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CARE PLAN FOLDER CONTENT

Every care plan folder should include an Index - clearly indicating what is in the care plan,this allows others to easily navigate their way to particular areas of the care plan. Ideally thecare plan folder should have dividers that match referencing.

As we all know there is no one way of setting up a care plan folder, this is guidance basedon good practice and can be used by you if you feel this is appropriate for you, your staffand the people you support.

Good practice guidance suggests that a care plan folder should have 6 sections:

1. Initial Assessment

2. Person Centred Profile

3. Support and Risk Management Plans

4. Daily care notes and other professional notes

5. Risk Assessment Charts as required

6. Reviews

Each section will be described separately.

The fundamental principle to remember is that this care plan is for theindividual, it enables the individual to confirm and agree how they wish tosupported by staff - it is not a tool or a folder simply for staff - it belongs to theindividual.

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CARE PLANNING INDEX

Section 1Initial assessment

■ How I communicate■ My care and wellbeing■ What is working/not working for me■ Initial Assessment

Guidance notes for Section 1● How I communicate (example)● My care and wellbeing (example)● What is working/not working for me (example)● Initial Assessment (example)

Section 2Person Centred Profile – This is about me

■ One page profile■ All about me and my life■ My circle of support■ People I like to stay in contact with■ What is important to me■ To support me you need to know me■ End of life support■ Good/bad days■ How I make decisions■ Likes/dislikes■ Service users signature

Guidance notes for section 2● Person centred profile guidance● All about me and my life (example)● My circle of support (example)● People I like to stay in contact with (example) ● What is important to me (example)● To support me you need to know me (example)● End of life support (example)● Good/bad days (example)● How I make decisions (example)● Likes/dislikes (example)● Service users signature (example)

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Section 3Support Plans and Risk Management Plans

■ Care plan at a glance■ My Daily Routine■ Care Support Plan (generic)■ Communication■ Medication and pain management■ Personal Care and Dressing■ Risk Assessment■ Risk Management Plan

Guidance notes for section 2Examples for Older persons and Physical disability● Communication● Medication and pain management● Personal Care and DressingExamples for Learning disabilities● Communication● Medication and pain management● Personal Care and Dressing

Section 4Daily Care Notes and other professional notes

● Daily Care Notes● Residents daily log report

● Monday● Tuesday ● Wednesday● Thursday● Friday● Saturday● Sunday

Section 5Risk Assessment Charts Guidance

Section 6Reviews recordGuidance on reviews

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How I communicate verbally

Gestures I may use and what this may mean

Body Language and what this may mean – how I may sit, stand, facial expressions etc.

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HOW I COMMUNICATE WITH OTHERS

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Behaviour and what this may mean – how will you know I am happy, how will you know I am sad, what do Isay when I am angry

Other ways I may communicate – example other communication support I may use

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My medical well being

I have the following medical diagnosis: What do I not want to happen:

My social well being

How you can support my social well being What do I not want to happen

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MY CARE AND MY WELL BEING

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My emotional well being

How you can support my emotional well being What do I not want to happen:

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INITIAL ASSESSMENT

What’s working for me right now?

What is not working for me right now?

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Personal Information for

My Full Name

My First Name

Other names I have

My Surname

I like to be called

Previous Address Current Address

My Date of Birth My Nationality

My relationship status My religious beliefs

My Maiden Name My previous occupation

Details of my immediate next of Kin

Contact for person holding Lasting Power of Attorney if applicable

Reason that I have been referred for care and support

Date of referral

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Eye Colour Height Build

Hair Colour Weight

My sensory needs

Any known allergies I have

Any special needs / comments I have

Any concerns I have regarding pressure sores or skin concerns

Emergency Contact Details

Emergency Contact should I need someone to represent my best interest for care andsupport

Other Family Contact details I want you to know

Any Other contact details for me

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Health Service contact details

My GP Contact Details

My Hospital Contact Details

My Physiotherapist Contact Details

My speech and language therapist Details

My Occupational Therapist Contact Details

My Consultant Contact Details

Any Community Team Details

My Care Manager Details

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Other contact details I need you to know

My Medical History

My nutritional needs and any existing dietary requirements

Please tell us if you are selfmedicating

Yes / No

Medication / Dosage

Instructions

Start Dates

Notes

Further Information

Medication / Dosage

Instructions

Start Dates

Further Information

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Signed by Service User…………………………………………….Date

The following people have supported me in this initial assessment

Signed by relevant staff member................................................ Date

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ONE PAGE PROFILE

Things that are important to me How best to support me when I need help

Insert photo here

What those who know me say they like and admire

about me?

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ALL ABOUT ME AND MY LIFE

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MY CIRCLE OF SUPPORT

WHO IS IN MY LIFE

This could be otherfamily, friends,neighbours

People Closest to me.

