Assessment and Care Planning Process for Mental Health Patient

Introduction

This assignment will focus on the assessment and care planning process of I think for a patient that is getting care in an assessment unit for mental health, for a severe and enduring mental illness. All patients have a nurse assigned to them who will coordinate with other teams, which is expected to address the issues of the most seriously services users with complex illness. The unit works with hard to draw in services users, proactively working towards keeping up their mental prosperity. I will give a short story and background that will include of the service user, medical findings, a concise history and any applicable social conditions.

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All through the provision of care in my role as a student associate practitioner I use the 6Cs of nursing within my place of work. The use of the 6Cs of was developed to educate caring staff how to effectively demonstrate quality care. As part of compassion in practice (NHS England, 2012) the vision and methodology for all nursing staff, were employed to give benchmarks to the standard of care we endeavour to convey.

As a matter of first importance 6 are Care which is our primary business, this is the care we convey to an individual patient which thusly will enhance the care framework in general.  Being compassionate which can be portrayed as how the care is conveyed this can be shown through our relational connections, regarding our patients showing compassion. Competence is the third, this is to guarantee that all people utilised in a caring role have the appropriate level of skill to give the right care and to a high level. Communication is the fourth, although debatably the most vital, this does just empower us to discuss viably with our patients, building restorative connections. Good communication within a team is vital to conveying an elevated expectation of care.

The fifth of the 6Cs is courage, this attention on our quality as a professional person to speak up for the benefit of our patients or out against issues we cannot help contradicting.

The last 6c is commitment to our patients. We need to build on our commitment to improve the care and experience of our patients, to take action for all and meet the health, care and support challenges ahead.

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To ceaselessly wish to enhance our aptitudes and thus enhance the models of care. (Hardicre, 2014)

I will demonstrate an understanding of The Care Programme Approach (CPA) by exploring how this is utilised to deliver patient centred care. I will also explain the key features of my chosen nursing model the tidal model (Barker and Buchanan-Barker, 2004) which is a model of care with a holistic approach which be evident throughout my assignment, incorporating the use of assessment tools. I will recognise the need for effective communication skills and ability to engage with a patient, building a rapport and enabling a therapeutic relationship to grow. I will also show an understanding of the care planning process by identifying the patient’s needs, and the agreed interventions. To conclude this assignment, I will summarise the care delivered and reflect upon my role in practice and my learning.

Throughout the assignment I will keep in mind the importance of respecting a patient’s right to confidentiality, following the Nursing and Midwifery Council (NMC) code of conduct. Therefore, any identifiable information such as names of patients, staff and places has been changed to protect their identity. (NMC, 2015). I will refer to my patient as ‘John’ throughout this assignment. This will ensure I follow guidelines set out by the Data Protection Act (1988) protecting my patient’s right to privacy. I gained consent from John, to use his information in this assignment and explained to his that I would protect his right to privacy throughout.

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The Tidal Model

While breaking down administration client mind, it is basic to pick up from rehearses effectively demonstrated to work towards enhancing the prosperity of our patients. The should be possible by using nursing models made as of now. Remembering this when I have initiated with the evaluation and care arranging process, I used the Tidal Model and its out lined standards.

The Tidal Model (Barker and Buchanan-Barker, 2004) is a model of care which has an all-encompassing methodology rotating around recuperation that is individual for each patient. It accentuates being organised around the patients lived encounters, being understanding focused and engaging. The model urges the need to connect with a man in a period of emergency; it additionally considers the significance of hazard. Barker and Buchanan-Barker (2004) utilise the expression “spanning” to portray this basic demonstration in supporting a man. Barker Buchanan-Barker made an arrangement of ‘Ten duties’ regarding permit experts an enhanced information of the centred esteems the model concentrates on.

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These duties can give nurture the pathway expected to review and convey the Tidal Model into their consistently conveyance of care. They Discuss the benefit of time and enabling the procedure to direct the length of the evaluation (Petersen, et al. 2014) Although perceives that the patient is the ace of their entire story and in addition the pioneer in the way their recuperation takes after (Copeland, 1997), the medical caretaker can work cooperatively to reveal the patients shrouded potential and forecast of recuperation. (Buchanan-Barker and Barker, 2008).

