Care Plan

Planning is essential to ensure that those we care for benefit from the best possible care available.

In itself, planning alone does not achieve anything – those plans only have value if they are implemented, checked, reviewed and changed when necessary. Furthermore, care planning for its own sake is merely a paper exercise which has to be avoided because the objective of the care plan is to provide the best possible care outcomes for the Service User.

For example, one important function of the care plan is to develop, set, and agree realistic aims, objectives, and goals to promote the independence of the service user.

The Registered Manager and Clinical Care Manager are ultimately responsible for care planning and the on-going reviews and changes.

Care plans start before admission when we undertake a pre-service needs assessment for which we have a separate policy.

Managing a person‚” care involves working with the Service User to balance the extent to which we assist them without reducing their independence whilst not exposing them to unnecessary difficulty.

Achieving this means we develop care plans, in a suitable and appropriate manner according to each circumstance, with the Service User and other relevant parties such as relatives, friends, representatives, health care professionals etc.

Naturally, circumstances change, which means we review all care plans to an agreed regular programme and when circumstances change between those regular reviews. Again, staffs are actively included in the development of the care plan to achieve the best possible outcome.

Staff have to be familiar with the care plans for those to whom they provide care services and they must be assisted to carry out those care plans properly. This means we provide relevant training on an ongoing basis with regards to care planning and its application.

Care plans are carefully recorded. When something changes, the previous details are filed for reference and only the current plan is available for implementation. However, before we
implement those changes, we notify the Service User and / or their representative, in writing, of the changes to be made in the care plan.

It is possible that something could go wrong; we need to be sure that the integrity of the care plan is robust enough to demonstrate that we had done everything possible to prevent that which went wrong and were able to manage the situation effectively because of the integrity of the care plan.

For confidentiality and data protection, we keep a written list of who has access to what care plan information and under what circumstances. If you access care plan information and are not authorised to do so as per that list, this constitutes gross misconduct for which dismissal may arise for staff involved.

Care Plan – List of Contents

As a basic minimum, the care plans must (wherever relevant) record the following:

• Pre assessment
• Social Worker assessment
• Service User involvement in own care
• Their family‚” involvement
• Their friend‚” involvement
• Their advocate‚” involvement
• Their G.P.‚” involvement
• Their carer‚” involvement
• Other health professional‚” involvement
• The extent of ‚”personal‚” care
• Physical wellbeing of Service User
• Dietary needs
• Dietary preferences
• Nutritional needs
• Weight and weight management objectives
• Sight
• Hearing needs
• Communication with, to and from Service
• User
• Language needs
• Oral health
• Hand care
• Foot care
• Hair care
• Personal appearance
• Mobility circumstances and needs
• Dexterity
• Falls history
• Safe movement around the premises and
• beyond
• Continence management
• Toileting needs
• Medication
• Self medication
• Mental state
• Cognition
• Propensity to aggression or violence
• Interests
• Hobbies
• Social needs
• Cultural needs
• Ethnic needs
• Religious needs
• Personal safety
• Dressing / undressing
• Skin care
• Bathing
• Showering
• Eye careEar care
• Shaving
• Nail care
• Pressure care managementLevel/s of independence and dependence
• Scope for personal managed risk taking