What is the purpose of a "Person Centred Care Plan"?

[Polly H]

Hi folks,

Does anyone out there know the answer to this question?

My query is a very genuine one. I'm confused. What is the care plan's purpose? Who sees it and how is it used? Maybe it's me, but the reality in my Dad's case is falling well short of my expectations. I'd be grateful if someone could put be straight about this.

My Dad has been in the same residential care home for over 4 years. He is in the advanced stages of AZ and the new care manager(the 4th since he has been there) has asked family members to contribute to Dad's new "person centred" plan. The format looks like a "bought in" IT package but there is no clear statement as to its overall purpose. I would have thought that if the work put into it is to be worthwhile then it's purpose and how it is to be used (or not used) needs to be made explicit and understood by everyone.

Perhaps I'm stating the obvious but I feel I want to know the answer (from other carers, not just Dad's care home) before I make my "contribution". The way I feel now I could "to town" about the lack of explicitly stated detail of Dad's "care needs" and upset the manager big style. (I need to take a slow and long intake of breath before "launching"!)

Incidently, Dad's annual review is due soon.

I'd be grateful for your comments.

Polly H

 

[Vonny]

Hi Polly,

It sounds as though there has been a lack of consistency about your dad's care if the managers keep changing.

In my mum's case, the care plan was put together by mum's SW to provide a holistic package which was in mum's best interests. Admittedly the family probably had a bigger say than you've had because mum was cared for at home but all factors were considered: medication, nursing care, psychiatric needs, personal hygeine assistance and support for the family to help us care for mum.

I don't know what issues you have with the current manager, but maybe a frank and polite conversation is in order, to tell them your concerns and ask if the new care plan will be adhered to and actually have a purpose.

Good luck

 

[danny]

Hi Polly,these are plans have to be done as part of the CQC regualations.
Care plans are wonderful if they are used and read by all members of staff,updated regularly and shared with relatives.

If they are left sitting idlily on a computer or in a drawer then what is the point.

Person centered care planning means putting the person first and foremost and formulating a program of care specifically for that one person,taking into account the persons likes,dislikes,choice of clothes,food,where to get washed and when,their background,family,significant life events,job,hobbies etc etc.
All the medical history is put in as well as a risk assessment.
Everyone reads it ,family as well,agrees or amends anything and then it is signed by all.

That is the easy bit,the most important bit is using it!!!

 

[Sandy]

Hi Polly,

If you really want to know chapter and verse, I would suggest looking at the National Minimum Standards for Care Homes for Older People from the Dept for Health website.

This is a large document (101 pages) but it is worth reading:

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4135403.pdf

I would look at Standards 3 (Assessment) and 7 (Service User Plan) in particular.

Take care,

 

[EmJ]

From my experience with my Granny's care at home the care plan was to satisfy the Care Commission and was definitely not about the person.

It is meant to be used to inform all those working with the person of the persons needs and is meant to be reviewed regularly to ensure the persons needs continue to be met appropriately.

My granny's care plan rarely changed and when it did it was just to add that the family were doing more...

I continuously changed her daily routine as her needs changed. No one from the social work department had a clue of her real needs. There are too many cases for them to deal with so if there's a family - the family will do most of the work.

When the care commission is coming to inspect the service they suddenly review everyone and make it look like they are interested. Then once the inspections past they go back to doing nothing again!

I can't really give you much view point from a care home perspective but given the changes in management "consistency" for your relative would be vital.

It is good if they want to personalise the care plans and want to involve families. Take the opportunity to be positive about the things that are going well and raise any other issues you may have.

I know there are people who use the care plan properly and genuinely recognise the importance of person centred care & reviews. But "sometimes" it is seen as an inconvenience which has to be done to please inspectors...

Take care,
EmJ

 

[Polly H]

Thank you for your replies... one and all.

I'm feeling a bit more positive. It is just that I have spent a great deal of time with a previous care manager and it just seems that the "care plan" is a ritual to satisfy inspectors rather than meeting Dad's needs.

