Sharing Assessment in Health and Social Care: A Practical Handbook for Interprofessional Working
Publication Year: 2009
Shared assessment is the standardized approach to assessment and the sharing of information and documentation within and between health and social care. This book offers students and practitioners a step-by-step guide to the process, helping them to overcome some of the anxieties of change and providing realistic guidance on the process.
- Offers comprehensive coverage – follows a logical structure looking at context, policy, and practice
- Focuses on the practitioner's understanding of an individual's experience and the roles of staff within the process
- Discusses confidentiality and anti-discriminatory practice
- Provides four chapter-long case studies that take the reader through the stages of assessment and subsequent roles and responsibilities
The book includes pedagogical features such as a glossary of terms, a comparative grid for Standardized Assessment Frameworks, examples of career assessments, reflective ...
- Front Matter
- Back Matter
- Subject Index
Part 1: Where it All Began
Part 2: Applying Theory to Practice
- Chapter 3: Meet the Family
- Chapter 4: Mr Doug Williams
- Chapter 5: Mrs Betty Mitchell
- Chapter 6: Mr Robert Griffiths
Part 3: Opportunities and Challenges for Individuals, Staff and Organisations
© Carolyn Wallace and Michelle Davies 2009
First published 2009
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
SAGE Publications Ltd
1 Oliver's Yard
55 City Road
London EC1Y 1SP
SAGE Publications Inc.
2455 Teller Road
Thousand Oaks, California 91320
SAGE Publications India Pvt Ltd
B 1/I 1 Mohan Cooperative Industrial Area
Mathura Road, Post Bag 7
New Delhi 110 044
SAGE Publications Asia-Pacific Pte Ltd
33 Pekin Street #02-01
Far East Square
Library of Congress Control Number: 2009920032
British Library Cataloguing in Publication data
A catalogue record for this book is available from The British Library
ISBN 978-1-4129-4574-5 (pbk)
Typeset by C&M Digitals (P) Ltd, Chennai, India
Printed in India by Replika Press Pvt. Ltd
Printed on paper from sustainable resources
We would like to thank all those people who helped us in developing and gathering the information for this book. In particualr the Florence Nightingale Travel Scholarship (Welsh Assembly Government sponsorship), Mark Culwick, Sharon Lane, Marie Nixon (Gwent Healthcare NHS Trust; Torfean LHB and Local Authority; Monmouthshire LHB and Local Authority; Blaenau Gwent LHB and Local Authority; Caerphilly LHB and Local Authority; Newport LHB and Local Authority); Rhondda Cynon Taf Local Authority; National Leadership and Innovation Agency for Healthcare for consent to use and adapt the ‘Knowledge Barometer’.
Appendix 1: Comparative Grid for Standardised Assessment Frameworks[Page 126]
Unified Assessment (WAG, 2002) Single Assessment Process (DoH, 2002) Single Shared Assessment (Scottish Executive, 2001a) Self
- Where people identify their own needs and propose their own solutions either as a sole assessment or in conjunction with other assessments
- They may receive professional advice or the support of an advocate.
- For information only
- Straightforward service requests
- Leading to contact assessment
- Basic Personal Information
- 7 key issues
- 2 domains max. from the overview
- Basic Personal Information
- 7 key issues
- Low level response
- May involve one or more agency
- Some coordination may be required
[Page 127] Overview – 12 domains with sub-domains
- User's perspective
- Disease prevention
- Personal care/physical wellbeing
- Mental health
- Carer's perspective/assessment
- Clinical background
- Activities of daily living
- Immediate environment and resources risk assessment
- Instrumental activities of daily living
Overview – 9 domains with sub-domains
- User's perspective
- Clinical background
- Disease prevention
- Personal care and physical wellbeing
- Mental health
- Immediate environment and resources
Care-Nap, an identification of need which is a tick box indicating ‘No Need’, ‘Met Need’ and ‘Unmet Need’
- Service user's perspective
- Carer's perspective
- Spiritual, religious and cultural matters
- Risk and safety
- Immediate environment and process
- Personal care and physical wellbeing
- Mental health
- Clinical background
- Disease prevention
- As defined by individual professional models, scales and local requirements
- As defined by individual professional models, scales and local requirements
- May be applied to simple needs of an individual or more complex needs which require more in-depth assessment
- Includes overview and in-depth assessments appropriate to service user need. An overall interpretation gained by the care coordinator of the assessment process required by a service user with complex needs
- A full overview assessment
- A range of specialist assessments with partial completion of the overview as required by service user need
- A range of specialist assessments and scales only
- Applies where a wider range and complexity of needs are indicated
- Likely to involve more than one agency
- Specialist assessment may be necessary
- Focus on coordination of assessment contributions
- People at risk of admission to residential or nursing home care should receive a comprehensive assessment with specialist assessment and intensive care management to explore options for rehabilitation and care at home
Role of care coordinator – identified according to patient need Role of lead assessor, care coordinator and Complex care manager Fair access to care
- Directly linked to assessment process
Fair access to care is not direclty linked to the SAP guidance Eligibility criteria linked to assessment
Appendix 2: Mrs Pam Griffith's Carer's Assessment[Page 128][Page 129][Page 130][Page 131][Page 132]
Appendix 3: Mrs Betty Mitchell's CPA Assessment[Page 133]Older Adults' Mental Health Service[Page 134][Page 135][Page 136][Page 137][Page 138][Page 139][Page 140]
Appendix 4: Glossary of Terms[Page 141]
Autonomy ‘Autonomy is an intrinsic personal quality … to be able to do … anything rather than nothing … the more autonomous a person the more a person is able to do. In this context the distinction between creating autonomy and respecting it is important’ (Seedhouse, 1998). BPI Basic Personal Information as described by the standardised assessment frameworks. In the unified assessment process this is described as name, address, telephone number, GP, type of accommodation, tenure of accommodation, date of birth, preferred first language, ethnicity, etc. (WAG, 2002, Annex 4). Care Management The processes undertaken by social services to assess service user needs through care planning and provision of appropriate care packages. Care Programme Approach The formalised process for assessing and managing the needs of people with mental health problems. CPN Community Psychiatric Nurse. DoH Department of Health. Empowerment Build on strength to encourage and promote choice. Independent Living ‘Independent Living means that we want the same control and the same choices in everyday life that our non-disabled brothers and sisters, neighbours and friends take for granted. We want to grow up in our families, go to the neighbourhood school, use the same bus, work in jobs that are in line with our education and abilities. Most importantly, just like everybody else, we need to be in charge of our own lives, think and speak for ourselves’ (European Network on Independent Living). Identifying Risk ‘Assessing the chance or probability of a disease or condition occurring’ (Naidoo and Wills, 2005). Health need A health need is either subjective or objective. A subjective need is defined by an expert and is usually influenced by whether the need can be met. While an objective need is viewed as something which may be viewed as a fundamental right (Naidoo and Wills, 2005). Learning disability ‘A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development’ (DoH, 2001, p. 14). Learning difficulties The preferred term of the self advocacy movement. Often the term used to define educational difficulties, but used interchangeably with ‘learning disability’. National Service Framework for Older People The document which sets out the national standards for health and social care provision for older people. Need
- Normative need is need which is identified according to a norm (or set standard); such norms are generally set by experts, for example, eligibility for services.
