei hewythr ai modryb.

Maen ymddangos ei bod wedi setlo yn ei chartre newydd ac maent wedi ei chenogi i chwilio

am gymorth i ddatrys ei phroblemau ynglyn chamddenyddio sylweddau ac maent yn dal i

gynnig cymorth ymarerol iddi. Mae ewythr a modryb Eleri (Tomas a Gwen) yn credun gry naddylid cael cyrinachau a bod angen fniau clir ac maent or arn bod rhannu problemau wedi

helpu i seydlogi seylla Eleri. Maent wedi dangos diddordeb yn ei goal ac wedi bod mewn

cyarod adolygu ac maent yn siarad yn aml chi dros y n. Mae Eleri wedi cytuno i rannu

gwybodaeth syn berthnasol iw goal. Er bod Eleri wedi symud oi chartre maen dal i weld ei

rhieni ac yn aml maent yn onior cydlynydd goal i holi am ei chynnydd neu i awgrymu

syniadau ynglyn i goal ai thriniaeth. Er enghrait, yn ddiweddar e oynnon nhw pam nad

oedd hi wedi ei chyeirio at uned breswyl syn adseydlu denyddwyr cyuriau. Mae Elerin

credu eu bod yn ymyrryd ond maen odlon ir tm rannu gwybodaeth gyda hwy gan od pawb

yn gwybod eu bod yn hurt...does neb am wrando arnyn nhw.

Mae Elerin denyddio gwasanaeth lleol i bobl syn camddenyddio sylweddau ac mae wedi

rhoir gorau i ddenyddio cyuriau. Mae Elerin cyarod ei Seiciatrydd (Rhys) bob dau fs i

adolygu ei meddyginiaeth. Maen mynd at ei meddyg teulu (Sian) yn gyson gan od ganddi rai

problemau iechyd cororol. Mae Eleri wedi bod yn helpu am 8 mis mewn cae cymunedol.

Rhan o brosiect ydyw syn cael ei redeg gan elusen leol. Maer rheolwr prosiect (Caroline) wedi

bod yn bresennol mewn adolygiad goal a thriniaeth 2 fs yn l a dywedodd ei bod yn alch o

gyraniad Eleri a bod Elerin cymysgun dda gyda sta a chwsmeriaid. Ychydig o rindiau sydd

gan Eleri ond maen agos iawn at Rosie. Maen ei hadnabod ers ychydig o ynyddoedd.

Mae Rosie heyd yn ddenyddiwr gwasanaeth gyda diagnosis o anhwylder personoliaeth

anseydlog emosiynol. Mae yn ei phedwar degau. Yn y gorennol roedd gan Rosie broblemau

oherwydd ei dibyniaeth ar alcohol ond mae bellach yn rhydd o hynny ers iw phlant gael eumabwysiadu oherwydd ei harerion yed trwm. Bellach mae Rosien eitha seydlog ac maen

tueddu i gymryd denyddwyr gwasanaeth el Eleri dan ei hadain. Mae Elerin dod yn gyson i

at bach Rosie ac maen tueddu i ymddiried ynddi. Mae Rosien genogol iawn tuag at Eleri ac

mae wedi ei hannog ai chymell i osgoi cyuriau ac ail adeiladu ei bywyd. Maen ystyried Eleri

el merch iddi.


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Handout 3

Eleri is a 22 year old woman who has experienced problems with psychosis and illegal drugs

use. She has been hospitalised on three occasions: each time ater neglecting her sel care,responding to auditory hallucinations/ voices, getting into conict with her parents and as a

consequence being orced to leave their home as they were unable to cope with her behaviour.

Following her last hospital admission Eleris parents reused to allow her to return to their

home. Many people in Eleris care network saw this as a good thing as the parents were elt

to be too controlling, critical and tended to oversimpliy solutions to Eleris difculties.

Eleri was subsequently taken in by her aunt and uncle. She seems to have settled into her

new home and they have supported her to seek help or her substance misuse and still

provide her with practical help. Eleris aunt and uncle (Tomas & Gwen) have a frm belie in no

secrets and frm boundaries and think that open sharing o issues has contributed to Eleriscurrent stability. They have been interested in her care and have attended a review meeting

and oten talk to you on the telephone. Eleri has consented to the sharing o inormation

relevant to her care. Despite Eleri moving out she still sees her parents and they will oten

telephone the care coordinator to enquire about her progress or to suggest their ideas about

her care and treatment. For example they recently asked why she was not reerred to a

residential drug rehabilitation unit. Eleri views them as interering but is happy or the team to

share inormation with them as everyone knows they are mad... nobody is going to listen

to them.

