CARE PLAN FOLDER CONTENT - Hampshire · CARE PLAN FOLDER CONTENT ... Other Family Contact details I want you to know Any Other contact details for me ... Any Community Team Details

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CARE PLAN FOLDER CONTENT

Every care plan folder should include an Index - clearly indicating what is in the care plan,this allows others to easily navigate their way to particular areas of the care plan. Ideally thecare plan folder should have dividers that match referencing.

As we all know there is no one way of setting up a care plan folder, this is guidance basedon good practice and can be used by you if you feel this is appropriate for you, your staffand the people you support.

Good practice guidance suggests that a care plan folder should have 6 sections:

1. Initial Assessment

2. Person Centred Profile

3. Support and Risk Management Plans

4. Daily care notes and other professional notes

5. Risk Assessment Charts as required

6. Reviews

Each section will be described separately.

The fundamental principle to remember is that this care plan is for theindividual, it enables the individual to confirm and agree how they wish tosupported by staff - it is not a tool or a folder simply for staff - it belongs to theindividual.

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PaCT Care Plans Text Final 31/03/2011 16:08 Page 1

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CARE PLANNING INDEX

Section 1Initial assessment

■ How I communicate■ My care and wellbeing■ What is working/not working for me■ Initial Assessment

Guidance notes for Section 1● How I communicate (example)● My care and wellbeing (example)● What is working/not working for me (example)● Initial Assessment (example)

Section 2Person Centred Profile – This is about me

■ All about me and my life■ My circle of support■ People I like to stay in contact with■ What is important to me■ To support me you need to know me■ End of life support■ Good/bad days■ How I make decisions■ Likes/dislikes■ Service users signature

Guidance notes for section 2● Person centred profile guidance● All about me and my life (example)● My circle of support (example)● People I like to stay in contact with (example) ● What is important to me (example)● To support me you need to know me (example)● End of life support (example)● Good/bad days (example)● How I make decisions (example)● Likes/dislikes (example)● Service users signature (example)

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Section 3Support Plans and Risk Management Plans

■ My Daily Routine■ Care Support Plan (generic)■ Communication■ Medication and pain management■ Personal Care and Dressing■ Risk Assessment■ Risk Management Plan

Guidance notes for section 2Examples for Older persons and Physical disability● Communication● Medication and pain management● Personal Care and DressingExamples for Learning disabilities● Communication● Medication and pain management● Personal Care and Dressing

Section 4Daily Care Notes and other professional notes

● Daily Care Notes● Residents daily log report

● Monday● Tuesday ● Wednesday● Thursday● Friday● Saturday● Sunday

Section 5Risk Assessment Charts Guidance

Section 6Reviews recordGuidance on reviews

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How

I c

om

mun

icat

e ve

rbal

ly

Ges

ture

s I

may

use

and

wha

t th

is m

ay m

ean

Bo

dy L

angu

age

and

wha

t th

is m

ay m

ean

– ho

w I

may

sit

, sta

nd, f

acia

l exp

ress

ions

etc

.

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HO

W I

CO

MM

UN

ICA

TE

WIT

H O

TH

ER

S


Beh

avio

ur a

nd w

hat

this

may

mea

n –

how

will

yo

u kn

ow I

am

hap

py, h

ow w

ill y

ou

know

I a

m s

ad, w

hat

do I

say

whe

n I

am a

ngry

Oth

er w

ays

I m

ay c

om

mun

icat

e –

exam

ple

oth

er c

om

mun

icat

ion

supp

ort

I m

ay u

se

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HO

W I

CO

MM

UN

ICA

TE

WIT

H O

TH

ER

S (C

ON

TIN

UE

D)


My

med

ical

wel

l bei

ng

I ha

ve t

he f

ollo

win

g m

edic

al d

iagn

osi

s:W

hat

do I

no

t w

ant

to h

appe

n:

My

soci

al w

ell b

eing

How

yo

u ca

n su

ppo

rt m

y so

cial

wel

l bei

ngW

hat

do I

no

t w

ant

to h

appe

n

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MY

CA

RE

AN

D M

Y W

EL

L B

EIN

G


My

emo

tio

nal w

ell b

eing

How

yo

u ca

n su

ppo

rt m

y em

oti

ona

l wel

l bei

ngW

hat

do I

no

t w

ant

to h

appe

n:

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MY

CA

RE

AN

D M

Y W

EL

L B

EIN

G (C

ON

TIN

UE

D)


INITIAL ASSESSMENT

What’s working for me right now?

What is not working for me right now?

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Personal Information for

My Full Name

My First Name

Other names I have

My Surname

I like to be called

Previous Address Current Address

My Date of Birth My Nationality

My relationship status My religious beliefs

My Maiden Name My previous occupation

Details of my immediate next of Kin

Contact for person holding Lasting Power of Attorney if applicable

Reason that I have been referred for care and support

Date of referral

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Eye Colour Height Build

Hair Colour Weight

My sensory needs

Any known allergies I have

Any special needs / comments I have

Any concerns I have regarding pressure sores or skin concerns

Emergency Contact Details

Emergency Contact should I need someone to represent my best interest for care andsupport

Other Family Contact details I want you to know

Any Other contact details for me

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Health Service contact details

My GP Contact Details

My Hospital Contact Details

My Physiotherapist Contact Details

My speech and language therapist Details

My Occupational Therapist Contact Details

My Consultant Contact Details

Any Community Team Details

My Care Manager Details

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Other contact details I need you to know

My Medical History

My nutritional needs and any existing dietary requirements

Please tell us if you are selfmedicating

Yes / No

Medication / Dosage

Instructions

Start Dates

Notes

Further Information

Medication / Dosage

Instructions

Start Dates

Further Information

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Signed by Service User…………………………………………….Date

The following people have supported me in this initial assessment

Signed by relevant staff member................................................ Date

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GUIDANCE ON INITIAL ASSESSMENT

Every service and organisation will have its own Initial Assessment process and paperwork –our intention is not to duplicate that but to enhance it in a person centred way.

Many Initial assessment processes and paperwork capture essential health and well beinginformation about the individual; the paperwork we are including focuses on many otheraspects of the individual, it looks at what they might want you to know rather thanwhat you need to know.There is a subtle difference!

On the Initial Assessment sheet you can add any other information you may feel is relevant.

You will see that there is a section on medication, simply completing this list of medicationdoes not replace any other medication responsibility i.e. obtaining, storage, handling,administration, disposal and MARS responsibility. You will need to have clear procedures inplace for how you support each service user with medication, this may also include ‘asrequired’ (PRN) medication.

We have included ‘How I communicate with others’ Not all communication is verbal. It isessential for your staff, the individual and their family to know how best the individualcommunicates, it offers other behaviour or body language that may be a form ofcommunication. If the staff and the individual do not have effective communication then itmakes everything else almost meaningless!

My care and well being asks the individual to tell you about their medical/social andemotional well being – physical well being is covered elsewhere. You will see that all of thepaperwork is written in the first person – it offers the individual ownership andempowerment – they are telling YOU rather than those discussions taking place with theminvolved – this is about the individual and or the family really leading this process.

What is working for me right now / What is not working for me right now? People arecoming into care or accessing care because something in their life is not working right now.It is crucial to find out from the individual what this is – what is it that is good for them andis working – this allows you to consider how you can support the individual to continuedoing this, allowing continued independence albeit with support. People may find it difficultto complete some of this paperwork – even if you are doing it with them / for them, peoplemay need lots of prompts and ideas. Ask people what they like doing and they will find iteasier to tell you what is working for them.

Equally so it is critical to find out what is not working, it allows you to consider how youcan support them so that they feel back in control. Offer prompts such as ‘Are there thingsyou used to do that with support you would like to do again’?

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We all have things in our lives that are not working and it leaves us feeling miserable andoften isolated – aim to put this right! It is fundamental to person centred care and support.

We all know that these two aspects of our life will constantly change – next week or in amonths time something else may not be working for us – that is why this document shouldalways be used as part of the review process (more information in the review section)

2


How

I c

om

mun

icat

e ve

rbal

ly

I am

abl

e to

com

mun

icat

e re

ason

ably

wel

l alt

houg

h la

tely

I h

ave

foun

d th

at t

he P

arki

nson

’s m

eans

I c

anno

tal

ways

get

my

word

s ou

t –

I d

o ge

t co

nfus

ed a

nd I

for

get

peop

le’s

nam

es a

nd t

hing

s th

at a

re m

eant

to

happ

en b

ut w

ith

rem

inde

rs I

am

ok.

Yo

u m

ay n

eed

to t

ell m

e th

ings

sev

eral

tim

es s

o th

at I

can

und

erst

and

what

is h

appe

ning

.

Ges

ture

s I

may

use

and

wha

t th

is m

ay m

ean

Som

etim

es I

get

con

fuse

d an

d m

ay a

sk f

or h

elp

with

han

d ge

stur

es in

dica

ting

wha

t it

is a

I n

eed

– I

know

what

I w

ant

but

cann

ot a

lway

s re

mem

ber

the

word

s so

will

poi

nt a

t th

ings

. Som

etim

es t

he w

ords

will

jus

t no

tco

me

out

so I

poi

nt.

Bo

dy L

angu

age

and

wha

t th

is m

ay m

ean

– ho

w I

may

sit

, sta

nd, f

acia

l exp

ress

ions

etc

.

I lik

e to

hav

e a

smile

on

my

face

. Fol

ding

my

arm

s do

es n

ot m

ean

I am

fed

up

it j

ust

help

s m

e wi

th m

ysh

akes

.

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3

HO

W I

CO

MM

UN

ICA

TE

WIT

H O

TH

ER

S


Beh

avio

ur a

nd w

hat

this

may

mea

n –

how

will

yo

u kn

ow I

am

hap

py, h

ow w

ill y

ou

know

I a

m s

ad, w

hat

do I

say

whe

n I

am a

ngry

I am

eas

y go

ing,

I li

ke a

cha

t. I

f I

am in

pai

n I

am q

uiet

I r

arel

y ge

t an

gry

– it

tak

es a

lot

– po

litic

ians

norm

ally

. I d

o sw

ear

som

etim

es b

ut n

ot a

t pe

ople

– o

nly

abou

t ev

ents

or

thin

gs t

hat

are

happ

enin

g –

peop

lewh

o ar

e do

ing

stup

id t

hing

s!

