Integrated Assessment Framework and Frailty Workshop

Integrated Assessment Framework and Frailty Workshop Date: 2nd October 2014 Venue: Optic Centre, St Asaph

For more information please email: Jane.Brailsford@wales.nhs.uk Visual minutes and facilitation by Fran O’Hara, to receive this document and visual minutes in an alternative format please email: ohara@scarletdesign.com

CONTENTS

Agenda...................................................................................................................................... Page 3 Overview................................................................................................................................... Page 4 Visual Minutes of Maria Bell and Dr Olwen Williams’ presentations..................................... Page 5 Integrated assessment............................................................................................................. Page 6 Session 1: What would FREDA say about frailty?

‘World Café’ group discussion tablesheet records............................................... Page 10 Discussion 1........................................................................................................................... Page 12 Session 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

‘World Café’ group discussion tablesheet records............................................... Page 18 Discussion 2........................................................................................................................... Page 21 Photostory.............................................................................................................................. Page 26 Attendee list............................................................................................................................ Page 28 Appendix................................................................................................................................. Page 30

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Integrated Assessment Framework and Frailty Workshop

AGENDA

9.00am

Welcome, Olwen Williams

9.15am

What Matters? (Integrated Assessment Framework) – Maria Bell*

9.30am

The Frailty Programme – Olwen Williams*

9.45am

Co-Production – Pam Luckock*

10.00am

Tea and Coffee

10.15am

Session 1 Question: What would FREDA say? The language of frailty and independence.

Session 2 Question: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

Session 3 Question: What keeps you well in your community - the ‘What Matters’ conversation – tell us your experience.

12.15pm

Closing remarks, Maria Bell

12.30pm Close

*Presentations available upon request, please email: Jane.Brailsford@wales.nhs.uk

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Integrated Assessment Framework and Frailty Workshop

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Visual Minutes of Maria Bell and Dr Olwen Williams’ presentations

By Fran O’Hara

© SCARLET DESIGN 2014. MAPS:WWW.FRANOHARA.COM

www.franohara.com

Integrated Assessment Framework and Frailty Workshop

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Integrated Assessment “My care is planned by me with people working together to understand me, my family and carer(s), giving me control, and bringing together services to achieve the outcomes important to me.”

Our aim: to have better ‘What matters to me’ conversations “There’s a ME in Integrated AssessMEnt” PAGE 6

Integrated Assessment Framework and Frailty Workshop

Session 1: What would FREDA say about frailty?

Integrated Assessment Framework and Frailty Workshop

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© SCARLET DESIGN 2014. MAPS:WWW.FRANOHARA.COM

Visual Minutes of Session 1 “World Café’ group discussion responses

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Integrated Assessment Framework and Frailty Workshop

Session 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care?

What would good look like?

Integrated Assessment Framework and Frailty Workshop

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SESSION 1: World CafÊ’ group discussion tablesheet records

Larger images of these table-sheets from Discussion 1 are available in the Appendix section of this document, page I.

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Integrated Assessment Framework and Frailty Workshop

SESSION 1: World CafÊ’ group discussion tablesheet records

Larger images of these table-sheets from Discussion 1 are available in the Appendix section of this document, page I.

Integrated Assessment Framework and Frailty Workshop

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DISCUSSION 1: What would FREDA say? The language of frailty and independence • Start with the person - strength/capacity • Need clinical/professional definitions/ scoring and continuum = standardised • Skill to have the conversations is key = cultural shift - training crucial • How do we balance the clinical side with the social side/person centred?

• Difficult to categorize • Need (medical v social) - capacity (what can you do?) - outcome (proportionate) • Soft skills training • Conversational skills • Motivational • Listening • Questioning techniques - open questions • For all > What about descriptors for mental health, substance abuse, learning disability?

• Narratives are really important (digital/ visual) • *See me* - as a person with a wealth of life experience and give me time in a genuine way before getting down to score me re frailty • Cultural shift/from needs to capabilities • Important not to stereotype • Listen with all senses • Genuine engagement and interest • Engagement on a human level PAGE 12

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Integrated Assessment Framework and Frailty Workshop

Clinical v person/life - bring it together Education/training Managing risks Rural transport Safety at home Improving quality of life Training need in questioning techniques/ discussion Change management Active listening skills *What matters?* Conversation The word *frail* has assumptions around the person’s inability to do things/need training fund for professionals to have the attitude “What can you do even if high risk and how can we help you achieve that?”

