weekley updates

21st feb 2011
7th March 2011
18th March 2011
5th April 2011
12th April 2011
21st April 2011
30th May 2011
18th June 2011
30th June 2011
6th July 2011


For Katrina if she looks at this blog. You said to Julanna on the: "We give her weekley updates."

We'll there's a few gaps and in reality your weekly updates are not very informative. wonder why none of them metioned the RN not being employed afterall you like to keep family imformed don't you. Most times the weekley updates went like this;
"Hi Julie,
Progress over the past couple of weeks, has been significant from a staffing prospective. Katelynd along with a couple of other members of CJP conducted 2 weeks of training for the Staff recruited for Montrose. The training was very successful and all staff participated well.

Kelly"

Not very informative afterall I now know some of what was going on with not finding a Dr, a pschy the rn being cancelled funny how none of that was in the "weekly updates"


Mmm in reality it's only on the things you feel we need to know or the lip service you give us and that way we won't cause a fuss. Afterall can't have family knowing too much.

Susie

In the last 13 months sue has had 118 incidents of challenging behaviour

I do not know how the Montrose model will work. I am worried about the quality of care and support she will get there.

Also she has had to be physically restrainted 31 times. Now i know it can take 5 staff to be able to safely restrain Sue, how are two going to do it at Montrose. Will the rn help, will the onsite psch help? It's still one less than needed. Yet another question not explained by the CJP.

I think they are to worried about money and not about safety and quality of life for Sue and a safe and well support work place for staff.

I do not understand how you could read Sue's notes and decide the best thing for her is to move her to somewhere with less. It has less than what she needs.

CJP

no reply yet, my god they are hopeless, even if they could not answer my question hows about an email back letting me know that.

it's not hard it could go something like this

"I'm sorry Julie but at this point we don't have a time frame as we are still looking to source a pschy for Sue."

easy isn't it


what is really going on though is the CJP are rude, arrogant and have their head soemwhere it should not be. And they wonder why i get angry with them.

Susies visit

Good visit today she was in a good mood, cheeky. She even ddin't mind me taking some photos. She ate al the treats then told me I could leave but it was in jest, so i stayed almost half an hour. The third time she said "you can go now" she meant it. She looks real good and has blonde hair at the moment and it really suits her. Told her she looked really cool with her, the blonde hair brings the colour of her eyes out.

Well I'm tired so I'm gonna go I wonder how long till the CJP email me?

Dr pulls out of treating Sue when she moves

I was visiting Sue today and found out once again how bad the CJP are at contacting me. Th psych that they lined up for Sue has pulled out of being her Dr.
Now you'd think that would mean i would get an email form them to keep me up to date. But nope didn't get one, how rude is that. And they have the hide to tell Julanna that they do keep me informed, yeah right. So here is the email i sent Katrina:

Hi
I was visiting Sue today and was told the pschy (name omited for privacy reason) has decided not to work with Sue when she moves.

It would have been nice if yourself or Kelly sent me an email on this, but communication with family is not a strong point with the CJP.

Do you have a idea of how long it will take to find a replacement? Do not call me as per our agreement at the meeting email your reply.

Julie

Sue's move postponed

Will update blog with Sue's new move date as soon as I know.

CJP's reply

Good evening Julie

Will consult regarding new the new date for Sue’s transition given the delay in staff recruitment.

Yes re the walks will ensure that you receive a recreation planner which details staff attached to various activities for Sue, will discuss this with Lifestyles?

The Sykpe idea is brilliant, that would also be great for the other 2 women as well. I will discuss the implementation of this with Life styles also Kanangra.

Chat during the week re the various updates.

Cheers Katrina

Reply

Hi Katrina
Thank you for the email reply. In regards to Sue's walks at the first meeting the original proposal was: "Montorse staff would drive her to a park where she can walk. With two staff supervising her." Is this what you are envisioning, that two two staff would drive Sue to a park and walk with while the other staff remain behind. It's a bit unclear in your reply, presumably the other clients don't need the same supervision level as only one staff would be staying behind.

Due to the delays caused by the employment of new staff do you have the ammened move date for Sue?

Have you thought of Sykpe video calls as a means for Sue to maintain her contacts at Kanangra I believe it is very cost effective.


Julie

got my reply

Dear Julie,

I hope this clarifies some of you concerns. I would like the opportunity to talk with you again regarding the current issues also to try & reassure you that we will do all that is necessary to make Sue’s new move very positive and rewarding for her, I will ensure that all appropriate levels of staff resources for Sue and the other 2 women at the program are adequate at all times.

Is the Rn still going to be employed?
The Executive Director, Office of the Senior Practitioner, in consultation with Lifestyles Solutions has approved 14 hours per day for a registered nurse to be on site based at the Montrose program for Sue’s care only. This is not a shared staffing resource with the other 2 women who currently reside at the program.