Oth

er w

ays

I m

ay c

om

mun

icat

e –

exam

ple

oth

er c

om

mun

icat

ion

supp

ort

I m

ay u

se

Som

etim

es I

stu

tter

bec

ause

of

the

Park

inso

n’s

plea

se j

ust

give

me

tim

e an

d en

cour

agem

ent

to t

alk

to y

ou.

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HO

W I

CO

MM

UN

ICA

TE

WIT

H O

TH

ER

S (C

ON

TIN

UE

D)


MY

CA

RE

AN

D M

Y W

EL

L B

EIN

G

My

med

ical

wel

l bei

ng

I ha

ve t

he f

ollo

win

g m

edic

al d

iagn

osi

s:

I ha

ve h

ad t

wo k

nee

repl

acem

ents

and

des

pite

thi

sm

y m

obili

ty is

not

goo

d I

need

to

walk

wit

h a

fram

eor

I w

ill f

all.

I ha

ve P

arki

nson

’s an

d I

shak

e a

lot,

ther

e is

a lo

t I

cann

ot d

o fo

r m

ysel

f an

ymor

e wh

ich

is v

ery

frus

trat

ing

– so

met

imes

I f

orge

t th

ings

– li

kem

y m

edic

atio

n or

whe

n m

y da

ught

er is

com

ing,

wha

tda

ys I

am

sup

pose

d to

go

to A

ge C

once

rn.

Wha

t do

I n

ot

wan

t to

hap

pen:

I do

not

wan

t to

go

into

hos

pita

l if

I ca

n av

oid

it. I

want

to

stay

mob

ile s

o th

at I

am

not

in a

cha

ir a

ll of

the

tim

e.

My

soci

al w

ell b

eing

How

yo

u ca

n su

ppo

rt m

y so

cial

wel

l bei

ng

I lik

e to

hav

e lo

ts o

f fa

mily

vis

its

thro

ugho

ut t

heda

y, I

like

goi

ng o

ut a

ltho

ugh

I ca

nnot

do

this

on

my

own

anym

ore.

I u

sed

to b

e a

keen

gar

dene

r an

dal

thou

gh I

do

very

litt

le g

arde

ning

I li

ke t

o go

sho

ws.

Wha

t do

I n

ot

wan

t to

hap

pen

I do

not

wan

t to

sto

p se

eing

my

fam

ily j

ust

beca

use

Iam

in a

hom

e. I

do

not

want

to

stop

doi

ng a

ll of

the

thin

gs I

like

doi

ng j

ust

beca

use

I am

not

abl

e to

go

out

on m

y ow

n.

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MY

CA

RE

AN

D M

Y W

EL

L B

EIN

G (C

ON

TIN

UE

D)

My

emo

tio

nal w

ell b

eing

How

yo

u ca

n su

ppo

rt m

y em

oti

ona

l wel

l bei

ng

I ha

ve w

orke

d pr

etty

muc

h al

l of

my

life

and

I ha

vese

en h

ard

tim

es s

o I

am t

ough

rea

lly!

and

as lo

ng a

sm

y gi

rls

are

ok I

am

ok

– if

the

y ar

e ha

ppy

I am

happ

y. I

like

to

chat

and

laug

h an

d he

ar a

ll th

e ne

ws.

Wha

t do

I n

ot

wan

t to

hap

pen:

For

me

to n

ot s

ee m

y fr

iend

s an

d fa

mily

. I w

ould

fee

law

ful i

f I

coul

d no

t ta

lk o

n th

e ph

one

to p

eopl

e an

d I

have

eve

n le

arnt

to

text

.

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What is working for me right now?


This sheet should be completed at initial assessment and then reviewed every month.

Date of initial assessment 20th august 2010

I am still mobile if someone is with me and I do like to go out andbe with my family. I enjoy my TV and other hobbies and pastimesthat I have done for many years. I want to hang onto thisindependence for as long as I can.

I like my own company but I also enjoy others – there is a balance- and many of my friends and dear family have passed on and I cannot get out as easily as I could 10 years ago to meet other people.I enjoyed going to Age Concern lunches and would like to keepgoing but am worried that this may not be possible.

I found my large house and garden too much trouble and wantedthe peace of mind that I can be supported as I go into later life. Istruggled with my medication –I had difficulty getting the bottlesopened and even the pack they gave me. Because of my Parkinson’sI couldn’t cook anymore and I couldn’t open tins and packets sosomeone had to come in from my neighbours to give me food – thiswas ok short term but not long term.

My house was large and I loved having my children and grandchildren fill the house but now they are all grown up and the housewas empty and lonely, that made me very sad. I also found I couldnot keep up with the repairs and the cleaning. I had someone comeand do the roof and my daughter said he charged me double – howwould I know! It made me cross but I only knew this wouldn’t getbetter. I am worried how I will like it here.

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ALL ABOUT ME AND MY LIFE

1

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MY CIRCLE OF SUPPORT

WHO IS IN MY LIFE

This could be otherfamily, friends,neighbours

People Closest to me.

3

This could be healthprofessionals, day centrestaff

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5

PEOPLE I LIKE TO STAY IN CONTACT WITH

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

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7

WHAT IS IMPORTANT TO ME?

What Is Important to Me?

Support I Need To Make This Happen

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How

to

sup

port

me

in m

aint

aini

ng m

y re

lati

ons

hips

and

fri

ends

hips

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou

to h

elp

me

wit

h

Fit

ness

and

Mo

bilit

y S

uppo

rt

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp m

ew

ith

9

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

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TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

My

pers

ona

l car

e su

ppo

rt

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou

to h

elp

me

wit

h

My

med

icat

ion

supp

ort

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h

10

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TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Get

ting

up

and

goin

g to

bed

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou

to h

elp

me

wit

h

My

eati

ng a

nd d

rink

ing

supp

ort

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h

11

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TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Sta

ff s

uppo

rt

How

wo

uld

you

like

staf

f to

appr

oac

h yo

u an

d tr

eat

you?

Wha

t ar

e yo

u co

ncer

ns a

bout

co

min

g he

re a

nd h

ow s

taff

will

sup

port

you?

Oth

er a

reas

of

supp

ort

as

requ

ired

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h

12

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TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Lo

oki

ng a

fter

my

envi

ronm

ent

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou

to h

elp

me

wit

h

Act

ivit

ies

I lik

e an

d ho

bbie

s

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h

13

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TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

My

sexu

alit

y

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou

to h

elp

me

wit

h

Lo

oki

ng a

fter

my

finan

ces

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h

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Ple

ase

tell

us a

bout

any

arr

ange

men

ts y

ou

curr

entl

yha

ve in

pla

ce, i

nclu

ding

whe

ther

yo

u ha

ve a

Will

.

If y

ou

do n

ot

have

any

thin

g in

pla

ce h

ow w

oul

d yo

ulik

e us

to

sup

port

yo

u w

ith

any

arra

ngem

ents

?

Do

yo

u ha

ve a

ny s

peci

fic s

piri

tual

bel

iefs

tha

t yo

uw

oul

d lik

e su

ppo

rt w

ith?

Who

wo

uld

you

like

wit

h yo

u?

15

MY

EN

D O

F L

IFE

PL

AN

CP ver1


MY

EN

D O

F L

IFE

PL

AN

(CO

NT

INU

ED

)

16

CP ver1

Sho

uld

this

sit

uati

on

aris

e w

ho e

lse

wo

uld

you

like

usto

co

ntac

t to

let

them

kno

w?

If y

ou

do n

ot

have

any

one

who

can

sup

port

yo

u w

oul

dyo

u lik

e us

to

sup

port

yo

u w

ith

an a

dvo

cate

or

befr

iend

ing

serv

ice

to o

ffer

sup

port

?

Wou

ld y

ou li

ke a

ny s

peci

al a

rran

gem

ents

in y

our

room

?

Wo

uld

you

like

any

oth

er s

peci

al a

rran

gem

ents

?


17

PERSON CENTRED PROFILE

The Following are examples of what a good day is for me – pleasehelp me to have good days

The Following are examples of what a bad day is for me – pleasehelp me NOT to have a bad day

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18


HOW I MAKE MY DECISIONS

Please work from the basis that I want to be involved in all of my decisions

19

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20


MY LIKES & DISLIKES

Activities/Leisure

Food/Drink

Anything Else

I Like I Dislike

I Like I Dislike

I Like I Dislike

21

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22

Signed by Service User ........................................................ Date

The following people have supported me in this assessment and it forms part ofmy agreed care plan

Signed by relevant staff member ........................................................ Date

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1

PERSON CENTRED PROFILE – THIS IS ABOUT ME.

Now let’s get really person centred and find out as much as we can about the individual,their life, their loves, their hopes and fears and their continued aspirations.

This is not a section that you can complete in one meeting or even one week – it should bea section that you are continuously adding to and learning about the individual, this way youbecome truly ‘person focussed’. You will have to work with your staff to look at how youcan do this.

Regulatory bodies may ask you to provide a care summary for the individual, this summarywill pull together all of the information into a one page summary that allows staff to give fullsupport. Try not to just pull pre assessment information and risk assessment informationinto this – include how the individual communicates, what is working for them right nowand what is not, along with other information included in this section.

All about me is exactly as it says, remember the person you are supporting may have livedmany years and seen many changes, they may have lived through many Prime ministers,many inventions and many disasters as well as joyous times – don’t summarise someone’sglorious life into a one page summary!

This is a live document that you and your staff can keep adding to during all of their timeliving with you.

To help with finding out information about the individual you will see the document Whatmy family and friends would like you to know about me

Please give one of these sheets to people who visit and ask them to complete at the timeor bring it back next time, please add this to the care plan folder, this helps you build theLife Profile and know as much as possible about the individual so that you can supportthem.

CP ver1


People I like to stay in contact with should be fairly straight forward.

My circle of support looks further than just my immediate family and friends, it could eveninclude pets. Some people are not able to take pets with them into care and other familymembers may look after them, however this pet may have been the most significant supportthat person has had for some time.

This tool can be used to really clarify who is and has been part of this individuals life – youwill already gather information on immediate next of kin and friends who the individualwishes to continue to visit, but what about people who they sometimes phone or onlycontact at Christmas and birthdays? What about neighbours, community people, clubs, otherhealth professionals, people at the individuals church or faith group, people the individualhas loved and lost.

Use this tool to help you see all of the relationships that this person has had / is still having/ wants to maintain / or people who potentially the person could lose contact with as theyare not close by or are not next of kin. The Circle of Support links in very well to People Ilike to stay in contact with as it allows you to support the individual with rememberingsignificant others and significant dates.

