A care plan is a comprehensive document that outlines all of a person’s specific health and social care needs and the actions required to address them. It serves as a roadmap for the care and support a person requires from health care professionals, caregivers, and family members.
A detailed and well-crafted care plan includes all the information needed to ensure that a person’s physical, emotional, and social needs are met. By clearly defining the level of care a person requires and how that care will be provided, a care plan ensures all caregivers are always working towards the same goals.
Learn more about the importance of care plans, what they include and how they are created and implemented at The Good Care Group.
What is a care plan?
A care plan is a working document that outlines the specific care needs of an individual and how those needs will be met by a care team. By carefully detailing all the information required in a person’s care, care plans ensure that people receive care that is tailored to their unique needs and preferences.
At its core, a care plan is really just a roadmap that ensures caregivers know exactly how to meet the physical, mental and social needs of the people they care for. By documenting the individual’s health care needs, personal history, preferences, goals and other relevant information, a care plan allows care teams to provide consistent and person-centred care.
Care plans are typically created in collaboration with the individual, their family, and any other healthcare professionals involved in their care. The process of creating a care plan often involves a thorough assessment of the person’s needs, as well as ongoing review and revision to ensure the care plan is always achieving positive outcomes and is up to date.
Why are care plans important?
Care plans are crucial because they provide a detailed, individualised roadmap for the care and support of a person. They ensure that all involved parties, including the person receiving care, family members, and carers, are aware of the person’s needs, preferences, and goals, and how those needs will be met. They are also an important contractual agreement between both the care provider and the care receiver, and care will not be able to commence until an agreement is reached by both sides.
Care plans help to ensure that the care provided is consistent, coordinated, and of the highest quality. They can also help to prevent misunderstandings, miscommunications, and errors that could negatively impact the person’s health and well-being.
Care plans also provide a record of the care provided and the person’s progress, which can be useful for evaluating the effectiveness of the care and making any necessary adjustments. Finally, care plans are essential for meeting regulatory and legal requirements, such as those related to safeguarding, health and safety, and data protection.
How often are care plans updated?
Care plans are updated every six months. The care team, the individual (if possible) and their loved ones will provide feedback on the existing care plan before a care plan review meeting commences. The review meeting will then take place usually at the client’s home with those present including the care manager, the carers, the client and any loved ones who are involved in their care. At the review meeting, a care manager will meet with the client, their carers and their loved ones and discuss all aspects of the existing care plan and any amends that need to be made.
Care plans can also be updated sooner than this if there are any incidents. For example, hospital discharge, infection or fall.
What is included in a live-in care plan?
Since care plans are tailored to the individual, no two will ever be the same. However, there is some information that should be included in every live-in care plan:
- Folder
A care plan should be kept in a folder that should have the person’s name and address written on the spine and front cover for easy identification.
- Personal information and contacts
Important information is right at the front of the care plan, including emergency contacts, health professionals involved in the client’s care i.e. GP, district nurse, etc., care manager’s details, and if there is a Do Not Resuscitate (DNR) document in place and where it can be found in the client’s property. A safeguarding telephone number and contact is also within this section, so that an individual can raise concerns at any time if they wish.
- Daily routine
Here, information focuses on the daily routine of the client, including what time they like to get up and what time they like to go to bed, how many hours of care they should be receiving and when, their general routine during the day, evening and night time (if care is provided overnight), any scheduled weekly activities such as attending social events, going to the hairdressers or other appointments, and what happens during carers’ breaks.
- Daily average hours agreement (DAHA)
A DAHA is an agreement between both parties on the amount of care hours that will be delivered to suit the client’s needs. This makes it clear when the carer is expected to deliver care and when they aren’t, whilst also ensuring they receive ample breaks. This section will also detail whether the client requires any care during the night, which will be delivered by a different carer than the daytime.
- Scheduled weekly activities
There is a list of agreed activities and appointments that the client will regularly attend, including health care appointments, the hairdressers and any regular visitors such as a cleaner or gardener.
- Social interests & activities
This section covers social activities and hobbies the person likes along with how to encourage participation to promote well-being. At The Good Care Group, we ask questions during the initial assessment such as: What are your wishes? How do you like to live your life? What are your hobbies and interests?
We also ask clients about their likes and dislikes, along with any needs relating to race, culture, gender, age, religion/spirituality, disability, or sexuality.
- Life history:This section should contain information about the person’s life and background. It should be built up and added to over time, rather than a one-time information-gathering exercise. A life history allows carers to truly understand the person they are caring for as an individual and what is important to them.
There are several free and paid tools available to support you to undertake life story work such as:
Life Story Book – Dementia UK
Life Story Work – AgeUK
Remember Together – Alzheimer’s Society
- The pool activity:This section is only completed for those who have dementia and is a tool to determine how well they can function cognitively and if any support is required. An experienced care manager will go through nine different categories with the client to give them an understanding of their functional capabilities, and then scoring them using the tool, which provides a detailed plan of how best to support the client to live well with dementia.
