1. What is a Care Plan?
After an assessment has been completed by staff (see Assessment chapter) and before the adult starts receiving care from staff in the care home, a care plan should be completed.
The plan should be based on information collected in the adult’s assessment. It should cleraly state their care and support needs, how they will be met by the service and the outcomes that the adult wants to achieve.
Care planning gives the adult choice and control over their care and should provide them with the support they need to ensure their physical and emotional wellbeing and maintain their connections to family, friends and community.
If a local council is also involved in the adult’s care and support (for example if they are paying for the adult to receive the service), there will also be a local authority care and support plan.
2. Involving the Adult
The adult should be involved throughout the planning process – they should be at the centre of the process – and be given every opportunity to produce the plan with staff, if that is what they want. Some adults may need help to be involved. If so, the process should make sure they are supported by relevant family or friends or another relevant person, in making decisions. The options and choices should be presented to them simply and clearly.
The care plan must reflect the adult’s physical, mental, emotional and social needs, including their cultural background and lifestyle.
If the adult lacks mental capacity and is not able to make any or all of the decisions for themselves, staff involved in the care plan process should make sure that there is a family member, friend or other representative to support them.
3. Reviewing the Care Plan
The plan should be reviewed regularly and the next date agreed at the end of each review.It can be reviewed urgently, if there is a sudden change in the adult’s health or circumstances.
Where everyone involved in the plan agrees that there is a change in the adult’s health or circumstances that affect the way the service is able to deliver care and support to them, the manager may ask for a new assessment to be completed which will help everyone decide what action needs to be taken to make sure the adult’s needs are met.
This may result in a change in the way that the service delivers care and support to the adult, or that the adult needs to move to a different service as the current provider is unable to offer the care and support that they need, due to the change in their health or circumstances.