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This could be healthprofessionals, day centrestaff

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PEOPLE I LIKE TO STAY IN CONTACT WITH

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

Name:

Address:

Birthdays:

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WHAT IS IMPORTANT TO ME?

What Is Important to Me?

Support I Need To Make This Happen

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How to support me in maintaining my relationships and friendships

This is why I need support This is what I can do for myself This is what I need you to help mewith

Fitness and Mobility Support

This is why I need support This is what I can do for myself This is what I need you to help mewith

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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS

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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS (CONTINUED)

My personal care support

This is why I need support This is what I can do for myself This is what I need you to help me with

My medication support


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Getting up and going to bed


My eating and drinking support


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Staff support

How would you like staff toapproach you and treat you?

What are you concerns about coming here and how staff will supportyou?

Other areas of support as required


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Looking after my environment


Activities I like and hobbies


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My sexuality


Looking after my finances


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Please tell us about any arrangements you currentlyhave in place, including whether you have a Will.

If you do not have anything in place how would youlike us to support you with any arrangements?

Do you have any specific spiritual beliefs that youwould like support with?

Who would you like with you?

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MY END OF LIFE PLAN

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MY END OF LIFE PLAN (CONTINUED)

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Should this situation arise who else would you like usto contact to let them know?

If you do not have anyone who can support you wouldyou like us to support you with an advocate orbefriending service to offer support?

Would you like any special arrangements in your room?

Would you like any other special arrangements?

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PERSON CENTRED PROFILE

The Following are examples of what a good day is for me – pleasehelp me to have good days

The Following are examples of what a bad day is for me – pleasehelp me NOT to have a bad day

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HOW I MAKE MY DECISIONS

Please work from the basis that I want to be involved in all of my decisions

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MY LIKES & DISLIKES

Activities/Leisure

Food/Drink

Anything Else

I Like I Dislike

I Like I Dislike

I Like I Dislike

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Signed by Service User ........................................................ Date

The following people have supported me in this assessment and it forms part ofmy agreed care plan

Signed by relevant staff member ........................................................ Date

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My Support plan in brief Highlight all appropriate boxes

My healthand wellbeing

My physical healthis good

I have severalconditions that causeme difficulties

I have diabetes I have epilepsy

I have no knownallergies

I am allergic to :- I self medicate I need assistancewith mymedications

I am happy to takemy medication

I do not like to takemy medication

I suffer with pain I am able to tell youabout my pain

I need you toobserve me forsigns of pain

I have a dementia

My Communi-cation

I am able toverbalise all mywishes

I have limited abilityto make wishesknown

I use sign / gestures/ body language tocommunicate mywishes

I am not able tocommunicate mywishes

I have goodunderstanding ofwhat is said to me

I have limitedunderstanding ofwhat is said to me

I have a goodmemory

I have a poormemory

I can becomeconfused andmuddled / anxiousat times

I can becomeconfused and crossat times

I can be verballyaggressive at times

I can be physicallyaggressive at times

I have good eyesight

I have poor eyesight I wear glasses allthe time

I wear glasses forreading

I have good hearing I have poor hearing I wear hearing aidin left ear

I wear hearing aidin Right ear

I can use the nursecall system

I am unable to usethe nurse call system

My mobilityand safety

I am fully mobile I have good balance I have poor balance I can transferindependently

I have restrictedmobility

I use a walking stick I use a walkingframe

I use a wheelchair

I need assistance of1 person walk /transfer

I need assistance of2 people to transfer

I use the hoist totransfer

I forget that I needhelp

I am cared for inbed

I have bed rails whenin bed

I am able to movemyself in bed

I need assistance tomove in bed

I am at risk of falls I would find stairsdangerous

I am at risk ofleaving the building

I smoke

I would like myfood cut up

I eat a soft diet I eat a puree diet I am at risk ofchoking

I eat a diabetic diet I need a fortified diet I have foodrestrictions

I drink normal fluids

I have thickenedfluids

I have a goodappetite

I have a smallappetite

I have adaptedcutlery

I have a PEG/ PEJfeed

I am unable to takediet or fluids

I need assistancewith eating anddrinking

I need assistancewith mouth care


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My personalcare

I am fullyindependent

I need a littleassistance from 1person with someaspects of personalcare

I need fullassistance of 1person with mostaspects of personalcare

I am unable toparticipate andneed full help of 2people

I prefer to bath I prefer to shower I prefer female carestaff

I prefer male carestaff

I need assistancewith oral hygiene

I wear dentures I need assistancewith shaving

I like to wearjewellery and/ ormake up

Mycontinence

I am able to use thetoilet independently

I need assistance toreach the toilet

I am sometimesincontinent of urine

I am sometimesincontinent offaeces

I am doublyincontinent

I wear continenceaids

I have a catheter I have a stoma

My SkinCare

My skin is healthy My skin is dry /fragile

My skin isoedematous

I like / need to havecream applied

I am at risk of skinbreakdown

I need assistance toreposition toprevent skinbreakdown

I use pressurerelieving equipment

I have a wound/s

At night I am independent My night time needsand abilities are thesame as in the day

