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Care and Support (Personal) Plans for Social Care Services (Wales) Policy
Note:
[This policy template can be adapted for both care homes and domiciliary support services in line with the relevant Wales service standards, which apply to all social care services — see below.]
Policy Statement
This care service 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 Social Services and Well-being (Wales) Act 2014, and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, specifically Regulations 15–18.
The care and support plan is drawn up with people’s involvement after a thorough assessment of the new person receiving cares’ needs, abilities and aspirations. It could be based on the following sources of information.
- A summary of the care plan prepared under any previous health and care/local authority assessments.
- An assessment made by {{org_field_name}}’s own staff (including where the care and support is being obtained privately).
In line with the relevant care regulations, the assessment covers all aspects of the person’s health, personal and social care needs. The ensuing care and support plan sets out in detail the actions to be taken to meet the person’s care and support needs.
A care and support plan will follow all appropriate health and 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.
The service recognises its duty to provide safe care and, accordingly, assesses all risks that threaten individual safety and wellbeing.
The person who uses the services is always central to the procedures for planning their care. The person who uses the services must, therefore, sign or otherwise signify active consent to their personal plan and to the attendant risk assessments.
Where the person who uses the services 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 personal plan.
The service 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 who uses the services’ permission and to recognised standards of confidentiality, will involve other professionals and agencies in the care planning.
It is for the person who uses the services 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 who uses the services and others involved in their care can understand. This is made as an “active offer” for Welsh speaking people receiving care. The plan is kept in a secure place (in a care home or the person’s own home), and the people who use the services 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 who uses the services for their care and support, and how the goals will be achieved
- will embrace all aspects of the person’s welfare agreed from the needs assessment
- will include measures to manage identified risks to individual wellbeing and how positive risk-taking, which promotes independence, can be supported
- recognises and builds on the person’s strengths and abilities to meet their own needs
- will describe {{org_field_name}}’s responsibilities for the welfare of the people receiving care 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 the 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 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 CIW inspection.
Planning and Meetings
{{org_field_name}} holds regular meetings on people’s personal 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 who uses the services (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 who uses the services 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 who uses the services 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 further developed and reviewed with all concerned by the end of the first week after the start of service in line with the requirements of Regulation 15 (paragraphs 4 and 5) and Regulation 18 (provider assessment) of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.
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 who uses the services and key others, and no less than three monthly formal reviews with all involved to meet the requirements of Regulation 16 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.
- 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 consider any new information which is available and any significant changes in the person’s needs, strengths, abilities and aspirations.
- Care will be taken to ensure that the person who uses the services 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, which include changes made from the monitoring and reviewing procedures. - The records will be written in a style and language readily comprehensible to the person who uses the services, including in the Welsh language if that is their preference.
- 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 the 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 person’s care and support 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 individual. 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 receive training in person-centred care, which includes the planning of a person’s care and the use of care plans. The induction training is based on the All Wales Induction Framework for Health and Social Care.
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 and in line with Social Care Wales guidance and frameworks.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
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Next Review Date: {{next_review_date}}
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