Probably one of the most important documents in a person centred plan is What isimportant to me. This documents looks at what’s important TO (what makes us happy,content, fulfilled) from what’s important FOR (health and safety, having support withpersonal care) which is captured in all of the other documents.

It is really the balance of what is my life all about, what makes me get up in themorning and what allows me to function so that I can have the life I chose. It is oftendifficult to complete this document and people may need time and or support to get itright. People may think of immediate comforts like food and warmth and actually the mostimportant thing to them is taking Communion or seeing a grandchild open birthdaypresents.

Give people time to think about this, it has to be meaningful, and of course once written itcan be changed as people suddenly say ‘actually this is what is truly important to me’

Get this right, and ensure you can support the individual with both sides of the balance, andyou really are truly person centred!

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2


To support me in my life you need to know this covers various aspects of the other sideof the scale – what is important for me. You may need to prompt people with each section sothat you get as much information as you possibly can.

You can ask questions on mobility such as: how independent are you, what walking aids doyou use, what assistance you need when walking/standing / getting in and out of a chair, haveyou had any falls, how can staff support you.

On personal care you can give prompts on all aspects of washing and dressing, you may needto give prompts as people may not remember all aspects of support such as washing /washing and brushing hair/ teeth care / shaving as applicable / makeup and creams / gettingdressed and undressed / toileting support / wearing any pads.

Medication support needs to determine how much someone can do for themselves and whatlevel of support they need from you.

Getting up and going to bed may include during the day as well as at night, do people wantyou to check on them and what level of support may they need during the night.

Food and drink support will look at support to cut up food, support to eat food and or usespecial utensils.

Find out from people how they like their food prepared and presented – do they have anysensory needs that result in food being presented in a certain way, this is important forsomeone’s overall enjoyment of food and meal times, where do they like to sit, have they anyknown allergies.

Understanding how someone likes to be treated and then ensuring that this is how staffbehave towards the individual offers the person respect and dignity.

Looking after my environment can cover looking after my clothes, my laundry needs, myroom, my keys, my plants.

All of us acknowledge our own sexuality and even if this is limited it should be acknowledgedby those around us. For many of us it is important to look good and feel good – this is part ofour sexuality. It can be putting on makeup and lipstick every day or when I go out ormaintaining my sexual relationship.

Finances can cover day to day money or more complex support.

My end of life plan of care often completely missed out of any care planning process until itis ‘necessary to complete’

Many staff and individuals find this aspect of care planning very difficult, often it is left until theindividual is actually dying, and trying to gather really person centred information at this time isvery difficult.

CP ver1

3


Acknowledge that at the point of receiving any form of support it will be difficult for theindividual to talk about their end of life, if anything they may be hoping that care andsupport will prolong their life substantially. Work with family and the individual so that yougather this information at a time to suit both parties - this is critical.

As young parents we spend endless time planning birth and involving others and yet at theother end of life we avoid talking and planning – we as individuals have more control overour death than we certainly do over our birth! So celebrate this opportunity.

Establish some of the legalities and practical arrangements – such as is there a Will, doesanyone have Power of Attorney – if so what sort and who holds the documentation; is anyfuneral plan in place – if so who with.

You should be looking at Advanced Care Planning to support this whole process howeveryou and staff must know how to manage this and understand how critical effectivecommunication is at this stage – ACP is not simply filling out a form. If and when someonewants to complete an Advanced Care Plan establish with them who else they may want tobe involved.

It may be relevant to discuss any Advanced Decisions to Refuse Treatment – ADRT – sameprinciples apply – staff must understand the legalities of this and have skills to complete this.You should seek support from other health Professionals when completing an AdvancedCare Plan and other health Professionals must be involved when completing an ADRT. Forfurther information on Advanced Care Planning or ADRT you could visit www.endoflife-careforadults.nhs.uk

Do find out about any spiritual support / pastoral / ministerial / other faith leaders support.Check how people may want their room, who they want present and or notified, whatworries they may have about end of life and how you can support them.

Similar to what is important to me, what is not working for me - Good days / Bad days isan essential document as a person centred tool. YOU need to know what a bad day lookslike and feels like for the individual so that you can all work together to prevent bad days,similarly you want to know what a good day looks like so that you can aim to provide thisevery day.

4

CP ver1


5

Making sure that the people you support are constantly empowered and in control is partof having a person centred approach to the support you offer, part of this support isembedded in decision making. The aim should be to support and empower individuals tomake their own decisions or at least have someone represent their best interests. Using thetool How I make decisions allows you to understand the decision making process for theindividual and who else they may wish to involve. This document is not intended to be usedas a mental capacity check, it is about being able to offer the correct level of support whilstacknowledging that the individual should always be in control and able to make their owndecisions, care is not about having someone else make those decisions on their behalf(other than best interest)

My likes and dislikes should be fairly straight forward – refer to case study for anexample of how to complete.

All of this documentation should not be static, you should be reviewing and updating asoften as you feel is required, as none of us stay the same.

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CP ver1

6


7

ALL ABOUT ME AND MY LIFE

My name is Jane Smith and I am 83 years old. I was born in the‘sound of bow bells’ although I have never considered myself as acockney. My mum was Margaret and my dad was Albert. My mumdidn’t work but my dad had a fish stall in Billingsgate market and Ihave many happy memories of helping him in the market. As youcan imagine I love fish and especially shell fish.

I have one brother David who is 5 years younger than me who ismarried to Elizabeth – we see each other once a month when hevisits me and I speak to him several times a week on the phone.I grew up during war years and when I was 15 I worked for theRed Cross helping out during the blitz. I went onto work at Bootsthe chemist after the war had finished and that is where I metSid. Sid was the Manager of Boots and the Pharmacist, he was 10years older than me but we fell in love and got married. Sid and Ihad 4 beautiful daughters and between them I now have 9 grandchildren and 2 great grand children.

Sid had a stroke not long after he retired and we all looked afterhim at home until he was very poorly and he then went into anursing home. I visited him every day until he died 6 years ago.My girls are the most important thing in my life and all of themvisit weekly at least and so do the grand children. They have allbeen so good at looking after me but it is time now to let someoneelse have that responsibility as much as I love them. Sid and I hada big house with lots of grounds and I just couldn’t look after it –it worried me all the time and the bills just kept coming in. Now Ican relax and enjoy my time with my children and grand childrenwith none of the responsibility.

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CP ver1

8


9

WHAT IS IMPORTANT TO ME?

What Is Important to Me?

Support I Need To Make This Happen

Being Respected andgiven Dignity

By staff explaining to other people that live with me, thatI expect the same dignity and respect as that they do.

Having all my thingsaround me

I need staff to support me to ensure my possessions arekept safe in my room.

To stay in contactwith my family

I need staff support to help me to telephone my familyregularly and co-ordinate visits to them.

Being able to makemyself a cup of teawhenever I want to

I need staff to support me if required to make myself acup of tea when I want to and not wait until the next teatime.

To have a televisionand video in my room

I need staff to support me to ensure that this is workingat all times. I need staff to support me to purchase newvideos if I require them.

To spend time on myown in my room

I need staff to understand that I need to have my ownspace and to give me the opportunity to have this. I do notalways like people coming into my room. So please respectthis. I don’t mind staff knocking and coming in.

I like to go out asoften as possible andwant to be able to dothis

I need staff to offer me opportunities to go out andsometimes help me get ready. I like to go out for daysand hope that staff will support me on this, either takingme or helping me to find out who I can go with – family,friends or community groups.

I am a tidy person andlike my room to beclean and tidy at alltimes

I have always been very tidy and like to look after my ownthings, it helps me to feel independent but now I mayneed help with this – I would like staff to support me.

To know what staffare working on shift

Staff to inform me who is working if I ask them.

I worry about beingsnapped at or beingcalled darling

Please don’t snap at me I am doing my best. My name isJane and please always call me that and not any term ofendearment.

To have choices To support me to have a choice in

• If I have bath or wash in the morning

• To go shopping to choose my clothes

CP ver1


CP ver1

10


TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

11

How

to

sup

port

me

in m

aint

aini

ng m

y re

lati

ons

hips

and

fri

ends

hips

Thi

s is

why

I n

eed

supp

ort

I no

w ne

ed s

uppo

rt t

o go

out

as

my

mob

ility

and

my

Park

inso

n’s

mea

nsI

cann

ot g

o al

one.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ha

ve lo

ts o

f fr

iend

s wh

o vi

sit

me

– I

now

rare

ly g

et t

o vi

sit

them

but

I am

abl

e to

tal

k on

the

pho

nean

d en

joy

thei

r vi

sits

.

Thi

s is

wha

t I

need

yo

u to

hel

p m

ew

ith

I wo

uld

like

to s

till

go o

ut s

o I

need

hel

p pl

anni

ng t

hat

– wh

o wi

llta

ke m

e an

d wh

en; m

y fa

mily

tak

em

e ou

t lo

ts a

nd s

o do

my

frie

nds.

Iwi

ll ne

ed h

elp

to g

et r

eady

.

Fit

ness

and

Mo

bilit

y S

uppo

rt

Thi

s is

why

I n

eed

supp

ort

My

mob

ility

is n

ow p

oor

and

I ha

veto

wal

k wi

th m

y fr

ame

at a

ll ti

mes

.Th

is is

wha

t I

can

do f

or m

ysel

f.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n ge

t up

out

of

the

chai

r an

d ou

tof

bed

as

long

as

this

is n

ot t

oohi

gh; a

ltho

ugh

I m

ust

mak

e su

re m

yfr

ame

is c

lose

by

me.

I a

m s

low

but

I ca

n wa

lk w

ith

the

fram

e. M

y fa

mily

had

a wh

eelc

hair

whi

ch t

hey

used

when

ever

we

went

out

so

that

I d

idno

t ha

ve t

o wa

lk f

ar. I

cou

ld g

et o

utof

the

car

e an

d wa

lk in

to t

he h

ouse

it j

ust

take

s m

e a

bit

of t

ime.

Thi

s is

wha

t I

need

you

to

help

me

wit

h

I ne

ed s

taff

to

mak

e su

re I

hav

em

y fr

ame

at a

ll ti

mes

and

let

me

walk

abo

ut in

the

hom

e. I

can

wal

kto

the

bat

hroo

m a

nd a

roun

d m

yro

om.

