Regulations 9 and 20 of the Health and Social Care Act (Regulated Activities) Regulations 2010 and Outcomes 4 and 21 of the Care Quality Commission’s essential standards of quality and safety require the registered person to draw up a care plan for each service user based on the assessment information obtained. To comply with the Regulations and meet the relevant standards the care plan must be reviewed regularly (at least monthly is usual in care homes for the elderly) and updated as necessary to reflect changing needs.
Currently there is growing pressure from social care policy makers and some commissioners of services for care plans to be written in the first person. It is argued that this demonstrates a ‘personalised’ approach that directly represents the service user’s views and promotes ‘ownership’ of the care plan. That is a laudable aim but the practice also has inherent drawbacks. Our view is that the main purpose of care planning is to provide staff with a practical and accessible working tool containing a clear explanation of the service user’s needs and wishes regarding his or her care and lifestyle and how these are to be met within a risk assessment framework. This objective is achieved through proper consultation with the service user as well as objective assessment of each need area identified and is best expressed neutrally in the third person. Many service users either do not want to discuss certain key matters or are only capable of expressing themselves in very basic terms that do not adequately cover the issues that need to be addressed. In such cases, when adopting the first person style, in order to produce an effective document the person writing the plan is obliged to include statements, purportedly made by the service user, that he or she has not and never would have said. That is unethical, particularly if the service user has dementia or another mental disorder that affects his or her ability to speak coherently. For that reason The Care Standards Consultancy does not advocate writing care plans in the first person unless the service user is actively involved in the care planning process and has sufficient verbal ability to communicate clearly.
A separate numbered sheet should be used for each separate care area addressed. This makes regular updating simpler as rewrites can be restricted to only those care plan headings that need to be changed at the time. For a new service user the initial care plan should be derived from the information obtained during the pre-admission assessment process. The list of headings below covers the areas that should normally be covered although extra areas may need to be considered in individual cases. Well drafted risk assessments with appropriate control measures covering all areas where risk has been identified in relation to the individual service user’s daily life should be inserted in the relevant sections of the care plan so that they are easily accessible to the reader. It is vital that the control measures attached to each risk assessment correspond to the details in the care plans i.e. that there are no inconsistencies or contradictions between them. The care plan should be produced in a user-friendly big print format that both staff and the resident can easily read and understand. If appropriate, pictures and symbols should be used as aids to clarification of some points.
1. Admission information sheet: to include all compulsory details listed, including contact details of significant other people i.e. relatives, GP, social worker etc.
2. Personal profile: including as much social history as can be ascertained e.g. family background, jobs, hobbies, major life events, personality, character traits etc., conveying a good sense of the person as a human being. This will help to give the reader an insight into the service user 's character and may provide useful hints for ways to communicate with the person.
3. Mental health diagnosis: including details of any relevant conditions (for example impaired cognition due to stroke or dementia), a summary of their principal effects i.e. how they affect the individual and whether or not they are controlled, for example by medication. The medical professionals involved in the case should be listed with contact information. Where there is genuine doubt regarding the individual’s mental capacity to make significant decisions (bearing in mind that mental capacity has to be presumed under the Mental Capacity Act 2005 unless it can be established that it is lacking), two stage mental capacity assessments should be carried out and best interests meetings conducted and detailed records should be placed on the personal file.
4. Cognition/mental health needs: including clear descriptions of the person's normal presentation and behaviour pattern with specific instructions on how staff should proceed when problematical behaviour arises. Also there should be clear descriptions of the typical changes in presentation (verbal, physical, body language, behaviour etc.) that occur when the person is becoming more difficult to deal with as well as details of any known triggers to look out for. The care plan should contain explicit descriptions of the person's known patterns of behaviour and a very clear set of instructions as to how staff should deal with the various situations that are likely to occur, for the best possible outcomes. It will always be helpful to include extra information on particular approaches or techniques that have been found to work well e.g. the use of empathy and validating the person's feelings, breakaway techniques or methods to divert attention away from counterproductive behaviour cycles. In summary, a care plan in this area should set out how any cognitive impairment or mental illness involved affects the person and may change his or her perception of things. It should clearly explain the actions that have been agreed to deal with the range of situations presented. Details should also be included of any medication prescribed by the GP to be given to the service user “as required” (PRN). All this will demonstrate a well considered approach designed to produce care matched to the person's identified needs.
5. Communication methods: the service user's abilities/disabilities e.g. relating to speech, hearing and sight should be noted as well as sensible instructions to staff on how to achieve effective two-way communication on an ongoing basis. For example, if the service user is deaf in one ear the care plan should instruct staff to approach from the ‘good’ side to maximize the chance of him or her hearing them. In fact any problems the service user has with communication should be noted, as well as typical speech or behaviour patterns including body language and other non-verbal methods the resident uses to indicate a desire or need for attention. Proven techniques that staff can use to communicate effectively with the person should also be noted, especially if he or she has dementia. As with all the other care plans, communication issues must be considered within the context of the service user’s cognitive capability as well as his or her cultural and ethnic background.