- Comparative need concerns problems which emerge by comparison with others who are not in need.
- Felt need is need which an individual feels, a need from the individual's perspective.
- Expressed need is the need which an individual or a group of people say they have. An individual can feel need which s/he does not express.
Overview Assessment The holistic assessment as integral to the Single Assessment Process which provides a synopsis of a person's health and social care needs as proportionately mapped to the relevant assessment domains. Person-Centred Planning The planning process based on inclusion and the social model of disability. WAG Welsh Assembly Government.
Appendix 5: Resources[Page 142]
Patient Care Record – Booklet 1; ADL Nursing Assessment; Consent to Share Information; Discharge Checklist; In Depth Nursing Assessment; Unified Assessment & Care Management Summary Record; Additional Information for Community Learning Disabilities Team; Further Personal Information – Booklet 2.Patient Care Record – Booklet[Page 143][Page 144][Page 145][Page 146]ADL Nursing Assessment (To Be Completed within 24 Hours of Admission)[Page 147][Page 148]Assessment Information for Discharge or Transfer[Page 149]Consent to Share InformationDischarge Checklist[Page 150][Page 151]Guide for Use of Document
- Red pages in Hospital Enquiry Booklet must be completed on admission, including initial risk assessments.
- Yellow pages – which include the ADL Assessment & care plans must be completed within 24 hours.
- Specialist referrals, made as appropriate.
On Admission to Ward:
- Hospital Enquiry Booklet 1 must be completed, information must be checked. Risk assessments and care plans to be updated. Specialist referrals, as appropriate, their summaries added to Specialist Assessment Log in Booklet 2.
- If there are concerns re: discharge, further information in Booklet 2 must be collected, prior to discharge planning.
- If you need to refer to social services: you will need to provide information from Booklet 1.
- If no further intervention is required, ensure all documentation is complete & filed in the Medical Notes.
- If further assessment or ongoing treatment is required within the community, including referral to District Nurses, ensure Booklets 1 & 2 are complete, copied and sent to the lead professional / agency on discharge.
Consent must be obtained to share information
On Transfer to Community Hospitals:
- Ensure Booklet 1 is completed & Booklet 2 commenced.
- Care plans and risk assessments will be reviewed and updated, as necessary.
- All documentation will move with the person, to ensure a full Unified Assessment is undertaken.
- An In Depth Nursing Assessment must be completed, as well as the Individuals and Carer Perspectives in Booklet 2. Any Specialist Assessment Summaries must be added to the Specialist Assessment Log.
On Discharge from Community Hospitals:
- The Summary Record (Booklets 1 and 2), plus any relevant information appropriate to continued care in the community (risk assessments) will be copied and sent to the lead professional/agency on discharge.
Consent must be obtained to share information.
- The In Depth Nursing Assessment and the Nursing Needs Decision Record must be completed, when starting to plan discharge. Consideration must be given to Continuing Health Care.
Complex Needs or Trigger for Unified Assessment:
- If person has complex needs, a full Unified Assessment is required – Booklets 1 and 2.
Screening Triggers for a Full Unified Assessment:
[Page 153][Page 154][Page 155][Page 156][Page 157]Unified Assessment & Care Management Summary Record
- health, social care and/or housing problems that may lead to a complex discharge
- 3 or more hospital admissions within previous 6 months
- people who normally reside in residential/nursing homes
- disability, illness, mental health problems or learning disability (permanent and substantial) affecting ability with activities of daily living
- socially isolated and/or vulnerable adults
- history of falls
- terminal illness
Unified Assessment Summary plus Care Plan
- Enquiry Record
- Additional Information for Community Learning Disabilities Team
- Outcome of Enquiry
- Additional personal details
- Additional address information
- Professionals involved
- Individuals Perspective
- Carer's Perspective
- Domain Selection Sheet
- Information on Domains
- Risk Domain
- Risk Management Plan
- Record of specialist referrals
- Specialist Assessment Log
- Summary of Assessment
- Care Co-ordinators Log
- Mental Capacity Log
- Care Plan
[Page 159][Page 160][Page 161]Additional Information for Community Learning Disabilities TeamOutcome of Enquiry[Page 162]Consent to Share Information
[Page 163]Additional Personal Details:
[Page 164]Additional Address Information:
Service Currently Received: Info provided by:
[Page 165]Other Professionals or Agencies Used: include care co-ordinator, advocate, interpreter, dentist, optician, pharmacist etcUACM: Individual's Perspective[Page 166]UACM: Carer's PerspectiveUACM: Domain Selection Sheet[Page 167][Page 168]UACM: Risk DomainUACM: Risk Management Plan
[Page 169]Record of Specialist Referrals Made:
[Page 170]UACM: Specialist Assessment Log[Page 171]UACM: Summary of Assessment
[Page 172]Information Collected by:UACM: Care CO-ordinators Log
Please give details of the current Care Co-ordinator, where the Summary Record is held, the reasons why the role of Care Co-ordinator moves to another professional, their name and contact details must be completed.[Page 173]UACM: Mental Capacity Assessment Log
If a ‘Capacity Assessment and Best Interest Record’ has been completed for a significant decision, please summarise below:[Page 174]UACM: Statutory Review[Page 175][Page 176]UACM: Individual's Perspective[Page 177]UACM: Carer's Perspective[Page 178]Medication[Page 179][Page 180]In-Depth Nursing Assessment
Use this assessment in conjunction with the relevant risk assessments.
Consider each domain and the relevant sub domains through the assessment.
Disease Prevention Domain:
- Nutrition: Current diet / Swallowing ability / Difficulties chewing / Fluids / Any assistance required for eating & drinking
- History of Blood Pressure monitoring:
- Drinking & smoking history:
- Exercise pattern:
- Vaccination history: e.g., Flu
- History of screening: e.g., Breast/cervical
- Pattern & nature of disease/disability/illness
[Page 181]Clinical Background Domain:
- Breathing: Any difficulties with breathing / Shortness of breath, at rest or on exertion / Productive cough / Uses any equipment / Requires oxygen
- Falls History: Any history of falls / Any injurious fall in last 1 2 months / Any fear of falling. If yes to any of these – a falls pathway will be required
- Medical History / Diagnosis / Medication & ability to self medicate / Recent hospitalisation information should already be recorded within Booklet 1 & 2.