CP ver1


12

CP ver1

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

My

pers

ona

l car

e su

ppo

rt

Thi

s is

why

I n

eed

supp

ort

My

mob

ility

and

sha

kes

mea

ns t

hat

I ca

n no

long

er d

o lo

ts o

f th

ings

for

mys

elf.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n st

ill w

ash

my

face

and

bru

shm

y ha

ir. I

usu

ally

hav

e m

y ha

ir c

utat

Age

Con

cern

. I c

ould

get

in t

hesh

ower

at

hom

e be

caus

e I

had

asp

ecia

l cha

ir a

nd s

lip m

ats

alth

ough

I wa

s be

ginn

ing

to f

eel w

orri

edab

out

this

as

my

mob

ility

is n

ot a

sgo

od a

s it

use

d to

be.

Thi

s is

wha

t I

need

yo

u to

hel

p m

e w

ith

If s

omeo

ne c

ould

cle

an m

y de

ntur

es a

t ni

ght

and

rins

e in

the

mor

ning

ple

ase.

I c

an g

et t

o th

eba

thro

om a

nd w

ash

my

face

and

han

ds b

ut t

here

st o

f m

y bo

dy I

can

no

long

er d

o. I

wou

ld li

keso

me

help

wit

h th

is a

nd h

elp

with

a s

howe

r –

just

know

ing

som

eone

is t

here

and

can

hel

p m

e in

,tu

rn o

n th

e wa

ter,

hel

p m

e ou

t an

d dr

y m

e al

lov

er.

I am

abl

e to

get

to

the

toile

t by

mys

elf

and

man

age

this

at

the

mom

ent.

I d

o no

t we

ar a

nypa

ds.

My

med

icat

ion

supp

ort

Thi

s is

why

I n

eed

supp

ort

I am

sha

key

and

do f

orge

t ti

mes

Iam

sup

pose

d to

tak

e th

em a

ndwh

at m

edic

atio

n is

for

wha

t. I

cann

ot g

et b

ottl

es a

nd p

acks

ope

nTh

is is

wha

t I

can

do f

or m

ysel

f.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n ac

tual

ly t

ake

my

med

icat

ion

if s

omeo

ne g

ives

it t

o m

e.So

met

imes

I m

ay s

hake

and

dro

pth

em –

I d

o no

t m

ean

to d

o th

is.

Thi

s is

wha

t I

need

you

to

help

m

e w

ith

I ne

ed h

elp

with

tim

ings

for

my

med

icat

ion

– wh

at I

tak

e an

d wh

en.

Plea

se h

and

me

the

med

icat

ion

and

watc

h to

mak

e su

re I

do

not

drop

them

. Ple

ase

can

you

man

age

all o

fth

e re

orde

ring

and

the

col

lect

ion.


13

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Get

ting

up

and

goin

g to

bed

Thi

s is

why

I n

eed

supp

ort

I no

w st

rugg

le t

o ge

t un

dres

sed

and

dres

sed

and

it t

akes

me

a lo

ngti

me.

I h

ave

had

to w

ear

easy

clot

hes

with

eas

y fa

sten

ers.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

If I

can

hav

e he

lp g

etti

ng d

ress

edI

am a

ble

to c

hose

all

of m

y ow

ncl

othe

s.

Thi

s is

wha

t I

need

yo

u to

hel

p m

e w

ith

Plea

se h

elp

me

to g

et d

ress

ed a

ndun

dres

sed.

My

eati

ng a

nd d

rink

ing

supp

ort

Thi

s is

why

I n

eed

supp

ort

I am

not

abl

e to

pre

pare

my

food

anym

ore

and

my

shak

es s

omet

imes

mea

n I

spill

som

e fo

od a

nd d

rink

.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n ea

t an

d dr

ink

mys

elf

– I

dono

t ne

ed t

o be

fed

! Som

etim

es I

ask

for

help

wit

h cu

ttin

g up

foo

d. I

am a

ble

to m

ake

all o

f m

y ow

nch

oice

s.

Thi

s is

wha

t I

need

you

to

help

m

e w

ith

I ne

ed s

taff

to

help

me

eith

er g

etto

the

din

ing

room

or

brin

g m

efo

od a

nd d

rink

to

my

room

. I w

illas

k if

I n

eed

help

cut

ting

it u

p.

CP ver1


14

CP ver1

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Sta

ff s

uppo

rt

How

wo

uld

you

like

staf

f to

appr

oac

h yo

u an

d tr

eat

you?

I lik

e st

aff

to c

all m

e by

my

nam

e–

Jane

– n

ot a

ny o

ther

nam

e –

espe

cial

ly n

ot lo

vey!

I c

an b

e qu

iet

and

on t

hese

occ

asio

ns w

hen

I am

quie

t an

d or

tir

ed p

leas

e re

spec

tth

is a

nd d

o no

t tr

y an

d ge

t m

ein

volv

ed in

oth

er t

hing

s.

Wha

t ar

e yo

u co

ncer

ns a

bout

co

min

g he

re a

nd h

ow s

taff

will

sup

port

you?

Staf

f ne

ver

havi

ng e

noug

h ti

me,

thi

nkin

g I

am o

ld a

nd s

tupi

d.

I wo

rry

abou

t wh

ethe

r I

can

do a

ll of

the

thi

ngs

I ha

ve b

een

doin

g, c

anm

y fa

mily

sti

ll co

me

in a

nd s

pend

tim

e wi

th m

e?

Oth

er a

reas

of

supp

ort

as

requ

ired

Thi

s is

why

I n

eed

supp

ort

Thi

s is

wha

t I

can

do fo

r m

ysel

fT

his

is w

hat

I ne

ed y

ou t

o he

lp

me

wit

h


15

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

Lo

oki

ng a

fter

my

envi

ronm

ent

Thi

s is

why

I n

eed

supp

ort

I lik

e to

kee

p m

y ro

om t

idy

and

thin

gs in

cer

tain

pla

ces

– th

is h

elps

me

rem

embe

r wh

ere

they

are

.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I am

abl

e to

mov

e th

ings

aro

und

but

I ca

nnot

do

any

clea

ning

.an

ymor

e

Thi

s is

wha

t I

need

yo

u to

hel

p m

e w

ith

Plea

se h

elp

me

keep

my

room

tid

yan

d in

the

way

I w

ant

it.

Act

ivit

ies

I lik

e an

d ho

bbie

s

Thi

s is

why

I n

eed

supp

ort

My

mob

ility

and

Par

kins

on’s

dise

ase

have

res

tric

ted

the

thin

gs I

can

now

do.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n st

ill g

o ou

t an

d I

can

still

enjo

y a

pub

lunc

h. M

y fa

mily

tak

em

e ou

t a

lot

and

I do

not

wan

t th

isto

sto

p. I

love

goi

ng t

o ga

rden

show

s bu

t I

do n

eed

som

eone

to

take

me.

I lo

ve m

y TV

and

my

soap

s. I

hav

em

y ow

n re

cord

er a

nd li

ke t

o re

cord

late

pro

gram

mes

tha

t I

then

wat

chin

the

day

tim

e.

Thi

s is

wha

t I

need

you

to

help

m

e w

ith

Plea

se h

elp

me

arra

nge

how

and

when

I c

an k

eep

goin

g ou

t wi

thfr

iend

s an

d fa

mily

.

Plea

se h

elp

me

set

up m

y re

cord

eran

d he

lp m

e if

it is

not

wor

king

.So

met

imes

I p

ush

a wr

ong

butt

onan

d it

doe

s no

t wo

rk I

do

not

do it

delib

erat

ely.

CP ver1


16

CP ver1

TO

SU

PP

OR

T M

E I

N M

Y L

IFE

YO

U N

EE

D T

O K

NO

W T

HIS

(CO

NT

INU

ED

)

My

sexu

alit

y

Thi

s is

why

I n

eed

supp

ort

I st

ill w

ant

to lo

ok a

nd f

eel g

ood

when

I g

o ou

t an

d I

may

nee

dsu

ppor

t to

do

this

.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I ca

n st

ill m

ake

sure

my

hair

isni

ce a

nd I

like

to

have

my

lipst

ick

on.T

his

is w

hat

I ne

ed y

ou t

o he

lpm

e wi

th.

Thi

s is

wha

t I

need

yo

u to

hel

p m

e w

ith

Plea

se h

elp

me

to g

et d

ress

ed a

ndlo

ok g

ood

for

when

ever

I h

ave

visi

tors

or

when

I g

o ou

t.

Lo

oki

ng a

fter

my

finan

ces

Thi

s is

why

I n

eed

supp

ort

I ge

t co

nfus

ed w

ith

my

bills

and

fina

nces

.

Thi

s is

wha

t I

can

do fo

r m

ysel

f

I lik

e to

hav

e m

oney

in m

y pu

rse

soth

at w

hen

I go

out

I c

an b

uyth

ings

.

Thi

s is

wha

t I

need

you

to

help

m

e w

ith

My

daug

hter

has

alw

ays

help

ed m

ewi

th t

his

but

I m

ay n

eed

you

tore

min

d m

e to

tak

e m

y pu

rse

with

me.


MY

EN

D O

F L

IFE

PL

AN

17

Ple

ase

tell

us a

bout

any

arr

ange

men

ts y

ou

curr

entl

yha

ve in

pla

ce, i

nclu

ding

whe

ther

yo

u ha

ve a

Will

.I

do h

ave

a W

ill a

nd m

y da

ught

er h

as t

he c

opy.

Iha

ve v

ario

us in

sura

nces

tha

t m

y da

ught

er k

nows

all

ofth

e de

tails

for

.

If y

ou

do n

ot

have

any

thin

g in

pla

ce h

ow w

oul

d yo

ulik

e us

to

sup

port

yo

u w

ith

any

arra

ngem

ents

?M

y Fu

nera

l pla

n is

all

agre

ed w

ith

my

daug

hter

s.

Do

yo

u ha

ve a

ny s

peci

fic s

piri

tual

bel

iefs

tha

t yo

uw

oul

d lik

e su

ppo

rt w

ith?

I am

Chu

rch

of E

ngla

nd, I

hop

e th

at I

can

con

tinu

eto

hav

e Co

mm

unio

n he

re.

Who

wo

uld

you

like

wit

h yo

u?M

y fa

mily

is t

oo b

ig f

or e

very

one

to b

e he

re –

but

Iha

ve f

our

daug

hter

s an

d I

am s

ure

they

will

wan

t to

be h

ere

– if

the

y do

n’t

that

is f

ine.

