This home will ensure that each resident has an individual plan of care which will provide the outline of the care to be delivered.
The initial plan will be drawn up on the basis of a thorough assessment of the prospective resident’s needs, abilities and aspirations. This will be based on a summary of the care requirements assessment made by the home’s manager before admission and information gained from the resident and their family/next of kin on the day of admission. A thorough, detailed care plan will be developed over the first 4 weeks post admission, drawing on the pre-assessment details together with post-admission knowledge of the resident’s needs.
This assessment will cover all aspects of the prospective resident’s health, personal and social care needs. The residents plan will set out in detail the action which needs to be taken by care staff to ensure appropriate attention to all aspects of the care needs of the service user.
The plan will meet all appropriate clinical guidelines produced by relevant professional bodies and will include objectives for care, strategies to meet those objectives, statements of responsibility for staff and others, and appropriate timescales.
The home recognises its duty towards the safety of its residents, but it does not guarantee a risk-free environment, and considers some risks to be necessary, important in maintaining independence and even enjoyable. Any action in the plan which involves a measure of risk will be subject to a risk assessment which will set out the balance of dangers and benefits for the resident to take an informed decision. Particular attention will be paid to the risk of falls.
The resident is always central in the home’s procedures for planning care. The resident must therefore sign or otherwise signify active consent to the plan of care and risk assessments. In instances where the resident is not able personally to take responsible decisions, every possible step will be taken to consult a relative, advocate or other representative who can unequivocally represent the resident’s interests in the planning process.
The home will make available relevant managerial, care and other staff as appropriate to assist in producing and carrying through the plan of care and, subject to the resident’s permission and to recognised standards of confidentiality, will involve others from outside the home that may have a part to play. It is for the resident to specify which relatives, friends or others they wish to be involved in drawing up and implementing the plan.
Reviews of the objectives, strategies, responsibilities, timescales, and risks in a plan of care will be carried out by the resident, relevant manager or nurse and appropriate care workers monthly, or more frequently depending on changes in need, incorporating new information and changes in the resident’s needs, abilities or aspirations.
In this home records relating to a resident’s plan of care are kept electronically and in an individual care file and will be written in readily comprehensible language and kept in a secure place accessible to the resident and their family.
Policy for Residents Plans of Care
Objectives and strategies
1. The resident’s plan of care, will be drawn up on the basis of the assessment, and will identify the objectives which this home and the resident agree for the care this home will provide.
2. The aims of care will embrace all aspects of the resident’s welfare.
3. For each stated objective, the home will develop a range of strategies to be used to attain the objective, to allocate responsibilities and where appropriate to set time-scales.
Risks and risk assessment
1. Although this home attempts to provide for its residents an environment that is relatively free of danger it is not a totally risk-free environment.
2. Residents will not be denied the chance to take reasonable risks which they feel will enhance their fulfilment. As part of the process of planning care this home will help each resident assess the risks involved in any proposed activity, weighing the benefits and possible adverse effects, and coming to a measured conclusion. Such risk assessments will be recorded as part of the resident’s plan of care.
Planning and Meetings
This home holds regular meetings on resident’s plans of care. The first meeting takes place before or on the day of admission, the initial objectives will then be discussed and agreed, and the resident should give formal consent preferably by signing the care plan and risk assessments. Where the resident is unable to sign or give consent the care plan should be signed by the next of kin or person with power of attorney.
Implementation
1. The plan of care will be readily accessible to both the resident and the care staff.
2. The plan of care will be regularly consulted by staff and others who have legitimate access, as a guide to the care they should be aiming to provide.
3. The manager, named nurse and/or the key worker will continue to monitor the work undertaken with the resident to ensure that other staff are acting in accordance with the plan.
Reviews
1. In addition to the regular monitoring of the plan on a day-to-day basis, the home will arrange more formal reviews at least monthly.
2. Reviews involve at least the resident, residents next of kin or person with power of attorney, the manager, named nurse and/or the key worker where the progress of the plan will be discussed.