The Community Justice Program has also funded Lifestyle Solutions to appoint a Psychologist full time 5 days per week based on site at Montrose.

There are also 2-3 disability support workers per shift (3 shifts per day).


What are the day activities for Sue, how often and who will do them? Is it separate staff to her staff?
As far as possible we have tried to replicate Sue’s daily activities as it currently is at Kanangra. The house staff on shift will be able to support Sue and participate with her in those activities. In addition, CJP has also funded another service provider (PSA) who can be utilised for day program activities. This is provided by Sunshine Homes.


What is the ratio of staff to Sue to the whole centre?
When Sue moves in she will be the third person living at Montrose. There will be 3 staff on shift during the day and 2 staff on shift overnight.

The housing/funding model changed, what funding is left?
Ageing, Disability and Home Care fund Lifestyle Solutions to operate the Montrose program as an Intensive Residential Service. Funding benchmarks are not for public disclosure. Lifestyle Solutions are funded for placements not individuals as per benchmark regulations.


How do you propose that Sue will do her daily walks?
Sue can exercise on site. There are also 3 parks close to the property where Sue could go walking with staff. Discussions have also occurred in relation to having a treadmill in the Recreation Area that Sue would have supervised access to.

How is Sue going to visit her friends at Kanangra? How is Sue going to maintain contact her friends both staff and other clients at Kanangra?

We have documented plans for Sue to visit Kanangra to maintain those relationships e.g. attending concerts and Christmas parties. Her friends are also welcome to visit her. Regular contact can also be maintained with phone calls and mail. We also have the contact details of her friend that lives in the community so that arrangements can be made for the monthly catch-ups to continue. Montrose staff and vehicle will be available to facilitate these visits.

Regards Katrina

Email sent to CJP after they have not replied to any of my emails today

ok you're forcing my hand by not replying. I'm going to have to go public with this. Maybe see a minister or two or the reporter who covered the Watagan Centre story.
Next move is yours
you have until five
it is not hard to relpy to an email.

Julie

Katrina CJP

Hi
couple of questions
Is the Rn still going to be employed?
What are the day activites for Sue, how often and who will do them? Is it seperate staff to her staff?
What is the ratio of staff to Sue nto the whole centre?
The housing/funding model changed, what funding is left?
How do you propsoe that Sue will do her daily walks?
How is Sue going to visit her frinds at Kananagra?
How is Sue going to maintain contact her friends both staff and other clients at Kanangra?


I want direct answers. Sick of the policy waving.

REPLY
Good afternoon Julie,
Could you please make a time to catch-up with me ASAP, regarding the various ongoing issues re Sue Transition?
I’m more than happy to schedule a meeting with you tomorrow.
Many thanks Katrina

REPLY BACK
Hi
Surely you can answer the questions in an email.

Julie

SECOND REPLY BACK
Hi Katrina
I am actually busy today. You will have to email me. I forgot the CJP have already told me it is Sunshine Homes that will provide day activites for Sue, I found the info in my notes. But I would still like to know what they are offering her. I do expect an email back with answers by the end of the day.

Julie

email to gaurdain

Hi Peter

I have sent you now 4 emails and left three mesasages. The duty manager yesterday said he would put a pop up on your computer when it was started up this morning telling you to call me.

So either email me about where you satnd on Sue's move now the RN is not being employed. Or call me on my mobile.

I expect to hear back from you today it is now 5 days since I first contacted you.

Come Monday if I haven't heard form you I will lodge a complaint.

Been patient enough i think.

Julie

OPG complaints

so they tell me staff can not remotely access their email or voice mail, in this day and age how archaic is that.

So in a job where it requires you to be out of the office you have to be in the office to get your message, stupid just plain stupid.

OPG (Gaurdian)

is not in the office today. This is frustrating beyond belief. no replies to my email and no replies to my voice message. What the hell use are you.

CJP

no reply to email so far, two days since i sent it. They are also making me mad, they should know by now DON'T PISS JULIE OFF

OPG (Gaurdian)

ok two messages left and an email for the Gaurdian no reply so far.

What is going on. Making me mad, not a good thing to do?

Watagan Centre

WATAGAN CENTRE FORMER RESIDENTS

The Hon. PATRICIA FORSYTHE: In relation to funding for the support of former Watagan Centre residents did the Minister for Community Services, Minister for Aged Services, and Minister for Disability Services last week tell the media that they would always receive the level of funding necessary to support their needs? Did he also tell the media:

Naturally as the level of support they require lessens, the funding necessary to maintain them in their group homes can be reduced accordingly.


