Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
CP ver1
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.
1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 1
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 2
CP ver1
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)
3
PaCT Care Plans Text Final 31/03/2011 16:08 Page 3
CP ver1
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
4
PaCT Care Plans Text Final 31/03/2011 16:08 Page 4
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
.
CP ver1
1
HO
W I
CO
MM
UN
ICA
TE
WIT
H O
TH
ER
S
PaCT Care Plans Text Final 31/03/2011 16:08 Page 1
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
CP ver1
2
HO
W I
CO
MM
UN
ICA
TE
WIT
H O
TH
ER
S (C
ON
TIN
UE
D)
PaCT Care Plans Text Final 31/03/2011 16:08 Page 2
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
CP ver1
3
MY
CA
RE
AN
D M
Y W
EL
L B
EIN
G
PaCT Care Plans Text Final 31/03/2011 16:08 Page 3
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:
CP ver1
4
MY
CA
RE
AN
D M
Y W
EL
L B
EIN
G (C
ON
TIN
UE
D)
PaCT Care Plans Text Final 31/03/2011 16:08 Page 4
INITIAL ASSESSMENT
What’s working for me right now?
What is not working for me right now?
CP ver1
5
PaCT Care Plans Text Final 31/03/2011 16:08 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:08 Page 6
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
CP ver1
7
PaCT Care Plans Text Final 31/03/2011 16:08 Page 7
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
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:08 Page 8
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
CP ver1
9
PaCT Care Plans Text Final 31/03/2011 16:08 Page 9
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
CP ver1
10
PaCT Care Plans Text Final 31/03/2011 16:08 Page 10
CP ver1
Signed by Service User…………………………………………….Date
The following people have supported me in this initial assessment
Signed by relevant staff member................................................ Date
11
PaCT Care Plans Text Final 31/03/2011 16:08 Page 11
CP ver1
12
PaCT Care Plans Text Final 31/03/2011 16:08 Page 12
CP ver1
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’?
1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 1
CP ver1
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
PaCT Care Plans Text Final 31/03/2011 16:08 Page 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
.
CP ver1
3
HO
W I
CO
MM
UN
ICA
TE
WIT
H O
TH
ER
S
PaCT Care Plans Text Final 31/03/2011 16:08 Page 3
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.
CP ver1
4
HO
W I
CO
MM
UN
ICA
TE
WIT
H O
TH
ER
S (C
ON
TIN
UE
D)
PaCT Care Plans Text Final 31/03/2011 16:08 Page 4
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.
CP ver1
5
PaCT Care Plans Text Final 31/03/2011 16:08 Page 5
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
.
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:08 Page 6
What is working for me right now?
What is not 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.
CP ver1
7
PaCT Care Plans Text Final 31/03/2011 16:08 Page 7
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:08 Page 8
ALL ABOUT ME AND MY LIFE
1
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:08 Page 2
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 3
CP ver1
4
PaCT Care Plans Text Final 31/03/2011 16:08 Page 4
5
PEOPLE I LIKE TO STAY IN CONTACT WITH
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:08 Page 6
7
WHAT IS IMPORTANT TO ME?
What Is Important to Me?
Support I Need To Make This Happen
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 7
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:08 Page 8
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 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
(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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 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
(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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 11
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 12
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 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
)
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
14
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:08 Page 14
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
PaCT Care Plans Text Final 31/03/2011 16:08 Page 15
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
?
PaCT Care Plans Text Final 31/03/2011 16:09 Page 16
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 17
CP ver1
18
PaCT Care Plans Text Final 31/03/2011 16:09 Page 18
HOW I MAKE MY DECISIONS
Please work from the basis that I want to be involved in all of my decisions
19
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 19
CP ver1
20
PaCT Care Plans Text Final 31/03/2011 16:09 Page 20
MY LIKES & DISLIKES
Activities/Leisure
Food/Drink
Anything Else
I Like I Dislike
I Like I Dislike
I Like I Dislike
21
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 21
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
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 22
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
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!
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 4
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.
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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.
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 7
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 9
CP ver1
10
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 11
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 12
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 13
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 14
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 15
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 16
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 17
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
)
PaCT Care Plans Text Final 31/03/2011 16:09 Page 18
CP ver1
INITIAL ASSESSMENT
Date of initial assessment 20th August 2010
19
PaCT Care Plans Text Final 31/03/2011 16:09 Page 19
CP ver1
20
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 21
CP ver1
22
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 23
CP ver1
24
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 25
CP ver1
26
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 3
CP ver1
4
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 7
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 9
CP ver1
10
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 11
CP ver1
12
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 13
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 14
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 15
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
......
......
......
......
......
......
.... D
ate
Sig
ned
by r
elev
ant
staf
f m
embe
r ...
......
......
......
......
......
......
. Dat
e
Bac
k up
Pla
n - W
hat
coul
d go
wro
ng?
