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18th April 2011

Care Planning – Assessment and Review

Effective assessment is the key to care planning which produces positive results. This article, the second in a series dealing with care planning, looks at Assessment in detail. In doing so it also covers Review, which is the process which looks at the effectiveness of the care plans derived from the previous assessment or review.

Using the information recorded since the previous assessment or review, the care plans are then adjusted as necessary in order to improve their effectiveness in the future.

To remind readers, the first article in the series, entitled The Care Plan Cycle, explained care planning as:

“The objective of care planning is to identify service user needs and to enable all staff having contact with that service user, directly or indirectly, to have the information they need to support the service user to receive the service which they consider best meets their needs”, and the stages of care planning as:

  • Assessment
  • Documentation
  • Development
  • Choose
  • Plan
  • Record
  • Review, looping back to Assessment.

The full article can be found in the folder “News categories – Care Planning” in the box on the right of this screen.

Assessment is the process by which the care service gathers information about the potential or actual service user, with a view to identifying their abilities and their needs.  Establishing abilities is critical in helping to avoid medicalisation of the service user.  Like any member of our society, a service user is a rounded person, with significant abilities who has achieved much in their life, but who happens to have developed certain needs which they are to be supported in dealing with, within their life as a whole.  Therefore, when assessing for the purposes of care planning, it is as important to identify and record abilities to stand alongside the possibly more obvious needs, in order to assist the service to develop a fully supportive and effective set of care plans.

A positive constraint to assessment is its status in law.  Regulators of registered care services in the UK require the service to judge that they are fully able to meet the needs of an individual service user, before they are offered a service.  This formal process and offer, which should be made in writing, is the lynch pin by which the regulator judges the service.  Woe betides any service found to be providing services to a service user whose full needs they are unable to meet, whether by lack of competent assessment, lack of effective care planning resulting from the assessment, or lack of delivery of a care plan.  This requirements means that the assessment must be complete and competent, otherwise the service user and the service are at risk.

Who carries out the assessment and review?

The service users themselves, and a person who is competent and knowledgeable in gathering information and recording it accurately.  For an initial assessment before service begins, this may be a senior person such as a manager, given the legal status of the process, but may also include the proposed Key Worker.  On an on-going basis, the service user and Key Worker would lead the assessment and review process, assisted by any other people with particular knowledge of relevant parts of the service affecting the service user.

Comments by the service user who owns the care plan should be quoted in their own words and written within quotation marks.  Lack of substantial instances of such quotes could be taken as prima facie evidence of lack of involvement, consultation and choice experienced by the service user.

Key workers or special carers nominated to deliver the individual’s care plans are best equipped to deliver the care as they are able to concentrate their daily attention on the group of service users for whom they have special responsibility.  They are able to provide additional detailed information to support the evidence for review of the suitability of the care plan details to meet each of the individual’s assessed needs, and their responses to the elements of the care treatment and support.

What areas of activity should an assessment or review cover?

All aspects of life as experienced by the service user.  If we continue to use the phrase “care plan”, the word “care” needs to be expanded in this context to include the obvious care and support activities, the less obvious but usually included social care, religious requirements, catering requirements, laundry services,  and personal network support, but also the less often included areas of housing or maintenance support , and transport.  In effect, everything that impinges on or affects the life of the service user, not just their “care” in the narrow conventional sense.  The reason for this wide ranging definition in this context is that failure to analyse and plan any effect on a service user is at best going to lead to wasted effort, probably potential conflict between the various elements of the deliver team, and certainly a less than optimal experience by the crevice user.

All assessments must take into account the cultural, religious and other belief systems of the service user, and sensitively respond to them is developing the care plans.

What needs to be borne in mind during assessment and review?