6. Personal care needs: with specific details of any particular individual preferences of the service user as to how he or she wishes to be cared for e.g. regarding toiletries, frequency of bathing, hairdressing, deodorant etc. If no preferences are expressed or evident, that should be clearly stated on the care plan. The individual’s ability to manage independently should be noted as well as the amount of assistance from staff that is necessary for each personal care task e.g. dressing, bathing etc. and any useful tips for staff on how to achieve the best outcome that leaves the individual feeling clean, well cared for, happy and in control. Care staff always know what works well but this is rarely written down as it should be. Where appropriate the degree of prompting from staff that may be necessary should be documented as well as a definition of the limits of staff intervention so that staff actively encourage and support the service user to maintain an acceptable standard of personal hygiene and appearance without imposing unwanted or unnecessary ‘help’ in a paternalistic way.
7. Mobility: the service user’s mobility should be assessed, indicating areas of strength and weakness. If the latter applies the care plan should clearly indicate the amount of support needed from staff when mobilizing or transferring and any aids that should be provided to keep the person safe and reasonably mobile such as walking stick, zimmer frame, wheelchair or hoist. If the service user is non-weight bearing the care plan should specify the hoist to be used and the correct sling size. Falls risk assessments should be in place and the control measures deemed necessary to minimise the risks in all situations identified. It is worth noting that the use of bed rails is normally contra-indicated for individuals with dementia due to the ancillary risks associated with that condition.
8. Tissue Viability: all service users in elderly person’s care homes should be assessed in relation to the risk of pressure sores. Most homes use the Waterlow risk assessment tool that produces a risk rating score. Where the service user is assessed to be at risk of developing pressure sores the care plan must state the agreed plan for ensuring this negative outcome does not occur. This may involve maintaining sufficient nutrition by various means, devising a turning regime for bedridden or non-weight bearing individuals, and particular attention to managing the effects of incontinence. In severe cases, where a pressure sore has occurred, a referral should be made via the GP to the tissue viability nurse for external professional advice. The particular circumstances of each service user, including all relevant factors, should be set out and explained in the care plan with clear instructions for staff to follow for the best outcome.
9. Continence management: The care plan should contain a description of the service user’s current status regarding continence i.e. how well he or she controls the situation. If the service user is still able to manage with help, the management plan for maintaining independence in this area e.g. gentle prompting by staff to go to the toilet should be set out. Conversely, if the person cannot manage unaided, details of any incontinence aids e.g. the correct pad size should be noted as well as the typical intervals between pad changes. A suitable risk assessment should be in place that links with the tissue viability care plan. Particular attention should be paid to maintaining the service user’s dignity, personal hygiene and comfort and how it is proposed that this will be achieved.
10. Medical needs: full details of the service user’s current prescribed medication should be kept in the medication file. However a general statement of medical needs should be included in the care plan, with brief details of the purpose and efficacy of the various drugs prescribed as well as the agreed action to ensure the proper administration of medication. Where the resident wishes to self-medicate and is deemed capable of safely managing independently this should be noted, agreed between the service user and the manager and a risk assessment placed on file. The service user must have a lockable storage space for medication in his or her bedroom. In cases where the service user has a history of refusing medication the care plan should clearly state that staff must respect the individual’s right to refuse and must explain the risks and benefits associated with the medicines concerned to the service user. If experience has shown that the service user can be persuaded to take prescribed medication at a later time, how that works should be noted on the care plan as a procedure for staff to follow. Any covert medication administration regime proposed must be covered by a mental capacity assessment relating to the decision and a best interests meeting involving external health and social care professionals that must be documented on the file.
11. Family/social contact: the service user’s personal preferences must be noted very clearly. Where it is considered that the person would benefit from greater social contacts the way it is proposed for this to be achieved should be clearly described whilst recognizing the service user’s right to decide what he or she wants to do. Any agreed restrictions on the resident's freedom of action should be based on well thought out, reasonable grounds agreed with the individual and clearly documented so that there is no room for misinterpretation.
12. Income: details should be included of the resident's current income and how this is to be managed in the context of his or her lifestyle and spending priorities. Assistance needed in respect of dealing with the Benefits Agency should be recorded. Any agreed restrictions on daily access to money or a budgeting plan (especially for smokers or shopping addicts) should be clearly detailed and agreed with the resident. We recommend that care homes generally avoid involvement in service user’s finances but where money is to be held in the office for safekeeping on behalf of the service user an agreement to this effect should be drawn up and signed by the manager and the resident and all transactions should be accurately recorded.
