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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Developing and Managing Care Plans Policy

1. Purpose

This policy ensures that care plans at {{org_field_name}} are developed and managed effectively to provide high-quality, person-centred care in compliance with CQC Fundamental Standards, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Mental Capacity Act 2005, and NICE Guidelines. Care plans are essential for maintaining the health, wellbeing, and dignity of people we support, ensuring that care is tailored to their individual needs and preferences.

2. Scope

This policy applies to all staff responsible for the assessment, development, review, and implementation of care plans at {{org_field_name}}. It covers all aspects of care planning, including risk assessment, consent, collaboration with families and healthcare professionals, and documentation.

3. Related Policies

• Person-Centred Care Policy (CH07)
• Mental Capacity and Deprivation of Liberty Safeguards Policy (CH39)
• Safeguarding Adults from Abuse and Improper Treatment Policy (CH13)
• Confidentiality and Data Protection (GDPR) Policy (CH34)
• Risk Management and Assessment Policy (CH18)

4. Policy Statement

{{org_field_name}} is committed to developing and maintaining care plans that reflect the individual needs, preferences, and rights of people we support. Care plans will be comprehensive, regularly reviewed, and updated to reflect changes in health conditions, risks, and personal choices.

5. Principles of Care Planning

Care plans at {{org_field_name}} must be:

• Person-centred: Tailored to the unique needs, preferences, and goals of each individual.
• Holistic: Addressing physical, emotional, psychological, and social needs.
• Evidence-based: Incorporating best practices and guidelines from regulatory bodies.
• Collaborative: Developed with input from people we support, their families, advocates, and healthcare professionals.
• Regularly reviewed: Ensuring care remains relevant and responsive to changes in condition.
• Legally compliant: Adhering to legislation, including consent and data protection laws.

6. Initial Assessment and Care Plan Development

• A comprehensive initial assessment must be conducted before a care plan is developed.
• Information gathered includes:
  • Personal history, preferences, and daily routines.
  • Medical conditions and medication requirements.
  • Mobility, nutrition, hydration, and personal care needs.
  • Mental health, emotional wellbeing, and social interaction preferences.
  • Communication needs and sensory impairments.
  • Risks, including falls, choking, skin integrity, and self-neglect.
• The assessment should involve the person we support, family members, and relevant professionals.
• The care plan must be agreed upon with the person we support, ensuring they understand and consent to their care arrangements.

7. Risk Management within Care Planning

• Every care plan must include a detailed risk assessment to identify potential hazards.
• Risk management strategies must be documented and regularly updated.
• Where restrictive practices are necessary, they must comply with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).
• All risks must be communicated to staff, and mitigation strategies should be clearly outlined.

8. Consent and Decision-Making

• Care plans must be developed with the full involvement and consent of the person we support.
• If an individual lacks capacity to consent, decisions must be made in their best interests, following the Mental Capacity Act 2005.
• Consent must be reviewed regularly, and any changes in capacity must be documented and acted upon appropriately.

9. Care Plan Implementation

• Staff must be trained on the contents of each care plan to ensure accurate implementation.
• Care plans should be accessible to all relevant staff while maintaining confidentiality.
• Staff must follow the care plan precisely, adapting only when necessary and documenting any deviations.
• Any concerns, changes, or incidents affecting a person’s care must be reported and reviewed immediately.

10. Reviewing and Updating Care Plans

• Care plans must be reviewed at least every six months or sooner if there is a change in needs.
• Reviews should involve the person we support, family members (where appropriate), and professionals such as GPs, nurses, or therapists.
• Care plans should be updated if:
  • There is a significant change in health, mobility, or mental wellbeing.
  • A new risk is identified.
  • A different approach to care is required due to feedback or concerns.
• A multi-disciplinary approach must be used for complex cases.

11. Care Plan Documentation and Confidentiality

• Care plans must be accurately documented in a structured and readable format.
• Records should be securely stored, in line with GDPR and Data Protection Laws.
• Access to care plans must be restricted to authorised personnel only.
• Staff must record all interventions, changes, and reviews in real time.
• Any breaches of confidentiality must be reported to the Data Protection Officer.

12. Involvement of Families and External Professionals

• Family members and advocates should be encouraged to contribute to care planning.
• Healthcare professionals, including GPs, dietitians, physiotherapists, and speech therapists, should be consulted where appropriate.
• Decisions affecting a person’s care must be discussed transparently, ensuring they align with the individual’s best interests.

13. Training and Staff Responsibilities

• All care staff must complete mandatory training on care planning.
• Staff should be trained in risk management, communication techniques, and consent processes.
• The Registered Manager is responsible for overseeing care plan compliance and staff training.
• Keyworkers and team leaders must ensure care plans are followed and updated as needed.
• Staff must communicate effectively with colleagues to ensure continuity of care.

14. Quality Assurance and Compliance

• Regular internal audits must be conducted to ensure care plans meet CQC requirements.
• Care plans should be checked for accuracy, completeness, and effectiveness.
• Feedback from people we support and their families should be actively sought and incorporated into reviews.
• Non-compliance with care planning processes must be addressed through staff training or disciplinary procedures if necessary.

15. Complaints and Feedback

• Individuals and their families must have clear access to a complaints procedure regarding care planning.
• Complaints must be investigated promptly, and any necessary changes to care plans should be made.
• Feedback should be used to improve care planning processes.

16. Policy Review This policy will be reviewed annually or sooner if changes in CQC regulations, best practices, or operational needs require an update.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.