Act
ion
agre
edW
ho w
ill b
e re
spo
nsib
le
16
RIS
K M
AN
AG
EM
EN
T P
LA
N (C
ON
TIN
UE
D)
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 16
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 3
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 4
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 6
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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 7
CP ver1
8
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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.
PaCT Care Plans Text Final 31/03/2011 16:09 Page 9
CP ver1
10
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 11
CP ver1
12
PaCT Care Plans Text Final 31/03/2011 16:09 Page 12
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 am
abl
e to
com
mun
icat
e we
ll al
thou
ghat
tim
es I
can
be
slow
get
ting
my
word
sou
t be
caus
e of
the
Par
kins
on’s.
Iun
ders
tand
mos
t th
ings
alt
houg
h I
can
get
conf
used
abo
ut m
y m
edic
atio
n,ti
min
gs o
r so
met
imes
abo
ut t
hing
s I
amsu
ppos
ed t
o be
doi
ng.
To e
njoy
bei
ng h
ere,
get
to
mee
t ne
wpe
ople
and
enj
oy a
cha
t. T
o kn
ow t
hat
staf
f un
ders
tand
me
and
are
pati
ent
if I
do n
ot h
ear
them
or
am c
onfu
sed.
I d
on’t
want
to
be a
nxio
us a
bout
my
care
.
Staf
f to
:Sp
end
tim
e ch
atti
ng t
o Ja
ne, e
spec
ially
abou
t wh
at is
hap
peni
ng in
the
hom
e so
tha
tsh
e ca
n m
ake
info
rmed
cho
ices
abo
ut w
hat
isha
ppen
ing
and
what
Jan
e wo
uld
like
topa
rtic
ipat
e in
.Be
pat
ient
if J
ane
is h
avin
g di
ffic
ulty
gett
ing
word
s in
to a
sen
tenc
e.Ja
ne m
ay b
ecom
e qu
iet
and
anxi
ous
if in
pai
n.Be
awa
re o
f an
y ch
ange
s an
d di
scus
s wi
thJa
ne h
ow s
he is
fee
ling.
Rec
ord
and
Repo
rtan
y ch
ange
s ac
cord
ingl
y.Ja
ne d
oes
like
to c
hat
with
peo
ple
and
will
enjo
y do
ing
this
wit
h st
aff
and
othe
r pe
ople
livin
g he
re. W
hen
she
does
not
wan
t to
tal
ksh
e wi
ll be
qui
et –
sta
ff s
houl
d ch
eck
that
she
is n
ot in
pai
n or
wor
ried
abo
ut a
nyth
ing
and
then
res
pect
her
pri
vacy
.
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
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 ca
n ta
ke m
y ow
n m
edic
atio
n bu
t ca
nno
t di
spen
se it
– s
omet
imes
I f
orge
t th
eti
me
and
take
my
med
icat
ion
late
. My
Park
inso
n’s
mea
ns t
hat
som
etim
es I
dro
pth
e m
edic
atio
n.
I wa
nt s
uppo
rt t
o ta
ke m
y m
edic
atio
n at
the
corr
ect
tim
es s
o th
at I
kno
w m
yhe
alth
and
pai
n is
und
er c
ontr
ol.
To b
e pa
in f
ree
at le
ast
to h
ave
supp
ort
to k
eep
this
und
er c
ontr
ol.
Staf
f to
:Ch
eck
MA
RS s
heet
s be
fore
sup
port
ing
and
iden
tify
cor
rect
med
icat
ion
for
Jane
. Che
ck t
hat
tim
e is
cor
rect
.D
ispe
nse
med
icat
ion
into
sm
all m
eds.
pot
and
pla
cein
fro
nt o
f Ja
ne w
ithi
n re
ach.
Ask
Jan
e if
she
wou
ld li
ke a
fre
sh d
rink
to
take
med
icat
ion
and
get
this
.Ja
ne w
ill t
ake
med
icat
ion
whils
t yo
u ar
e pr
esen
t.
Jane
will
be
able
to
pick
up
pot
and
tip
med
icat
ion
into
her
mou
th –
sta
y wi
th J
ane
to m
ake
sure
she
is a
ble
to d
o th
is a
nd d
oes
not
drop
any
med
icat
ion.
Com
plet
e M
ARS
she
ets
sign
ing
and
dati
ng.
Ask
Jan
e ho
w sh
e is
fee
ling,
not
ice
any
chan
ges
that
may
indi
cate
incr
ease
d pa
in; i
f Ja
ne s
ays
she
is in
pai
n th
en c
heck
MA
RS s
heet
s an
d m
edic
atio
nre
cord
s an
d gi
ve C
o D
ydra
mol
as
pres
crib
ed b
y GP
.Su
ppor
t th
is m
edic
atio
n as
abo
ve. C
ompl
ete
MA
Rssh
eets
. Mon
itor
Jan
e’s
pain
man
agem
ent
duri
ng t
heda
y.