The Care Programme Approach

To do a full and definite appraisal of a patient alluded to the Assertive effort group (AOT) the evaluation paper work was finished (informative supplement 1). This evaluation is delivered in view of the Care Program approach, presented by the Department of wellbeing (DH) in 1991, giving an all-encompassing way to deal with survey the patient all in all. It looks to convey a methodical, broad and multi-disciplinary way to deal with patients persisting serious psychological well-being ailments and complex needs (Rethink, 2013). Amid a troublesome time in psychological well-being administrations, with the spotlight from the push on various occurrences, The Care Program approach was presented by administrations in 1990 (Sullivan, 1997). Comprising of 4 phases which incorporate evaluating the individual and their present circumstance, building up a care design cooperatively covering their requirements and objectives, allotting a care facilitator to encourage their movement through the care pathway giving a principle purpose of contact for the patient and different administrations included (Downing and Hatfield, 1999). A key factor is the customary audit of the care design and the care being conveyed, to find out whether this keeps on addressing the necessities of the individual (The Sainsbury Centre for Mental Health, 2005).

The part of the care facilitator is a perceived endeavour at joint working (Simpson, 2005) as a component of the MDT they will work intimately with the patient and their family (Callaghan, Playle and Cooper, 2009) to guarantee sufficient emergency arranging and hazard administration are set up to streamline the results for the patient.

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Biography

John is an 84-year-old Man, who has a diagnosis of Alzheimer’s Dementia about 8 years ago he has been living with his wife for many years at his home address until his illness become too hard for John and his wife to cope with, John’s family agreed to give some background on John life while living at home before his diagnosis with Alzheimer’s Dementia. His wife, son and daughter-in law began with: John has always working till he retired, been a very active man, taking part in many sporting activates as a young man such as rugby and football, enjoyed family holidays in and out of the UK. As John got older he still walking to the local shop in the morning to get the local paper, taking their 11-year-old dog for walks in the local park area. His wife informed that over the last 15 years or so John appeared to her as getting slower/more forgetful and began to get worried about John walking on his own as he gotten lost from walking back from the local shops and local people brought him home, during the night John began to sleep lest was walking around the house during the night due to his wife would also be awake with him, his had negative effect on his wife health and she became unable to care for John, John was offered rest bite care from his local GP  for 4 weeks to help his wife recover and also give time for the family to think about what might be in John best interest for the future. During John’s time in rest bite he attacked another resident and also reports from staff working close with John there was many times that they had to intervein before to stop John from appearing to attack others. This was very unsettling for the family to hear and his son was concerned that would his mum be a risk when John returned to the family home. John’s GP referred him to the local community team who would come and see John at home one week after her had returned form rest bite care, to make an assessment on him, His wife inform me that when John returned home he appeared to have lost weight and also appeared not to recognise the layout of their home and would forget where the toilet was and other areas, John would wake up around 2-3 o’clock in the morning and attempt to open the front door due to John’s safety the family would lock the front door and remove the key, John on one occasion had attacked his wife when she attempted to interact with him while he was trying to open the front door, the police wasn’t called and no serious injury was coursed to his wife. A few days later his wife woke up to find John had a pillow over her face and attempted to suffocate her, John’s wife managed to roll off their bed onto the floor and left the room, she called their son who came over and later the police were called, on that day john was sectioned under the mental health act 1983 detained on a section 3 of the MHA.

Alzherimer’s Dementia

Alzheimer’s is a type of dementia that causes problems with memory, thinking and behaviour. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.

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Alzheimer’s is the most common form of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life. Alzheimer’s disease accounts for 60 to 80 percent of dementia cases. (Alzheimer’s society)

The greatest known risk factor is increasing age, and the majority of people with Alzheimer’s are 65 and older. But Alzheimer’s is not just a disease of old age. Information from Alzherimer’s Society there are Approximately 850,00 people in the UK who are living with dementia, 42,00 younger people under the age of 65 have younger-onset Alzheimer’s disease (also known as early-onset Alzheimer’s).

