Care and Support Plan

The Care and Support plan must be completed prior to, and no later than 2 days after, the service commences. For emergency services, the Care and support plan must be completed as soon as possible. It is good practice to state on the person’s record that this was an emergency admission. Care and support plans should not be completed based on the enquiry form or Local Authority Care and support plan alone.

It should be:

  • Personalised / tailored to the person.
  • Easy to Navigate / Indexed.
  • Co-Produced with the person and/or Family/advocate (evidence of this needs to be provided).
  • Reviewed, Evaluated and updated (frequently, and as and when) with the person and/or family – Care files can become complicated with unnecessary or outdated information, therefore they should only contain the current documents (any documents over 2 years or with contradictory information should be archived).
  • If you are still using paper-based recording, do not use tippex, highlighter pens or coloured ink other than blue/black (other colours do not photocopy well). Important information may need to be asterisked e.g. *allergic to Penicillin*.
  • Enabling (focusing on what the person can do for themselves and what is needed to ensure that they can achieve/maintain this).
  • Linking to Connected Lives Principles- details here.
  • Precise / Descriptive – to ensure there is no ambiguity and care professionals are clear on exactly what they need to do – e.g., Mary needs to be assisted to be repositioned every 4 hours.
  • Respectful – the care and support plans are seen by other professionals and families, therefore the language used must be respectful and factual, rather than subjective. They must also meet Equality, Diversity and Inclusion (EEDI) standards.
  • Written in the first person, (where the individual has been supported to write the care plan. If the person is unable to share their views or contribute, it would not be the expected to be written in first person), and written in plain English.
  • Available in an accessible format appropriate for the person and/or their advocate.
  • Mindful of identification of risk whilst undertaking care/ support planning.
  • Please do not leave any section of the care/ support plan blank – If there are sections in the care/ support plan that are not relevant to the person write ‘Not Applicable’.

Desired Outcomes:

  • Providers will need to encourage the person to think about the things they wish to improve, maintain or prevent for each section of the care plan and should document desired outcomes.
  • To meet an enabling care approach, care providers should encourage setting SMART goals with the person however, if the person does not have any desired goals for a section, this needs to be recorded.
  • Whilst there are outcomes and goals for each section of the care and support plan, it is recommended that an overall outcomes/ goals section is included towards the front of the care and support plan to ensure that care professionals have this at the front of their mind.

Desired Social Care Planning:

  • Providers must make sure the system is robust and secure, with a contingency plan in place in case there is a problem with the system.
  • Electronic records are encouraged in line with the Governments ‘Putting People at the Heart of Care’ Whitepaper – please choose a system where there is an option for free text.
  • NHS England have compiled a list of Assured Suppliers who adhere to the above suggestions Assured solutions for digital social care records (DSCRs). Click here to view them.
  • Some digital providers have basic packages that do not automatically enable access all of the relevant sections that you will require. Please use the sections of this guidance document to ensure all necessary content is available in your digital care plans.
  • You must assure yourself that any electronic record / electronic care/ support plan is compliant with GDPR and your contractual terms and conditions, including where / how the information is stored (i.e., where is the ‘cloud’ actually based?’), security and data retention. You should consider Information Governance Impact Assessment. To meet this ensure you have a Data Protection and Security Toolkit updated yearly.
  • DNACPR’s must be clearly indicated. Most systems will have a clear code or ensure that the DNACPR is highlighted at the top of the care/ support plans. Other documents such as TEPs (Treatment Escalation Plan), Respect or Peace may need to be uploaded to the system as well as a paper copy.

Risks:

  • Every section of the Care/Support plan has prompts to consider risk and further actions that need to be taken, when the person commences a care package with your organisation.
  • ALL Risk Assessments need to be completed prior to the person commencing care, and thereafter reviewed as needs change or under specific timeframes. Reviews of Care Plans and assessments should be clearly recorded on the review form and within the daily record.

GDPR:

  • The data you collect on a person must be compliant with GDPR, i.e., documents containing sensitive information should be locked/electronically stored securely. Relevant staff should be aware of the location. This also means gaining the person’s consent before collecting data, only collecting data that is relevant and necessary for Care/Support plan and protecting their data.