Personal Care & Physical Wellbeing Domain:
- Pain: Is there any experience of pain / Able to manage their pain / Able to express if they have pain / Does anything relieve the pain
- Oral health: Condition of mouth – lips, gums, tongue / Own teeth / Dentures / Caps or crowns
- Foot care: Include circulation
- Skin condition: Pressure areas / Wounds / Ulceration / Skin rash / Oedema / Any history which could affect tissue tolerance or contribute to wound infection / Prevention – Relief of pressure.
- Mobility: In & out of the home – level of independence / Any aids used
- Ability to use stairs and slopes: Level of independence / Any aids used
- Continence: Usual pattern of elimination / Urinary incontinence / Faecal incontinence
- Sleeping patterns: Usual sleeping pattern / Difficulty sleeping / Number of pillows / Assistance required e.g., medication, special routines
[Page 182]Senses Domain:
- Speech and communication: Cognition / Understanding / Speech impaired / Any aids used
- Sight: Glasses / Contact lenses / Visualy impaired / Blind
- Hearing difficulties: Hearing aid / Hearing impaired / Deaf
- Touch / Dexterity:
- Smell / Taste:
Activities of Daily Living Domain:
- Washing: Hands / Face / Body
- Bathing / Showering: Any aids used or help required
- Grooming: Hair care / Shaving / Applying make up
- Dressing / Undressing: Any aids used
- Ability to access & use the toilet: Any aids used
- Transferring: On & off toilet / On & off chair / On & off bed
- Support needed for eating & drinking: Any aids used or help required
- Ability & opportunity to make choices / Have control over environment:
- Is any equipment used:
Mental Well Domain:
- Cognitive ability: Orientation / Memory / Wandering
- Confusional states:
- Depression / Worry / Anxiety / Fatigue:
- Emotional distress / Agitation:
- Life change: Loss / Bereavement
- Behaviour: Inappropriate / Challenging / Aggressive – Verbal or Physical
- Paranoia states: Unusual ideas / Delusions
- Other emotional difficulties:
- Circumstances in relation to substance misuse:
- Suicide Risk: Worthing / Dices
- Abuse / Neglect: Risk of neglect / Abuse / Exploitation
- Other aspects of personal safety: Ability to summon help / Awareness of danger
- Public safety & hazards:
- Manual Handling Assessment:
- Vulnerable Adult / Child Protection Issues:
- Carer support: Strength of caring arrangements
- Ability to care for others: Partner / Children / Parents
- Sex & sexuality: Personal relationships
- Social support: Networks / Involvement in leisure, hobbies, religious groups etc.
- Cultural awareness issues:
[Page 184]Instrumental Activities of Daily Living Domain:
- Cooking: Preparing snacks / Meals / Hot drinks
- Heavy housework: Cleaning / Laundry
- Shopping: For food, clothes, prescriptions etc
- Keeping warm:
- Care in the home: Using household appliances
- Managing affairs: Finances / Paperwork
Immediate Environment & Resources Domain:
- Accommodation: Noise / heating / physical hazards / location / access
- Level & management of finances: Need for benefit advice / Collecting pensions / Accessing cash
- Access to local facilities & services:
- Participating in community activities: Work / Education / Learning / Socialising
- Transport needs: Access to car / Public transport
Is there any other information that would be beneficial to this assessment?
Please complete the Nursing Needs Assessment Decision Record.[Page 185]UACM: Specialist Assessment Log
Specialists – please give details of your professional involvement, including contact details.[Page 186]UACM: Care Co-ordinators Log
If required, please complete this log.
On discharge, the MDT may refer to a community team for a care co-ordinator (which team will depend on presenting need). Please give details of the current Care Co-ordinator, where the Summary Record is held, the reasons why the role of Care Co-ordinator moves to another professional, their name and contact details must be completed.[Page 187][Page 188]UACM: Summary of Assessment / Episode of Care[Page 189]UACM: Care Plan[Page 190][Page 191]UACM: Care Plan Continuation Sheet (Number ¨ ¨)[Page 192]
References[Page 193]2003) Social Work and Empowerment,(3rd edn. Basingstoke, Palgrave Macmillan.2007) Foundations of Health and Social Care. Basingstoke, Palgrave MacMillan.(2005) Social Work Futures: Crossing Boundaries, Transforming Practice. Basingstoke, Palgrave MacMillan., and (Age Concern (2006) What Older People Want from Community Health and Social Care Services. London. http://www.ageconcern.org.uk/AgeConcern/Documents/community-health-aper0106.pdf.2000) Nursing Models and Nursing Practice,and (2nd edn. Basingstoke, Palgrave MacMillan.2005) Integrating the Single Assessment Process into a Lifestyle Monitoring System. http://www.computing.dundee.ac.uk/staff/jarnott/ICOST2005-SAP.pdf., , , and (2004) ‘Public health nurses' perspectives on collaborative Partnerships in South Africa’, Public Health Nursing21, 277–286. http://dx.doi.org/10.1111/j.0737-1209.2004.021310.x, and , (2008) ‘Comprehensive nursing assessment in the care of older people’, Nursing Older People, 20(1): 36–40.and (Audit Commission (1998) A Fruitful Partnership. Effective Partnership Working. http://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/A190CA25-7A7E-47D1-BCAB-373A86B709C0/A%20Fruitful%20Partnership.pdf.Balloch, S. and Taylor, M. (eds) (2001) Partnership Working. Policy and Practice. Bristol, The Policy Press.2006) Ethics and Values in Social Work,(3rd edn. Basingstoke, Palgrave MacMillan.2007) Effective Approaches to Risk Assessment in Social Work: An International Literature Review. Final Report. Scottish Executive. Social Research Centre University of Stirling. http://www.scotland.gov.uk/Resource/Doc/194419/0052192.pdf., (1981) ‘The sickness impact profile: development and final revision of a health status measurement’, Medical Care19, 787–805. http://dx.doi.org/10.1097/00005650-198108000-00001, , , (1968) General System's Theory: Foundations, Development, Applications. New York: George Braziller., (Billings, J. and Leichsenring, K., (eds) (2005) Integrating Health and Social Care Services for Older People. Evidence from Nine European Countries. Aldershot, Ashgate.2008) ‘Inter sectoral partnerships, the knowledge economy and intangible assets’, Policy and Politics, 36(2) 209–224. http://dx.doi.org/10.1332/030557308783995035, , , , (1972) ‘A taxonomy of social need’, New Society (March) 640–3.