The

y wi

ll wa

ntth

eir

own

child

ren

to v

isit

and

the

y wi

ll ag

ree

this

as

tim

e go

es.

CP ver1


Sho

uld

this

sit

uati

on

aris

e w

ho e

lse

wo

uld

you

like

usto

co

ntac

t to

let

them

kno

w?

I wo

uld

like

my

daug

hter

s to

let

all m

y ot

her

frie

nds

and

fam

ily k

now.

If y

ou

do n

ot

have

any

one

who

can

sup

port

yo

u w

oul

dyo

u lik

e us

to

sup

port

yo

u w

ith

an a

dvo

cate

or

befr

iend

ing

serv

ice

to o

ffer

sup

port

?

Wo

uld

you

like

any

spec

ial a

rran

gem

ents

in y

our

roo

m?

I wa

nt it

qui

et, m

y da

ught

ers

pres

ent

and

able

to

stay

as

long

as

they

wan

t.

Wo

uld

you

like

any

oth

er s

peci

al a

rran

gem

ents

?

CP ver1

18

MY

EN

D O

F L

IFE

PL

AN

(CO

NT

INU

ED

)


CP ver1

INITIAL ASSESSMENT

Date of initial assessment 20th August 2010

19


CP ver1

20


21

PERSON CENTRED PROFILE

The Following are examples of what a good day is for me – pleasehelp me to have good days

The Following are examples of what a bad day is for me – pleasehelp me NOT to have a bad day

I am at my happiest when my family and friends visit and we cango out for lunch or in the summer visit a garden. I enjoy my foodand sharing a good laugh and a chat with someone.

I like to get up in the morning and have my breakfast, I amnormally up by 8, I like to watch my programmes I have recorded. At least one afternoon a week I go to Age Concern to meet myfriends, we have some coffee and a chat and sometimes I havearomatherapy there. I prefer to have my shower in the evening, Ithen have my tea with a Gin and Tonic watch my tele and go tobed no later than 8.30.

Sometimes I sleep badly and for no reason. If this happens I feelexhausted the next day, I sleep a lot and generally feel off colour.I don’t feel like doing much and often have to miss things I wouldhave planned. Sometimes I go back to bed in the afternoon.

CP ver1


CP ver1

22


23

HOW I MAKE MY DECISIONS

Please work from the basis that I want to be involved in all of my decisions

Important Decisionsthat I may need tomake

How I must beinvolved

Who can help memake these decisions

If I am unwell andneed my GP or Ineed to go to thehospital I want tomake thesedecisions.

Please talk to meabout this anddiscuss why this ishappening.

Please ring mydaughter so that sheknows the situation.

At the moment I candecide all of my carechoices – such aswhat I need / whenI need it / how Ineed it.

Please do not takethese decisions away– do not makeassumptions on mybehalf.

My family ifnecessary.

I like to decide howmy room is set outand what goes in it.

Please discuss withme – I know this ismy home but I alsoknow other peoplelive here and stafflook after me.

The manager, my keyworker and otherstaff.

I like to go out andhave a pub lunch,maybe even do a bitof shopping and havea coffee somewhere;I want to continuedoing this with myfamily and friendswho can take me out,I don’t always wantto go with everyoneelse who also liveshere.

Talk to me about theoptions.

Family, friends, andthe staff.

CP ver1


CP ver1

24


25

MY LIKES & DISLIKES

Activities/Leisure

Food/Drink

Anything Else

I Like I Dislike

Cakes Salad

Biscuits Gravy

Crisps Custard

Sausage Rolls Oranges

Toast

Chicken

Beef

Curries

Puddings

Burgers

Pizza

Shepard’s Pie

Pies

Pasties

I Like I Dislike

Going out Bingo

Preparing Meals Not having my own space sometimes

Cooking Meals Sports on TV

Baking Cakes Cats

Reading Pantomimes

Cleaning Vera Lynn

Watching TV

I Like I Dislike

Playing Cards Being called luvvey or darling

Meeting New People Loud Music

People moving my possessions

CP ver1


CP ver1

26


MY DAILY ROUTINE

If I have one I would like to complete this

Time Routine Support I may need to do this

1

CP ver1


CP ver1

2


Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Sup

port

pla

n co

mpl

eted

by

Dat

e o

f co

mpl

etio

nS

ched

uled

nex

t re

view

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

3

SU

PP

OR

T P

LA

N

CP ver1


CP ver1

4


SU

PP

OR

T P

LA

N

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Sup

port

pla

n co

mpl

eted

by

Dat

e o

f co

mpl

etio

nS

ched

uled

nex

t re

view

Co

mm

unic

atio

n

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

5

CP ver1


CP ver1

6


SU

PP

OR

T P

LA

N

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Med

icat

ion

Sup

port

and

pai

n re

lief

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

7

CP ver1


CP ver1

8


SU

PP

OR

T P

LA

N

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Mo

bilit

y

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

9

CP ver1


CP ver1

10


SU

PP

OR

T P

LA

N

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Pers

ona

l car

e an

d dr

essi

ng n

eeds

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

Pers

ona

l car

e

Hai

r w

ashi

ng

Den

ture

/ te

eth

care

Mak

eup

and

crea

ms

Dre

ssin

g

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

11

CP ver1


CP ver1

12


Ris

k A

sses

smen

t D

etai

ls

1. W

hat

is t

hede

cisi

on

or

cho

ice

to b

em

ade?

2. W

hat

are

the

pote

ntia

lbe

nefit

s?

3. H

ow li

kely

are

thes

e to

be

achi

eved

?

4. W

hat

coul

d go

wro

ng?

Is t

here

apo

ssib

ility

tha

tan

yone

may

be

harm

ed?

5. a

) H

ow li

kely

is t

his

to o

ccur

?b)

If

som

ethi

ngw

ent

wro

ng,

wha

t w

oul

d th

ese

veri

ty o

f th

eo

utco

me

be?

6. W

hat

are

the

exis

ting

fac

tors

whi

ch p

rom

ote

bene

fit a

ndre

duce

the

chan

ces

of

anyt

hing

go

ing

wro

ng?

7. W

hat

addi

tion

al a

ctio

nsw

ould

pro

mot

ebe

nefit

and

redu

ce t

hech

ance

s of

som

ethi

ng g

oing

wro

ng?

8. W

hat

risk

s w

illre

mai

n af

ter

acti

on p

lan

is in

plac

e?

Plea

se c

ompl

ete

addi

tiona

l she

et fo

r an

y ot

her

choi

ces/

decis

ions

to

be c

onsid

ered

13

RIS

K A

SS

ES

SM

EN

T

CP ver1


CP ver1

14

Ris

k A

sses

smen

t D

etai

ls

1. W

hat

is t

hede

cisi

on

or

cho

ice

to b

em

ade?

2. W

hat

are

the

pote

ntia

lbe

nefit

s?

3. H

ow li

kely

are

thes

e to

be

achi

eved

?

4. W

hat

coul

d go

wro

ng?

Is t

here

apo

ssib

ility

tha

tan

yone

may

be

harm

ed?

5. a

) H

ow li

kely

is t

his

to o

ccur

?b)

If

som

ethi

ngw

ent

wro

ng,

wha

t w

oul

d th

ese

veri

ty o

f th

eo

utco

me

be?

6. W

hat

are

the

exis

ting

fac

tors

whi

ch p

rom

ote

bene

fit a

ndre

duce

the

chan

ces

of

anyt

hing

go

ing

wro

ng?

7. W

hat

addi

tion

al a

ctio

nsw

ould

pro

mot

ebe

nefit

and

redu

ce t

hech

ance

s of

som

ethi

ng g

oing

wro

ng?

8. W

hat

risk

s w

illre

mai

n af

ter

acti

on p

lan

is in

plac

e?

Plea

se c

ompl

ete

addi

tiona

l she

et fo

r an

y ot

her

choi

ces/

decis

ions

to

be c

onsid

ered

RIS

K A

SS

ES

SM

EN

T


Ris

k M

anag

emen

t P

lan:

Ple

ase

give

det

ails

of

acti

ons

agr

eed

whi

ch w

ill p

rom

ote

ben

efit

s an

d re

duce

the

cha

nces

of

som

ethi

nggo

ing

wro

ng, a

nd s

pec

ific

ally

how

ris

ks r

emai

ning

iden

tifi

ed (

colu

mn

8) c

ould

be

man

aged

and

who

will

be

resp

onsi

ble

for

thes

e.

Ris

k M

anag

emen

t P

lan

- Act

ion

agre

edW

ho w

ill b

e re

spo

nsib

leW

hen

will

thi

s be

rev

iew

ed

15

RIS

K M

AN

AG

EM

EN

T P

LA

N

CP ver1


Plea

se c

ompl

ete

addi

tiona

l she

et fo

r an

y ot

her

actio

ns a

gree

d

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

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RIS

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CP ver1


GUIDANCE ON SUPPORT PLANNING

Personalised care planning is essentially about addressing an individual’s full range of needs,taking into account their health, personal, social, economic, educational, mental health, ethnicand cultural background and circumstances. It recognises that there are other issues inaddition to medical needs that can impact on a person’s total health and well-being.You will see from all of the templates that have been developed that these have a realpersonalised approach embedded in them and they should help you build holistic supportneeds for someone.

The new Essential Standards are looking at how you can support and meet an individual’soutcomes. All of us make decisions every day on all sorts of issues – on what we want todo and as importantly what we do not want to do. We all need some level of control overour lives – it’s a basic human need.

Quality of life is complex and depends a great deal on how individuals view what makes lifeenjoyable, meaningful and worth living for them.

The shift is simply from needs based care to outcomes based care.

So what does an outcome look like?

The Department of Health says:

An outcome = a measure of the success of the service delivered.

The equation used is as follows:

Outcome = Activity + Results + Experience

Regulatory authorities, such as CQC and commissioners, seek evidence that people whouse the service achieve a ‘good life’ and this is dependent on meeting their personal choicesand preferences, over and above their needs and requirements.

For the purpose of this folder the individualised support needs are referred to as Support Plans.

Each Support Plan supports the individual’s independence and self esteem by establishingwhat the individual can do for themselves and then establishing the support that theindividual requires from staff to meet his or her outcome.