Eleri is attending a local substance misuse service and has stopped using drugs. Eleri meets

with her Psychiatrist (Rhys) every two months to review her medication. She is a regular

visitor to her GP (Sian) as she has some physical health problems. Eleri has been helping

or 8 months at a community ca. This is part o a project run by a local charity. The project

manager (Caroline) attended a care and treatment review 2 months ago and reported that

she was pleased with Eleris participation and that Eleri engaged well with both sta and

customers. Eleri has a ew riends but is very close to Rosie whom she has known or a

ew years. Rosie is also a service user with a diagnosis o emotionally unstable personality

disorder who is in her orties. In the past Rosie had problems with alcohol dependency but

has been alcohol ree since her own children were adopted because o her heavy drinking.

Rosie is now quite stable and tends to take service users such as Eleri under my wing.

Eleri is a requent visitor to Rosies little at and tends to confde in her. Rosie is verysupportive towards Eleri and has encouraged and motivated her to avoid drugs and rebuild her

lie. She views Eleri like my daughter.


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Taen wybodaeth A: Disgrifadau rl (Ymarer Cysylltu llinynnau)

Eleri:

Rydych yn hapus bod pobl yn eich helpu gydach cynllun goal. Rydych yn awyddus i gael trenunwaith eto ar eich bywyd. Mae gennych amser ich rhieni ac rydych yn deall eu bod wedi

ceisio deall eich problemau. Ond, rydych heyd yn argyhoeddedig bod eu diyg dealltwriaeth go

iawn yn eeithio ar eich gwellhad, elly rydych yn awyddus iw cadw hyd braich.

Mae eich ewythr ach modryb wedi bod yn ynhonnell awr o gymorth i chi. Maent wedi gosod

rhai rheolau sylaenol er mwyn byw gydach gilydd ac rydych yn cadw atynt.

Maent yn rhan bwysig och goal ac yn cynnig llawer iawn o gymorth.Mae eich cydlynydd goal

yr un mor barod ei gymorth ac mae gennych berthynas dda gydag e. Gallwch ddweud bopeth

wrtho wy neu lai.

Mae Rosie wedi bod yn hwyl garw ac rydych yn alch ei bod yn rind i chi. Maen deall bodgennych broblemau ac maen genogol. Maen wahanol iawn ir holl bobl yr ydych yn eu

hadnabod, oherwydd yn amlach na pheidio, gweithwyr iechyd proesiynol neu bobl syn siarad

am eich cynllun goal sydd och cwmpas. Maen bra cael rhywun syn ddim ond rind.

Modryb ac ewythr:

Rydych yn awyddus i helpu Eleri ac rydych yn credu mai chi ywr rheswm pam ei bod yn gwneud

cystal. Mae eich cred mewn agwedd agored a gonest tuag at ei phroblemaun bwysig iawn i

chi. Heyd, rydych yn credun gry bod yn rhaid gosod fniau, a chadw atynt, ac rydych yn credu

bod y fniau hynny wedi bod o gymorth mawr i Eleri. Rydych wedi dod yn ho iawn o Eleri ac

mae gennych eddwl mawr ohoni.

Rosie:

Rydych wedi dechrau mwynhau cwmni Eleri ac rydych yn ei hystyried el merch neu rind gorau

iau. Gallwch ynd allan gydach gilydd a chael llawer o hwyl.

Rydych chithau heyd wedi cael nier o anawsterau ac rydych yn ymdrechu i reolir pethau syn

rhoi straen ar eich bywyd. Ar adegau anodd rydych yn dibynnu ar Eleri ich helpu trwy ynd chi

allan a chael amser da gydach gilydd.Rydych yn gwybod bod gan Eleri gydlynydd goal a does

dim llawer o bwys gennych os ydych yn rhan oi goal ai peidio.

Dim ond unwaith neu ddwywaith yr ydych chi wedi gweld y cydlynydd goal, maen well gennych

chi gadw allan oi ordd.

Rhieni:

Mae gennych eddwl mawr o Eleri ac rydych yn hapus ei bod wedi setlo. Y criw yr oedd yn

cymysgu hwy sydd iw beio am ei phroblemau ac rydych yn alch nad yw gyda nhw nawr.

Rydych yn credu y dylai od yn l el yr arerai od yn uan iawn gan nad ywn cymryd cyuriau

nac yn gweld y bobl yna. Rydych yn amau nad yw Elerin gwneud llawer o ymdrech i wella gan

od ei thraed dan y bwrdd lle mae hi nawr. Rydych yn ho o gadw mewn cysylltiad ag Eleri a

heyd gydai chydlynydd goal.

rri

rri

rri

rri


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Inormation Sheet A: Role descriptions (Strings attached exercise)

Eleri:

You are happy that people are helping you with your care plan. You are keen to get your lieback on track. You have time or your parents and understand that they have struggled to

understand your problems. However, you are also convinced that their lack o real

understanding hampers your recovery, so you like to keep them very much at arms length.

