The Modus Care Pathway
Our Approach to Autism & Aspergers Syndrome Care
The first step is to get to know each other. Initial contact is informal, and can be by phone, email or through our website.
If you wish to speak to us about our services or refer someone to our services, you can contact our assessment co-ordinator Kelly Melrose or the assessment administrator Joanna Klimek if Kelly is unavailable. Both Kelly and Jo are based at Modus Head Office in Kenton
We gather more information using a referral form, visits and in-depth discussions with advocates and appropriate professionals.
If it seems that we may have an appropriate service to meet your needs or someone you are acting for, we will send you an initial referral form. You will be asked to complete as much information as you can (electronically if possible) and return to the assessment team via Modus Care Head Office. This brief form asks for outline details of the service required so that we can quickly let you know if we have any potentially suitable services.
We will aim to contact you within 5 working days of receiving this document. At this stage we will discuss with you whether we feel that a full assessment may be appropriate or if we do not feel that we will be able to meet your needs (or the person you are acting for).
A thorough assessment and care planning process is tailored to individual needs and leads to a full report.
The success of a placement will be dependent on the quality of the assessment and transition planning. Therefore before any admission is agreed a detailed assessment will be undertaken. The initial information gathering process will determine the skill mix of the assessment team. Our assessment team consists of Behaviour Specialists, Specialist Nurses and Consultants, Registered Managers and Mental Health Act Advisors.
We always aim to meet you (or the person you are acting for) as part of the assessment process to gain information and get your / their perspective on the service needed. During the assessment process we will look to gather as much relevant history as possible. This is usually via interviews, accessing reports, looking at the current and past placement and liaising with interested stakeholders (where appropriate). The assessment team will produce a report entitled ‘Service Needs Assessment’ which will set out the type of service that is required to meet individual needs and areas of development.
Our senior management team evaluates the needs of the individual and determines whether we can provide the right service.
The specific service that can be offered will then be set out in the ‘Individual Service Proposal’. This is a tool we use to set out responsibilities for various elements of the proposed care package, such as staffing, activities, facilities and other resources. This assessment will form a key component in the development of the transition plan, reactive strategies and the care planning and risk assessment process.
The completed assessment is then shared with our Admissions panel who will ensure that any offer reflects our current services and statement of purpose for the proposed location. Costs for the service are then calculated based on this information and submitted to whoever is commissioning the care package along with the Service Needs Assessment and Individual Service Proposal.
Every aspect of the transition is thoroughly planned, structured and tailored to the individual’s needs.
Moving into a different environment can be extremely difficult for anybody but it has the potential to cause significant difficulties for someone with an Autistic Spectrum Disorder and or associated condition. It is regrettably often the case that transitions and admissions take place at a time of crisis and breakdown in current placement. Modus Care has direct experience of the provision of services to those with complex care needs and challenging behaviour who are moving between services and may be in crisis. Modus Care is able, through our detailed assessment and transition process, to properly plan and manage the transition process. This process involves working closely with the current placement provider, the identification of appropriate resources and environment and the production of a detailed transition plan along with initial care and behavioural plan.
Children to younger adult services
This approach is especially important in managing the transition and admission of children / young people into adult services, where the challenges associated with a life changing move occur at the same time as the person is undergoing significant personal and emotional development. The needs of children and young people are either addressed within our bespoke children’s services or where there are variations in adult services to accommodate those under the age of 18
From the start, our care teams create detailed individual care plans, activity schedules, and risk assessments.
The Service Needs Assessment mentioned previously forms the basis of transition planning and risk assessment. Within Hospital services, this system is managed in line with the Care Programme Approach, a system for Health Authorities and Social Services Departments to arrange the care and treatment of mentally ill people.
The care programme approach operates on four main levels;
- Care planning
- Allocation of a key worker (Care Co-ordinator)
- Regular reviews
Within Modus Care the provisions of the CPA are applied via thorough initial Service Needs Assessment, allocation of a named nurse to supervise the development of a detailed care plan, systematic risk assessment & management and regular reviews of care.
For more information on the Care Programme Approach, go to http://www.cpaa.co.uk/
The risk assessment system in place with regards to service users and the management of adverse events is based on a relatively simple risk analysis tool. This tool has been developed to guide staff and service users in identifying potential hazards associated with certain activities; establishing who may be affected; evaluating the impact of these hazards should they occur; considering control strategies that could be implemented to minimise the risks and setting appropriate review schedules.
