Care and Support Plans in Social Care Policy

Policy Statement

{{org_field_name}} always develops an individual plan of care which describes what care and support is needed and how it will be delivered. It recognises the key role of well-documented care in the provision of high-quality care in line with the requirements of the Care Act 2014, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The care and support plan is drawn up with people’s involvement after a thorough assessment of the needs, strengths, abilities and aspirations of new people receiving care. It could be based on the following sources of information.

A summary of the care plan prepared under any previous health and care assessments.
An assessment made by {{org_field_name}}’s own staff (including where the care and support is being obtained privately).
A plan produced under the (mental health) Care Programme Approach (if applicable).

In line with the relevant care regulations, the assessment covers all aspects of the health, personal and social care needs of the new people receiving care. The ensuing care and support plan sets out in detail the actions to be taken to meet the people’s care and support needs.

A care and support plan will follow all appropriate clinical guidelines produced by relevant professional bodies. It includes the person’s care goals and how they will be achieved within agreed timescales and staff responsibilities.

Any person who has learning disabilities will have access to health services in line with Health Action Planning policies and will have the opportunity for an annual health check in addition to any other healthcare and treatment needed.

{{org_field_name}} recognises its duty to provide safe care and, accordingly, assesses all risks that threaten individual safety and wellbeing. The person using the services is always central to the procedures for planning their care. The person must, therefore, sign or otherwise signify active consent to their plan of care and to the attendant risk assessments.

Where the person cannot take responsible decisions, best interests’ assessments will be carried out in line with the requirements of the Mental Capacity Act 2005 to develop their care and support plan.

{{org_field_name}} will make available relevant managerial, care and other staff as appropriate to assist in producing and carrying through the care and support plan, and subject to the person’s permission and to recognised standards of confidentiality, will involve other professionals and agencies in the care planning.

It is for the individual to specify which relatives, friends or others they wish to be involved in drawing up and implementing their care and support plan.

People who use services are central to the reviewing of their care and treatment. Reviews are carried out regularly with the involvement of the person receiving care, their relevant others, the service’s management and care staff and, where applicable, other professionals who contribute to their care and wellbeing.

The care and support plan is always written in language and formats that the person using the services and others involved in their care can understand. It is kept in a secure place (in the person’s own home), and people who use services know that they can always have access to it.

How we develop our care plans

The care and support plan:

is drawn up from the needs assessment and identifies the goals agreed with the person for their care and support, and how the goals will be achieved
will embrace all aspects of the welfare of the people who use the services agreed from the needs assessment, including any risks and how they will be managed
recognises and builds on people’s strengths and abilities to meet their own needs
will describe {{org_field_name}}’s responsibilities for the person’s welfare and limits to their responsibilities
will relate {{org_field_name}}’s responsibilities to those of other professionals and agencies so that everyone’s contributions are clear to all concerned.

Risks and Risk Assessment

Risk assessments and corresponding management plans are integral to the care planning process. They are made to ensure that the service is providing safe care and treatment in line with their registration requirements.
The service recognises that people who use services have the right to take risks, but through the care and support plan, it will take all reasonable steps to ensure any risks to which people who use services are exposed, are well controlled.
As part of the care planning, the service helps each person to assess the risks involved in any proposed care and treatment, weighing the benefits and possible adverse effects, and coming to a measured conclusion. All risk assessments are recorded on the care plan.
If a person does not already have the mental capacity to take part fully in their care planning, the plans will be drawn up with the involvement of their relatives and lawful representatives, including anyone with power of attorney for their welfare following Mental Capacity Act 2005 (and Mental Capacity Amendment Act 2019) procedures. Care plans will include any restrictive measures agreed under deprivation of liberty safeguarding authorisation procedures. These will be regularly reviewed and will always be available to CQC inspection.

Planning and Meetings

{{org_field_name}} holds regular meetings on people who use services’ care and support plans. The first meeting takes place before or very shortly after an agreement about the service to be provided has been made. At this meeting, the purpose of the care and the care provision will be discussed and agreed. The person receiving care (or lawful representative where the person lacks mental capacity) should then give their formal consent to the care and treatment proposed by signing the care plan.

Implementation

The care and support plan will be readily accessible to both the person receiving care and the care staff.
It will be regularly consulted by staff and others who have legitimate access, as a guide to the care they should be aiming to provide.
The manager and the key worker/care co-ordinator will continue to monitor the work undertaken with the person to ensure that other staff are acting in accordance with the plan.

Emergencies and Discharge from Hospital

Where the service agrees to provide a service in an emergency, and where no pre-service assessment and personal planning has been possible, it will develop a provisional plan within 24 hours of the start of the service.

The plan will then be developed and reviewed with all concerned by the end of the first week after the start of service, and further reviewed by the end of the first month (if still applicable).

The service will follow all professional needs assessments, advice and guidance for people who are being discharged from hospital and include these in their care and support plans, including any rehabilitation and reablement recommendations.

Reviews

In addition to regular monitoring, the service will carry out monthly checks wherever practical of the plan with the person receiving care and key others, and no less than three monthly formal reviews with all involved.
Reviews involve the person who uses the services, their relevant others, a care manager, key worker or care co-ordinator, and where involved, other professionals, where the progress of the plan will be discussed.
Reviews will, among other matters, critically consider the appropriateness of the original plans, the feasibility of the care methods being used, the outcomes of any risks taken, respective roles and responsibilities, and timescales.
Reviews will take into account any new information which is available and any significant changes in the person’s needs, abilities and aspirations.
Care will be taken to ensure that the person is in full agreement with any modifications or additions made to the plan.
Reviewing the care and support plan is a continuing process of counting achievements, setting new goals and adjusting the care. After each review, the other stakeholders involved in the care will be briefed on changes which require their action or attention.

Records

Each person will have a file prepared before start of service, which will contain at least:
a. a page with basic information (name, age, etc)
b. the initial assessment documentation
c. the first plan of care
d. risk assessments
e. records of reviews of the plan, with any changes made to the plan from the monitoring and reviewing procedures.
The records will be written in a style and language readily comprehensible to the individual, particularly where their first language is other than English.
The records will be securely kept, where practical, in the user’s accommodation, with authorised access for care staff who need to record their work and for management and administrative purposes. People who use services have access to their own care plans in line with data protection laws and the service’s access to records policy.
When changes are required to the care and support of the people who use services they will be made on the care plan with retention of the previous information.
Corrections/amendments (eg because of recording errors) made to the care records should be signed by the person making them with, where appropriate, the agreement of the person. There should be a brief explanation as to the reasons for the correction/amendment. The changes should then be verified by a line manager.
All care and support plans, including those that are kept electronically, must comply with the General Data Protection Regulation and Data Protection Act 2018.

Training

All new staff are given training in the development and use of the service’s person-centred care plans and further training as required, following the Care Certificate standards framework.

Staff with or who are studying for a formal qualification are expected to develop their knowledge and skills in line with their roles and responsibilities for care planning, eg as key workers/care co-ordinators/managers. Their training is tailored to their specific learning needs.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

S23. Care and Support Plans in Social Care