  • There must be trackable evidence of the continuous assessment, monitoring, evaluation and outcomes in relation to the social, psychological, physical and health needs of the service user.
  • Only record real evidence of planning for purposeful action taken by any people who offer care, support and services to meet the individual service user’s preferences and needs.
  • The information documented must be factual, informative, useful and not subjective opinion.
  • It is essential that all staff involved in the delivery of care and support read the care plans, and know the details of the programme in order to deliver care and support which is specifically designed by a person who is knowledgeable and competent in assessment and care planning to meet service user’s needs.
  • Care plans must provide evidence of the use of all of the information gathered during the assessment and review processes.

How does assessment and review fit in with the daily record of activity?

The daily record is the evidence of daily review of planned programme delivery, well-being, events, activity of the service user and a record of care, support and treatment given in that day, and by whom each was delivered. The record must provide evidence of the delivery of the programme and the service user’s response to it.

Daily recording, ideally, provides cross referenced information on each element of a full care plan set, in order to provide the data for review.  Without the full set of historical data, review is not possible, however many words are written.  Daily recording should also provide information outside of this data set where a carer has information which they think may be of relevance to the next review.

In order to be able to deliver responsive care for all service users, care staff need to understand the care plans for all service users with which they may come into contact, but be more fully involved in the detailed care planning for those for whom they are nominated carers or key workers.

Sub title - How do you like your tea?

A proposal for a title for this article was “How do you like your tea”?  This simple question can illustrate some of the more important and occasionally less observed elements of assessment and review.

Asking the question “how do you like your tea” with consistency requires a consistent format for carrying out the assessment to ensure that important questions are not missed.  In this case the question is likely to arise from using a catering requirements and needs assessment format.

Having asked the question, there must be a record of the answer within the assessment pack.

If there is an answer, there must also be a plan of care which includes that information, probably in this case within an overall catering plan of care.

If a plan of care exists, there must be a method of disseminating that information to everyone who may be involved with delivering a suitable cup of tea.  In theory that includes in this case, all care, support and catering staff, and possibly even others who may informally offer and deliver cups of tea.  Each of these needs to have access to and knowledge of the catering care plan.  But, more than that, prompts are required, which in this case may be in the form of a list of individual service user’s cup of tea requirements put up in the kitchen, or on a tea trolley in a care home setting.  Even the person responsible for ordering foodstuffs needs the information, particularly if the service user has a requirement for a particular type of tea.  There may be safety issues to be taken into account in the development of the care plan, depending on the physical abilities of the service user.  Or prompting to drink may be required, for instance in the event of dementia, in order to promote hydration.  Details of the importance of sugar, or lack of it may be determined by the health state of the service user.

The simple question “How do you like your tea” amply demonstrates the need for thought rather than rote in the case of assessment and then care planning.  One warning is relevant here.  The use of “core care plans” where already specified care plans are suggested for particular needs, can lead to either the antithesis of personalised care planning at one extreme if the core care plans are too simplified and generalist, all the way to spending time selecting complex and multiple options from drop down menus which would be better and more efficiently spent thinking about the real person.

The QCS Management System contains its assessments care plans within Packs.  The intention of this approach is to provide the user with a comprehensive set of assessments covering all the usual areas of concern, as an aide memoir to the process.  Given the experience of care consultants working with QCS, which is that they very often came across instances where apparent needs had been identified in the assessments, but nothing regarding those needs appeared in the care plans, a simple form is provided to prompt the user to, at the end of the assessment, record on one form all the needs and issues identified, and then systematically prepare a care plan for each.  Regulatory inspectors are becoming expert at tracking assessed needs through the system into care plans, and then daily records, followed by review.  Any break in that track is a major risk area, and likely to lead to censure.

One final note on the QCS pack approach -it leads to a substantial pack of paper.  The principle is that this pack leads the user by the hand through the process, and tries to encourage a thoughtful process and full analysis.  If a particular assessment is not applicable to an individual service user, mark the page as such and file it.  That way the user has evidence that they looked at the issue and made a professional decision.  Another expert may disagree with them, but that is a lesser sin than appearing not to have even considered the risk at all.  The cost of a piece of A4 paper and a small amount of printing is as nothing compared to an incomplete assessment and its potentially serious consequences.

Topics: Care Planning

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