This framework is intended to promote a culture of positive risk taking, whereby activities are carried out with due regard for the health, safety and wellbeing of staff and service users, without creating barriers to development and growth. Within Modus Care the risk assessment tool is closely linked to the care planning process and usually underpins a care plan element.
The risk assessment tool includes an assessment of historical forensic and clinical risk issues to form a part of the assessment and admission process, however is not intended to be a forensic / clinical risk assessment (where this is required an assessment would be commissioned from an appropriately qualified professional).
Service User Plans - Service users in Modus residential units do not usually come under the provisions of the Care Programme Approach, however are supported via a comprehensive service user plan. Service users are allocated a named key worker to oversee the implementation of the service user plan, and the service user is central to the development of this plan as far as possible.
All care plans, whether residential or under the CPA, are focused on increasing independence and improving standards of living wherever possible, keeping the needs and wishes of the service user or patient at its centre.
During the first 13 weeks, care plans are reviewed and shared with appropriate stakeholders. Care is further tailored to meet specific skills and needs.
Modus Care considers the Review process to be an essential element of the Care/Treatment Plan provided for each individual whether through admission to our hospital or residential services. The first 13 weeks of an admission to either a hospital or residential service will generally allow sufficient time for us to verify whether the information acquired through the assessment process has correctly identified the needs of the individual, and that the care package originally set out in the assessment were correct. We consider it essential that all Stakeholders e.g. the individual themselves (where possible and appropriate), the placing authority and parents/advocates are involved in this process.
The aim of the review will be to clarify if the placement can meet the identified needs of the individual and if not what elements of the care/treatment plan need to be amended. In our experience, our Assessments are sufficiently detailed to ensure that we have correctly identified the suitability of the placement and that we can appropriately meet all identified needs. However, it may be the case that the review period has identified behaviours etc., which were not previously known or documented and in most of these circumstances we would use the review to propose and agree new or amended care/treatment plans. In a small number of cases the review period has identified new and previously unknown behaviours which have placed the needs of the individual outside of our CQC registration admission criteria and have regrettably meant that we cannot agree to continue the service. In these instances we would endeavour to ensure all stakeholders (where appropriate) were aware before the review meeting in order to properly prepare a plan for identifying an alternative placement.
Regular reviews help the individual progress towards greater independence and less intensive support.
Regular service user plan reviews take place, involving multi-disciplinary agencies where appropriate, to ensure continued progress where possible.
Modus Care ensures that through the process of review, progress is kept at the forefront of the individual’s care/treatment plan. Formal reviews are scheduled on a 6 monthly basis within both residential and hospital services, unless required more frequently. All interested Stakeholders e.g. the individual themselves (where possible and appropriate), the placing authority and parents/advocates are invited to be part of this process. Reviews are recorded with clear outcomes and action points.
Care teams, under the direction of the named nurse or key worker, are required to review care plans, risk assessments, behavioural plans and capacity assessments on an ongoing basis. The level of review will be dictated by the changing needs of individual service users/patients
Our focus at every step of the Modus Care Pathway is to give the individual greater independence.
The guiding principle of Modus Care residential and hospital services is a clear care pathway for service users to progress into the most independent living environment that suits their needs and wishes. Our services are designed to offer flexibility of provision across the spectrum of abilities and challenges by providing support from a skilled staff team, in environments designed to allow for opportunities to move to less restrictive and more independent living.
The objectives of Modus Care are to provide;
- Safe, sound and supportive services that ensure compliance with service specifications and statements of terms and conditions as agreed at the point of admission.
- A home-like environment for care, accommodation and treatment where required.
- A safe, structured environment in which challenging behaviour can be safely managed.
- An effective way of supporting service users in achieving their dreams, goals and aspirations.
- A clear care pathway for service users to progress into the most independent living environment that suits their needs and wishes.
- An environment suitable for teaching and education of all staff.
- Care delivered flexibly, attentively and in a non-discriminatory fashion while respecting the right to independence, privacy, dignity, fulfilment, and to make informed choices.
- Services that ensure the needs and values are respected in matters of religion, culture, race or ethnic origin, sexuality and sexual orientation, political affiliation, marital status, parenthood and disabilities or impairments.
- Services that are managed efficiently and effectively to make best use of resources and to provide best value options for the purchaser.
- Services that meet individual needs in the least restrictive ways possible in a culture which is not risk averse.
- High standards of care which are promoted and maintained at all times.
- An environment free from abuse, discrimination, bullying or harassment.