What assessment process was carried out to determine the level of revised funding to support these people? Is it a fact that no new assessment was carried out, and that service providers merely received a "Dear Provider" letter?

The Hon. R. D. DYER: As I have said before in this House, a proud achievement of the Government is the devolution of the Watagan residents to group homes in the community. I was the first member of Parliament to ever bother to visit the former Watagan Centre, which was earlier known as Carynia Oaks, and I described it as a valley of the lost souls. I was shocked and dismayed at what I discovered when I visited with my colleague the honourable member for Lake Macquarie, Mr Jeff Hunter. I made a promise to myself then that if I ever had the opportunity, I would remove residents from that place. One of the first things I did as Minister was to honour that commitment.

I am pleased that the Treasurer helped to achieve that objective by funding the necessary 80 places to relocate those people in the community. The Treasurer informs me that today he has given me more money. I am not sure what for, but I assure the House that whatever the Treasurer gives me will be gratefully accepted and very well spent. Thank you, Treasurer. I move on to what is happening with the Watagan Centre residents. When they moved out from Watagan to group homes in the community they were assisted at considerable public expense - more than might ordinarily be the case - given the extreme levels of disabilities and low levels of functioning occasioned by the many years they had spent at the Watagan Centre with practically no day programs, therapy or anything else.

In relocating the residents I was assisted in particular by the Hunter Mission, which did an excellent job, and by the Ageing and Disability Department. That department prepared individual service plans that were fashioned to suit the individual needs of each resident relocated from the Watagan Centre to group homes in the community. I not only said to the media but probably said in the House as well in response to an earlier question, that some of these 80 people are functioning at a greatly improved level, to such an extent that some no longer require permanent supported accommodation from the Government. Some who are living in ordinary homes in the community are receiving drop-in assistance. I have endeavoured to ensure that residents continue to receive the support they require.

On 21 November 1995 I gave a guarantee that when residents move from large residential establishments into the community, they will receive the level of care and support they need. All consumers have received that guarantee; the Government has been honouring that guarantee and will continue to honour it. It remains the case that funding for these people is monitored. I do not particularly care whether the Hon. Patricia Forsythe believes that, but these people have individual service plans and are provided with funding packages commensurate with their individual needs - full stop. Page 11102

WATAGAN CENTRE FORMER RESIDENTS

The Hon. PATRICIA FORSYTHE: I ask a supplementary question. Is the Minister currently reviewing and reducing the amount of money available to services providing accommodation and support to former residents of the Watagan Centre? Is he putting at risk the progress of those people? Can he guarantee that the programs aimed at improving the integration of those people into the community will not be cut?

The Hon. R. D. DYER: I will always ensure, and this Government will always ensure, that adequate resources are made available to care for people with disabilities who are in permanent supported accommodation places, including former residents of the Watagan Centre. It is true to say, though, that as time passes and as the level of functioning of certain clients increases, the support levels previously warranted can in some cases be reduced. That is a matter of individual judgment regarding particular clients.

afterthought, Email sent to the Gaurdian

Hi Peter

The other thing that is of concerns is that the house is not sound proofed and the ammount of noise that Sue can make will surely lead to complaints from neighbours. The CJP have not addreesed this concern, even though it has been raised with them at least twice.

Also has anyone considered the fact that at the rate Sue is aging, she is aging quite fast due to her genetic disorders, that by the time Kanangra offically closes she may not need this high level of securtiy. She may just not be physically able to be a threat anymore. I think because the current model is so far away from the original propasal you need to rethink giving permission for the CJP to house Sue.

Ta
Julie

email to the two K's at CJP

Hi
couple of questions
Is the Rn still going to be employed?
What are the day activites for Sue, how often and who will do them? Is it seperate staff to her staff?
What is the ratio of staff to Sue not the whole centre?
The housing/funding model changed, what funding is left?
How do you propsoe that Sue will do her daily walks?
How is Sue going to visit her frinds at Kananagra?
How is Sue going to maintain contact her friends both staff and other clients at Kanangra?

I want direct answers. Sick of the policy waving.

Julie

email to the gaurdain

The gaurdian is out of the office today I'veleft message and emialed hi.

Hi Peter

I have grave concerns about the changes in the model for Sue's housing at Montrose. I have been told the the CJP are out of money for the matiance of the house and that any cost would be incurred by Lifestyles. So far the CJP have nto told me how this occurs.

I beleive there is not goign to be an RN employed anymore so how is Sue goign to get her IMI's?

The day activites seem to be slipping away as well.

I do not think she should be moved as the Montrose of today is not what they promised for her.

Thanks
Julie

my reply back

Hi Kelly,

Just remove the shelf, as I have said three times now the tempered glass does not solve the problem as such, if she breaks the shelf Sue may decide to ingest the glass fragments if she cannot cut herself.