13. Activities/lifestyle. Considerable emphasis should be placed on the service user’s aspirations and particular desires to lead the lifestyle that suits him or her. Assessment information should ideally include any interests or hobbies that the person has pursued over the years, always bearing in mind that it is his or her current priorities that count. The care plan should also refer to any new ideas that have been put forward that may be suitable to help the service user lead a more rewarding life. There should also be some reference to the person's capabilities (intellectual, emotional, practical, physical, financial etc.) It is very important that the resident's attitude and motivation towards taking part in activities is fully explained, especially in cases where this is largely negative. Where the service user adamantly refuses to participate in any activities or even socialise with the other service users this should be formally acknowledged and the agreed plan for staff to follow written to reflect the resident's position whilst noting the need to continue regularly to suggest or put forward a range of interesting possibilities and opportunities. If the service user subsequently steadfastly refuses to try anything, all this must be very clearly documented with a note that the person’s wishes must be respected. The delivery of the activities plan agreed with the individual i.e. what actually happens needs to be accurately recorded and regularly reviewed to provide clear evidence that the home has made ongoing attempts to address the service user’s social needs. Risk assessments should be carried out and placed on file covering activities such as going outside the building alone, using kitchen equipment and laundry appliances, and any other activity that creates a perceived risk. All control measures determined should be negotiated and agreed with the service user. It is important not to be unduly risk averse as that would breach the service user’s right to lead a normal life - in which some risk is inevitable.
14. Nutrition and Diet: all service users should be nutritionally screened as a matter of course (most care homes today use the MUST tool) and if necessary a formal risk assessment drawn up. Any particular cultural requirements and food preferences should be noted e.g. likes/dislikes or obsessive behaviour patterns regarding food. Also any specific dietary needs arising from medical conditions such as diabetes or chronic weight loss should be noted, with clear instructions on what foods should be encouraged or avoided. As in all the care plans, the actions agreed with the service user should be clearly set out, with any limits on food intake or snack frequency e.g. sugar restrictions or the promotion of healthy eating choices, should be clearly documented with accurate records kept of what actually occurs to demonstrate that the action plan has been followed. The service user’s weight should be monitored regularly and if necessary the GP should be approached regarding a possible referral to a dietician. Any plan suggested by the dietician should be implemented with the service user’s agreement or the risks and benefits of refusing the recommended course of action explained to him or her by staff. CQC are very keen on this and often rigorously scan files for suitable evidence of proactive management of this issue by staff. Although it is undoubtedly good practice to record how well each service user eats and drinks we are not in favour of implementing formal food and fluid intake charts unless a service user is at severe risk of malnutrition and/or dehydration. Such charts are of limited practical value and experience shows that over time staff rarely complete such records diligently and patchy record keeping allows CQC inspectors and local authority contracts monitoring personnel to make unfounded but damaging assumptions about the care provided to service users. Consequently our advice is to limit the use of food and fluid intake charts and thereby avoid making a rod for your own back.
15. Cultural and faith needs: information should be included about any specific cultural or religious needs such as ethnic considerations and traditions. Reference should be made to the service user's religious background (if any) and any particular wishes expressed to remain or become involved in religious activities. Any actions agreed with the service user to facilitate this should be documented and any participation in religious activities should be recorded on the activities record. As with the activities care plan, if the service user presents no obvious cultural or spiritual needs or expresses no interest in spiritual/religious matters this should be clearly noted to indicate that the matter has been conscientiously addressed in the care planning process.
16. Death and Dying. The service user needs to feel reassured that staff know and will carry out his or her specific wishes and requirements, whether cultural or personal, in respect of how he or she is to be cared for as death approaches and immediately thereafter. Therefore for every service user an end of life care plan should be in place that details any specific rituals required as well as clear instructions regarding burial or cremation if the home is to be responsible for making the arrangements. Where the service user’s mental condition is such that it is considered unwise or prejudicial to the resident's equilibrium to broach this delicate matter or he or she flatly refuses to discuss the matter, this must be clearly recorded on the care plan sheet with a reasoned explanation and an indication that the matter will be raised at a more opportune time in the future. For service users who lack the mental capacity to make the necessary decisions it may be necessary to consult relatives or friends for a reasonably informed view. The service user should be asked whether he or she has made any advance decision to refuse medical or lifesaving treatment and the answer should be noted, with the relevant documentation added to the file if an advance decision has been made. If the proper forms are not in place there is a risk that the service user’s wishes may be ignored no matter how clearly expressed, which would be poor practice. It is important that this is not left unresolved as too difficult to achieve or simply forgotten about. End of life care is certainly a significant issue for service providers and staff need to know what they should do when the time comes.
© The Care Standards Consultancy 2013