I need moreassistance at nightwhen I am tired

I like to choosewhen I go to bedand get up

I am continentduring the night

I get up during thenight to use thetoilet

I like to use acommode at night

I use a bottle

I am incontinent atnight

I use continence aids I can use the nursecall system

I sleep well at night

I sleep poorly I take medication tohelp me sleep

I like the bed railsup

EOL wishes I wish staff toattemptresuscitation

I do not wish staff toattempt resuscitation

DNACPR is inplace

Other comments / things I would like you to know

My preferred daily routine

Staff Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . .


MY DAILY ROUTINE

If I have one I would like to complete this

Time Routine Support I may need to do this

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Name of individual Place of residence Date of birth

Support plan completed by Date of completion Scheduled next review

What are my Abilities, What can I do? What are the Outcomes I wish toachieve?

What do I need support with?How can my needs be met by the care staff

The following people have supported me in this assessment

Signed by Service User ........................................ Date Signed by relevant staff member ........................................ Date3

SUPPORT PLAN

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SUPPORT PLAN


Support plan completed by Date of completion Scheduled next review

Communication




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SUPPORT PLAN


Care plan completed by Date of completion Scheduled next review

Medication Support and pain relief





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SUPPORT PLAN



Mobility





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SUPPORT PLAN



Personal care and dressing needs



Personal care

Hair washing

Denture / teeth care

Makeup and creams

Dressing


Signed by Service User ........................................ Date Signed by relevant staff member ........................................ Date

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Risk Assessment Details

1. What is thedecision orchoice to bemade?

2. What are thepotentialbenefits?

3. How likely arethese to beachieved?

4. What could gowrong? Is there apossibility thatanyone may beharmed?

5. a) How likelyis this to occur?b) If somethingwent wrong,what would theseverity of theoutcome be?

6. What are theexisting factorswhich promotebenefit andreduce thechances ofanything goingwrong?

7. Whatadditional actionswould promotebenefit andreduce thechances ofsomething goingwrong?

8. What risks willremain afteraction plan is inplace?

Please complete additional sheet for any other choices/decisions to be considered

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Risk Assessment Details

1. What is thedecision orchoice to bemade?

2. What are thepotentialbenefits?

3. How likely arethese to beachieved?

4. What could gowrong? Is there apossibility thatanyone may beharmed?

5. a) How likelyis this to occur?b) If somethingwent wrong,what would theseverity of theoutcome be?

6. What are theexisting factorswhich promotebenefit andreduce thechances ofanything goingwrong?

7. Whatadditional actionswould promotebenefit andreduce thechances ofsomething goingwrong?

8. What risks willremain afteraction plan is inplace?

Please complete additional sheet for any other choices/decisions to be considered

RISK ASSESSMENT

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Risk Management Plan: Please give details of actions agreed which will promote benefits and reduce the chances of somethinggoing wrong, and specifically how risks remaining identified (column 8) could be managed and who will be responsible for these.

Risk Management Plan - Action agreed Who will be responsible When will this be reviewed

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RISK MANAGEMENT PLAN

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Please complete additional sheet for any other actions agreed


Signed by Service User ........................................ Date Signed by relevant staff member ........................................ Date

Back up Plan - What could go wrong? Action agreed Who will be responsible

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I (complete name:)

. …………………………………………………………………………………..

confirm that I have contributed and consent to the content of each of the following plans:(Complete plan titles) 1. 2.3.4.5.6.

Signed: Dated:

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I ……………………………………………………………………………………….

Representative of service named:

…………………………………………………………………………………………

having carried out an assessment** recorded it and my rationale, can confirm that thefollowing plans were unable to be consented to by:

…………………………………………………………………………………………..

and that they have therefore been developed and will be followed with the person’s bestinterest in mind at all times.

(Complete plan titles) 1. 2.3.4.5.6.

Signed: Dated:

**consider using the Hampshire County Council Mental Capacity Toolkit


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DAILY CARE NOTES

Name of service user: ..................................................

Date Report Signature

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SUPPORT PLAN REVIEW RECORD

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Service Users name: D.O.B

Date Comments Signatures:Service UserRelativeCare ManagerKey WorkerOther People presentand involved


SUPPORT PLAN REVIEW RECORD (CONTINUED)

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INITIAL ASSESSMENT

What’s working for me right now?

What is not working for me right now?

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