This section needs to clearly document if the individual requires personal care and it should provide clear details that will guide the care professional to know exactly what needs to be done. It is good practice to include prompts that uphold dignity and support e.g. ‘I would like my care professional to ask me if I am ready to have a shower and support me to wash the areas that I may struggle to reach, but only if I need the assistance’. Does the person have any cultural/religious aspects associated with personal care, I.e. do they preferer to be washed in a particular way
Support required: please highlight the support required from the list below and indicate whether they need:
Do not need any support / Need some support / Verbal prompt / Need full support / Need equipment / I do not use/need that.
Personal Care
- Have a bath/shower
- Strip wash
- Get in and out of the bath/shower
- Wash my face
- Wash my back
- Wash my legs
- Wash my hair
- Apply cream to my body
- Shaving
- Oral hygiene
- Dry myself
- Manage my skin integrity
- Other
Getting Dressed
- Get dressed
- Get undressed
- Get ready for bed
- Other
Toileting / Continence management
- Go to the toilet
- Get on and off the toilet
- Empty / change my catheter
- Empty / change my stoma bag
- Change pad
- Other
My personal space
- Make the bed
- Tidy my room
- Get my things ready for a wash
- Other
Please use the information above to create a detailed plan that details how the individual is to be supported and assisted with their personal care. If cared for in bed or has double incontinence, please specify the times of the day that support is required: am/ lunch/teatime/ pm. Please add how toiletries are provided.
Weight – Record observations from care professionals and act as directed by healthcare professionals where clinical intervention is necessary and registered manager where this is not needed (i.e., changes to personal care routine). Where there are concerns, these should be directed to the correct professional, this may be the registered manager, GP, dietician, OT or other healthcare partner.
Example of recording in the daily notes: “I have noticed that Sam has lost weight and may need to be seen by his GP again.”
Skin Integrity Plan
Assessing the skin is an ongoing process which requires great sensitivity. It is helpful to consider the environment when you carry out the assessment, be sure to check the entire skin. It may be appropriate to do an initial assessment to start with and carry out a full assessment once the care package has begun and the care professional is assisting with personal care.
- Is the individual in need of a skin integrity plan?
- Is the individual in need of a continence plan?
- Is a body map completed when required, for example following a pressure sore or lesion. Are these monitored and closed appropriately once healed?
- Is the person in need of a repositioning chart? (if yes, does the chart indicate the frequency of repositioning required and allow the care professional to record the new position the individual has been supported in to?)
- Is there a Waterlow assessment in place for the individual?
- Other
Please use the information above to create a detailed plan that details how the individual is to be supported and assisted with their skin integrity. Highlight positioning and frequency; creams to be used, when and what for; pressure relief, and pressure relief equipment such as mattresses, cushions etc; Please add any risk assessments as required. Please add any professionals that may be involved with skin integrity care such as GP, district nurse etc. look out for changes to skin integrity for different skin types, e.g. bruises might appear differently for each person. Record observation from professionals and intervention.
Oral Health Plan
Care providers should be implementing an Oral Health Care Policy.
My Continence Plan
Clear continence plan to be drawn up; what continence support is required; frequency and timings of continence to be checked; add any risk assessment as required; add any professionals that may be involved with skin integrity care such as GP, district nurse, OT etc.
My COSHH Plan
In this section, please list any hazardous substances or chemicals used for domestic and personal care purposes, such as sprays, creams etc. Note a COSHH risk assessment will need to be completed.
My Personal Care and Support Plan
Please use the information above to create a detailed plan that details how the individual is to be supported and assisted with their personal care needs.
My Desired Outcomes for My Personal Care
In this section, please highlight the desired goals in relation to their personal care, e.g., ‘I would like to be able get in and out from the bath/ shower by myself’. Please also detail how this goal will be met and what/who needs to be involved.