(2003) ‘Care pathways: the road to better health services’, Journal of Health Organization and Management, 17(3): 164–80. http://dx.doi.org/10.1108/14777260310480721and (1995) Empowering Practice in Social Care. Buckingham, Open University Press.and (1986) ‘Independent living and the medical model of disability’, Disability Handicap and Society, 1(2): 173–8. http://dx.doi.org/10.1080/02674648666780171(British Council of Disabled People. http://www.bcodp.org.uk/.[Page 194]British Geriatric Society (2004) Rehabilitation of Older People. http://www.bgs.org.uk/Publications/Compendium/compend_1-4.htm.British Institute of Learning Disabilities Factsheet (undated). Learning Disabilities. http://www.bild.org.uk/05faqs.htm.2006) Rights for Real. Older People, Human Rights and the CEHR. England, Age Concern.(2006). ‘Involuntary hospitalization of medical patients who lack decisional capacity: an unresolved issue’, Psychosomatics, 47: 5. http://dx.doi.org/10.1176/appi.psy.47.5.443, , and , (2002) Understanding Care, Welfare and Community: A Reader. London, Routledge.(Care Service Improvement Partnership (CSIP) (2008) ‘High impact changes for health and social care: an inspirational collection of organisational initiatives which are changing health and social care services and their lives of people who use them’, http://www.csip.org.uk/silo/files/hics-doc-11th-march.pdf.Carenap Users Forum (CNUF) (2005) The Carenap Assessment Toolkit. http://www.nationalpracticeforum.org/.Central and Local Information Partnership (CLIP) (2002) Report (part 2) of the Technical Working Group on PSS Statistics. http://www.clip.local.gov.uk/lgv/core/page.do?pageId=40423>.Centre for Public Services (2004) Modernising Social Services? Evidence from the Front Line. Sheffield: Centre for Public Services. http://www.european-services-strategy.org.uk/publications/essu-reports-briefings/modsocialservices/.2004) ‘The value of specialist clinical assessment of older people prior to entry to care homes’, Age and Ageing, 33(1): 25–34. http://dx.doi.org/10.1093/ageing/afh007, , , , , and (The Change Agent Team (2007) National framework for the NHS continuing healthcare and NHS funded nursing care. Thoughts for the week. Monday 13 August 2007. http://www.changeagentteam.org.uk/_library/Thoughts%20for%20the%20week%20-%20part%205.pdf.1999) ‘System's thinking’ in Currie, W. and Galliers, R. (eds) Rethinking Management Information Systems: An Interdisciplinary Perspective. Oxford, Oxford University Press.(2001) ‘Satisfaction with the care-managed support of older people: an empirical analysis’, Health and Social Care in the Community, 9(1): 32–42. http://dx.doi.org/10.1046/j.1365-2524.2001.00280.x, and (2003) ‘Improving service approaches and outcomes for people with complex needs through consultation and involvement’, Disability & Society, 18(7): 935–53. http://dx.doi.org/10.1080/0968759032000127344and (2004) ‘The assessment gap’, Community Care, 15 July. p. 38–9.and (2003) ‘Nursing theory: its importance to practice’, Nursing Standard, 17(46): 33–7.(Commission for Healthcare Audit and Inspection (2006) Living Well in Later Life: A Review of Progress Against the National Service Framework for Older People. http://www.healthcarecommission.org.uk/_db/_documents/Living_well_in_later_life_-_full_report.pdf.Community Care and Health (Scotland) Act (2002) http://www.opsi.gov.uk/legislation/scotland/acts2002/asp_20020005_en_1.2006) ‘Inclusion or control? Commissioning and contracting services for people with learning disabilities’, British Journal of Learning Disabilities, 34(4): 200–205. http://dx.doi.org/10.1111/j.1468-3156.2006.00403.x(Costello, J. and Haggart, M. (eds) (2003) Public Health and Society. Basingstoke, Palgrave Macmillan.1998) Social Work Practice: An Introduction,and (3rd edn. Basingstoke, Macmillan/BASW.2006) Social Work Practice.and (4th edn. Basingstoke, Palgrave Macmillan.2005) Social Work with Older People. Exeter, Learning Matters Ltd.and (2003) Knowledge Review One: Learning and Teaching in Social Work Education: Assessment. London, SCIE., , and (1995) Anti-oppressive Practice: Social Care and the Law. Buckingham, Open University Press.and ([Page 195]Data Protection Act (1998) http://www.england-legislation.hmso.gov.uk/acts/acts1998/ukpga_19980029_en_1.Davis, S. (ed.) (2006) Rehabilitation: The Use of Theories and Models in Practice. Edinburgh, Churchill Livingstone Elsevier.1998) ‘A review of loneliness: concepts and definitions, causes and consequences’, Reviews in Clinical Gerontology, 8, 73–80. http://dx.doi.org/10.1017/S0959259898008090, (Department for Constitutional Affairs, Justice, Rights and Democracy (2003) Public sector data sharing- a guide to data sharing protocols. http://www.foi.gov.uk/sharing/toolkit/infosharing.htm.Department of Health (DoH) (1990) Health Circular, (90) 23/LASSL(90)11.Department of Health (DoH) (1998) Modernising Social Services: Promoting Independence, Improving Protection, Raising Standards. London, The Stationery Office.Department of Health (DoH) (1999a) Caring About Carers: A National Strategy for Carers. London: Department of Health Publications.Department of Health (DoH) (1999b) National Service Framework for Mental Health: Modern Standards and Service Models. London, Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598.Department of Health (DoH) (2000) NHS plan: A Plan for Investment A Plan for Reform. London, Department of Health.Department of Health (DoH) (2001a) National Service Framework for Older People. London, Department of Health.Department of Health (DoH) (2001b) Valuing People: A New Strategy for Learning Disability for the 21st Century. London, HMSO.Department of Health (DoH) (2001c) The Essence of Care. Leeds, Department of Health.Department of Health (DoH) (2002) Guidance on the Single Assessment Process for Older People. London, Department of Health.Department of Health (DoH) (2003a) Essence of Care: Patient Focused Benchmarks for Clinical Governance. London, Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications Publications Policy And Guidance/DH_4005475.Department of Health (DoH) (2003b) Discharge from Hospital: Pathway Process and Practice. Health and Social Care Joint Unit and Change Agent Team. London, Department of Health.Department of Health (DoH) (2003c) Fair Access to Care Services. Guidance on Eligibility Criteria for Adult Social Care. