What is a care and support plan?

Another load of paperwork some people say!! But, this is very important paperwork!


Once it has been determined that an individual requires care, whether at home or in a care home setting the care home manager/social care manager must prepare a care and support plan for their stay. It is a document owned by the resident in the care home and identifies the outcomes which need to be met by the home for them. As the care and support plan is owned by the resident they can see and review it and so can their family if they are given permission.


When a care and support plan is completed the resident and the home manager/social care manager are involved in its completion. If a plan is prepared for someone who lacks capacity it can be completed by their legal representative and the home manager/social care manager. In these circumstances decisions are made in the best interests of the individual requiring care and family needs to be consulted. The aim is to show how care and support will be delivered and how outcomes identified in the plan will be met.


Things that should feature in a care plan are:-


- how someone wishes to get up and go to bed

- how they move from chair to bed

- the specifics of how they wash and bathe and dress and all elements of personal care

- how are decisions to be made about dressing

- what happens with medication

- the need for social activities

- monitoring of eating and drinking

- proposals for health management including appointment keeping

- specialist needs ie skin management, catheterisation or stoma bag usage

- dealing with correspondence


This is just some of the areas that need to be featured.


A duty is placed on the shoulders of a care home to notify the local authority if any of these issues start to deteriorate or improve, if there is constant refusal to co-operate, safeguarding concerns, accidents or hospitalisation or changes in capacity.


Once a care plan is put in place it does not become a piece of paper that sits in a cupboard. The first review should take place eight weeks after a placement in a care home has taken place. After this a review should be an annual event, if not more frequently if parties involved with care feel it is appropriate. Unfortunately, we often hear of family members not being involved to care plan reviews. This should not happen. A review should involve the resident, their family and their social care manager. These reviews are important to make sure that the outcomes which were identified at the last review are being met or whether things need to change.


The care plan does not just get looked at once a year. It should be reviewed by the care home at least once a month. This way changing needs can be identified, feedback from the resident can be obtained, special requirements can be identified and the need for a more formal review can be addressed.


In addition the care home should check their ability to continue to meet the needs of the resident every six months.


So, moving a family member into a care home is not a one off job. Make a note of when these reviews should take place and check they have. Check the care plan each month to make sure it has been reviewed by the home and ask every six months whether the home have clarified if they can still meet the needs of your family member.


If you are not happy with something in the care plan challenge it. It's about getting it right to make sure the care for your family member is what they need and want, not what someone else feels they need or want. When your loved one does not have capacity to jump up and down if something is wrong, borrow their shoes and do it for them!



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