1

CP ver1


CP ver1

2

The Support Plan should show:What my needs are and what I can doWhat my OUTCOMES areWhat Support I need from staff

You should have one plan for each area of support and this plan should be as above andinclude a Risk Assessment. It should be really clear how each section has been Reviewedand where the Review paperwork is. This may be separate or after each section of care

The following are suggested areas of care support:

1. My Communication needs2. My Safety needs 3. My Behaviour4. My mental health well being. 5. My emotional well being6. My health, medication and pain needs7. My mobility support needs8. My Eating and Drinking needs 9. My nutritional plan10. My toileting needs and continence care needs11. My Personal care and dressing needs12. Mt continence needs13. My skin care needs14. My Dental care15. My eye care16. My Hearing aid care17. My Social well being needs18. Activities I enjoy and how I can be supported19. My night time care plan20. My End of Life Plan21. My Living Will / Power of Attorney

This list is by no means exhaustive; Support Plans should be built around the individual andtheir needs not around a template format!

Remember! Good recording is essential – if the individual and you require the staff to docertain tasks to support the individual then the Support Plan must indicate this – don’tassume that staff know how to support an individual or what the individual requires. Remember if it isn’t written down your staff may not do it!

Support Plans should indicate what’s important to the individual; a Support Plan mustsupport the individual first and foremost and not be seen as a staff tool. The individualshould be happy with the Support Plan, and how you and staff are going to support them.

All Support Plans will be reviewed regularly. Reviews will be covered in the next section.


CP ver1

3

GUIDANCE ON RISK MANAGEMENT ANDASSESSMENT PLANS

Risk assessment is one step in a risk management process. A risk assessment is simply acareful examination of what potentially could cause harm to people, it is managing anuncertainty with a possibility that it may occur with potential harmful outcomes for theindividual. The risk management process should look at the likelihood of somethinghappening and the severity of the outcome of this happening.

In social care, risk assessment and risk management must be seen to promote positive risktaking that supports people to live their lives and make their own choices, positive riskassessment is about supporting people and staff to see the benefits of some risk takingwhilst also identifying the harms.

The five basic principles of risk assessing:1. Identify the risks 2. Decide who might be harmed and how 3. Evaluate the risks and decide on precaution 4. Record your findings and implement them 5. Review your assessment and update if necessary

In many care settings the risk assessment process is ‘controlled’ by managers and staff,rarely do individuals who are using services lead this process to the point where they feelempowered to identify risks they want to take and identify the support they want from staffand managers. Risk assessment often supports staff in minimising harm to the individualrather than allowing the individual to achieve their desired outcomes.

It is not possible to eliminate all risk, we all take risks on a daily basis knowing that we maybe at risk but it is a part of life, and is normally a good thing. Taking risks gives us choiceand control, independence and empowerment, for many it is a real buzz – otherwise no onewould be allowed to bungee jump! Not taking risks can mean that people are not able tofeel all of these emotions, and may be prevented from doing things which make them happy.Therefore people should be supported to make real choices, even when these choices maysometimes be unwise or could lead to harm.

In certain circumstances it may not be possible to apply this approach if there is a safeguardingissue or where someone does not have capacity, however, where someone does not have capacity,decisions made in their best interest must have those best interests at heart and be the leastrestrictive.


CP ver1

4

Robust risk management involves the individual, people they have identified as wanting to beinvolved, staff and any other relevant professionals; the assessment and risk planning processshould take in the 5 steps identified above and support the individual to weigh up theadvantages and disadvantages of a proposed course of action, this allows the individual tomake an informed choice.

In order to support the individual with effective seamless care and support youshould ensure that the Risk Assessment and the Risk Management Plan are linked tothe Support Plan. We suggest that when setting up the Care Plan Folder all of theSupport Plans have the relevant Risk Assessment and Risk Management Plantogether. This allows the individuals, their family as required, staff and otherprofessionals to see how the Support and the Risks are planned and managed.

Throughout the assessment practitioners will need to ensure that they are makingprofessional judgements based on all the information available to them from their ownknowledge, and information provided by others. Information provided directly by theperson including their wishes and aspirations must be at the centre of the assessment sothat this can be balanced against other available information. Practitioners should beparticularly careful to ensure that they take into account the person’s own view of risk,including any cultural factors.

It is important when doing this to find out why the person wishes to make a particularchoice, what this will bring to their life, and how their life may be adversely affected if theyare prevented from making this choice. You still have a duty of care throughout this wholeprocess and the process must be robust enough to offer you consideration of the balanceof risk between benefit and harm.

When considering safeguarding, mental capacity and risk, practitioners and managers shouldalso consider any legislation, guidance or standards which may apply.

When completing the risk assessment, each choice or decision must be consideredseparately. For each decision, it may also be necessary to carry out a separate riskassessment to look at the potential benefits and harms of:

a) Making the choice e.g. deciding to do something, or carry out a particular courseof action

b) Not making the choice e.g. deciding not to do something or carry out a particularcourse of action

c) Partially making the choice e.g. deciding to partly undertake an activity or carryout a particular course of action

For example, for someone in hospital, the choices to return home or not to return homemay have different risk factors which need to be considered. It is important that time isspent planning the risk assessment and determining the decisions which need to beconsidered and how they should be broken down to ensure that all the choices andpotential risks are considered.

The following is Guidance to support the Risk Management Plans included in this Care Plan.


CP ver1

5

What is the decision or choice to be made?

This is an essential part of the risk assessment process. Defining the decision/s to be madeis a key part of the assessment and sufficient time needs to be given to this task.

What are the potential benefits?

It is essential that these are seen from the point of view of the person who is the subject ofthe assessment, and includes their wishes and aspirations, as well as more tangible benefitssuch as fewer falls, less dependency on others, safer environment.

How likely are these to be achieved?

This may be expressed in terms of likelihood (definite, likely, unlikely) frequency (always,sometimes, regularly, rarely) but must be described in relation to the specified decision andmust be based on good information and evidence. If it is unknown then this should bestated, this may be the case if there is no information on which to base a prediction. Thelikelihood of achieving a benefit may depend on other factors, which could be considered incolumn 7. Past history can be considered but needs to be up to date, relevant, andevidenced. If the information is based on the statements or observations of others, it isparticularly important to weigh this carefully and to seek evidence or corroboration whereappropriate.

What could go wrong? Is there a possibility that anyone may be harmed?

The potential harms to the person or others needs to be considered here – what could gowrong in the person’s life or with their support plan. If there is potential harm to othersthis should be specified to ensure the risks are considered fully. There may be risk to acarer (family member or other), a care worker, other people or professionals involved inthe person’s social or health care, or to the wider public. It is essential that these potentialharms are based on good information and evidence, and in relation to care workers & otherprofessionals that they take into account health and safety legislation.

How likely is this to occur?

As with Column 3, the way this is described should be appropriate to the potential harmspecified, and must be based on good information and evidence and consider the samefactors – is the information up to date? Is it relevant? Can it be evidenced?

If something went wrong, what would the severity of the outcome be?

It is essential that there is an assessment of the severity of harm which could arise. It isimportant to consider a worst case scenario e.g. death, serious injury, admission to hospital,loss of accommodation. This may then be balanced by factors in Column 6 and Column 7.


CP ver1

6

What are the existing factors which promote benefit and reduce the chances ofanything going wrong?

Consider the person’s current situation, the environment, what their family/friends/othersupport network are already contributing.

What additional actions would promote benefit and reduce the chances ofanything going wrong?

Consider what could be done to manage the risks and promote benefits. Not everythingmay be achievable, and this will in part inform the risk decision. State here what has beenconsidered and who could do this.

What risks will remain after action plan is in place?

It may not be possible to manage all the risks, and it is important to identify where this isthe case. Unmanaged risks may impact on the success of the risk management plan, and willinform the risk decision, depending on the severity and likelihood of any risks which cannotbe managed within a risk management action plan.

Risk Management Action Plan

In this section the components of the risk management plan should be specified: whatactions have been agreed, and who will be responsible for them. It is important that therisk management plan is reviewed and that the timescale for this is agreed. Differentaspects of the risk management plan may need to be reviewed at different times dependingon how they are to be carried out and how significant they are to the success of the plan.If unmanaged risks have been identified in column 8 of the risk assessment, the riskmanagement plan must include details of how these could be managed, how this will bemonitored, and who will be responsible.

Back up Plan – what could go wrong?

This section should be used to consider anything which could go wrong with the agreedplan, using the information in the risk assessment. Any foreseeable problems should beconsidered here and details provided about what actions have been agreed and who will beresponsible for them. This should include information about who can be contacted toprovide information or support in such circumstances.


CP ver1

7

When carrying out risk assessments and risk management, the following factors should beconsidered:

● The identification, assessment and management of risk should promoteindependence and social inclusion

● Risks may be minimised, but not eliminated● It may not be possible to manage all risks● Identification of risk carries a duty to do something about it, i.e. to manage the

risk● Risks may change as circumstances change, and should be reviewed – an

assessment is a snapshot, whereas risk assessment is an ongoing process

It is essential that the risk assessment process is recorded, and that recording clearly showsidentified risks and decisions and actions agreed as a result of the process. Recording shouldalways evidence:

● The risks identified ● The potential benefits and harms and likelihood these will occur● The risk management plan that supports decision making, to include the rationale

behind the decisions made.● Who made the decision and who was involved● When the risk assessment will be reviewed● Who is responsible for any actions agreed and how support will be given to the

individual if this is part of the plan of support.

Risk assessment and risk management should be part of all assessment and planning for theprovision of social care. Therefore all assessment documentation should identify the typesof risk assessed, and contain the necessary information to enable a decision to be madewhich takes account of the potential benefits and harms, and the likelihood of theseoccurring.

● Daily recording should include the steps staff have taken on a daily basis to followthe risk management actions.


CP ver1

8


CP ver1

9

GUIDANCE AROUND CONSENT, MENTALCAPACITY ASSESSMENTS AND SUPPORTPLANNING.

Good practice and CQC outcomes require that care/support plans are consented to by theindividual receiving the care.

The Mental Capacity Act requires that capacity is assumed and so with this in mind allindividuals capable of doing so should contribute to and consent in writing to their careplan.

As a provider if you have reason to believe that an individual lacks capacity to contributeand consent to part or all of their care plan you must document that you have ‘reasonable’grounds for believing that the person lacks capacity in respect of the area and what led youto that decision. To have ‘reasonable’ grounds you must have taken ‘reasonable’ steps toestablish that the person lacks capacity to contribute to and consent to their plan.

Having carried out an assessment and recorded your rationale, objective reasons and stepsto establish capacity you can then assess and develop the care/support plan in the person’sbest interests.