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009653.Department of Health (DoH) (2004a) Single Assessment Process for Older People. Audit of Progress up to 1st April 2004 and Further Developments During 2004/05. London, Department of Health.Department of Health (DoH) (2004b) Care Management for Older People with Serious Mental Health Problems. London, Department of Health.Department of Health (DoH) (2004c) Achieving Timely ‘Simple’ Discharge from Hospital – A Toolkit for the Multidisciplinary Team. London, Department of Health.Department of Health (DoH) (2004d) Single Assessment Process for Older People: Assessment Tools and Accreditation. http://www.virtualward.org.uk/silo/files/single-assessment-toolsdoc.doc.Department of Health (DoH) (2006a) Our Health, our Care, Our Say.Department of Health (DoH) (2006b) Reviewing the Care Programme Approach 2006: A Consultation. http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH063354.Department of Health (DoH) (2007) A Recipe for Care- Not a Single Ingredient. Clinical Case for Change: Report by Professor Ian Philp, National Director for Older People. Department of Healthhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065224.[Page 196]Department of Health (DoH) (2007a) New Deal for Carers: Findings from Stage One of the Adult and Young Carers' Engagement Programme. Opinion Leader.Department of Health (DoH) (2007b) Single Assessment Process. http://www.dh.gov.uk/en/Policyandguidance/SocialCare/Chargingandassessment/SingleAssessmentProcess/index.htm.Department of Health (DoH) (2007c) Our Health, Our Care, Our Say: A New Direction for Community Services: Health and Social Care Working Together in Partnership. NHS, HM Government.Department of Health (DoH) (2008a) Carer's at the Heart of the 21st Century: Families and Communities. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085345.Department of Health (DoH) (2008b) Long Term Conditions Model. http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_084296.Department of Health (DoH) (2008c) Integrated Care Pilot Programme – Prospectus for Potential Pilots. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_089338.Department of Health (DoH) (2008d) Framing the Nursing and Midwifery Contribution: Driving Up the Quality of Care. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086471.Department of Health (DoH) (2008e) Transforming Social Care LAC(DH) (2008) 1. http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/LocalAuthorityCirculars/DH_081934.Department of Health (DoH) (2008f) Refocusing the Care Programme Approach Policy and Positive Practice Guidance. http://cpaa.org.uk/files/DH_083649.pdf.2008) Evaluating Outcomes in Health and Social Care. Bristol, The Policy Press.(1996) ‘A critique of the role of the traditional charities’ in Barton, L. (ed.) Disability and Society: Emerging Issues and Insights. London, Longman Press.(2008) ‘The meaning of integrated care: a systems approach’, International Journal of Integrated Care, 8(23) October. http://www.ijic.org/.(2008) SCIE Knowledge review 20: Commissioning personcentred, cost-effective, local support for people with learning disabilities. London, Social Care Institute of Excellence.and (2002) ‘The MRC trial of assessment and management of older people in the community: objectives, design and interventions’, BMC Health Services Research, 2(21) http://www.biomedcentral.com/1472-6963/2/21., , and (2006) Partnerships in Social Care. A Handbook for Developing Effective Services. London, Jessica Kingsley Publishers.(1975) ‘Mini-mental state. A practical method for grading the cognitive state of patients for the clinician’, Journal of Psychiatric Research, 12(3): 189–98. http://dx.doi.org/10.1016/0022-3956%2875%2990026-6, and (1996) ‘Caring for older people. Loneliness’, British Medical Journal, 313(7053): 352–4. http://dx.doi.org/10.1136/bmj.313.7053.352(2002) The New Health Strategy – Organisation Development and the Leadership Challenge. http://www.tohm.ie/download/rtf/evpaper_fritchie.rtf.(2002) Partnership: an analysis of the concept within the nurse-client relationship, Journal of Advanced Nursing, 40(2): 149–57. http://dx.doi.org/10.1046/j.1365-2648.2002.02357.x, and (2003) Towards Inclusion: Learning Disabilities. Edinburgh, Churchill Livingstone.(2003) Hospital Discharge: Integrating Health and Social Care. Abingdon, Radcliffe. Medical Press.(2008) Partnership Working in Health and Social Care. Bristol, The Policy Press.and (2004) The Health and Social Care Divide: The Experiences of Older People,and ([Page 197]2nd edn. Bristol, The Policy Press.2006) ‘Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward’, Journal of Clinical Nursing, 15: 588–98. http://dx.doi.org/10.1111/j.1365-2702.2006.01371.x, , , , , and (2002) Partnerships, New Labour and the Governance of Welfare. Bristol, The Policy Press., and (2006) Outcomes Focused Services for Older People. Adults Services Knowledge Review. University of York, Social Care Institute for Exellence. http://www.icn.csip.org.uk/_library/Outcomes_focused_services_for_older_people.pdf., , , , and (2008) ‘Progress and problems in developing outcomes-focused social care services for older people in England’, Health and Social Care in the Community, 16(1): 54–63. http://dx.doi.org/10.1111/j.1365-2524.2007.00724.x, , , and (2006) The Collaborative Partnership Approach to Care. A Delicate Balance. Toronto, Mosby Elsevier Canada., and (2006) ‘Theories of ageing as basis for assessment’, MEDSURG Nursing, 15(2): 77–83.and (2007) ‘A multi-level perspective on the synergies between work and family’, Journal of Occupational and Organizational Psychology, 80: 559–74. http://dx.doi.org/10.1348/096317906X163081, , and (2004) Models of Assessment. Open Learning Partnership, University of Central England and RNIB.(1993) Understanding Organizations,(4th edn. London, Penguin Business Management.1999) ‘Dimensions of choice in the assessment and care management process: the view of older people, carers and care managers’, Health and Social Care in the Community, 7: 483–91. http://dx.doi.org/10.1046/j.1365-2524.1999.00217.x, and (1997) Direct Social Work Practice,, and (5th edn. Pacific Grove, CA, Brooks/Cole.A Common Assessment Framework for Adults. Dept. of Health. NHS Connecting for Health: Health and Social Care Integration Project. http://www.nbpct.nhs.uk/sap/docs/meetings/minutes/rsap_120707/CAF%20-%20Cheshire%20Presentation.ppt#265,1,A Common Assessment Framework for Adults.