Care Plans

Although my organisation isn't residential I have given customer support planning a great deal of thought and feel that it should be a living document that's reviewed on a regular basis. Therefore when I start working with a new customer, I spent time getting to know them and identifying what's importnat to them; what their goals and aspirations are, who does what and why etc, etc.We then develop a plan around the customer's identified goals and in partnership with family, friends and or other providers we develop those into a service for that customer. I think its important to have measurable outcomes for each customer and this process helps to form these. The customer's support plan is initially reviewed after 3 months to see if it is meeting customer expectations and if it isn't we look at why and try to take action to rectify that. After the initial 3 month review we would normally review on a 6 monthly basis, although some customers are happy to review annually - I'm less keen on this as I fear that the plan could risk becoming forgotten.

I realise residential care is slightly different, but the principles are similar in that a customer is paying for a service to meet their particular/individual needs. Hope this is of some help.

Hi,

I don't often subscribe or involve myself in these forum discussions,
however the subject of care plans, or support plans is very close to my
heart.

I have been instrumental in working on registered care homes and
domiciliary care services, and it is my view that in every case every
client, customer, service user, whatever we know our resident's/clients
by MUST have a living person centred plan.

A forum member before this asked if in a care home they can be kept in a
residents room, of course they can (as long as they are confidential in
as much not documents available to all, only those with the clients
consent).

I do not subscribe to this theory (below) of a set review period. -
Every "plan" should have a living current action plan, which is to a
SMART format, which needs to be reviewed at every time framed action
point as agreed with the client.

That is my view for what it's worth. I would be happy to share my
passion for the topic with anyone directly. Hope that helps someone!
Mac.

I absolutely agree with Alan's comments. There are still a lot of organisations who are continuing to treat Support Planning/Care Planning as a paper exercise and it's so much more than this. My organisation isn't residential either, although I am sure the principles are the same as any plan should be centred around the person we are caring for. It's crucially important that those undertaking a Care Needs Assessment understand how to use the information obtained and help the individual translate this into their Care Plan, with agreed achievable outcomes. This must then be communicated to those that are providing the care, ensuring they understand what the plan needs to achieve and not to assume they will be providing the same amount of care forever. At all times, the customer should be at the centre of all decisions and be comfortable with the progress. The plan should be continuously discussed to keep it alive and care staff should be encouraged to participate in the process of changing and amending the plan.
The Plan should not be tucked away in a folder, waiting for an annual review or CQC to carry out an inspection. Sadly this happens - it will take time to change the culture.

Hi,

I would like to suggest that this discussion is really important to the work that My Home Life UK does around the UK. http://www.myhomelife.org.uk/WhatIsMyHomeLife.htm I have mentioned this before in one of my other replies - but do have a look.

I am Chair of My Home Life Wales and will certainly mention this discussion at our next steering group meeting tomorrow.
Care Plans ARE living plans and need to be updated when anything changes. They also need to contain real evidence that the person as well as their family/advocate/friends have input - with consent. This is then relationship-centred care planning. Have a look at Mike Nolan's work on the Senses Framework - on relationship centred care plans.
It saddens me when I read in various care home reports that I look at frequently that there is no evidence that residents in care homes are consulted about their care plan. This is the professional model or 'gift' model and represents power and control over the residents even if it was not intended that way.

Have a read of the Care Standards Act 2000 and the Standards and Regulations as it is expected that this should be attended to. Also the NSF Framework and Human Rights should cover residents in all types of care homes via the contracting activites via NHS Continuing Health Care and Local Authority funding.
No excuse, and inspectors need to advise and promote the use real living and person-centred care plans more fervently than I read in inspection reports.
Tell me if I am wrong.

I teach on one of the OU older people courses (K337) and read some wonderful accounts from nurses, health and social care support workers and social workers about what they have achieved regarding person-centred care in care planning activities.
This is the positive note that I would like to end on - there is good practice out there and hopefully MHL is one tool to facilitate this.

Regards,

Lorraine
Chair - My Home Life

Hi Lorraine,
We are of like minds!!! I too am so passionate about effective living
person centred support plans which evidence "clients" involvement,
wishes, choice, dignity, (and everything else the Dignity Challenge
throws at us) anything less, and we do them a great disservice.
Mac.

thank you for all your replies i appreciate your thoughts. i have raised this at a staff meeting and they were all positive about keeping plans in rooms but they did raise 2 points, one was confidentiality and another about some individuals with dementia moving the plans to communal areas and leaving them there so i suppose again confidentiality, any ideas how that could be managed?

MY VIEW ON ACTIVITIES SHEETS
DO THE ROYAL FAMILY HAVE A ACTVITIES SHEETS ABOUT THEIR ACTIVITIES?
WHO THE DISABLED HAVE A ACTIVIES SHEETS IN CARE HOMES

IN NEXT LINE OF TEXT WE ARE TALKING ABOUT TREAT DISABLE PEOPLE THE SAME LIKE OTHER PEOPLE

MY VIEW ON ACTIVITIES SHEETS
DO THE ROYAL FAMILY HAVE A ACTVITIES SHEETS ABOUT THEIR ACTIVITIES?
WHY THE DISABLED TO HAVE A ACTIVIES SHEETS IN CARE HOMES?

IN NEXT LINE OF TEXT WE ARE TALKING ABOUT TREAT DISABLE PEOPLE THE SAME LIKE OTHER PEOPLE

we use a one page person centred care plan which we laminate and put up in the persons room with a picture of them in the middle, this makes it live and real for the person.
and gives quick tips and an essence of the person.