Service User Care Plans
A care plan is used to identify the Service User’s needs, the aims of the care, the action that is taken to help meet these needs and the outcome of the care. The plan is drawn up in consultation with the Service User, General Practitioner, CPNs, relatives and other disciplines. It is the responsibility of the homes Manager, or “Senior Carer” to draw up each individual Residents “Care Plan”.
Procedure
Care Plan Development
The Service User’s Care Plan will be developed in two stages using three sets of Forms:
- Snapshot form used at the initial meeting
- A more in-depth Assessment Form with information collected from the service user’s family or advocate.
- An analysis of information provided by the care team on the daily log sheets during the initial 28 day trial period which will complete the snapshot form.
A full Plan of Care will be completed in the first 28 days. Prior to this an Emergency Plan of care will be put in place.
Arrangements will be made within 24 hours of admission for the Residents GP to carry out an assessment or registration of the Service User to a new GP if not previously local. The “Senior Carer” will act as the co-ordinator for developing the Service User’s person centred Care Plan and be responsible for keeping the Service User’s Care Notes.
The “Senior Carer” will therefore start a “Care File” to hold the Residents Care Records. The Service User or if not appropriate their family or advocate will be consulted as to the content of the care plan. A signature will be sought from the Service User or the appropriate person to evidence consultation.
All Carers have a responsibility to read the “Care Plan” so that they are aware of the care required and the reasons that particular care is given. Instruction regarding “Care Plans” is given to carers during Induction Training; each “Care Plan” is discussed with the carers on an individual Service User basis.
Care Plan Reviews
Care Plan Reviews are carried out on four levels to ensure the service user is receiving the appropriate care.
Daily, on a shift-to-shift basis. At staff shift changeover the Service User’s daily care notes are handed by the out-going shift to staff on the in-coming shift and the Service User’s responses and activity patterns discussed as needed. Changes to the Care Plan may be proposed at this point.
At the end of the four-week settling-in period. Thereafter a formal review is held with Care Staff on a regular basis but never any longer than once a month. A review is held regularly at least yearly, or sooner if required, where all interested parties are invited to discuss the plan of care and its effectiveness and to propose any changes that may enhance the quality of life for that service user.
All amendments to the Care Plan will require the authorisation of the Manager or Senior Carer. Certain amendments may require the authorisation of the Service User’s GP. All amendments to the Care Plan must be recorded in full.