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02nd February 2011

The Care Planning Cycle

" Care planning " and "care planning cycle" are probably the most frequent terms searched for within care services. While in some senses care planning can be seen as a simple process, for instance the recording of the major needs of a service user and the definition of what the service is going to do about that need; any lack of understanding of the full cycle can lead to at best sub-optimal results, and at worst non-compliant care.

Effective care planning is the "key technology" of care and support, and its application can have fundamental effects on services.

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.

This article (the third in a series) will look at the key concepts and issues within care planning.

  1. The care planning cycle
    1. The care planning cycle is utterly logical, is a closed loop, and is the same for all service types.  If the full cycle is not completed, care planning will not meet its function of managing the service
      1. Assess: Carry out an assessment of the needs of the service user.  There are a number of needs assessments in the QCS care planning pack, appropriate to the service type.  If a particular assessment is not appropriate for an individual service user, record that fact and the reason on the assessment and keep it with the completed assessment.  Good practice is that one person carries out this process – the key worker, or, in the case of a nursing home , the key worker with the Named Nurse. A key worker or named nurse will normally have a handful of service users for which they are key worker – 3 to 10 max.  The carrying out of the assessment must be done with the agreement of, and in full consultation with, the service user, and the results must be shared with them for comment.
      2. Document: Document those needs, using the assessments forms provided.
      3. Develop: Develop strategies/support/treatment to meet those needs, identifying pros and cons for each strategy.
      4. Discuss: Offer the various strategies, including the pros and cons, to the Service User.
      5. Choose: The servicer user chooses their preferred option.  This may involve negotiation if the key worker perceives that the service user is taking a sub-optimal option which may harm their future safety, health or wellbeing, but however it is done, the end result must be the agreement of the service user.
      6. Plan: prepare a written plan of care for each need.  The plan contains:
        1. The assessed need, specified in terms everyone can understand i.e. the service user, and any staff who have responsibility for services to the service user.
        2. The aim of the strategy/support/treatment – how the chosen strategy is intended to meet the identified need.
        3. The specific instructions for all staff who have any contact with the service user, stating what they must do in order to meet the stated aims.
          1. There is a one page form for each assessment type in the QCS care planning pack for this; one should be used for each identified need.
    2. Record: each worker who carries out any action which contributes to any care or support aim must record what they have done, as well as the result of their action - in terms of meeting the aim, or not.  The format for this record is in the QCS care plan pack, and is called the ADL (Activities of Daily Living) Record.  This record should be entered into at least once per shift for each plan of care.  Normally any person who has contact enters a record of their contact, and the key worker checks the record when they are on duty and maybe expands it.  Key workers are not nurses, and are responsible for the psycho-social aspects of the service user support and therefore will record all non-nursing activity; a Named Nurse in a nursing home will (only) be responsible for the clinical care, and only record clinical care.  Activities staff should also record their contact with the service user in the ADL record.  There would normally be an activities/social care assessment and plan(s) of care for each service user.  Best practice is for each plan of care to be given a unique reference, and each plan of care reported against explicitly, using the same reference in each 24 hour period.
    3. Review: at regular intervals a designated person (key worker and named nurse) will
      1. Together with the service user, review each risk assessment, looking for changes in needs. If any significant changes are identified, a full reassessment must take place, leading to a new plan of care.  The daily record is used as partial evidence for changed needs.
      2. Even if no changed needs are evident, review the daily record and consult with the service user to assess how successful each plan of care has been in meeting the identified needs, adjusting the aims and instructions of the plan of care (most likely the instructions) to better meet the needs and aims.
        1. Either way, the review purpose is to refresh each plan of care and make sure it is doing the job of managing the need.
        2. “Regular” in this context means:
          1. i.     Care home – at least once a month, or more frequently if the need is changing more rapidly, and always immediately on a change of circumstances e.g. a fall, a new illness etc.
          2. ii.     Domiciliary care and supported living – there is no specific period, our recommendation is a monthly overview which may be office based, with a quarterly full review together with the service user in their own home, or more frequently if the need is changing more rapidly, and always immediately on a change of circumstances e.g. a fall, a new illness etc.
    4. The regular review closes the loop back to (i) Assess, above.  It is a continuous process, very similar in concept to the Deming continuous improvement cycle.
    5. At all stages, the service user must be involved, consulted with and in control.

Don't forget, QCS can help solve your care planning and compliance documentation requirements the simple way - ensuring you always operate fully CQC compliant care plans..

Topics: Care Planning

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