Alzheimer’s is a progressive disease, where dementia symptoms gradually deuterate over a number of years. In its early stages, memory loss is mild, but with late-stage Alzheimer’s, individuals lose the ability to carry on a conversation and respond to their environment.

Dementia is the leading cause of death for women in the UK, heart disease remains the leading cause of death for men in the UK with dementia being the second by a report from the BBC 2015.  Those with Alzheimer’s live an average of eight years after their symptoms become noticeable to others, but survival can range from four to 20 years, depending on age and other health conditions.

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Although current Alzheimer’s treatments cannot stop Alzheimer’s from progressing, they can temporarily slow the advancing of dementia symptoms and improve quality of life for those with Alzheimer’s and their cares. There is a worldwide effort under way to find better ways to treat the disease, delay its on-set, and prevent it from developing.

Just like the rest of our bodies, our brains change as we age . Most of us eventually notice some slowed thinking and occasional problems with remembering certain things. However, serious memory loss, confusion and other major changes in the way our minds work may be a sign that brain cells are failing.

The most common early symptom of Alzheimer’s is difficulty remembering newly learned information because Alzheimer’s changes typically begin in the part of the brain that affects learning. As Alzheimer’s advances through the brain it leads to increasingly severe symptoms, including disorientation, mood and behavior changes; deepening confusion about events, time and place; unfounded suspicions about family, friends and professional caregivers; more serious memory loss and behavior changes; and difficulty speaking, swallowing and walking.

People with memory loss or other possible signs of Alzheimer’s may find it hard to recognise they have a problem. Early diagnosis and intervention methods are improving dramatically, and treatment options and sources of support can improve quality of life.

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Alzheimer’s and the effect it has on the brain, Ninety percent of what we know about Alzheimer’s has been discovered in the last 20 years according from the Alzheimer’s society. (Alzheimer’s society)

Some of the most remarkable progress has shed light on how Alzheimer’s affects the brain. The hope is this better understanding will lead to new treatments.

The brain has 100 billion nerve cells (neurons). Each nerve cell connects with many others to form communication networks. Groups of nerve cells have special jobs. Some are involved in thinking, learning and remembering. Others help us see, hear and smell. (live science)

To do their work, brain cells operate like tiny factories. They receive supplies, generate energy, construct equipment and get rid of waste. Cells also process and store information and communicate with other cells. Keeping everything running requires coordination as well as large amounts of fuel and oxygen.

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Scientists believe Alzheimer’s disease prevents parts of a cell’s factory from running well. They are not sure where the trouble starts. But just like a real factory, backups and breakdowns in one system cause problems in other areas. As damage spreads, cells lose their ability to do their jobs and, eventually die, causing irreversible changes in the brain.

Researchers are working to uncover as many aspects of Alzheimer’s disease and related dementias as possible.  Ninety percent of what we know about Alzheimer’s has been discovered in the last 20 years. Some of the most remarkable progress has shed light on how Alzheimer’s affects the brain. The hope is this better understanding will lead to new treatments. Many potential approaches are currently under investigation worldwide.

Assessment Process

The Assertive Outreach Team give mind in the group to grown-ups 18 + with an extensive variety of emotional wellness needs, to perceive the objectives and meet the distinguihed needs the recuperation approach is used amid the appraisal and care arranging stages. The Assessment procedure can be depicted as having two phases, gathering of data and after that utilising the data properly to recognise the requirements of the customer (Norman and Ryrie, 2013). Care conveyed rotates around this progressing procedure, consistently evaluating whether the necessities continue as before, or if intercession is never again required. It is scratch that the medical caretaker and customer work firmly together amid the appraisal time frame to build up a successful care design. The Key standards of the Tidal model can be utilised amid the time of appraisal as this loan an all-encompassing methodology (Barker and Finlay, 2004), by using these standards it enables the assessor to pick up a more prominent comprehension of the customer’s needs from their view point. Aggleton and Chalmers (2000) examine that keeping a subjective approach and an individual medical caretaker’s perspectives being the concentration should be maintained a strategic distance from. To utilise a fitting model will guarantee that the evaluation procedure will be founded on the estimations of the model, thusly improving the nursing procedure. Amid the evaluation arrange medical attendants will either assemble verifiable data, which could be the customer’s appearance. Another being express data, when the customer’s needs, considerations or sentiments are plainly imparted by the individual (Norman and Ryrie, 2013).