I know I need to be fair and give the new manager a chance but I have already supplied a great deal of written information which does not appear to have been used on the "first draft"

I'll give it my best shot. Afterall, Dad should be at the centre of all our thinking.... including mine!

Polly H

 

[Charlyparly]

A care plan should act almost act as a “guide” if you will, for staff working in the home and also for visiting health and medical professionals to refer to. A good care plan should tell a new or agency staff member, paramedic or GP etc everything there is to know about a person.

My care plans have sections with Consent and agreement forms (consent for relatives to access and contribute to care plan / for taking and using photos / consent to share with professionals etc)

There is a general “summary of care” which is roughly two or three pages with information about that person including details of how, when and why they came into the home, what their previous and existing difficulties are and how these are managed, any important information such as allergies, medical conditions and specific likes, dislikes and preferences.

It also includes a general overview of what that person’s normal daily routine is, i.e. what time they like to get up, what assistance they require, how staff should provide this assistance etc.

The next section holds risk assessments for mobility and any moving and handling needs, falls risks, dietary needs and preferences, Waterlow score (pressure sore risk), weight, continence, psychological etc. These are updated at least once a month (or sooner is needs change) and the whole care plan updated to reflect the same.

 

[Polly H]

Dear Charlyparly,

Your comments are very informative about the purpose of the plan. You have also given me some real pointers as to what is missing!

Thank you for taking the time to write such a detailed post. It is very helpful.

I will do my best to try to make sure Dad's Care Plan is "truly person centred"

If I am truly honest I think my initial reaction to the manager's first draft was one of resentment that perhaps she expects the family to do her job for her! This is probably my own baggage after my experience with the previous two managers.

I will try to stay focussed about what is important here i.e. Dad!

Polly H

 

[JPG1]

I have little to add to Charlyparly's suggestions about the reasons for and importance of a care plan.

Apart from:

The Care Plan must never leave the care home, otherwise 'agency staff' and other staff (including emergency/GP/locums) will not be able to refer to it, if it's AWOL.

It can be difficult to get 'signed consent to share info' from people with dementia, and that's where the Care Home needs a modicum of 'common sense' so that they find a way to allow next-of-kin, and close family members (who may all be sharing that caring role with NOK) to look at the care plan on request. Otherwise, important issues may be missed, especially if the named NOK is unable to visit for a week or two, for whatever reason. And that may well help the care home staff to provide better care.

Also, it's important for the care plan to show exactly how much 'assistance' a person needs with eating and drinking. As soon as any problems with, say, swallowing difficulties are identified, then there must be a full log of 'intake and output', both in terms of quantities of food eaten, drink taken, and in terms of output. (Just an example.)

I would like to add that the care plan must be updated as soon as 'circumstances change' or as soon as a new medication is introduced.

Also, question any care plan or section of care plan that is written entirely in CAPITAL LETTERS.

Most important of all, in my view, is to make sure the c/h manager knows that you want that care plan to be made 'available on request' and also the Daily Log of 'the day's events'.

In fact, the Daily Log may actually be most important of all. Because you may see within that daily log of events things that will not yet have been noticed by anyone, other than you. The person who knows your relative best is you. Not the care home. So I recommend looking at the Daily Log, regularly. Look at it on a weekly basis, as a minimum. Or more often, if you have any concerns whatsoever.

After all, it's your relative's care that you care about.

 

[Charlyparly]

Oooh yeah – I forgot about the other thread where some care plans have gone off on a little, ahem - "excursion" with staff.
Yes, as JPG rightly points out, care plans must not leave the premises for any reason. They must be available to a senior staff member 24/7.

It is important that they are not readily available for anyone who might fancy having a read either. Believe it or not, I knew one care home which stored its care plans in an area that several relatives would go into from time to time. One such relative (and a nosey one at that) was about to get herself comfortable and have a good look through one afternoon as I happened to walk in! From that day to this, care plans live in a locked cabinet to which only senior staff can access.

