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.