You really have not listened to anything anyone in the consultation process has told you. Sue does not have anything other than plastic or paper options in her own space at Kanangra. She will break crockery and she will inflict harm on herself or others but in the end that is your problem I guess seeing you do not listen to anyone has told you. And as the plates etc only being used in times of necessity (she will have at least three meals daily) well it doesn't take long for a plate to be broken once it's in her hands. You think I'm angry you would be right. I don not understand why the CJP seem intent on not minimising known risk factors.

"The unit has been funded by the CJP and there is a purchasing and planning team that continues to work with the service provider around the funding parameters" That really doesn't answer my question. I was told the money was all spent for the unit and that maintenance would have to come out of Sue's lifestyle funding. Now is there separate funding for the property and her day activities, massage et or is it all one lump amount?


In the end if things go wrong then the CJP will have to wear it. As there have been numerous attempts on my part to open your eyes to potential problems, which you chose to ignore.


Julie

CJP's reply

Hi Julie,



Thankyou for your correspondence on the 14.07.11, please find to follow information in relation to the issues you raised in your email below.



· The glass shelves in the refrigerator are tempered safety glass and should be a safe option for Sue in her unit. Alternatively the glass shelving could be removed from the refrigerator as an immediate solution if needed. Sue’s fridge will also initially be locked at all times with access provided only during staff supervision.

· All units are equipped with locked cabinets for storage and security. The kettle and toaster in Sue’s unit will be placed in these lockable cabinets until they are required and will be returned and locked after each use. Procedures are in place so that staff check unit cabinets and locked areas, when she accesses these items, prior to leaving Sue’s unit. Sue will also have access to the kitchen within the common area and staff unit. This space will only be used when staff are present, the kitchen in this space has been modified to ensure safety for all and kitchen equipment such as toaster, kettle etc will also be locked away.

· Plates and cutlery were purchased with staff and client safety in mind so are for example shatterproof and less likely to inflict serious harm if used for purposes other than those intended. All cutlery and plates will also be in lockable cabinets and be used only during times of necessity.

· The service provider has already purchased linen and towels and these are available on site. Sue’s unit will have her linen and towels ready when she moves.

· The unit has been funded by the CJP and there is a purchasing and planning team that continues to work with the service provider around the funding parameters.

· Options to make the fencing higher on the side of the property are being considered and progress on this will be provided when available. There are unit procedures in place for staff to monitor and physically check the property perimeter on a regular daily basis and the unit is staffed around the clock to provide appropriate support to clients.

· Sue’s shutters will be operated only by staff and after further consultation with all stakeholders plans will be put in place for Sue to learn to operate and access them independently.



Thanks for the email.



Kelly

Email sent to CJP after visit to property

Hi Katrina
I meet with H*** at Montrose today. Ok now for my concerns there is still glass in Sue's space. There is a glass shelf in the fridge and he is pretty sure the mirror in the bathroom is glass. This was asked to be rectified last visit I suggest you fix this now.

Also you should remove the kettle and toaster from Sue's space. As I said before she has no access to the kitchen at Kanangra. Or ask them how to manage this new situation. Also what are you going to use for cutlery, plates, mugs etc for her?

What linen, bedding and towels are going to be provided for her? And by who?

H*** told that the CJP funding for the house has been used up. What funding does the CJP have left for Sue? Can you give me a monetary break down of Sue's allocated funding?

It is nice to see the screening suggestion and the need for higher fencing I had for the front entrance has been taken on board. Disappointing that the access to the side of the property is still not rectified but it seems everyone bar me see this as a non issue because of the drop where as I see the fact that it has a drop off the side of the property as a reason to secure it.

Heihena said that my suggestion to grow some climbing plants is also going to be used. Also good to see that privacy. shutters for Sue's space. How will she get access to use them?


Julie

reply to my email about Sue case plan

Hi Julie,



Thankyou for your emails of 01.07.11 and 04.07.11. Please find to follow additional information in relation to the issues you raised in your emails. The updated Case Plan has also been attached for your reference. The Plan is a working document and as such the term incomplete has been used within the Plan to identify key areas where work is currently in process but not finalised as yet. These items are being worked on with the view to them being finalised as far as is possible prior to Sue moving to Montrose.