About enabling building resilience and less dependent Frailty score wording in itself is not very dignified and from 3 onwards wording is not very respectful Working over the phone difficult Can they hear well?

Write the number down?

Enabling communities to support their elderly Culture change Capturing qualitative data

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Danger of labels and stereotypes Need to still categorize Clinical v social (person) Frailty syndrome Doesn’t define the person but helps to inform/empower the person To plan Frail/frailty used in a negative way Catch all - inevitable decline Wellbeing Frailty scores should be sense checked by someone who knows the person Frailty scores are a clinical tool not a label Frailty scores without context are meaningless SU’s age - used to professionals using jargon Who are you? Who were you?

On the end of the bed - my health - my CV Frailty > wellbeing - the whole person Q - Is there a purpose to the term “frailty”?

Has the term been muddied?

Originally used to define a set of symptoms on a spectrum Wellbeing is more positive than frailty is negative Capability Keep term for medical use universally

DISCUSSION 1: What would FREDA say? The language of frailty and independence

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clinical tool recognized but people facing use here is a big question Think this through before initiating any “frailty score” on a record that is given to the person Timing of use of frailty score is important - pre-admission logs don’t make decision when in hospital “iInsulting” Danger that it defines our approach/how we treat people Frailty score good for planning services/ commissioning Flip/turn over from negative - what person can’t do - to what the person can do and choose/select a more positive term ie capability score The co-production approach used today should be used as part of the approach to train operational staff in “what matters” ...a need to start the cultural change and challenge thinking Lifestyle capabilities Frailty syndrome Wellbeing Diminishing ...

Frailty should ...

Wellbeing Capability ...

• Capacity ...

• Ask questions relevant to them that they believe would benefit them or make life easier • Don’t make promises • Sometimes conversations over the phone are inadequate takes a face to face approach for some to understand the questions • What matters • Open questions - not to give yes/no answers • What able to do • Mindset - not the form • Training important • SPoA - need a lot of operators • Plain English - language of choice • Don’t rush • Probing questions • Listening skills • How do we stop giving solution before we’ve had the whole story?

• Understand that some people don’t want ... (adaptions eg) their choice • Appreciative enquiry - asset based approach rather than cultural of us delivering everything • (Some) public culture of entitlement needs to change

• Cost • If I am honest about what matters to me how will - and who will - provide these services?

• Ability score • SPoA • Multi channel • Agents • Knowledge management • Proportional approach • Integrated operators (staff) • Community wellbeing services • Directors - services - information - assets • Self/citizen - responsibilities and rights • Not a form • G = WMC> co-production • What matters - not connected to SPoA but the person • SPoA - staff, resources • Time - issues with completing WMA • Comprehensive questions • Mindset of service users • Persons perspective of themselves • Frailty - negativity • Discrimination • Can be taught mindset • Third sector organizations understanding WMA referrals methods via WMA Integrated Assessment Framework and Frailty Workshop

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DISCUSSION 1: What would FREDA say? The language of frailty and independence • • • • • • • • • • • • • • • • • • • • •

Good listening skills Open questions Number of staff in SPoA Time to complete conversation fully to get the “what matters to me” information Solution can come from self or family or network - recognizing that Prevention of deterioration Speak to the right people - may not be the client Capability not frailty Low level support for lots of people Everybody is an individual Mental as well as physical ability determine well being Me compared to me Take circumstances (eg family support) into account as well Reflective comparison Independence Concordant planning Mental + physical + social = person Working with other support agencies/ clubs/groups - shared information “Relative to ...”

Personal history not someone else or “population” Not just physical - scoring is physical

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Integrated Assessment Framework and Frailty Workshop

based - social - lifestyle - mental health and wellbeing - ask “why” EIA what place?

Danger scoring leads conversation ... conversation first Tick box - put in a box?