Every effort should still be made as the care and support is delivered to communicate withthe person to find out if they still lack capacity and the action is still in their best interests.


CP ver1

10


CP ver1

11

I (complete name:)

. …………………………………………………………………………………..

confirm that I have contributed and consent to the content of each of the following plans:(Complete plan titles) 1. 2.3.4.5.6.

Signed: Dated:

================================================================

I ……………………………………………………………………………………….

Representative of service named:

…………………………………………………………………………………………

having carried out an assessment** recorded it and my rationale, can confirm that thefollowing plans were unable to be consented to by:

…………………………………………………………………………………………..

and that they have therefore been developed and will be followed with the person’s bestinterest in mind at all times.

(Complete plan titles) 1. 2.3.4.5.6.

Signed: Dated:

**consider using the Hampshire County Council Mental Capacity Toolkit


CP ver1

12


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CP ver1


CP ver1

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n.

SU

PP

OR

T P

LA

N

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

CP ver1


CP ver1

6


SU

PP

OR

T P

LA

N

7

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Pers

ona

l car

e an

d dr

essi

ng n

eeds

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

Iw

ish

to a

chie

ve?

Wha

t do

I n

eed

supp

ort

wit

h?H

ow c

an m

y ne

eds

be m

et b

y th

e ca

re s

taff

Pers

ona

l car

eI

am a

ble

to w

ash

my

face

and

han

ds b

utca

nnot

was

h ot

her

part

s of

my

body

.I

do n

ot t

ake

a ba

th n

ow a

s I

can

not

get

in a

nd o

ut o

f th

e ba

th b

ut I

can

tak

ea

show

er a

nd I

do

this

mos

t da

ys.

Hai

r w

ashi

ngI

wash

my

hair

whe

n I

am in

the

sho

wer.

I wa

nt t

o ke

epin

depe

nden

t, f

eel c

lean

and

supp

orte

d,pa

rtic

ular

ly w

ith

the

thin

gs I

can

no

long

er d

o.

I wo

uld

like

my

hair

cut

ever

y si

x we

eks

eith

erhe

re if

I li

ke t

he w

ay t

heha

irdr

esse

r do

es it

or

atA

ge C

once

rn w

here

Iha

ve b

een

goin

g an

d th

eycu

t it

as

I lik

e it

Staf

f to

:In

the

mor

ning

ask

Jan

e wh

at s

uppo

rt s

he n

eeds

, she

will

be

able

to

wash

her

own

fac

e an

d ha

nds.

Che

ck o

ther

are

as o

fbo

dy J

ane

may

req

uire

was

hing

.Cl

ean

and

rins

e de

ntur

es f

or J

ane

so t

hat

they

are

rea

dy f

orhe

r wh

en s

he w

ants

the

m.

Jane

is a

ble

to m

anag

e he

r ow

n to

ileti

ng n

eeds

.A

sk J

ane

what

she

wou

ld li

ke t

o we

ar a

nd a

ssis

t Ja

ne is

gett

ing

dres

sed.

Jane

is a

ble

to b

rush

her

own

hai

r an

d lik

es t

o pu

t on

her

lipst

ick,

mak

e su

re it

is w

ithi

n he

r re

ach

Chec

k ea

ch d

ay in

the

aft

erno

on, n

ear

5 o’c

lock

if J

ane

isha

ving

a s

howe

r. A

sk J

ane

to p

ull t

he c

ord

when

she

is g

oing

to h

ave

a sh

ower

or

let

a st

aff

mem

ber

know

so

that

som

eone

can

go in

run

the

sho

wer,

hel

p Ja

ne t

o ge

t un

dres

sed

and

get

in t

he s

howe

r, w

ash

Jane

’s fe

et, l

egs

and

back

.Ja

ne is

abl

e to

man

age

the

othe

r as

pect

s of

hav

ing

a sh

ower

.O

nce

wash

ed J

ane

will

need

hel

p ge

ttin

g dr

ied

and

dres

sed.

CP ver1


8

CP ver1

SU

PP

OR

T P

LA

N(C

ON

TIN

UE

D)

Pers

ona

l car

e an

d dr

essi

ng n

eeds

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

Iw

ish

to a

chie

ve?

Wha

t do

I n

eed

supp

ort

wit

h?H

ow c

an m

y ne

eds

be m

et b

y th

e ca

re s

taff

Den

ture

/ te

eth

care

I ha

ve f

alse

tee

th t

op a

nd b

otto

m a

ndth

ese

need

cle

anin

g ea

ch n

ight

whe

n I

goto

bed

– I

can

do

this

but

I d

o ne

edso

me

ster

aden

t –

my

daug

hter

will

get

this

for

me

Mak

eup

and

crea

ms

I do

n’t

wear

any

dai

ly m

ake

up b

ut I

do

use

E45

crea

m a

s m

y sk

in g

ets

very

dry

.I

can

rub

this

in m

ost

plac

es b

ut n

ot m

yba

ck o

r m

y an

kles

and

fee

t

Dre

ssin

gI

can

dres

s m

ysel

f al

thou

gh I

do

find

itdi

ffic

ult

and

have

had

to

wear

clo

thes

with

eas

y fa

sten

ers.

For

the

pas

t tw

oye

ars

I ha

ve n

ot w

orn

any

sock

s or

stoc

king

s as

I c

an n

ot b

end

down

to

get

them

on.

Oft

en m

y fe

et g

et v

ery

cold

as

a re

sult

Book

a h

aird

ress

er a

ppoi

ntm

ent

with

the

hom

e ha

irdr

esse

r as

req

uire

d fo

r Ja

ne. C

heck

tha

t Ja

ne is

hap

pyto

con

tinu

e go

ing

to t

he h

ome

hair

dres

ser.

If J

ane

wish

es t

o us

e an

alt

erna

tive

hai

rdre

sser

dis

cuss

with

Jan

e wh

en s

he w

ould

like

to

go. S

uppo

rt J

ane

tom

ake

the

appo

intm

ent

if n

eces

sary

. Che

ck J

ane’

str

ansp

ort

need

s to

get

to

the

appo

intm

ent,

if r

equi

red

phon

e an

d bo

ok t

he R

edib

us t

o ta

ke a

nd c

olle

ct J

ane

tohe

r ap

poin

tmen

t.

Jane

will

req

uire

som

eone

to

go in

and

sup

port

eac

h da

ywi

th r

ubbi

ng E

45 in

to h

er b

ack

and

her

legs

, ank

le a

ndfe

et.

This

nee

ds t

o be

don

e af

ter

Jane

has

had

her

show

er if

pos

sibl

e in

the

late

aft

erno

on o

r ev

enin

g.

Chec

k th

at s

kin

is n

ot d

ry.

Jane

nee

ds a

ssis

tanc

e to

get

dre

ssed

and

ass

ista

nce

with

doi

ng u

p bu

tton

s or

fas

tene

rs

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e


SU

PP

OR

T P

LA

N

1

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Sup

port

pla

n co

mpl

eted

by

Dat

e o

f co

mpl

etio

nS

ched

uled

nex

t re

view

Co

mm

unic

atio

n

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

I’m

not

ver

y go

od a

t re

adin

g an

d wr

itin

g.If

som

eone

sen

ds m

e a

lett

er I

won

’t be

able

to

read

it.

I lik

e to

tal

k to

eve

ryon

e, b

ut s

ome

tim

es I

get

“m

ixed

up”

. I

use

Mak

aton

alo

t to

hel

p m

e un

ders

tand

.

I wa

nt s

omeo

ne t

o re

ad m

y le

tter

s to

me.

I w

ant

to m

ake

my

own

deci

sion

s. I

want

sta

ff t

o be

abl

e to

hav

e ta

lks

with

me.

Staf

f to

att

end

Mak

aton

tra

inin

g.St

aff

to r

ead

Pete

rs’ l

ette

rs t

o hi

m,

liste

n to

his

dec

isio

ns, a

nd s

uppo

rt h

imto

com

plet

e an

y ac

tion

s fr

om h

isde

cisi

ons.

Staf

f to

com

mun

icat

e wi

th P

eter

verb

ally

, usi

ng M

akat

on a

s a

supp

ort

tohi

s ve

rbal

com

mun

icat

ion.

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

CP ver1


CP ver1

2


SU

PP

OR

T P

LA

N

3

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Med

icat

ion

Sup

port

and

pai

n re

lief

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

I w

ish

toac

hiev

e?W

hat

do I

nee

d su

ppo

rt w

ith?

How

can

my

need

s be

met

by

the

care

sta

ff

I fo

rget

to

take

my

med

icat

ion

I ca

n ta

ke m

y ow

n m

edic

atio

n, b

ut I

don’

t lik

e th

e ta

ste

of it

, som

etim

es I

won’

t ta

ke it

bec

ause

it t

aste

s ba

d. M

ydo

ctor

has

sai

d th

at if

it t

aste

s ba

d I

can

put

it in

my

weet

abix

.

I wa

nt t

o ke

ep t

akin

g m

y m

edic

atio

n,be

caus

e it

kee

ps m

e we

ll.

I kn

ow m

y m

edic

atio

n is

impo

rtan

tbe

caus

e it

kee

ps m

y fi

ts a

way.

Staf

f to

adm

inis

ter

med

icat

ion

to P

eter

at

the

corr

ect

tim

e.

Staf

f to

che

ck M

ARS

she

ets

befo

resu

ppor

ting

and

iden

tify

cor

rect

med

icat

ion

for

Pete

r. D

ispe

nse

med

icat

ion

into

sm

all

med

s. p

ot a

nd p

lace

in f

ront

of

Pete

r wi

thin

reac

h. I

f Pe

ter

is h

avin

g a

bad

day,

he

will

put

his

med

icat

ion

into

his

wee

tabi

x, t

here

isa

lett

er f

rom

his

GP

in h

is f

ile t

o sa

y th

at h

eha

s ag

reed

tha

t th

is w

ill n

ot a

ffec

t th

epe

rfor

man

ce o

f th

e m

edic

atio

n an

d th

at h

eis

hap

py f

or P

eter

to

take

his

med

icat

ion

inth

is w

ay.

Staf

f sh

ould

obs

erve

Pet

er t

akin

ghi

s m

edic

atio

n.

Com

plet

e M

ARS

she

ets

sign

ing

and

dati

ng.

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

CP ver1


CP ver1

4


SU

PP

OR

T P

LA

N

5

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Mo

bilit

y

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

Iw

ish

to a

chie

ve?