(undated)2002) ‘Interprofessionality in health and social care: the Achilles' heel of partnership?’Journal of Interprofessional Care, 16(1): 7–17(11). http://dx.doi.org/10.1080/13561820220104122(2007) Organisations and Management in Social Work. London, Sage. http://dx.doi.org/10.4135/9781446211670, and (Human Rights Act (1998) http://www.legislation.gov.uk/acts/acts1998/ukpga_19980042_en_1.2000) ‘The synergism of expertise in clinical teaching: An integrative model for nursing education’, Journal of Nursing Education, 39(6): 278–82., , , , , and (2005) Managing to Collaborate: The Theory and Practice of Collaborative Advantage. Abingdon, Routledge.and (2004) Essentials of Nursing Leadership and Management. New York, Thomson Delmar Learning.(1996) Good Practice in Risk Assessment and Risk Management. London, Jessica Kingsley Publishers., and (King's Fund (1980) An Ordinary Life. London, King's Fund Centre.King's Fund (2006) ‘Informal care’, in Securing Good Care for Older People. London, King's Fund Centre.[Page 198]2000) ‘On levels of analysis and theoretical integration: models of social behaviour’, Behavioral & Brain Sciences, 23(2): 260–61. http://dx.doi.org/10.1017/S0140525X00342431(2001) Support Partnerships: Collaboration in Action. London, David Fulton Publishers.(2007) ‘Assessing older people with complex care needs using EASY-care, a pre-defined assessment tool’, Research Policy and Planning, 25(1): 43–56., , and (1981) ‘Models and model building in nursing’, Advances in Nursing Science, 3(3): 31–42.and (Leathard, A. (ed.) (1994) Going Interprofessional: Working Together for Health and Social Care. London, Routledge. http://dx.doi.org/10.4324/9780203137796Leathard, A. (ed.) (2003) Interprofessional Collaboration: From Policy to Practice in Health and Social Care. London, Brunner-Routledge. http://dx.doi.org/10.4324/9780203420690Learning Disability Advisory Group (2001) Fulfilling the Promises: Report to National Assembly for Wales.Learning Disability Coalition. http://www.learningdisabilitycoalition.org.uk/.1999) ‘Five laws for integrating medical and social services: lessons from the United States and United Kingdom’, The Milbank Quarterly, 77(1): 77–110. http://dx.doi.org/10.1111/1468-0009.00125(2005) ‘Reflections on integrating medical and social care: five laws revisited’, Journal of Integrated Care, 13(5): 3–12. http://dx.doi.org/10.1108/14769018200500034(2008) ‘Social work practice with Older People: working in partnership’, in K.Morris (ed.) Social Work and Multi-agency Working: Making a Difference. London, The Policy Press. pp. 147–165.(2005) Integrated Care: A Guide for Policy Makers. http://ns1.siteground169.com/~healthan/healthandfuture/images/stories/Documents/integrated%20care%20%20a%20guide%20for%20policy%20makers.pdf.and (Local Government Data Unit Wales (October 2008) Local Authority Registers ofPeople with Learning Disabilities, 31 March 2008. http://www.wales.gov.uk/statistics.2008) Independent Review of Delayed Transfers of Care in Wales. WIHSC. http://www.wihsc.co.uk/content/public/publications/resource/?id=603., , , , , , , and (1997) Collaboration in Health and Welfare: Working with Difference. London, Jessica Kingsley.(2005) Social Work with Older People: Context, Policy and Practice. London, Sage. http://dx.doi.org/10.4135/9781446211687(2006) ‘United we stand? Partnership working in health and social care and the role of social work in services for older people’, British Journal of Social Work, 36(7): 1119–34. http://dx.doi.org/10.1093/bjsw/bch348(2004) ‘Older people and community care in Scotland – A review of recent research’, Scottish Executive Social Research. http://www.scotland.gov.uk/socialresearch.(1970) Motivation and Personality,(2nd edn. New York, Harper and Row.2005) ‘Adults with a learning disability living with elderly carers talk about planning for the Future: Aspirations and concerns’, British Journal of Social Work, 35: 1377–92. http://dx.doi.org/10.1093/bjsw/bch241and (2004) ‘Enabling adults with learning disabilities to articulate their housing needs’, British Journal of Social Work, 34: 709–26. http://dx.doi.org/10.1093/bjsw/bch086, and (2006) Public Policy Scottish Statistics Desktop Research. Equal Opportunities Commission. http://126.96.36.199/sitearchive/eoc/PDF/PublicpolicyScottishstatisticsresearchreport2006.pdf?page=19329., (Mental Health Act 2007http://www.opsi.gov.uk/acts/acts2007/ukpga_20070012_en_1.2002) Assessment in Social Work.and ([Page 199]2nd edn. Basingstoke, Palgrave.1991) The Illness Experience: Dimensions of Suffering. Newbury Park, CA, Sage Publications.and (2008) Communication Skills for Health and Social Care. London, Sage.(1998) Understanding Social Work: An Empirical Approach. Atlantic Heights, NJ, Athlone Press.(2005) Health Promotion: Foundations for Practice,and (2nd edn. London, Bailliere Tindall.2004) ‘Responses to the spiritual needs of older people’, Journal of Advanced Nursing, 48(1): 6–16. http://dx.doi.org/10.1111/j.1365-2648.2004.03163.x, , , , and (National Assembly for Wales (NAFW) (2000) Social Services Wales, The Community Care (Direct payments) ammendement (WALES) Regulations 2000. UK, The Stationery Office. http://www.opsi.gov.uk/legislation/wales/wsi2000/wsi_20001868_mi.pdf.National Assembly for Wales (NAFW) (2001) Improving health in Wales: a plan for the NHS with its partners. NHS Wales.National Assembly for Wales (NAFW) (2004) NHS funded nursing care in care homes guidance 2004. WHC: 024. Cardiff.National Assembly for Wales (NAFW) (2005) Hospital discharge planning guidance. WHC: 035. Cardiff.National Assembly for Wales (NAFW) (2006) Further advice to the NHS and Local Authorities on continuing NHS healthcare. WHC 046. Cardiff.National Health Service Institute for Innovation and Improvement (2007) Encourage Collaboration. Issue 12. http://www.executive.modern.nhs.uk/inview/inviewarticle.aspx?id=201.National Leadership and Innovation Agency for Healthcare (NLIAH) (2008) Passing the Baton: A Practical Guide to Effective Discharge Planning. Change Agent Team.NHS and Community Care Act 1990. http://www.opsi.gov.uk/acts/acts1990/ukpga_19900019_en_7#pt3-pb1-l1g42.Nies, H. and Berman, P.C. (eds) (2004) Integrating Services for Older People: A Resource Book for Managers. European Health Management Association (EHMA). http://www.ehma.org/_fileupload/Publications/IntegratingServicesfoOlderPeopleAResourceBookforManagers.pdf.2004) Factsheet – What is a Learning Disability? Kidderminster, British Institute of Learning Disabilities. http://www.bild.org.uk.