Daily Notes:

  • It is good practice to regularly audit the daily notes to ensure that they clearly evidence how the desired outcomes and goals have been met.
  • It is ok to make suggestions on how to meet a person’s needs, however there should be provision made for ongoing discussions between the person and care professionals, about personal preferences and changing desires. There should be clear evidence of the person’s involvement, including any input from families and advocates. 

Advance Care Planning:

  • Make sure end of life planning is addressed with the person and family/advocate.  ACP/ Future Planning/and other documentation used in different settings regarding Living with your illness and then ACP dying with your illness. This should include any specific cultural or religious considerations or preferences related to death/ how the deceased body is handled/ by whom.
  • Check what documentation you need in place based on your local area. Find details here.
  • The status of ‘do not resuscitate’ should be considered alongside the question of an advance directive as this is the only document that a medic will take note of if they attend. Please ensure all of these are referenced into the main care/ support plan and staff have easy access.
  • You will find more information and guidance on advance decisions, advance statements and living wills by clicking here.
  • If you are using paper-based records, you may hold these in a separate folder. If this is the case, please ensure you have a system within the care/ support plan to identify where this information is kept.

DNACPR (or equivalent paperwork RESPECT/PEACE:

  • A persons DNACPR decision should be reviewed regularly to ensure it is still relevant, this should be reviewed with the person or family/advocate and/or GP if they lack capacity. A Best Interests Assessment should be completed alongside a DNACPR for anyone that lacks capacity to make this decision.
  • Check what paperwork is used for DNACPR depending on your area of the county. Click here.
  • DNACPR must be accessible to ambulance crews. Although some digital systems have the capability to send directly to ambulance services, please ensure you have an original copy accessible for emergency services that will be passed to them if the person is admitted. If original copies are lost of details changed these must be updated by the GP.
  • DNACPR/ReSPECT forms must be clearly indicated. Most systems will have a clear code or ensure that the DNACPR is highlighted at the top of the care/ support plans.
  • Other documents such as ADRT/TEP/PEACE may need to be uploaded to the system as well as a paper copy.

Cultural or religious considerations:

  • Are there any cultural or religious considerations related to diet, e.g. significance of culture and heritage in terms of food preferences and preparation, dietary restrictions in terms of religious observances; Lifestyle and activities for example attendance or access to religious festivals and support to maintain attendance and involvement in groups or activities important to the individual, death/ how the deceased body is handled/ by whom. It is very important to glean this and be prepared. Also, to think about care of the dying after.
  • Need to remember that culture is multi-dimensional. White British people have culture too and should be also be given the opportunity to discuss these with the care professional.

Accessible Information Standard:

  • When creating the Care/Support Plan, you will need to consider creating the plan in a format that suits the person’s communication needs particularly if the person has a disability or sensory nee. E.g. easy read documents.

Positive Behaviour Support (PBS):

  • If required, consider putting a positive behaviour support plan in place with clear outcomes linked to wellbeing. It is good practice to add these to the care/ support plans.
  • ABC charts (Antecedent, Behaviour, Consequence) are an applied psychology tool for identifying causes and patterns of behaviour. They rely on detailed descriptions of the behaviour as well as what was happening directly before and immediately after the behaviour in question. Care and support plans may need to be adjusted based on this data.
  • If required, ABC behaviour charts may be used to document any behavioural incidents. These must form part of your recording and reporting procedures. A template ABC chart as well as a completed example can be found by clicking here.
  • If unsure of physical health on behaviour utilise symptoms checklist here.
  • You will need to have up-to-date contact details for external support e.g. Community Commissioning for Disabled Adults (CCDA) formally known as Adult Disability Service (ADS), Crisis Assessment Team (CAT), Social Worker via call centre, Single Point of Access (SPA) number for Hertfordshire Partnership Foundation Trust (HPFT).
  • Referrals can be made through a GP or self-referral.

Purple Folder (for individuals with a learning disability)

  • This is required for people who have a learning disability. This is also applicable for Older People services who care for someone with a Learning Disability.
  • The organisational annual health support plan must be available to monitoring officers.
  • A GP health action plan should be kept in the purple folder.
  • Purple folders should be held in a secure location. This can be in the persons room so long as it is kept secure in compliance with GDPR regulations.
  • All resources and support can be found on the HCC website here.