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
3
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 3
CP ver1
4
PaCT Care Plans Text Final 31/03/2011 16:09 Page 4
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 am
mob
ile o
nly
with
my
fram
e an
d ne
edth
is w
ith
me
at a
ll ti
mes
. I c
anno
t wa
lkfa
r re
ally
– I
can
wal
k fr
om t
he h
ouse
to
the
care
but
not
any
fur
ther
.
I m
anag
ed a
roun
d m
y ho
me
beca
use
Ikn
ew w
hat
I co
uld
hold
ont
o.W
hen
I go
out
I h
ave
been
usi
ng a
whee
lcha
ir
I am
abl
e to
get
into
bed
and
out
of
ach
air
if it
is n
ot t
oo lo
w. I
can
not
get
ina
bath
I wa
nt t
o st
ay m
obile
and
inde
pend
ent.
I w
ant
toco
ntin
ue t
o go
out
as
I ha
veal
ways
don
e
Staf
f to
com
plet
e fa
lls a
sses
smen
t an
d m
ovin
g an
d ha
ndlin
gas
sess
men
t an
d re
view
as
requ
ired
.In
agr
eem
ent
with
Jan
e we
will
arr
ange
an
asse
ssm
ent
for
whee
lcha
ir
Enco
urag
e an
d su
ppor
t Ja
ne w
ith
walk
ing
in a
nd a
roun
d th
e ho
me
usin
g Ja
ne’s
fram
e at
all
tim
es. C
heck
tha
t sh
e is
hap
py w
ith
this
.If
Jan
e wi
shes
to
walk
to
the
dini
ng r
oom
or
loun
ge s
uppo
rt h
erby
mak
ing
sure
she
has
her
fra
me
Ask
Jan
e at
all
tim
es w
hat
supp
ort
she
woul
d lik
e.
Jane
may
ask
for
a s
taff
mem
ber
to w
alk
with
her
f.
Chec
k in
Jan
e’s
room
whe
n su
ppor
ting
tha
t th
ere
is n
othi
ng o
nth
e fl
oor
that
may
hin
der
Jane
’s m
obili
ty.
If J
ane
is g
oing
out
che
ck t
hat
she
has
supp
ort.
Jane
may
like
to
walk
out
into
the
gar
den
and
will
need
sup
port
from
a m
embe
r of
sta
ff t
o be
wit
h he
r ge
ttin
g in
and
out
and
arou
nd t
he g
arde
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 7
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 8
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 3
CP ver1
4
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
CP ver1
6
PaCT Care Plans Text Final 31/03/2011 16:09 Page 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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 7
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
w it
’s no
tgo
od w
hen
I fo
rget
to
brus
h m
y te
eth.
I do
n’t
like
my
nails
to
belo
ng, I
wan
t to
kee
p th
emsh
ort.
I lik
e to
look
nic
e an
dti
dy w
hen
I go
out
.
taff
to
rem
ind
Pete
r to
bru
sh h
is t
eeth
. St
aff
to m
ake
regu
lar
dent
al a
ppoi
ntm
ents
for
Pet
er a
s he
is u
nabl
e to
do t
his
him
self
.
Staf
f to
be
min
dful
of
Pete
rs’ d
islik
e fo
r lo
ng n
ails
.St
aff
need
to
ensu
re t
hat
regu
lar
appo
intm
ents
are
kept
wit
h th
e po
diat
rist
to
cut
Pete
rs’ t
oena
ils, a
nd w
hoal
so c
uts
his
fing
er n
ails
. Th
e ap
poin
tmen
t m
ust
alwa
ysbe
wit
h hi
s na
med
pod
iatr
ist
as it
has
tak
en P
eter
a lo
ngti
me
to b
uild
a r
elat
ions
hip
with
thi
s pr
ofes
sion
al.
Staf
f to
sup
port
Pet
er t
o ta
ke t
ime
to f
aste
n bu
tton
san
d zi
ps b
efor
e go
ing
out
in t
o th
e co
mm
unit
y.
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
PaCT Care Plans Text Final 31/03/2011 16:09 Page 8
1
DAILY CARE NOTES
Name of service user: ..................................................
Date Report Signature
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
CP ver1
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
1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
CP ver1
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
1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
1
SUPPORT PLAN REVIEW RECORD
CP ver1
Service Users name: D.O.B
Date Comments Signatures:Service UserRelativeCare ManagerKey WorkerOther People presentand involved
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
SUPPORT PLAN REVIEW RECORD (CONTINUED)
CP ver1
2
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
CP ver1
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
1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 1
2
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.
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 2
3
REVIEW
What’s working for me right now?
What is not working for me right now?
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.
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 3
CP ver1
4
PaCT Care Plans Text Final 31/03/2011 16:09 Page 4
5
CP ver1
INITIAL ASSESSMENT
What’s working for me right now?
What is not working for me right now?
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 5
6
CP ver1
PaCT Care Plans Text Final 31/03/2011 16:09 Page 6