Julanna’s involvement in Sue’s life not documented: this has been rectified and the Plan now includes Julanna’s involvement.
Sue’s belongings: This section has been included to document Sue’s possessions and to ensure that they are ALL moved with her. It has been left blank at this stage and will be completed on the day of Sue’s move. The Plan has been amended to make this more clear.
Reactive Strategies in place of IMI: This remains incomplete at this stage until the completion of Prevention and management of violence and aggression training. The strategies discussed will be embedded into the response strategies.
Community based Psychiatrist: Community based Psychiatrists have previously been contacted and indicated that they would not be in a position to take Sue on as a client. We are currently placing a referral with a community based Psychiatrist who is taking on new referrals at the moment and has recently seen one of the other ladies currently living at Montrose.
Community based GP: there were some difficulties with the local GP’s not being in a position to provide the services we needed. This has been rectified with the identification of an appropriate GP, more details are in the Plan.
Briefing the local Mental Health Team: Based on discussions with Kanangra, a 3 tiered mental health plan has been developed with the local mental health team being the 3rd tier. Consequently the mental health team can be briefed once we have engaged the services of a community based Psychiatrist and at the direction of that Psychiatrist.



Tier 1 – Montrose Staff

o Implementation of positive programs

o Implementation of Psychiatrist's recommendations

o Monitoring of symptoms

- repetitive hand movements

- repetitive touching of nose

- decreased enjoyment of preferred activities

- decreased participation in daily activities

- persistent low level of mood

- changes to sleep patterns

- changes to eating habits

- loss of skills

o Data collection

Tier 2 – Sue’s Psychiatrist

o Regular review

o Monitoring, review and prescription of medication

o Recommendations for intervention

o Referral to local Mental Health Team

Tier 3 – local Mental Health Team

o Support with management of major episodes of mental illness e.g. major depression

o Support with management of emergency situations



Clinical Indicators that Sue is not coping: This item is to acknowledge that Sue’s transition needs to be person centred. The clinical indicators have been documented and therefore the item is complete. (See Tier 1 descriptors, developed by Kanangra staff) If there is clinical evidence that Sue is ‘overwhelmed’ or not coping (as observed through the clinical indicators) then decisions will be made at that time in order to support Sue more effectively.
Day Activities: are currently marked as post transition given they will commence after Sue has moved. A daily schedule has been developed based on Sue’s current activities at Kanangra. Day activities such as music and dance are already available through LS Community Justice Performing Arts Programme. There are 3 local parks that have been identified. Options for Sue to exercise on the premises are also being investigated. Risk assessments need to be completed for community access e.g. the parks. CJP has also funded a organisation to provide activities for CJP clients. This service will be available to all Montrose clients.
Appropriate staffing levels: As you’re aware Sue’s levels of support in Kanangra vary through out the day from no direct support when in her unit to the highest level of staffing being 2:1. Montrose plan to duplicate this level of support.
PMVA Training: This will be completed before Sue moves into the unit.
Mental Health First Aid Training: This training has been added to Montrose training calendar; this specific training is not required before Sue’s move. Staff will however have client related training around Sue’s mental health needs prior to her moving in and will have access to plans and strategies.

My Respone

Hi
Two thing i noticed on a quick read through is there is no mention of Julanna's involvement is Sue's life, please rectify this. Julanna see's Sue regularly. Also there is no mention of Sue's items beig taken with her, in fact it's blank. She has posessions, music, dvd's clothes etc you neeed to make it clear that all her posessions including personal itmes such as photos and Sarah's artwork go with her.

I'll read it in full later.

Julie


Second Reply sent to the CJP
Ok
I have read this document.
In action objective/rationale you have an incomplete in the "Develop appropriate and effective Reactive Strategies to be used in the place of PRN - IMI" when will that be complete? It should have been by now.

Also in action objective/rationale "Handover from current Psychiatrist to community based Psychiatrist: Incomplete" Do you have a communtiy based Psychiatrsit in place?

Also in actions objective/rationale "Handover from current MO to community based GP who is able to provide home visits: incomplete" So does Sue have doctor lined up?

Also in action objective/rationale "Brief local community mental health team (Blacktown): Incomplete. When will this be done. All of these vital resources should be in palce and finalised by now. You have got to be kidding that a month before she moves things like this are incomplete. Hopeless and in a lot of ways disrespectful and neglectful.

Now in objective/rationale actions you have a complete that i don't know how you've done it "Document key clinical indicators that Sue is ‘not coping’ with the transition. The transition can then be modified accordingly based on Sue’s needs e.g. increase / decrease the speed of the transition into the community if there is clinical evidence that Sue is ‘overwhelmed’" Explain?

Now do you have Sue's day activites organised, where she can go walking worked out, her massage and music therapy set up, dances, etc, becasue all it says is post transition can you clairfy what you have in place for her in this area of her life?

Now in actions objective/rationale staffing: "Appropriate staffing levels not less than 2:1 (Staff:Sue) with additional back-up staff in immediate vicinity incomplete." Explain in detail?

Also in actions objective/rationale staffing: "Restraint/Escort Training e.g. PMVA (Graham Davies) or similar: incomplete" When will that be completed?