With regards to residents who aren’t able to give their consent and agreement, next of kin are asked to do this on their behalf. Residents or NOK are free to access the care plan and daily report sheets any time they wish. They can also contribute via a “communication sheet” at the back. It might be something as simple as “Bought Mum some new tights, have named them, and put them in top drawer. Would staff please let me know when she is running low?”

A full review of each person’s care plan is carried out at least once a month but I’m a sod for checking key workers have updated any changes in the meantime and for going through care plans with a fine tooth comb and pulling up staff about things they’ve missed. I often set aside a whole day just to check documentation and God bless the girls, they twitch when I start picking on one of theirs.

As daft as it might sound, documentation is absolutely crucial because it this is poor and falls below standard, so will the type and level of care being given.

 

[danny]

Just thought I would throw something else into the mix,wait for when you ask a carer to say pick up a newspaper or pop some washing in the machine{domiciliary care here] and their reply is "it isn`t in the care plan" Arrghhhh

 

[Charlyparly]

Just thought I would throw something else into the mix,wait for when you ask a carer to say pick up a newspaper or pop some washing in the machine{domiciliary care here] and their reply is "it isn`t in the care plan" Arrghhhh

Now this, I can sympathise with from both sides!!!

I have met (and worked with) some real gems – the kind that take issue with picking up a sock off the floor and give their reasons as being “it’s not in the care plan”. It’s not unreasonable to do (or to request)the odd thing over and above what you’re supposed to do, provided it’s not causing a problem or taking up time the carer hasn’t got to spare. It is about common sense.

Having said that, I’ve also been in the situation where families have taken advantage and I’ve had to put my foot down and remind them what the care plan says I’m there to do. I used to do a few wake and watch nights in one house (10pm – 7am) and once decided to shift a pile of ironing that the lady said she’d been dreading doing.

Good grief, did I wish I had not done that?

It was my fault entirely and a lesson learned because with each night, the list of chores grew to a point I had to tell her I was no longer willing to help.

 

[Lynne]

Hi Charly

May I ask, at what point & how often do the front-line carers (meaning the hands-on carers, as opposed to senior staff) get an opportunity to read & digest the individual care plans?
(I appreciate you can only speak from your own practice & experience.)

 

[Charlyparly]

May I ask, at what point & how often do the front-line carers (meaning the hands-on carers, as opposed to senior staff) get an opportunity to read & digest the individual care plans?
(I appreciate you can only speak from your own practice & experience.)

I guess this varies between care homes, depending what their own routines and managers put into place.

What I tend to do when new people come to us is ensure senior care staff thoroughly read the person’s care plan before starting their shift (seniors come in 30 mins earlier but still provide “hands-on” care during the course of their shift) and provide a verbal handover to other staff in the first instance. During staff breaks, I ask that they spend five or ten minutes reading the new person’s care plan and notes whilst they are having a brew etc.

Staff tend to do this as a matter of course and because it’s done as each person is admitted, it’s not particularly time consuming or seen as being a chore.

I worked in the community a long while ago so can’t say how they are realistically supposed to take in all the care plan details, risk assessments etc.

 

[muse]

This is an interesting thread. Thanks, Charly, for giving us a professional's input. It all helps to understand the system.

I'll keep following this thread, as I'm a great believer in learning from other poeple's experiences.

Thanks - Kathy

 

[LEEANN4832]

care plan

a care plan is all about the person centred and there needs....it should also have a true understanding of your father b4 he had this illnes and all sbout his likes and dislikes his previous jobs and all about his life...a care plan is also for the use of new staff so they can get to nno your dads needs what he likes to do activities...it should have all about his medical needs and each day should get filled in and anything significant shouldbe documented such as any falls,cuts bruises ect..........
you can ask to see his care plan at any timeand im sureyoul be asked to sign each support plan thats iv you agree with what they have wrote ...let me no how you gt on hope you find this useful