(Nursing and Midwifery Council (2008) The Code in Full. Accessed on 13 June 2009 at http://www.nmc-uk.org/aArticle.aspx?ArticleID=3056.1987) ‘A guide to personal futures planning’, in G.Bellamy and B.Willcox (eds) A Comprehensive Guide to the Activities Catalogue: An Alternative Curriculum for Youth and Adults with Severe Disabilities. Baltimore, Paul H Brooks.(Office for National Statistics (ONS) (2001) The Census in England and Wales. http://www.statistics.gov.uk/census/default.asp.Office for National Statistics (ONS) (2004) Consultations with an NHS GP: by sex and age, 2001/02: Social Trends 34. Dataset ST340808. http://www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=7401&More=Y.Office for National Statistics (ONS) (2006) Gender. http://www.statistics.gov.uk/cci/nugget.asp?id=1657.Office for National Statistics (ONS) (2007) 2006-based national population projections. http://www.statistics.Office of Public Sector Statistics (2005) Mental Capacity Act (2005) http://www.opsLgov.uk/acts/acts2005/ukpga20050009en1gov.uk/cci/nugget.asp?id=1352.1990) The Politics of Disablement. Tavistock, Macmillan.(2001) Nursing: Concepts of Practice. St. Louis, MO, Mosby.(1993) Coordinating Community Care: Multidisciplinary Teams and Care management. Buckingham, Open University Press.([Page 200]2003) Social Work Practice: Assessment, Planning, Intervention and Review. Exeter, Learning Matters Ltd.and (2000) Constructive Social Work: Towards a New Practice. Basingstoke, Palgrave Macmillan.and (2005) Nursing Models for Practice,, and (3rd edn. Edinburgh, Butterworth Heinemann.2006) ‘The single assessment process in primary care: older people's accounts of the process’, British Journal of Social Work. 24 May., , and (2006) ‘Carers and confidentiality in mental health care: considering the role of the carer's assessment; a study of service users', carers' and practitioner's views’, Health & Social Care in the Community, 14(4): 357–65. http://dx.doi.org/10.1111/j.1365-2524.2006.00631.x, , and (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh, Churchill Livingstone., and (2003) ‘Partnership, co-ordination of care and the place of user involvement’, Journal of Mental Health, 12(1): 59–70. http://dx.doi.org/10.1080/09638230021000058300(1999) The Roy Adaptation Model. London, Prentice Hall.and (Royal College of Nursing (2004) Nursing Assessment and Older People. A Royal College of Nursing Toolkit. Royal College of Nursing.2006) The Strengths Perspective in Social Work Practice,(4th edn. Boston, MA, Allyn & Bacon.2006) ‘Rates of acute care admissions for frail older people living with met versus unmet activity of daily living needs’, Journal of the American Geriatrics Society, 54(2): 339–44. http://dx.doi.org/10.1111/j.1532-5415.2005.00590.x, , , , and (Savin-Baden (2000) Problem-based Learning in Higher Education. Buckingham, Open University Press.Scottish Executive (1999) Strategy for Carers in Scotland. http://www.scotland.gov.uk/library2/doc10/carerstrategy.asp.Scottish Executive (2000) Our National Health: A Plan for Action, A Plan for Change. NHS Scotland.Scottish Executive (2001a) Guidance on Single Shared Assessment of Community Care Needs. Circular No: CCD8.2001. Health Department. Directorate of Policy.Scottish Executive (2001b) The Same as You? A Review of Services for People with Learning Disabilities. http://www.scotland.gov.uk/Resource/Doc/159140/0043285.pdf.Scottish Executive (2004a) Single Shared Assessment Indicator of Relative Need (SSA-IoRN). Circular No: CCD5. 2004. Health Department. Directorate of Policy and Planning.Scottish Executive (2004b) Guidance on Care Management in Community Care. CCD8.2004. Joint Futures Unit.Scottish Intercollegiate Guidelines Network (2002) Prevention and management of hip fracture in older people. A National Clinical Guideline. No. 56.Scottish Office (1998) Implementing the Care Programme Approach. http://www.scotland.gov.uk/library/swsg/care_prog-00.htm.1998) Ethics: The Heart of Healthcare,(2nd edn. Chichester, Wiley Blackwell.1998) The Disability Reader. Social Science Perspective. London, Continuum International Publishing Group.(1995) Cognitive-behavioural Therapy: Research, Practice, and Philosophy. London, Tavistock. http://dx.doi.org/10.4324/9780203450680(2005) ‘Determining older people's needs for care by registered nurses: the nursing needs assessment tool’, Journal of Advanced Nursing, 52(6): 601–8. http://dx.doi.org/10.1111/j.1365-2648.2005.03641.xand (1991) Empowering Users to Make Choices: Assessment Care Management and the Skilled Worker. Department of Health., , and ([Page 201]1993) Empowerment, Assessment and Care Management and the Skilled Worker. London, HMSO., , and (Social Care Institue of Excellence (2008) ‘Commissioning Person-centred, Cost-effective, Local Support for People with Learning Disabilities', Adults’Services Knowledge Review20, Lancaster University. http://www.scie.org.uk.2002) Review of Care Management in Scotland. Scottish Executive Central Research Unit, Edinburgh.and (2003) ‘Unemployment and Families: A Review of Research’, Social Service Review Sept. p. 399–430. http://dx.doi.org/10.1086/375791(2002) Working Across Boundaries: Collaboration in Public Services. Basingstoke, Palgrave.and (The Scottish Government (2002) Adding Life to Years: Report of the Expert Group on Healthcare of Older People. http://www.scotland.gov.uk/Resource/Doc/158645/0043038.pdf.The Scottish Government (2003) Free Personal and Nursing Care Guidance. http://www.scotland.gov.uk/Publications/2005/08/13113129/31305.The Scottish Government (2004) Single Shared Assessment-Indicator of Relative Need Operational Guidance User's Handbook. http://www.scotland.gov.uk/Publications/2004/08/19652/40274.The Scottish Government (2005a) Better Outcomes for Older People: Framework for Joint Services. http://www.scotland.gov.uk/Publications/2005/05/13101338/13397.The Scottish Government (2005b) The National Framework for Service Change in the NHS in Scotland: Building a Health Service Fit for the Future. A Report on the Future of the NHS in Scotland. http://www.scotland.gov.uk/Publications/2005/05/23141307/13104.The Scottish Government (2005c) Single Shared Assessment-Indicator of Relative Need Operational Guidance Resource Pack. http://www.scotland.gov.uk/Publications/2005/02/19542/39291.The Scottish Government (2006) Scottish Household Survey Analytical Topic Report: Characteristics and Experiences of Unpaid Carers in Scotland. http://www.scottishexecutive.gov.uk/Publications/2006/10/05115110/0.The Scottish Government (2007a) Planned Care