Also in actions objective/rationale staffing: "Mental Health First Aid Training incomplete." When will training be finsihed?

You have a lot of incompletes, when will these all finalised?

Also i would like to see the space again before you tell Sue of the move.

Regards

Julie

Version 2.1 (27.06.10)

Client Name: Susan ‘Sue’
CJP Staff: Katelynd CJP Staff: Kelly
Annual Review and new plan development date:
Formulation statement:
Sue is a 41 year woman with an intellectual disability and Phelan-McDerrid Syndrome. Her level of disability has been assessed over time from borderline to moderate, with later assessments indicating declined functioning. Sue was an adoptive child ......... She also experienced significant violence and sexual assault in her accommodation upon leaving boarding school and experienced a great number of accommodation changes. From reports, it appears her level of disability, genetic disease, frequent loss of relationships, poor attachment history and traumatic and possibly neglectful early environment interacted to result in severe emotional dysregulation and fears of abandonment. This is consistent with her diagnoses of Intermittent Explosive Disorder and more specifically Borderline Personality Disorder. Her poor emotional regulation stemming from her BPD, in combination with the traumatic losses, such as the loss of her daughter also explains her periods of Major Depressive Disorder with Catatonic Features. Her reported psychotic features are also consistent and common in those with BPD.

Sue currently resides at Kanangra Centre in Unit 4. Sue lives by herself in a self contained unit but has the ability to interact with other clients of Unit 3 during the day. Sue has recently experienced a period of generally positive mental health and behaviour following a number of sessions of Electro-Convulsive Therapy subsequent to a period of catatonic depression. Apart from the ECT, which alleviated the depression, it is suspected that her improved functioning revolves about her environment and pharmacotherapy, which includes the use of mane, nocte and pro re nata psychotropic medication.

A number of environmental factors at Kanangra appear to have been instrumental in Sue's improved functioning. Kanangra provides clear physical boundaries. This includes the ability to socialise and have day activities without leaving the grounds. It also includes reinforced fixtures which reduce risk of property damage, injuries to self and staff and absconding. These reduce risk of criminal justice involvement, relationship breakdown and consequential service breakdown, (which has historically reinforced some of her Borderline thinking and coping styles). A key element to the success of Kanangra has been the experience of staff in supporting people with severe challenging behaviour. This expertise revolves about their ability to quickly de-escalate critical incidents using distraction, environmental manipulation, communication strategies, PRN medication (including IMI) and applying effective and safe restraint procedures. Of great importance has been their non-dramatic appraisal of incidents which can reduce the function of the behaviour and thereby reduce the reinforcing value of the challenging behaviour. Staff have also been very consistent, with most having been there the entire time Sue has been at Kanangra. This has provided a degree of stability in her relationships that undermines her core belief about abandonment.

To ensure Sue does not regress or have the progress she has made squandered, it is imperative that she be supported in a model where there is a clear validating environment with stable, secure staff and other clients she relates well towards. These and the service recommendations from the SNRG assessment are strongly reflected in the accommodation and support model identified at Quakers Hill.

Relationship /Position Name Relationship /Position
Katelynd Casework Specialist CJP Carol Nursing Manager
Kelly Team Leader Case Management Julie Sister
Ellie RUNM Kanangra Peter Legal Guardian, OPG
Janine Psychologist Kanangra


1 Family
Objective / Rationale Actions Responsibility
Timeframe


Liaise with Julie and Sue’s mother regarding Sue’s transition into the community through invitations to meetings and the provision of regular updates CJP
Kanangra Ongoing

Maintain current schedules regarding contact and parcels (this includes food parcels to be reviewed by staff and provided to Sue in stages)Lifestyle Solutions Post Transition

Provide opportunities for visits between Sue and her family Lifestyle Solutions Post Transition

Assist Sue to display her photographs etc in her unit CJP Kanangra Lifestyle Solutions Incomplete
Memory book to be developed for Sue about her life at Kanangra Kanangra Incomplete

2 Physical Health
Objective / Rationale Actions Responsibility
Timeframe
Continue to monitor Sue’s weight Lifestyle Solutions Post Transition
Utilise ‘Light n Easy’ or similar to maintain her healthy eating as well as a means of meal preparation Lifestyle Solutions Post Transition

Regular Dietician review Lifestyle Solutions Post Transition
Provide regular schedule of physical activity to support a healthy weight range Lifestyle Solutions Post Transition
Identify suitable location where Sue can continue to enjoy walking Lifestyle Solutions Identified

Need Risk Assessment

Handover from current MO to community based GP who is able to provide home visits Kanangra Lifestyle Solutions Incomplete

Ongoing GP reviews Lifestyle Solutions Post Transition

Completion of CHAP tool (as necessary) Lifestyle Solutions Post Transition

Develop appropriate and effective Reactive Strategies to be used in the place of PRN - IMI CJP Lifestyle Solutions Psychiatrist Incomplete

