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Holistic assessment

Criteria
10a A holistic assessment is carried out with the service user and identifies:

• current and past mental health problems (including the informal carer's perspective)
• current and past interventions for these problems (including outcomes, adverse reactions and side-effects)
• personal, family and social circumstances
• strengths and aspirations
• physical health problems
• functioning (eg life skills assessment)
• service user needs assessment (eg Avon Mental Health Measure) and, where appropriate, informal carer needs assessment
• capacity to consent to care and treatment, and
• drug and alcohol use and misuse.

10b A target time for completion of the holistic assessment is recorded.

[Subsequent point of clarification:
'Capacity to consent to care and treatment' - this is not intended to mean that all service users are subject to a formal assessment (eg as under Adults with Incapacity (Scotland) Act 2000). The intention of the standard is to ensure that the service user is aware of and understands what they are signing up to in terms of receiving input from the team, etc.]

Supporting material for standard 10:

People entering a mental health service who have complex needs requiring multidisciplinary input, should receive a holistic assessment, which includes an assessment of strengths and a self-rated assessment of needs.

The assessor should be appropriately skilled and qualified to deal with the type and level of assessment. The holistic assessment will guide staff in creating a person centred care plan which aims to meet identified needs.

The assessment will be shared with the service user and with their consent, with informal carers.

The assessment should be repeated and the care plan amended as the person progresses through the steps on their journey of care. When a referral is made, some assessments may have already happened. A record of these assessments must be included with the referral documentation.

For people from minority ethnic communities, it is important to consider unique aspects relevant to the specific community. This may necessitate access to independent input during assessment eg trained interpreters and/or independent advocates/advocacy agencies.