Your aunt and uncle have been a great source o support or you. They have set some ground

rules or living with them which you abide by. They are important in your care and oer a great

deal o help.

Your care coordinator is equally helpul and you have a good relationship with them. You can

tell them pretty much anything.

Rosie has been great un to be around and you are glad that she is your riend.She understands you have difculties and is supportive. She is very dierent rom all the

people you know as so oten you seem to be surrounded by health proessionals or people

talking about your care plan. It is nice to have someone who is just your riend.

Aunt and uncle:

You are keen to help Eleri and believe you are the reason she has been doing so well.

Your belie in an open and honest approach to her problems is very important to you.

Additionally, you are frm believers that boundaries have to be set and maintained and again,

you believe that these boundaries have been very helpul to Eleri. You have come to really love

Eleri and you care or her a great deal.

Rosie:

You have come to really enjoy Eleris company and you do view her as like a daughter or a

younger best riend. You can go out together and have a lot o un.

You too have had many difculties and struggle to manage stressors in your lie. At difcult

times you rely on Eleri to help you by taking you out and have a good time together.

You know that Eleri has a care coordinator and you are not ussed i you are involved in her

care or not. You have only seen the care coordinator once or twice, preerring to stay out o

their way.

Parents:

You care a great deal about Eleri and are happy she is settled. You blame the crowd she was

mixed up in or her problems and are glad she is away rom them now. You believe she should

return to normal soon now that she is not taking drugs or seeing those people. You suspect

that Eleri is not really trying to get better as she has her eet under the table where she is.

You like to keep in contact with Eleri and also her care coordinator too.

cut

cut

cut

cut


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Taen 4:

Ymarer 3: Cenogi pan ydd y denyddiwr yn gadael y gwasanaeth Goynnwch ir

cyranogwyr ddarllen y senario isod

Roedd Nigel Hughes yn derbyn gwasanaethau iechyd meddwl am 5 mlynedd. Caodd ei

ryddhau 18 mis ynghynt i oal ei eddyg teulu. Mae ei am yn onior tm iechyd meddwl

cymunedol ac yn goyn i gael gair gydai gyn gydlynydd goal. Maen credu bod ei iechyd wedi

gwaethygu, ac maen goyn am gymorth. Mae ei gydlynydd goal blaenorol wedi gadael y

gwasanaeth.

Sut ydych chin ymateb ir cais hwn?


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Handout 4:

Exercise 3: Supporting discharge. Ask participants to read the scenario below

Nigel Hughes was receiving secondary mental health services or 5 years. He was discharged

18 months previously to the care o his GP. His mum telephones the community mental

health team and asks to speak with his ormer care coordinator. She believes his health has

deteriorated, and asks or help. His previous care coordinator has let the service.

How do you respond to this request?


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Taen 5: Ymarer cadarnhaol yn datblygu llythyr dod ach achos i ben

Annwyl Nigel

Ymhellach in cyarod diwetha rwyn ysgriennu atoch ich hysbysu or treniadau ynglyn dodach achos eo Gwasanaeth Iechyd Meddwl Dewi Saint i ben. Fel y cytunwyd gennym, rwy

heyd yn anon copi or llythyr hwn ar daen at eich meddyg teulu, Nicki ach rhieni.

Yn eich adolygiad diwetha ar 5 Mai cytunwyd gennym dylwn gau eich achos eor tm.

Penderynwyd hynny oherwydd eich bod yn odlon bod eich meddyginiaeth (Aripiprazole 10mg

unwaith y dydd) yn eich helpu i gadwn iawn a dim ond mn eeithiau andwyol, el teimlo

ychydig yn gysglyd yn y nos, yr oeddech yn eu prof. Fe ddywedoch chi od yr eeithiau hynny yn

bris bach iw dalu am od yn iawn. Rydych heyd wedi llwyddo i ynychur Coleg ac rydych chi a

Nicki (Gweithiwr Cenogi Dysgu) wedi dweud wrthy pa mor dda yr ydych yn ei wneud ar y cwrs.