Wha

t do

I n

eed

supp

ort

wit

h?H

ow c

an m

y ne

eds

be m

et b

y th

e ca

re s

taff

I lik

e wa

lkin

g, I

like

goi

ng o

ut t

o th

esh

ops

on m

y ow

n, b

ut c

ars

and

buse

sso

met

imes

fri

ghte

n m

e.

My

bedr

oom

is u

psta

irs

in t

he h

ouse

. I

like

it, I

am

ok

with

sta

irs.

I wa

nt t

o ke

ep w

alki

ng t

oth

e sh

ops

on m

y ow

n.

I do

n’t

want

to

mov

e to

anot

her

bedr

oom

.

Staf

f to

enc

oura

ge P

eter

to

keep

wal

king

to

the

loca

l sho

ps a

s it

ens

ures

he

keep

s as

inde

pend

ent

aspo

ssib

le.

Pete

r do

es n

ot h

ave

to c

ross

any

roa

ds w

hen

he g

oes

to t

he lo

cal s

hops

, how

ever

he

is c

once

rned

if t

here

is lo

ts o

f tr

affi

c ar

ound

. St

aff

mus

t re

ad c

urre

ntri

sk a

sses

smen

ts r

e en

suri

ng P

eter

s’ sa

fety

whe

n he

uses

the

loca

l sho

ps. P

eter

to

be e

ncou

rage

d to

tel

lst

aff

when

he

is g

oing

out

to

the

shop

Staf

f to

res

pect

Pet

ers’

deci

sion

.

The

fo

llow

ing

peo

ple

have

sup

port

ed m

e in

thi

s as

sess

men

t

Sig

ned

by S

ervi

ce U

ser

......

......

......

......

......

......

.... D

ate

Sig

ned

by r

elev

ant

staf

f m

embe

r ...

......

......

......

......

......

......

. Dat

e

CP ver1


CP ver1

6


SU

PP

OR

T P

LA

N

7

Nam

e o

f in

divi

dual

Pla

ce o

f re

side

nce

Dat

e o

f bi

rth

Car

e pl

an c

om

plet

ed b

yD

ate

of

com

plet

ion

Sch

edul

ed n

ext

revi

ew

Pers

ona

l car

e an

d dr

essi

ng n

eeds

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

Iw

ish

to a

chie

ve?

Wha

t do

I n

eed

supp

ort

wit

h?H

ow c

an m

y ne

eds

be m

et b

y th

e ca

re s

taff

Pers

ona

l car

eI

can

wash

mys

elf.

I d

o no

t ne

ed a

nyhe

lp.

I lik

e ta

king

a b

ath,

but

som

etim

es I

stay

in t

he b

ath

for

a lo

ng t

ime,

whi

chm

akes

me

late

if I

am

goi

ng s

omew

here

,th

en I

hav

e to

rus

h m

y br

eakf

ast

whic

hm

akes

me

angr

y.

I h

ave

talk

ed t

o th

est

aff

abou

t th

is, a

nd w

e ha

ve a

gree

dth

at o

n th

e da

ys w

hen

I go

to

the

day

serv

ice

I ta

ke a

sho

wer.

Hai

r w

ashi

ngI

wash

my

hair

whe

n I

am in

the

sho

wer

and

I do

not

nee

d an

y he

lp.

I wa

nt t

o fe

el c

lean

and

supp

orte

d.

I lik

e m

y ha

ir t

o fe

elcl

ean.

Staf

f to

look

at

Pete

rs’ d

aily

rou

tine

to

find

out

if it

ishi

s da

y fo

r da

y se

rvic

e th

en s

uppo

rt P

eter

wit

h a

bath

or s

howe

r as

he

has

indi

cate

d.

Staf

f to

ens

ure

that

Pet

er h

as a

n am

ple

supp

ly o

fsh

ampo

o an

d co

ndit

ione

r.

CP ver1


SU

PP

OR

T P

LA

N(C

ON

TIN

UE

D)

8

CP ver1

Pers

ona

l car

e an

d dr

essi

ng n

eeds

Wha

t ar

e m

y A

bilit

ies,

Wha

t ca

n I

do?

Wha

t ar

e th

e O

utco

mes

Iw

ish

to a

chie

ve?

Wha

t do

I n

eed

supp

ort

wit

h?H

ow c

an m

y ne

eds

be m

et b

y th

e ca

re s

taff

Teet

h ca

reSo

met

imes

I f

orge

t to

bru

sh m

y te

eth.

Nai

l Car

eI

cann

ot c

ut m

y ow

n fi

nger

or

toe

nails

.I

am f

righ

tene

d th

at t

he s

taff

mig

hthu

rt m

e wh

en t

hey

cut

my

nails

.

Dre

ssin

gI

can

dres

s m

ysel

f, b

ut s

omet

imes

I f

ind

butt

ons

and

zips

dif

ficu

lt.

I lik

e to

vis

it t

hede

ntis

t; I

kno

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e


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DAILY CARE NOTES

Name of service user: ..................................................

Date Report Signature

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GUIDANCE ON DAILY CARE NOTES AND OTHERPROFESSIONAL NOTES

Daily Diary notes and other professional notes are the umbilical cord of the care planfolder – they link daily care and support of the individual to the outcome focussed plans ofcare that allow the individual, you and all staff to know and fully understand how best tosupport the individual. These daily dairy notes should be factual, concise, legible, objective,person centred, signed and dated.

An example of a daily diary sheet is included but of course there are many variations! Usewhat suits you and what works well for you and your staff and the individual you aresupporting. If these notes do not feed the care planning process and the review process, ifthey are not written in such a way that supports the delivery of care to the individual thenmaybe you should revisit this process.

Notes you can include in this section

● Daily Diary Notes

● GP visits notes

● CPN visits notes

● Physio visits notes

● OT visits notes

● Relative visits notes / Visitors Log

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GUIDANCE ON RISK ASSESSMENT CHARTS

The following are Risk Assessment Tools that you could use, where applicable, to help youassess and support the service user. You will find a selection of these at the back of thisfolder. You should not use these routinely but rather where you and other professionals maythink there is a risk element in supporting the individual with a specific area of care

● Pressure Ulcers Grade Recording Chart● Waterlow Assessment● Braden Scale ● Malnutrition Universal Screening Tool● The Sensitive Barthel● Bed Rail Risk Assessment● Moving and Handling Assessment● Falls Screening Tool● Falls Prevention Action Plan● Post Fall Assessment Tool● Body Map● Mental Capacity Assessment Tool● Service User Best Interest Consultation● Pool Activity Level Checklist● Self Medication Assessment● Blood Monitoring Chart

These assessments are neither exhaustive nor compulsory, but you should only use anyforms where you feel it will allow you to assess and understand the needs of the serviceuser and how you can best support them.

Always consider why am I using this form, what will it tell me that I do not know andhow can I use this information.

Simply ticking a risk assessment chart will only tell people who have access to this care planfolder a limited amount of information; you will need to then think about how you plan tosupport the individual with minimising that risk – hence risk assessment plans of care

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SUPPORT PLAN REVIEW RECORD

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Service Users name: D.O.B

Date Comments Signatures:Service UserRelativeCare ManagerKey WorkerOther People presentand involved


SUPPORT PLAN REVIEW RECORD (CONTINUED)

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GUIDANCE ON REVIEWS

Care Plans and care planning is a continual cycle of implementing reviewing and updating.No one person’s care needs will stay the same and as such plans of care must be reviewedas often as required. Guidance will suggest that this is at least monthly should no otherfactors induce an immediate review.

The review process is supported by continuous assessment, if staff and managementembrace an environment where continuous assessment is part of every day care andsupport then peoples’ individual needs and desired outcomes are much more likely to bemet in a person centred way.

Assessment and review cannot be separated as without an assessment of progress andwithout knowing what is working well and what is not working well a review cannot trulyreflect the needs and desired outcomes of the service user. This is why we have included inthe Review section the document – What is working for me right now / what is notworking for me right now. Aspects of a person’s life that was working quiet well mighthave altered and this is no longer the case, conversely something that was not workingmight now be working really well, for this reason we suggest that this document forms partof every review process

Assessment and review may take place on a daily basis e.g. finding out that someone likesjam and not marmalade requires an update in the care plan and a communication to thestaff. A review of all plans of care on a monthly basis will be more detailed and may takeinto account a review of the risk plans, service user’s feedback, health care needs and staff’sown observations. Other reviews may involve other professionals.

The aim of good assessment and the review process for support planning is that peopleare provided with appropriate and sufficient support to enable them to livetheir lives, with as much control as possible over how their support is provided.

Traditionally many reviews look at the care that is being delivered and whether this ismeeting a need, if the review is to look at whether the individual’s outcomes are being metthen the review process has to focus on the individual and what they want.

To adopt a person centred approach to the review consider adopting the followingapproach to a review allowing the service user to be in control:

● All about me – What I like to do and what is important to me?● What is working and what is not working● What has changed for me?● Are my outcomes being met?● What have we tried and learnt from already● What can we do next

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As part of this whole process do be clear and check with the individual who else may needto be involved or who the individual wants to be involved. Use your own supervision processes to look at how support is being offered, what staffthink is working well or not working well – this is important as staff’s observations mayindicate something quiet different from how the individual see things.Make sure signatures and dates are included and that documentation show if someone elseis representing the person’s best interests.

On many occasions and when supporting many people it is not possible to involve family –possibly because they are not nearby / do not want to be involved / no family available tosupport, if the individual has limited communication then updating a care plan may bedifficult. This is why staff supervision is so essential to the review process as staff shouldhave good observation skills and will be able to represent their best interests.

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REVIEW



This sheet should be completed at initial assessment and thenreviewed every month.

Date of initial assessment 20th august 2010

Date of current review 20th September 2010

I have been here a month now and it is ok! I am getting to knowpeople and the staff. I have had lots of visitors and that is goodbecause I was worried that this would not be the case. The foodis good and it is great that it is all prepared and brought to me – Ican eat in my room or go to the dining room. Mabel is very nice andshe and I chat lots – we have similar interests in gardening andsoaps!

Sometimes I feel under pressure to join in the activities in themain room with everyone else – I don’t want to sit and sing oldsongs or listen to someone playing the piano!Sometimes the staff come in in the morning when I am still in bedand say ‘Jane are you getting up today’ – I am just having a lie inand then I feel bad about doing this.

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INITIAL ASSESSMENT



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