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An option evaluation show is that from a therapeutic point of view, which concentrates on signs and side effects at present introducing to the medical caretaker. This data can be important when endeavouring to analyse a patient and plan to cure their condition by offering treatment (Aggleton and Chalmers, 2000) conversely Barker and Buchanan-Barker (2003) prompted that supporting a patient with their perspectives and their reality can prompt recuperation without treatment.

John’s Assessment

John was at first hesitant to draw in with psychological wellness administrations, it was essential to make him open to amid the appraisal procedure. We completed this at an area of his picking, which was his folks’ home. The appraisal took after a casual meeting, to draw in John and ideally make Him feel calm. An Interview strategy offers a structure; significant inquiries should be asked by the medical caretaker and enables the customer to recount their anecdote about their life and encounters. In spite of the fact that Barker (2004) features the significance of medical caretaker’s not just picking up data with respect to the patient’s considerations and feeling, as this may just offer you the present issues and conclusion, it allows the attendant to pick up a knowledge into the patient’s life. (Manor and Gilbert, 2006; Norman and Ryrie, 2013).

The evaluation of John could stream as a discussion, enabling John to be open in he’s reactions. It is fundamental that the appraisal printed material was inside reach amid the meeting, this will have taken into consideration taking note of taking all through and provoked key talks. This takes into account recording to be precise as opposed to endeavouring reviewing data incorrectly (Barker, 2004).

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The evaluating medical caretakers need to reliably be aware of their potential bias, because of their mentalities and convictions. Remembering this through John’s evaluation will confine any impact this may have on any judgements or decision (Hart, 2014; Walker, Carpenter and Middlewick, 2013).

It was critical that I at first familiar myself with John, making him feel esteemed and start fabricating a compatibility (Heron, 2001). Peplau (1991) stresses the significance of relational connections amongst patients and attendants. I was aware of my stance and how I could make John feel quiet, I kept up great eye to eye connection with him and a characteristic open stance (Wosket,2006; Boyd and Dare, 2014) I clarified that I would be doing an appraisal to investigate his needs and objectives (Barker, 2009).

I utilised a blend of open and finihed inquiry while stealing away John’s appraisal. Using the open inquiries this enabled John the chance to speak uninhibitedly about his on-going circumstance and how he carries on while encountering a hyper stage. It gave me a more prominent profundity to the discussions as he had a decent level of correspondence. It likewise considers the Tidal Models ten duties (Barker,2004) on occasion when John found a subject troublesome, for example, when discussing his association with his late stride father, I started to utilise shut inquiries as it enabled me to increase particular data while he was battling with conveying viably (Videbeck, 2013).

All through my cooperation’s with John I should esteem the significance of the 6 c’s of nursing, one of which is correspondence this being fundamental in building a compatibility with John. Likewise, in imparting adequately will help me in showing, empathy towards him. The other 4 c’s care, responsibility, capability and strength will be shown all through my cooperation’s and the shared procedure of surveying and care arranging. (Hardicre, 2014).

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John started to talk openly and appeared to unwind after some time, while building a compatibility that lead John to feel bolstered and loose. Barker (2004) talk about the critical expertise of listening adequately to a patient amid the appraisal procedure, this thus enables the medical attendant to watch the patient’s non-verbal communication which can change all through the discussion, for example, while getting to be plainly upset. Watching viably and perceiving their non-verbal correspondence on occasion offer the attendant a more prominent knowledge into their emotions on the present theme (Hannagan, 2005).

