Care Planning

In line with the Care Act, care plans should be enabling and should focus on the assets the person has, what they are able to do for themselves and where they may require support to achieve their outcomes and keep safe. With individuals with complex or nursing needs, the focus will be on low level goals that can be achieved.

A plan that is person centred emphasises the perspective of the individual, can be completed in first person and captures the person's needs and wishes.

Care planning takes time and a multidisciplinary approach is advisable to ensure that plans are accurate and meet the individuals identified needs. Care plans should be reviewed regularly to ensure they remain factual, up to date and fit for purpose.

Content of Care Plans

Care plans can include but are not limited to the following documentation:

• Detailed contents sheet that clearly shows where each section of the plan can be located
• Pre Admission Assessment
• Details about the Individual  (name, age, ethnicity, DOB etc.)
• Consent photograph form including wound care
• Photograph of service user, chosen by them.
• Social history
• Preferred methods of communication.
• Health needs -Medication and if self-medicating
• Other health professionals involved in care plan e.g. CPN
• Mental and cognitive state.
• Sight and hearing.
• Mobility (including Aids and equipment used.
• Continence
• Cultural/religious needs.
• Daily living skills.
• Preferences related to diet, likes/dislikes.
• Who responsible for finances (service user representative, solicitor etc.)
• Interests and hobbies.
• Family/social contacts/advocate
• Maintenance of links with family, friends and communities.
• Wishes in the event of illness or death. End of Life Planning. Preferred
• Priorities for Care (PPC)
• Daily day and night-time routines
• Support to access therapeutic and fitness activities, hobbies lifestyle choices and social activity.
• Personal Grooming Dress and Custom.
• Nutrition, food and drink preferences and special dietary requirements. The MUST tool or equivalent  is used and action is taken when indicated
• Repositioning charts/food-fluid charts when necessary
• Weight recordings
• Healthcare needs and preferences, continence, pain management
• Medication and Choice to Self-medicate.
• Purpose of medication and potential side effects
• Skin Integrity/ Tissue Viability.
• Body Mapping.- updated monthly and as required
• Respiratory Support.
• Assistive Technology and Use of Special Equipment.
• Named Key worker (where appropriate)
• A record of professional visits