Roeddech yn cytuno eo cau eich achos ond roeddech yn poeni am ynd yn wael unwaith etoneu ynd oddi ar y llwybr pe na baem yn cyarod yn gyson. Rydym bellach wedi cael cye

i draod eich pryderon ac ystyried sut i ddelio hwy. Cytunwyd y dylai eich cyarodydd gyda

Nicki helpu. Mae hin odlon eich gweld cyn yr apwyntiad sydd wedii gynllunio a dywedoch

wrthy y byddech yn mynd at Nicki neu un or tm cenogi dysgu os ydych yn colli awydd a

chymhelliant i ynychur coleg. Bydd eich meddyg teulu, Dr Thomas, yn parhau i ragnodi eich

meddyginiaeth ac el y cytunwyd gennym, awgrymwyd y dylech ei chyarod o leia bob 6 mis i

adolygur dos ac unrhyw eeithiau positi neu negyddol.

O ran poeni am ynd yn wael eto, sylwyd mair arwyddion cynnar o hynny yddai:

Traerth mynd i gysgu a chysgu am wy na dwy noson yn olynol.

Meddyliau dryslyd yn eich atal rhag canolbwyntio ar eich gwaith, darllen neu wylior teledu.

Denyddio iaith elyniaethus tuag at bobl eraill, er enghrait gweiddi a rhegi arnynt.

Os byddwch chi, Nicki, neu eich rhienin sylwi bod y pethau hyn yn digwydd dylech gael gair

ch meddyg teulu ar rys. Neu, gallwch gael gair mi neu aelod or tm sydd ar ddyletswydd.

Y tu allan i oriau dylech ynd ir ganolan ddamweiniau leol a mynd chopi or llythyr hwn

gyda chi.

Yn ogystal r treniadau hyn mae gennych hawl i oyn am ail asesiad gan ein gwasanaeth.

Rwy wedi amgu taen yn egluro eich hawliau i gael ail asesiad a sut dylech wneud hynny.

Ar y rhan i hown ddweud y mod wedi mwynhau gweithio gyda chi am y ddwy ynedd a hanner

diwetha. Mae eich ymrwymiad i ail adeiladu eich bywyd wedi creu argra dda arna ac maen

bra gweld pa mor bell yr ydych wedi dod. Gobeithio y bydd pethaun parhau i ddatblygu

ymhellach i chi a phob dymuniad da ir dyodol.

Cofon cynnes

cc. meddyg teulu

cc. Nicki Roberts (Gweithiwr Cenogi Dysgu)

cc. Mr a Mrs Hughes


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Handout 5: Emerging positive practice discharge letter

Dear Nigel

Further to our last meeting I am now writing to inorm you o the arrangements or yourdischarge rom the Annwn Mental Health Service. As we agreed I am also sending a copy o

this letter and the leaet to your GP, Nicki and your parents.

At your last review on 5th May we agreed that you should now be discharged rom the team.

This was because you were satisfed that your medication (Aripiprazole 10mg once a day) was

helping you to remain well and that you were only experiencing very mild adverse eects such

as eeling a little sleepy in the evening. You said that these eects were a small price to pay or

remaining well. You have also successully continued your attendance at College and both you

and Nicki (Learning Support Worker) have told me how well you are doing on your course.

You were agreeable to discharge but were worried about becoming unwell again or going o

track i we did not meet regularly. We have now had an opportunity to discuss your worries

and think about how you can deal with them. We agreed that your meetings with Nicki should

help. She is also happy to see you beore a planned appointment and you told me you would

ask Nicki or one o the learning support team i you are losing your motivation to attend college.

Your GP, Dr Thomas will continue to prescribe your medication and as agreed we suggested

that you should meet with him at least every 6 months to review the dose and any positive or

negative eects.

In terms o your worries o becoming unwell we noted that the early signs o this were likely

to be:

Difculty alling asleep and staying asleep or more than two consecutive nights Racing jumbled thoughts that prevent you rom concentrating on your study, reading or

watching television.

Becoming verbally hostile to other people or example shouting and swearing at them.

I you, Nicki, or parents notice these things are happening you should speak to your GP as a

matter o urgency. Alternatively you can speak to me or a duty member o our team. Out o

hours you should attend the local accident centre and take a copy o this letter with you.

In addition to these arrangements you are entitled to request a reassessment by our service.

I have enclosed a leaet explaining your rights to seek reassessment and how you should

do this.

For my part I want to say how much I have enjoyed working alongside you over the past two and

a hal years. I am impressed by your commitment to rebuilding your lie and it is pleasing to see

just how ar you have come. I do hope things continue to progress urther or you and wish you

all the best or your uture.

With Kindest Regards

cc. GP

cc. Nicki Roberts (Learning Support Worker)

cc. Mr and Mrs Hughes

core unit 3: part 2 of the mental health (wales) measure 2010: the application of the measure

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