To guarantee that I had comprehended what John had talked about, I summarised happen to he’s announcements (Barker, 2004). Thinking about what John had portrayed empowered me to demonstrate an enthusiasm for what he had let me know and show compassion concerning his circumstance; he would now and again at that point keep on elaborating on the data (Norman and Ryrie, 2003).

John talked about his association with his accomplice and the elements of he’s family, he prompted that he thinks that it’s hard to reliably taking he’s drug, he is right now endorsed Lithium, and accordingly he’s inclination to withdraw from administrations.

While evaluating John, it was critical that I considered the need of the Multi-Disciplinary Team (MDT) and their part inside he’s care. The mediations offered must be the most suitable for the individual and that all view focuses from the group considered (Norman and Ryrie, 2013) this must fixate on the most pertinent and breakthrough confirm accessible (Lloyd, 2012). To guarantee a comprehensive way to deal with John’s care it is basic that correspondence inside group between all expert is successful (Lloyd, 2012).

Risk Assessment

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Hazard surveying is foremost to the way toward nursing (Hart, 2014). Hazard appraisal is a procedure by which you assess the potential results of different circumstances or conduct that may make hurt a man or individuals (Callaghan and Waldock, 2006). Investigating hazard considers a larger amount of care to be given, empowering positive hazard taking, and albeit failing to be ready to wipe out hazard the procedure empowers experts to lessen it (Woods and Kettles, 2009). While considering hazard evaluation, it is essential to remember that hazard is continually factor, it can’t be settled at any one time (Morgan, 2007). Various elements can impact the result, for example, the patient’s close to home conditions, changes in their condition, a lacking measure of assets, and a mind-boggling care facilitators case stack this is just to say a couple and is not comprehensive (Hart,2014). There are various different impacts that can influence a hazard evaluation; the setting of a movement can change the presumption of whether it is viewed as unsafe or not (Hart, 2014). Overseeing hazard while conveying consideration can now and again be viewed as prohibitive, and overprotective (Boardman and Roberts, 2014) this is in entire inconsistency to the recuperation focused way to deal with psychological wellness nursing that stresses the patient’s choice and seek after the future (Barker, 2012).

While evaluating John’s hazard amid he’s underlying appraisal (reference section 1) I expected to consider his past practices and episodes, for instance his medication utilises. Albeit taking medications bought on the bootleg market expands his hazard, he has not been known to have buy this with the end goal of over dosing. While talking about John’s accounted for danger of self-hurt this impacts the levels of hazard, in spite of the fact that John will normally do this unexpectedly and there is no expected danger of self-destructive ideations. John perceived various defensive factors throughout his life, for example, enhancing he’s association with he’s accomplice, keeping up concurred authority course of action with he’s little girl. John has additionally arranged an end of the week away with he’s family, including he’s little girl appearing forward arranging, John appears to be confident for what’s to come.

John required all through the underlying appraisal when chance was viewed as, I was unguarded with him in regards to the dangers we saw and he was given the chance to audit the result. This is in accordance with the rules set out by the Nursing and birthing assistance gathering (NMC) in regards to an attendant’s obligation of sincerity, guaranteeing straightforwardness with our patients and families all through the greater part of our practices (Hedges, 2015).

Care Planning

Following the consummation of the appraisal procedure is the definition of a care design, which is a relative blue print for the arranged intercessions. To empower medical caretakers to decide needs into particular, quantifiable, feasible, and sensible and time-bound (SMART) objectives (Tempest, 2012). The point of care arranging is to make sensible focuses on that are individual and vital to the patient (Hall, Wren and Kirby, 2013). This ought to be developed working intimately with the patient ensuring all parts of the individual are considered using a comprehensive approach, and a patient focused care design. To be close to home to the patient implies that a standard format can’t be utilised because of each individual having extremely one of a kind needs (Hall, wren and Kirby, 2013). The tidal Model proposes that the patient should lead the pack during the time spent care arranging and that the psychological well-being professional will encourage this incident, as the patient is the main master of their story (Buchanan-Barker and Barker, 2006). Including a patient in the arranging of their care has demonstrated to profit a man from numerous points of view, enhancing consistence, empowering autonomy and enhancing the nature of care (Anthony and Crawford, 2000). Higgins (1994) talks about that emotional well-being professionals can on occasion feel surplus to prerequisites with the cooperation and strengthening of the patient.