- Carer matching
At The Good Care Group, we pride ourselves on the way in which we match our carers to our clients. We want the match to work for both sides, so we get to know the preferences of both parties, including the health care needs of the client and the experience of the carer, before we make a match. This section focuses on exactly what the client would prefer in their carer, including gender, whether they mind having a carer that may smoke or if they require a carer that can drive.
- Health and diagnosis
Ensuring all information relevant to the client’s health and well-being is present in their care plan is extremely important, which includes any medical conditions they have, risk assessments relating to their health, medical appointments and their frequency, medication prescribed, and how any conditions affect their life on a daily basis.
- Medication: A care plan should include all the medications a person takes, the dosages, how they should be administered, and any special instructions or precautions. Include details of the prescribing doctor and any known allergies or adverse reactions.
- Sensory needs and communication: This section should include a person’s preferred communication methods, including their first language, and whether they are fully, partially or non-verbal. It should also note the use of any communication aids if necessary, such as glasses or hearing aids.
- Nutrition & hydration
Nutritional information should be included to ensure the person’s dietary needs are met and hydration should be monitored to prevent dehydration. There should also be details about what they like to eat, at what times in the day they prefer to eat, whether they need support to eat and drink and if they like to get involved with food preparation.
- Mobility and falls
A person’s mobility needs and any potential fall risks should be assessed and appropriate measures should be put in place to reduce the risk of falls. This section covers all elements of mobility including being in bed and getting in and out of bed, weight bearing, standing, walking, any equipment required and activities outside of the home.
- Personal care
Any assistance needed with daily living activities such as bathing, dressing, and grooming. This section also includes continence and whether any support or products are required to manage this with the client, including any risk of urinary tract infections (UTIs). All carers at The Good Care Group are trained in using UTI testing kits, so that they can identify if there is an infection present and thereby reducing the risk of the client becoming unwell or being admitted to hospital.
- Cognition, emotion and behaviour
Here is where information about the client’s general demeanour, wishes and behaviour are kept, as well as anything that impacts their cognition. Strategies to support the client will be detailed and completely bespoke to them and their needs, including tips on what to say to them if they are upset, anxious or happy.
- Consent and capacity
It is important to gain consent from the individual for any support that is given, or have the consent from the client’s power of attorney if they do not have capacity to make their own informed decisions. Best Interest Decision documentation is also necessary when a person lacks capacity.
- Domestic and money handling
Domestic requirements such as cooking, cleaning, laundry and gardening are listed here, with who will take responsibility for them – whether that’s the carer, family, external contractor or the client themselves – and when they will take place. Money handling is an important part of the care plan because it makes it clear who will be looking after the finances relating to shopping, trips out etc. and how this information will be recorded.
- Environmental safety
Assess all health and safety hazards associated with the property and the client’s welfare including fire safety, pets, water supply, fuse box, alarms, exits and the fire department to assess safety if the client is cared for in bed.
- Monitoring records
Tracking and documenting the person’s progress, needs, and changes. Care plans are ‘living’ documents that change as and when care needs change.
- Daily records: Documenting daily care activities, medications, and treatments provided.
- Care plan review records: Documenting and updating the care plan to ensure it meets the person’s evolving needs.
- Safeguarding, accidents and incidents
Ensuring the person’s safety and preventing harm, while addressing any accidents or incidents that may occur. These are also updated on a separate internal system at The Good Care Group so that care teams, clients and their loved ones can immediately see when any incident has occured.
The following is other important information that might be found in a care plan depending on the individual’s needs:
- Delegated health care tasks: If the client requires complex, nurse-led care, they may need delegated health care tasks to be completed by their carer. Delegated health care tasks are when a specially trained carer completes complex clinical tasks under the guidance of a nurse, who will have also trained the carer on carrying out the task(s). This may include PEG feeding, stoma and catheter care, blood sugar monitoring or wound dressings.
- Skin care & tissue viability: Information on preventing and treating skin breakdown, pressure ulcers, and wounds.
- Sleeping and night care: Addressing sleep-related needs and managing night-time care.
- End of life: Providing palliative care and support during end-of-life stages according to your wishes.
- Other care providers: The client may require another care provider to cover their regular live-in carer’s breaks. If so, details will be kept separately to the cover carers for what they need to do when they are caring for the client. This may be carried about by a different care company or by The Good Care Group’s hourly care team.
‘Outstanding’ home care from The Good Care Group
The care plan is an essential tool for ensuring that you or your loved ones receive the appropriate care and support you need to live a meaningful and fulfilling life. A detailed care plan helps to ensure that everyone involved in providing care, including family members and care professionals, is working together towards the same goals.
At The Good Care Group, we understand the importance of care plans in providing outstanding live-in care to our clients. We take a person-centred approach to developing and delivering care plans that meet the unique needs of each individual. Our care plans are based on a thorough assessment of each person’s needs, preferences, and goals, and are regularly reviewed and updated to ensure that they continue to meet their evolving needs.
If you or a loved one are in need of extra support, get in touch with us today. Our friendly team will be happy to explain how we can help you develop a care plan that meets your specific needs and supports you to live life on your terms.