DMWS - Diploma in Welfare Studies Includes skills to identify with the person What matters to the person Listening/counselling skills Help to signpost to appropriate support Independence - ability - capability - what matters > life choice/activity - social skills/ activity - healthcare needs - may be not service from health - may be other signposting - community - self help Positive in conversations and understanding About the professional knowing the individual and network around Comparative ability Benchmark against your previous history Ongoing assessment The conversation should lead discussion not the score/framework So important limitations to gaining the essence on the phone Learning environment As the frailty score stands major focus is

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physical sustainability emotional/mental wellbeing has a large part to play on finding missing detail from score Life points > continuum of life wellbeing score - holistic approach physical - emotional - mental life story Accepting loss of independence Self caring but on own terms Frailty does not marry with Freda Risk is a part of life but people can manage risk FRAILTY F = falls, freedom R = risk A = acceptance I = independence l = living well, limitations, life T = this is me, transition Y = young at heart Choice v risk Personalised information This is me (Alzheimers Society) Life book (Age Concern) This recorded/captured and information transferred IT systems working together cross organisations ie PARIS and PAS

DISCUSSION 1: What would FREDA say? The language of frailty and independence • Physical emotional mental > wellbeing focus • PERSON • Holistic approach • My life - my story - my journey • Genuineness - autonomy - prizing • Rainbow approach (refers to an approach in the Netherlands for older people) • Respect empathy dignity • Living well - wellbeing score (not frailty) • Language - active offer of welsh language services • Culture • Freda • I am an older person not frail • My needs are personalised to me not a standardised rule • The name doesn’t matter to me, what matters to me is ...

• Frailty baseline score is just as important as a current frailty score • Frailty has focussed staff on my care and my needs • Unsteady state and steady state scores?

• 65 - 75 equals young old, 75 - 85 = medium old, 85+ = old old • 65 year old in Cub 1 is different to 65 year old in Cub 2

• As a 50 year old who had a knee op, frailty score would be 6. I did not classify myself as a 6 at the time • Scores have to be used in primary care for it to be beneficial in acute • Don’t want to be tarred with the same brush • Dependence and independence score?

• ”What matters” conversation is more beneficial than a score • Freda • Not equal • I may need some help but I’m autonomous, I was a Mary Whitehouse champion, I look after myself • Not dignified at all, I’m not frail but I’m older • Not respectful “not frail” • Is 90 years - independent - vocal - full capacity - full pension, independent financially • Would affect her freedom • Older Person • Health visiting - NCM • Dependent society • Locality of dependence • Freda • “I’m not frail but I am older and wiser” • Integrated assessment and “what matters

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to me” is a positive step forward but in reality on a very busy hospital ward there is too much form filling and duplication.

We need simple and shared, we aren’t there yet Freda - who cares “what matters” - we all do Use photographs, visual tools, to share more about the person Good basic listening skills Prefer an independence score - positivity v negativity of frailty Freda wouldn’t say she was frail, she would say “I’ve worn myself out” or “my joints are letting me down” Emotional wellbeing is important Freda would not say she was frail Alternative name for frailty Would not want to admit to being frail > negative connotations around the word Trouble with my legs May be reluctant to admit needing help She would probably say she isn’t frail, she might be insulted Being frail doesn’t equal freedom Freda might prefer an independence score Frailty not recognized by some/most - a derogatory term “I’m not as good as I was”

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DISCUSSION 1: What would FREDA say? The language of frailty and independence • Freda would say “I can still do things but not as well as I used to” • But Freda wouldn’t say she was frail • Or an adult over 18 with needs is classed as frail • Frailty is for old people who can’t do things for themselves • Capability score - should we call it a score - labelling?

• I am the expert on me ... “Walk with me by my side don’t step into my shoes and tell me how it will be ...”

• I am not an illness, a carer, a wife a mother etc, I am me. I need some help - but not with everything. Ask what I can do for myself first - asset based approach.

• All behaviour is communication - don’t be afraid of not being the expert. I’ll help you to help me and we’ll both feel good.

• Not just about physical • I am not frail - I just need a bit more help today.

• Who am I, what’s my story • Help me to enable myself, don’t disable me • Freda says “Respect is working together toward a common goal - working together is dignified and values me - I feel equal, supported to make my own decisions - I am not frail” PAGE 16

• ”My life’s my own ... listen to me, who do you see ... I am old on the outside, I’m 23 inside”.

• Questions v discussion • Compassion and empathy • THIS IS ME • I can do this, following fall I am 6 on frailty score • I can’t do this at the moment because ...

• Personal record/diary showing likes and dislikes • What matters to me - taking my dog out my beautiful garden (weeds) - I’m lonely • What can be done to get me back to level 4 on frailty score - who do I contact? - how can I get help?