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It is key to work together with the patient as well as the MDT when mind arranging, enveloping various distinctive ability which can help the conveyance of care guaranteeing the consistent approach from an assortment of administrations, evacuating any hindrances enhancing care (HM Government, 1999).

John’s Care Planning

Following the appraisal procedure John with urge could distinguish zones in which he felt that he required help. Working with myself and other emotional well-being experts he could consolidate these into particular objectives and arranged mediations. The Assertive effort collaboration with patient’s long haul, in this way John distinguihed shorter term needs that will prepare for he’s more extended term recuperation process.

The principal objective that John recognised was he’s fluctuating states of mind, because of his non-concordance of pharmaceutical. He disclosed that because of he’s expanded hyper stages it was winding up progressively hard to work once a day. Here and now consented to start on Lithium by and by, because of the conceivable poisonous quality of this drug John’s physical wellbeing should be observed intently all through the underlying beginning. John will be required to have an ECG, and blood tests to guarantee he is sufficiently sound to be endorsed Lithium. His renal capacity should be observed while taking this medication. As Lithium utilise is related with a scope of glomerular and tubular issue bringing about constant kidney sickness and all the more once in a while built up renal disappointment (Kripalani et al., 2009).

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John wants to have the capacity to deal with he’s fluctuating states of mind, at first lessening this and in time understanding he’s ailment. I talked about with John’s the alternative of psychotherapy in the long haul particularly Cognitive Behavioural Therapy (CBT) which is an approach encompassing investigating emotions, musings and practices. It additionally considers a man’s responses and impression of specific encounters which may have caused a negative effect prompting mental misery (Norman and Ryrie, 2013).

The second objective that John distinguihed is the agony that he encounters every day because of physical afflictions. John discloses that because of low certainty he feels unfit to go to he’s GP surgery and dental specialist to take care of he’s physical wellbeing needs. With help from the Assertive effort group, John would like to go to these arrangements and address the on-going physical issues. John trusts that thus this will enhance he’s low disposition periods as constant torment is an impacting factor when he is feeling discouraged. Once more, CBT could be valuable as National Institute for Health Care and Excellence’s (NICE) rules (NICE, 2011) propose that a double approach is fitting for extreme wretchedness with unending physical medical issues. Which could comprise of 1:1 CBT treatment close by an upper drug, the contraindications with Lithium would should be considered by the expert specialist before recommending.

Care arranging needs should be consistently surveyed all through John’s pathway of recuperation, because of the idea of the Assertive effort group this will be a long-haul process until John no longer needs the help of the administrations. John was work in a joint effort with his care organizer as his principle purpose of contact, the MDT all in all will keep on playing an essential part in John’s recuperation.

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Conclusion

All through the voyage of this task I have used the appraisal and care arranging procedure to convey John’s care. I have perceived the significance of following a supporting nursing model while working inside the Care Program Approach structure and conveying excellent care.

I have talked about the significance of successful relational abilities, enhancing the compatibility I have worked with John. Having the capacity to help him through a troublesome stage in his life, while monitoring non-judgemental mentalities keeping my convictions to affect the care I conveyed. Which thus urged John to express his considerations and sentiments straightforwardly, enabling me to construct a restorative relationship.

I have esteemed the MDT in offering community oriented care, guaranteeing an all-encompassing way to deal with the care arranging process, imperatively including John all through the procedure.

This task has enabled me to consider my work on, including my relational abilities and the impact this can have on my capacity to mind. Taking during the time spent evaluation and care arranging, has helped me to end up noticeably an important individual from the Assertive Outreach Team. The task has educated me of the significance of with respect to all viewpoints in somebody’s care including rules and enactment. This proof base has empowered me to build up my insight further, enhancing the care I have conveyed to John which I will bring forward through my vocation and consistent self-awareness.

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Appendix 1:  Assessment

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INITIAL ASSESSMENT