This chapter should be used to guide the development of a person’s care / support plan when they receive services directly from a City Council operated provider.


Outcome Focused Support Planning Procedure.

1. Principles

When a person is referred to a service provider, they should already have a care/support plan which has been developed during assessment. This will detail what the person’s needs are what will be provided to meet those needs. The service provider must then develop the care plan to show the detail of how the assessed needs will be met. This process must be person centred and steps should be taken to make sure the customer’s needs, wishes and preferences are ascertained and are fully taken account of in the care plan.

2. Procedural Steps

Step Action By Whom
1. The keyworker will discuss the care plan with the customer and significant others, with the customer’s consent, in detail and ascertain their preferences regarding what is done, the way things are done and the times things are done. These should include (where appropriate), but are not limited to:
  • Times for waking and rising;
  • The times of meals, where they are taken and any support the person needs;
  • What the person likes to do in the mornings;
  • What they like to do in the afternoons;
  • What they like to do in the evenings;
  • Bedtime routine;
  • Personal hygiene;
  • Medication and general health;
  • Activities/occupations/links with family, friends and the community;
  • Likes and dislikes.
Keyworker/ all staff
2. If the customer has been assessed as lacking capacity to make decisions about their health and welfare and someone holds a current Lasting Power of Attorney (LPA) to make welfare decisions on the person’s behalf, this person must be fully involved in the process of developing the Care Plan. This does not take away the need to consult family and friends, but the decisions of the person who holds the LPA must be treated as if they were the decisions of the customer him or herself. Keyworker to consult
3. If the customer has difficulties in communicating their wishes, all reasonable steps should be taken to develop a means of communication which may involve the use of Makaton or other signs, pictures, observation of the person’s reactions to different options. Keyworker
4. If all attempts at direct communication have been fruitless, advice should be sought from the customer’s carers, other family members or friends about what their preferences are. When they are implemented, the person’s reactions should be monitored to make sure they are happy with the choices being made on their behalf. If the customer appears unhappy with something, alternatives should be sought. Keyworker
5. Any risks arising from the customer’s care plan should be assessed using the positive risk framework. See also Positive Risk Taking Policy. Keyworker
6. The plan agreed with the customer, or by others on their behalf should be detailed in writing giving as much information as is necessary to make sure the customer’s choices can be met by people who have not been party to the discussion. The completed plan should then be signed by the customer (or a carer on their behalf if the customer is unable to participate) and the manager of the service provided. Keyworker
7. Everyone providing care and support to the customers must familiarise themselves with the detail of the care plan and record any activity using the agreed paperwork. This will usually be the person’s diary sheet, but may be a person centred tool such as a communication log. All staff
8. The keyworker will monitor the effectiveness of the care plan in meeting the customer’s needs, wishes and preferences at regular intervals. This will vary according to the needs of the person and how long the care plan has been in place, but should always be done in time to give feedback at the person’s review. If the customer, their advocate or someone who holds a Lasting Power of Attorney to make welfare decisions on the person’s behalf requests an earlier review of the care plan, this should be facilitated as soon as possible. Keyworker
9. When appropriate, the person should be helped to plan for the end of their life. The scope and structure of this can vary according to the needs and wishes of the person, but the ‘Living Well’ document has been highly valued by many customers and their families within provider services. Keyworker