• Freda would say this is temporary, you will get back to how you were before your fall • Change frailty to ability • MY LIFE, MY WAY • I feel strongly that dignity is important when getting older and frailer • It’s nice to know that there is an organisation you can turn to when you worry • Professionals and family ask you to give up things you enjoy and ask you to do things you don’t want to do (like clear things out of my house)

Integrated Assessment Framework and Frailty Workshop

• Just because my body doesn’t work as well don’t assume my mind doesn’t work • My life, my decisions - ask me, don’t tell me • Freda might be afraid to tell statutory services how she feels • ME • What matters • Integrated services Care Co-Ordinator or Wellbeing Advocate • Provide support not create dependency • Primary care • Multi agency services • Rename frailty as wellness • Service providers to communicate together • Statutory and third sector services • Prevention prevents crisis but statutory deals mainly with crisis situation • Frailty chart - emotional? - not mentioned, affects mental health of individual • What about emotional support • Too many paid carers visiting Service Users home • Confusion who they are by family (service user and carer) • Paid carers had taken over the care • Carers (unpaid) are paramount and should also be given (“What Matters”) • Independent advocacy

This is a 'word cloud' generated to show the words used most frequently in delegates' responses.

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© SCARLET DESIGN 2014. MAPS:WWW.FRANOHARA.COM

Visual Minutes of Session 2 “World Café’ group discussion responses

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Integrated Assessment Framework and Frailty Workshop

SESSION 2: World Café’ group discussion tablesheet records

Larger images of these table-sheets from Discussion 1 are available in the Appendix section of this document, page XV.

Integrated Assessment Framework and Frailty Workshop

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SESSION 2: World Café’ group discussion tablesheet records

Larger images of these table-sheets from Discussion 1 are available in the Appendix section of this document, page XV.

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Integrated Assessment Framework and Frailty Workshop

DISCUSSION 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

• NO BLAME CULTURE - WE’RE IN IT TO WIN IT • LEARNING AS WE GO - WE HAVEN’T ARRIVED YET • INFORMATION NEEDS TO BE CURRENT • DOCUMENT ALL VIEWS EG FROM CARERS ALBEIT THEY MAY BE DIFFERENT • C0NFIDENTIALITY NEEDS TO BE ADDRESSED • COMMUNICATION IS KEY • THE PERSON NEEDS TO BE ABLE TO MANAGE RISKS - POSITIVE RISK TAKING - AVOID PATERNALISM • USE COMPLAINTS DATA TO IMPROVE SERVICES • EVALUATE SPoA PROJECTS TO DATE BY SHORT QUESTIONAIRE TO STAKEHOLDERS QUALITATIVE - SHARE RESULTS • INNOVATION • REFLECTION • What Matters Conversations • For it to work effectively, all professionals need to be involved eg GPs, are they all involved otherwise how do we capture the data • For the person to be in control: listen attentively (empathy) without making

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judgements or assumptions If they are unable to represent themselves they may need to have an advocate May need a visual representation which the person owns and contributes and reviews > Recovery Star How is the data collated to show trends There are different tools eg Recovery Star Everyone needs to be having these person centred conversations Share between all agencies, follow the person/updated Recovery Star - score themselves SPoA = single point for the complete picture - facilitate co-ordination Staff need the information, training and support to re-think about the way we do it Listen!

KEEPING WHAT MATTERS UP TO DATE Confidence in system ROBUST PROCESSES Single contract - What Matters reviewed revised amended one current copy available to all, so can work in an integrated way Care co-ordination > go to person SPoA Sharing information - data protection

• Permission - encouragement - risk averse informal approach • Third sector knowledge of community services • Won’t have good effect without education - cultural shift - resources to support and invest in this • Data needs to be current, co-produced, available and interpretable • Culture change in thinking • Receive training in completing forms • Receive active listening training/questioning techniques/Third sector services offered/ change management/confidentiality • Make time to have conversation with clients, with them not at them or to them • Services working together to provide best outcome for client - integrated assessment • Needs to be live working document which follows patient’s journey throughout their life • Staff need to be signed up to delivery of project • Residents need to be made more resilient and take more responsibility for their own health and wellbeing • Use of CVQs for information catalyst for third sector services in County in partnership with SPoA

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DISCUSSION 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