Improvement Programme: Patient Flow in Planned Care: Admission, Discharge, Length of Stay and Follow Up. http://www.scotland.gov.uk/Publications/2007/09/13094244/5.The Scottish Government (2007b) National Minimum Information Standards for all Adults in Scotland for Assessment, Shared Care and Support Plans., Review and Carers Assessment and Support-Consultation on the Compendium of Standards. http://www.scotland.gov.uk/Publications/2007/12/13130738/0.The Scottish Government (2008) Unmet Needs Pilot Projects – Recommendations for Future Service Design. Health and Community Care. Social Research. http://www.scotland.gov.uk/Publications/2008/11/13111303/32.Thistlethwaite, P. (eds.) (1996) Finding Common Cause. London, Association of County Councils.1998) ‘Nursing models extant or extinct?’, Journal of Advanced Nursing, 28(1): 77–85. http://dx.doi.org/10.1046/j.1365-2648.1998.00766.x(1999) ‘Training professionals in risk assessment and risk management: whatdoes the research tell us?’, in Parsloe, P. (ed.), Risk Assessment in Social Care and Social Work. London, Jessica Kingsley. pp. 217–47.(2001) ‘Critical pathways’ in J.Eisenberg and D.Kamerow (eds) Making Health Care Safer – A Critical Analysis of Patient Safety Practices, Evident Report/Technology Assessment No. 43, AHRQ Publications, Rockville, MD. http://www.ahcpr.gov/clinic/ptsafety.and (2004) The Person-Centred Approach: A Contemporary Introduction. Basingstoke, Palgrave., , , and ([Page 202]Union of the Physically Impaired Against Segregation (1976) Fundamental Principles of Disability. London, Union of the Physically Impaired Against Segregation.2005) ‘The prevalence of, and risk factors for loneliness in later life: a survey of older people in Great Britain’, Ageing and Society, 25: 357–75. http://dx.doi.org/10.1017/S0144686X04003332, , amd (Wales Audit Office (2007) Tackling Delayed Transfers of Care Across the Whole System – Overview Report Based on Work in the Cardiff and Vale of Glamorgan, Gwent and Carmarthenshire Health and Social Care Communities. http://www.wao.gov.uk/assets/englishdocuments/DToC_Overview_eng.pdf.2006) ‘Nursing in the context of unified assessment’, in Welsh Assembly Government, The Unified Assessment Process Implementation Toolkit. NHS Wales, SSIW.and (2007) The Role and Function of Lunch Clubs for Older People. Welsh Assembly Government. New Ideas Fund. Accessed on 8 June 2009 at http://new.wales.gov.ukld-sjlg/research/lunchclubs/lunchclubs.pdf?lang-en., and (2008) Wales Integrated Indepth Substance Misuse Assessment Tool (WIISMAT). Welsh Assembly Government. http://new.wales.gov.uk/topics/housingandcommunity/safety/publications/wiismat/?lang=en., and (2006) Social Work Processes and Practice: Approaches, Knowledge and Skills. Basingstoke, Palgrave Macmillan.and (2003) Collaboration in Social Work Practice. London, Jessica Kingsley Publishers., and (Welsh Assembly Government (WAG) (2002) Health and Social Care for Adults – Creating a Unified and Fair System for Assessing and Managing Care. Cardiff, NAFWC 09/02. WHC(2002)32.[Page 203]Welsh Assembly Government (WAG) (2003) Fundamentals of Care: Guidance for Health and Social Care Staff. Cardiff, Welsh Assembly Government.Welsh Assembly Government (2003) Mental Health Policy Guidance: The Care Programme Approach for Mental Health Service Users. A Unified and Fair System for Assessing and Managing Care. NHS Cymru Wales, Cardiff. http://www.dh.gov.uklen/Consultations/Closedconsultations/DH_063354.Welsh Assembly Government (WAG) (2004) Continuing NHS Health Care Framework for Implementation in Wales 2004. Cardiff, National Assembly for Wales.Welsh Assembly Government (WAG) (2005) Designed for Life: Creating World Class Health and Social Care in Wales in the 21st century. Health Challenge Wales, NHS Wales.Welsh Assembly Government (WAG) (2006a) National Service Framework for Older People in Wales. Health Challenge Wales.Welsh Assembly Government (WAG) (2006b) The Unified Assessment Process National Minimum Data Set. Version Number V1-2006 to 2008-SSIW. NHS Cymru Wales. Social Services Inspectorate Wales.Welsh Assembly Government (WAG) (2006c) Unified Assessment Process Implementation Toolkit.Welsh Assembly Government (WAG) (2006d) Wales accord on the sharing of personal information (WASPI) (Tier 1) for organisations involved in the health and social wellbeing of the people of Wales (including statutory, private and voluntary sector organisations). http://www.wales.nhs.uk/sites3/Documents/702/WASPI_tier1__lang%3Den.pdf.Welsh Assembly Government (WAG) (2006e) All Wales Bladder/Bowel Care Pathway. North Hampshire Primary Care Trust.Welsh Assembly Government (2007a) Nursing Needs Assessment Decision Record: A Training Pack. NHS Cymru Wales, Cardiff.Welsh Assembly Government (WAG) (2007b) A Strategy for Social Services in Wales over the Next Decade: Fulfilled Lives, Supportive Communities. Cardiff, Department for Health and Social Services.Welsh Assembly Government (WAG) (2007c) Carers Strategy for Wales Action Plan 2007. Cardiff, Department for Health and Social Services. http://wales.gov.uk/topics/health/publications/socialcare/carerpublications/carersactionplan?lang=en.Welsh Assembly Government (WAG) (2007d) Designed to Improve the Health and Management of Chronic Conditions in Wales: An Integrated Model and Framework. Cardiff, NHS Cymru Wales, Health Challenge Wales. http://new.wales.gov.uk/topics/health/publications/health/strategies/designedimprovechronic?lang=en.Welsh Assembly Government (WAG) (2008) Designed to Realise Our Potential. http://wales.gov.uk/topics/health/professionals/officechiefnursing/cnopublictions/realise/?lang=en.2005) ‘The structure of Nursing knowledge: Analysis and evaluation of practice middle range, and grand theory’, in J.J.Fitzpatrick, and A.L.Whall. Conceptual Models of Nursing Analysis and Application(4th edn.Upper Saddle Creek, NJ, Pearson Prentice Hall.1995) ‘Aspirations and realities: Community care at the crossroads’, Health and Social Care in the Community, 3(4): 227–40. http://dx.doi.org/10.1111/j.1365-2524.1995.tb00024.x(1972) The Principle of Normalization in Human Services. Toronto, National Institute on Mental Retardation.(1983) ‘Social role valorization: a proposed new term for the principle of normalization’, Mental Retardation, 21(6): 234–9.(2007) Stages and Transitions in the Experience of Caring. University of Leeds, Carers UK. http://www.carerscotland.org/Policyandpractice/Research/2569-carersukreport1.pdf., , , and (