Handover current Webster Pack Kanangra At Transition
Fill new prescriptions Lifestyle Solutions As needed

Mental Health
Objective / Rationale Actions Responsibility Timeframe

Identify appropriate community Psychiatrist CJP Lifestyle Solutions Dr Sophie Kavanagh

Handover from current Psychiatrist to community based Psychiatrist CJP
Kanangra Lifestyle Solutions Community Psychiatrist Incomplete

Develop mental health response plan based on identifying early warning signs and providing appropriate early intervention CJP Lifestyle Solutions Complete

Monitor mental health status through ongoing data collection Lifestyle Solutions Ongoing

Re-engage services for ECT/other appropriate treatment as indicated in mental health response plan Lifestyle Solutions As Required

Brief local community mental health team (Blacktown)CJP Lifestyle Solutions Incomplete

Accommodation Objective / Rationale Actions Responsibility Timeframe

Sharing Information consistently:
o1 Meeting with Sue’s family
o2 Meeting with OPG
o3 Meeting with Kanangra staff
o4 Meeting with Sue
CJP Kanangra Lifestyle Solutions Sue and her family OPG Ongoing

Transition to community accommodation:

o1 Staff buddy shifts at Kanangra Lifestyle Solutions Kanangra Ongoing

o1 Photographs of new home and discussions with Sue Lifestyle Solutions Incomplete
(Proposed for: 25.07.11)
o2 Visiting new Unit at Montrose Kanangra Lifestyle Solutions Incomplete (Proposed for: 02.08.11)
o3 Pack belongings
o4 Farewell Party at Kanangra Kanangra Sue and her family Incomplete (Proposed for: 03.08.11)
o5 Move into new Unit at Montrose CJP Kanangra Lifestyle Solutions Sue and her family Incomplete (Proposed for: 04.08.11)
o6 House warming party Lifestyle Solutions Kanangra Sue and her family Incomplete
(Proposed for: 05.08.11)
o7 Document key clinical indicators that Sue is ‘not coping’ with the transition. The transition can then be modified accordingly based on Sue’s needs e.g. increase / decrease the speed of the transition into the community if there is clinical evidence that Sue is ‘overwhelmed’ CJP Kanangra Complete

5 Education Objective / Rationale Action Responsibility Timeframe

Investigate formal adult learning opportunities for Sue if interested Lifestyle Solutions Post Transition

Continue informal learning opportunities through Activities of Daily Living (ADL’s) Lifestyle Solutions Post Transition

Continue with literacy and numeracy ‘lessons’ (1/2 hr/wk) that Sue currently enjoys Lifestyle Solutions Post Transition

7 Recreation Objective / Rationale Actions Responsibility Timeframe
Follow similar structure as current daily planner as far as is possible Lifestyle Solutions Post transition

Ensure Sue continues to have the opportunity to enjoy current preferred activities e.g. music therapy, walking, concerts Lifestyle Solutions Post transition

Continue structured community access activities Lifestyle Solutions Post transition

Provide Sue with the opportunity to develop new recreational activities Lifestyle Solutions Post transition

Maintain opportunities to visit peers and staff at Kanangra Lifestyle Solutions
Kanangra Post transition

8 Religion/Cultural beliefs Objective / Rationals Actions Responsibility Timeframe
Sue has attended Church at Kanangra of a Friday. She enjoys the music and the singing. Investigate ongoing contact with Church if Sue wishes to continue attending Church Lifestyle Solutions Post transition

9 Social Relationships Objective / Rationale Actions Responsibility Timeframe

Maintain Sue’s peer relationships at Kanangra with regular planned visits e.g. attending concerts Lifestyle Solutions Kanangra Post Transition

Maintain Sue’s relationships with Kanangra staff e.g. phone calls, staff visits Lifestyle Solutions Kanangra Post Transition

Provide opportunities for ongoing development of social interactions with peers in the community setting Lifestyle Solutions Post Transition

10 Functional Skills Objective / Rationale Actions Responsibility Timeframe
Continue to provide opportunities for informal learning regarding functional skills Lifestyle Solutions Post Transition

Utilise Individual Planning process to identify specific functional skills to target formally Lifestyle Solutions Post Transition

Consider skills assessment Lifestyle Solutions Post Transition

Develop skills development plans accordingly Lifestyle Solutions Post
Transition

Staff to assist with ADL’s as required in periods of depression Lifestyle Solutions
If and as required

11 Decision Making Objective / Rationale Actions Responsibility Timeframe

Liaise with OPG regarding Sue’s transition into the community CJP Kanangra
Lifestyle Solutions Ongoing