• Ever evolving voluntary community groups in County (no-one has all the knowledge) • Need a program of co-ordinated intermediate care in the community/third sector for very early intervention preventing admission to services • SPoA HUB - DECISION MAKER - THIRD SECTOR CO-ORDINATOR • Holder of What Matters • Co-ordinating care - community services • Requires robust processes, data must be good and current • District Nurses, GPs, self enquiry, discharge from hospital, therapists, Occupational Therapists, Physiotherapists • Permission - Train - Consistency • Ask the correct questions and listen to the answers • Client responsibility • Encourage responsibilty from client • Open questions • Not jump to problem solving • The jargon • Listen • Language - explain ourselves better • Empower ie educate people - give people permission to take control, ask them “what are you going to do about it” PAGE 22

• Need a revamp of our services • Market - use media stories/ ie Brand Coronation Street etc • People need training - need change agents to tip the scale – culture • Stop talking! Ask - “so what are you going to do about it?”

• Who owns the support plan - record of conversation • Continuous dialogue - not a one off • Listen - confirm - sense check - what difference did it make - what now • Listen and record the conversation of the person - their language not yours • Need to count to 10 • PR - facilitation not organisation illustrations in the public arena eg soaps • Identify Change Agents • The story could take time - needs concentration • Don’t jump to problem solving • Culture change for professionals and the public • Non judgemental - listen well • Appropriate time to have the conversation(s) • Managing risk well • Decision/choice of the individual

Integrated Assessment Framework and Frailty Workshop

• Positive experience • Language and culture • Building resilience - what can I do for myself and my well being and longevity self - community • Continuous evaluation - patient stories good and bad feedback • Manage expectations • Listen • Ask • Check • Share information • Feedback • Follow up • Review • Continuity • Detail • Good outcome • Effective recording - handover between - to help person - aid memoir - accountability • Leadership - you need to do X - how can you do X - what matters to you/me/ organisation • Complex issue • Accountability • Rights • Bringing the conversation back to the topic

DISCUSSION 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

• Can deflect from the real needs/issues • Coaching, listening, understanding (skills) pre-judge • Patient withholds information • Are you agents of change?

• Consider what matters to me as a professional/organisation > wellbeing, resilience • Checking out with person - non judgemental • Learning from everybody • Iterative process - building trust, a relationship • Asset map eg knitting club • Standards/checklist for communication skills • Non judgemental • Ask if they are happy with conversation/ summary of discussion • Check their understanding - reiteration • Listen - check - share • Professionals don’t always know best and lace of confidence in a person could make them agree when they don’t really want to = poor outcome • How do we know we are getting it right?

• WMC are correct when professionals said there is an accurate picture

• If not, we haven’t got it right • Organisations need to support with appropriate IT software otherwise our hands are tied behind our backs to share information onwards efficiently • Empower individual • Right approach • Don’t dictate • Appropriate language • TIme > appropriate point in time to do it for the person - worker setting aside enough time • Accessability > IT >Quality - non judgemental attitude • Training/understanding • Update/refresh communication and listening skills - managing expectations • Enabling conversations • Drawing out issues • Not using questions, use conversations • Know - “come away, research, find support, return to answer” - don’t have to solve today • Continual updating of form - not one session • Don’t like word solution • How do I know what information you need to know about me?

• “This What Matters form needs total rethink!” Act on complaints • Knowledge of local services • Capturing the conversation and sharing it • Exercise listening skills • Avoid bureaucracy • Work smarter • Make time to listen • Ability to contact key personnel accessability • Continuity with respect to personnel (care co-ordination) • Face to face better than over the phone • Confidentiality is information sharing • RESPECT - EMPATHY - DIGNITY • Workers need to tap into their hidden resources • Language and culture - active offer of welsh language services • Provide and deliver person centred care • Holistic - focus on the person on the whole - the needs of the person • Celebrate the abilities of the person • Workers have good knowledge of community support services - third sector organisations, that can help the person to live well in their own home • COMPLETE IN OWN WORDS WHAT

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DISCUSSION 2: What do workers need to do to ensure that the ‘What matters’ conversations enable people to exercise a strong voice, and to control decisions about their support or care? What would good look like?

