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Developing and Managing Care Plans Policy

1. Purpose

The purpose of this policy is to establish a structured, person-centred approach to the development, implementation, monitoring, and review of care plans for individuals receiving domiciliary support services from {{org_field_name}}. This policy ensures that all care plans are designed to meet the unique needs, preferences, and aspirations of service users, thereby promoting well-being, dignity, independence, and personal outcomes.

The policy also ensures compliance with the Regulation and Inspection of Social Care (Wales) Act 2016and The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, ensuring that the provision of care meets the required legal, regulatory, and ethical standards.

This policy underpins high-quality service delivery, enabling care staff to provide consistent, effective, and safe care while ensuring individuals receive support that is appropriate to their changing needs.

2. Scope

This policy applies to all staff involved in assessing, planning, delivering, and reviewing care and support services, including:

• Registered Managers
• Care Coordinators
• Care Support Workers
• Responsible Individuals

It is relevant to all individuals receiving support, including those with complex needs, disabilities, long-term conditions, and those requiring palliative care. The policy ensures that every individual is provided with a care plan that is:

• Person-centred, respecting their dignity and choices.
• Legally compliant with Welsh regulations.
• Continuously reviewed to adapt to changing needs.
• Safeguarding-focused, ensuring individuals are protected from harm.

This policy ensures that service users, families, and professionals involved in care delivery understand how care plans are developed, managed, and updated.

3. Principles of Effective Care Planning

3.1 Person-Centred Approach

Care planning must be individualised, with the service user at the centre of all decisions. This involves:

• A collaborative process, engaging individuals, their families, healthcare professionals, and advocates where necessary.
• Understanding the physical, emotional, psychological, and social needs of the individual.
• Promoting dignity, autonomy, and personal choice.
• Recognising and respecting cultural, religious, and lifestyle preferences.
• Supporting independent living wherever possible.

Service users must be encouraged to actively participate in setting their own care goals, ensuring that their care is tailored to their preferences, aspirations, and lifestyle.

3.2 Initial Assessment

Before any care is provided, an initial assessment must be conducted by a qualified assessor. This assessment must:

• Gather comprehensive information about the service user, including their medical history, daily routine, and personal preferences.
• Assess mobility, medication needs, cognitive ability, and communication preferences.
• Identify risks, including potential hazards in the home environment.
• Involve family members or legal representatives where appropriate.
• Be conducted in a respectful and professional manner.

The assessment findings should form the foundation of the individual’s care plan.

3.3 Developing the Care Plan

The care plan should be developed in consultation with the service user, ensuring that it:

• Outlines clear goals and desired outcomes.
• Defines specific interventions and support services required.
• Details the roles and responsibilities of care staff.
• Includes a schedule of care visits and time allocation.
• Provides emergency contact details and a contingency plan.
• Is signed by the service user (or representative) and the care provider.

Each care plan must be documented, securely stored, and made accessible to all relevant care staff.

3.4 Consent and Capacity

Every service user should provide informed consent to their care plan. This means:

• They must understand the proposed care plan.
• Consent must be given voluntarily, without pressure.
• They should have the option to refuse or modify aspects of their care.

If an individual lacks capacity, care decisions should be made:

• In line with the Mental Capacity Act 2005.
• In consultation with family members or advocates.
• Using best interest principles.
• Following any relevant Deprivation of Liberty Safeguards (DoLS) procedures.

3.5 Implementation and Monitoring

Once a care plan is in place, it must be implemented and continuously monitored to ensure:

• Care is delivered in accordance with the plan.
• Service users are comfortable and satisfied with the care they receive.
• Care staff accurately document daily activities and interventions.
• Issues, refusals of care, or concerns are reported immediately to the Registered Manager.
• Adjustments are made in response to changes in health or preferences.

Regular supervision meetings with care workers will ensure quality and consistency in care delivery.

3.6 Review and Evaluation

Care plans must be reviewed at least every six months, or sooner if:

• The service user’s health condition changes.
• Their personal circumstances change.
• They or their representative request modifications.

Reviews should involve:

• Face-to-face discussions with the service user.
• Feedback from family members, professionals, and care staff.
• Outcome measurements to assess whether the care plan is meeting goals.
• Updates and amendments to reflect current needs.

Any major changes should be documented, communicated, and re-approved by the service user.

3.7 Risk Management

A risk assessment should be conducted as part of the care plan development. This includes:

• Identifying potential hazards in the home.
• Assessing risks related to mobility, medication, and health conditions.
• Implementing preventative measures, such as fall prevention strategies.
• Regularly updating risk assessments in line with care plan reviews.

Risk management is essential to ensure safety without restricting autonomy.

3.8 Safeguarding and Reporting Concerns

All care staff must be trained in recognising and reporting safeguarding concerns. This includes:

• Identifying signs of abuse, neglect, or exploitation.
• Reporting concerns immediately to the Safeguarding Lead.
• Following the CIW Safeguarding Policy.
• Working closely with local safeguarding teams to protect vulnerable individuals.

A zero-tolerance approach must be taken towards any form of mistreatment or neglect.

4. Efficiency in Managing Care Plans

To ensure efficiency and effectiveness, {{org_field_name}} implements:

• Digital care planning systems for real-time updates and monitoring.
• Regular training sessions for care staff.
• Clear communication channels between staff, service users, and families.
• Internal audits to ensure compliance with CIW requirements.

Efficient management reduces errors, improves service quality, and enhances user satisfaction.

5. Related Policies

This policy is closely linked to:

• Initial Assessment and Care Planning Policy (DCW36).
• Person-Centred Care Policy (DCW07).
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13).
• Risk Management and Assessment Policy (DCW18).
• Mental Capacity and Deprivation of Liberty Safeguards Policy (DCW39).

6. Policy Review

This policy will be reviewed annually or sooner if legislative changes occur to maintain compliance and effectiveness.

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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}}
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