Provide documentation to assist in consent for move process CJP Complete

Obtain consent from OPG
Consent for Services, Exchange of Information etc (17.11.10)
Consent for Move (05.01.11)CJP Complete

12 Behaviour & Risk Management Objective / Rationale Actions Responsibility
Timeframe

Update current behaviour support and risk management plans in light of community accommodation and DBT model in collaboration with Kanangra CJP Ongoing

Review incident reports and data CJP Kanangra Ongoing

Provide staff training (see Section 13)(see Section 13)

Staff to have practical working knowledge of above plans Lifestyle Solutions
CJP Ongoing

Implement data collection and collation Lifestyle Solutions Ongoing

Regular review of plans as per policy (i.e. quarterly) Lifestyle Solutions Post Transition

13 Staff Provision & Training Objective / Rationale Actions Responsibility
Timeframe

Employ skilled staff Lifestyle Solutions Complete and Ongoing

Roster regular and stable staff Lifestyle Solutions Complete

Appropriate staffing levels not less than 2:1 (Staff:Sue) with additional back-up staff in immediate vicinity CJP Lifestyle Solutions Incomplete

Training recommended for staff working with Sue:

o1 CJP Establishment Training CJP Complete

o2 Client specific Training CJP Complete
o3 Restraint/Escort Training e.g. PMVA (Graham Davies) or similar Lifestyle Solutions Incomplete
o4 Buddy shifts with Kanangra staff Lifestyle Solutions Kanangra Ongoing
o5 Dialectical Behaviour Therapy Training (ongoing commitment) CJP Ongoing
o6 Behaviour Support Training CJP Ongoing
o7 Risk Management Training Lifestyle Solutions Ongoing
o8 First Aid Training Lifestyle Solutions staff Ongoing
o9 Mental Health First Aid Training Lifestyle Solutions Incomplete

14 Services Current Service Name / Contact Details Last Review / Attendance Date Community Based Service Complete Review Date
General Practitioner Dr Eric
Kanangra Centre
Hunter Residences
Department of Family and Community Services
Locked Bag No 3
Morisset 2264 Annual physical – 27 June 2011

Psychiatrist Dr Bruce 4 November 2010
Dentist Dr Wong 14 June 2011
Neurologist
Ophthalmologist
Psychologist Ms Janine 27 April 2011
Pharmacist Bowens Pharmacy
Podiatrist
Dietician Ms Wendy
Stockton Clinic 5 July 2010
Massage Therapist Mr Hedley 22 June 2011
Day Program Services Dilkara
Kanangra Centre Daily
Financial Services Leanne
Assistant Client Service Officer
Client Service Team 5 – Long Term
NSW Trustee and Guardian 27 May 2011
Outstanding Bills ? Pharmacy

15 Furnishings and Possessions
Indicate items, and actions by who and when Client Register Updated signed and dated by current manager

16 Clothing Register
Quantity: Date of
Purchase Item Description Signature

Transportation Company: Booked Date for Transport:


17 Clothing Register
Document Document Date Handover Date
Individual Plan (signed and endorsed and the resident/carer/family member and/or Guardian/Advocate) 4 July 2011
Health Care Plan (signed and endorsed by a doctor and the resident/carer/family member and/or Guardian/Advocate) 4 May 2011
Epilepsy Management Plan N/A
Nutrition and Swallowing Plan 15 June 2011
Oral Health Assessment/Management Plan
Comprehensive Mealtime Management Plan 5 July 2010
Asthma Management Plan N/A
Client Annual Health Review 24 June 2011
Key Health Issues 24 June 2011
Client Health Care Plan As above
Cumulative Medical History Ongoing
Client Risk Profile 4 May 2011
Client Risk Management Plan 4 May 2011
Client Manual Handling Plan (Mobility Management Plan) 15 June 2011
Transport of Clients Risk Review 15 June 2011
Guardianship Order for Banker arrangements and Financial Plan from NSW Trustee Estate managed since admission
Financial Plan – 27 May 2011
Person Responsible Public Guardian
Medical/Dental Consents 23 May 2011
Guardianship Orders 10 May 2011
Behaviour Support 27 April 2011
Behaviour Assessment December 2004
Comprehensive/Incident Prevention & Response Plan 27 April 2011
Lifestyle Review 27 April 2011
Skills Development Plan 27 April 2011
Communication
Communication Profile 15 June 2011
Communication Plan
Financial Plan 4 July 2011
Recreational Activity Preference 15 June 2011
Day Programme Assessment 6 July 2010
Client Profile 15 June 2011
Personal Belongings Inventory At transition
Personal Clothing Inventory At transition
Pension Card 30 Nov 2011
Medicare Card August 2011
Calender of forward medical appointments
Current funeral arrangements