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MATTERS TO THEM What is important to the person Find out what they/their families/friends were doing before What the person can do Promote independence Empower Complete enough so a decision can be made Listen Appropriate language LISTENING SKILLS Not make assumptions Find out what support mechanisms they have - family/friends Probing questions to obtain information Communication skills Allow them to talk Common language - their own words STEVE BAKER - District Nurse/Social Worker, CP/3rd, Falls Co-ordinator Listen Read body language Communicate with colleagues to avoid information being duplicated TAKE NOTICE - let the person speak and listen Simple easy to understand language, not

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Integrated Assessment Framework and Frailty Workshop

jargon = empowerment Trust, compassion, empathy They receive the full support needed, would be good.

They feel in control of what they need, would be good Listen - open questions, their past their life experience, their family support network, their problems/issues not our interpretation of, their wishes for future be open minded, don’t formulate solutions before you have all the information Then interpret, empower self sowing where possible, gathering information from other sources, engagement, who for what Access to discharge, re-assess the discharge LISTEN EMPOWER ASK OPEN QUESTIONS MOTIVATE GOOD IS Helping a patient get home when that is their biggest wish Recognise a need other than the medical one Gaining a patient’s trust Happy patients = happy nurses

• A nurse who knows what is most important to their patient • Making a difference • THINK • How would you feel if you were in their position • Tailor to your patient, not everyone is the same • Learn from experience • Listen - take time to hear from another’s perspective • Belive in our (patient/citizen/person/staff/ nurse/doctor) ability to influence what is needed.

• Good - looks like having someone listen and act on What Matters the first time.

• Who has the conversation?

• Ground rules • With who?

• Time • What happens if declined?

• Statistic - failure, rejection • Feel good factor of ‘What Matters’ conversation.

• Listening skills > Act on what you hear • Get the right story > invest time, it will save in the long run • Teams to share

This is a 'word cloud' generated to show the words used most frequently in delegates' responses.

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respect Positive experience Quality of conversations Age related illness - feedback from GP Good communication between each

service provider • Use appropriate language depending on audience • In depth knowledge and understanding of health/social care and 3rd Sector services available locally

• Conversation rather than questions • Listen and Hear • Use open questions and acknowledge what they say.

• Ground rules at very beginning Integrated Assessment Framework and Frailty Workshop

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PHOTOSTORY

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Integrated Assessment Framework and Frailty Workshop

PHOTOSTORY

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ATTENDEE LIST NAME

ORGANISATION

NAME

ORGANISATION

Alison Pring

Warden, Pennaf Housing Group

Christine Duffy

Service Manager, Flintshire County Council

Alistair Moulden

GP - BCUHB

Claire Brennan

I&BS BCUHB

Andrea Newman,

Alzheimer’s

Dawn Jones

Alzheimer’s

Angela Jones

Ruthin Hospital - District Nurses

Debbie Murphy

I&BS BCUHB

Anita Vale

Warden, Pennaf Housing Group

Deilwen Dafydd

Ruthin Hospital - District Nurses

Ann Perkins

Health and Social Care Facilitator, Medrwn Môn

Dianne Rimmer

BCUHB - Primary and Community Care

Ann Shield

Regional Manager, Safeguarding Older People in North Wales Project Age Connects North Wales Central (formerly Age Concern)

Dr Floreen Lim

Locality Lead GP, North & West Wrexham, BCUHB

Anna Newman

Clwyd Alyn Housing Association Ltd

Eirian James

Conwy Care & Repair

Annabel Chalk

Project Manager: North Wales Social Services Improvement Collaborative (NWSSIC) - North Wales RCF Dementia Project

Eirian Jones

BCUHB - Community Nursing

Elaine Nott

Community nursing sister team leader

Eleri Lloyd Burns

BCUHB

Anne Hooper

Care and Repair, Flintshire

Elin Williams

Isle of Anglesey County Council

Anwen Creegan

Lead Pre-assessment Nurse (West), Anaesthetics - BCUHB

Fiona Evans

British Red Cross

Barbara Roberts

Trustee FLVC & member of Wales Care Council

Fran O’Hara

Scarlet Design / ‘Working With Not To’ CoProduction Project

Bethan Nickson

Quality and Assurance Lead for Continuing Health Care - BCUHB

Frances Millar

Matron - BCUHB

Calvin Perry

Project Manager, Conwy SPOA

Geraint Davies

BCUHB Locality Lead - Conwy West and Health & Social Care Facilitator C/O CVSC

Carol Dove

Flintshire County Council

Glenda Lloyd Evans,

Gwynedd CC

Carol Hulme

Comm Nursing, BCUHB

Heather Piggott

Improvement and Business Support

Cathy Curtis-Nelson

Service Manager,

Heather Williams-Roberts Social Worker, Denbighshire County Council

Charlotte Walton

Service Manager, Wrexham County Borough Council

Helen Ingham

Falls Prevention Co-ordinator - BCUHB

Chris Jones

Deputy Ch Officer, North Wales Community Health Council

Iola Richards

Service Manager, Isle of Anglesey County Council

Jacqueline Armstrong

Age Concern

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Integrated Assessment Framework and Frailty Workshop

ATTENDEE LIST NAME

ORGANISATION

NAME

ORGANISATION

Jane Brailsford

I&BS BCUHB

Marian Hankin

Jane Moore

SPOA Project Manager, Flintshire County Council

Service Manager, Conwy County Borough Council

Janet Ellis

Primary & Community Services Programme Manager, BCUHB

Marie Bowler

Clinical Lead Nurse, Medicine, YGC - BCUHB

Maureen Roberts

Locality Co-ordinator, PCSM - BCUHB

Janette Williams

Vision Support

Mel Evans

Denbighshire County Council

Jenny Burgess

Unique Transgender Network

Mike Richie

Royal Voluntary Service

Jo Anne Williamson

Denbighshire Voluntary Services Council

Nerys Regis

Flintshire Local Voluntary Council

Jo Dolan

Locality Support Manager, PCSM, BCUHB

Nicola Eccles

Conwy Care & Repair

Jodie Berrington

I&BS BCUHB

Olwen Williams

ACOS, PCSM, BCUHB

John Cropper

POAC Nurse practitioner - BCUHB

Pam Lucklock

‘Working With Not To’ Co-Production Project

Julia Blakeman

Prescribing Support Pharmacist, BCUHB Denbighshire Locality Office

Robert Callow

Carers Measure Project Manager, Service User Experience - BCUHB

Julie Davies

BCUHB

Rosemarie Williams

MIND

Kate Newman

Flintshire Local Voluntary Council

Ruth Ballantine

Community Nursing - BCUHB

Katrina Jones

Person Shaped Support - PSS

Sandra Naughton

Kerry Hildrew

Community Nursing BCUHB

Community Services Partnership Manager, Denbighshire County Council

Lee Parry Williams

Public Health Wales

Sarah Williams

Community Staff Nurse - BCUHB

Liam Kurmos

Bangor University

Steve Baker

Wrexham Social Services

Linda Harper

Equality Stakeholder

Steven Robinson

Clwyd Alyn Housing Association Ltd

Lisa Leece

Service Delivery Manager North West, North Wales & ShropshireDefence Medical Welfare Service (DMWS)

Stuart Stevenson

Patient Representative

Tracy Stockin

Influence & Service Development Officer North Wales, Parkinson’s UK, Cymru

Llinos Wyn Parry

Stroke Association

Wendy Tee

Sister, LGH BCUHB

Lynne Regis,

Flintshire Local Voluntary Council

Yvette Drysdale

DAOM, BCUHB

Maria Bell

Denbighshire County Council

Yvonne Williams

Improvement and Business Support, BCUHB Integrated Assessment Framework and Frailty Workshop

PAGE 29

Appendix Session 1 ‘World Café’ group discussion tablesheet records

PAGE I

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Appendix Session 1 ‘World Café’ group discussion tablesheet records

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PAGE VII

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PAGE IX

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Integrated Assessment Framework and Frailty Workshop

PAGE XIV

Appendix Session 2 ‘World Café’ group discussion tablesheet records

PAGE XV

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PAGE XVI

Appendix Session 2 ‘World Café’ group discussion tablesheet records

PAGE XVII

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PAGE XIX

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Appendix Session 2 ‘World Café’ group discussion tablesheet records

PAGE XXI

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PAGE XXII

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PAGE XXIII

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PAGE XXVI

Appendix Session 2 ‘World Café’ group discussion tablesheet records

PAGE XXVII

Integrated Assessment Framework and Frailty Workshop

Integrated Assessment Framework and Frailty Workshop Date: 2nd October 2014 Venue: Optic Centre, St Asaph

For more information please email: Jane.Brailsford@wales.nhs.uk Visual minutes and facilitation by Fran O’Hara, to receive this document and visual minutes in an alternative format please email: ohara@scarletdesign.com