SCOPE OF THIS CHAPTER
When a person is referred to a service provider, they should already have a care and support plan, which will have been developed following a assessment of need. The assessment will set out the person’s needs, and as well as what services will be provided to meet these needs. The service provider must then develop the care and support plan, with more detail explaining how the assessed needs will be met. This process must be person centred and steps should be taken to make sure the person’s needs, wishes and preferences are established and are fully taken account of in the care and support plan.
2. Procedural Steps
|The key worker will discuss the care and support plan in detail with the person and significant others (providing the person consents to this), to ascertain their preferences regarding the care and support which is provided, and how it is provided. This could include:
|Key worker/ all staff
|If the person has been assessed as lacking mental 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 and support 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 person they are representing.
|Key worker to consult
|If the person receiving care and support has difficulties in communicating their wishes, all reasonable steps should be taken to develop a means of communicating with them. This may involve the use of Makaton / sign language, referral to an advocate, or the use of pictures, observation of the person’s reactions to different options.
|If direct communication remains difficult, advice should be sought from the person’s carers, other family members or friends about their preferences. 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 person appears unhappy with something, alternatives should be sought.
|Any risks arising from the person’s care and support plan should be assessed using the positive risk framework. See also Positive Risk Taking Policy.
|The care and support plan agreed with the person, or by others on their behalf should be detailed in writing giving as much information as is necessary to make sure the person’s choices can be met by people who have not been party to the discussion. The completed care and support plan should then be signed by the person (or a carer on their behalf if they are unable to participate) and the manager of the service provided.
|Everyone providing care and support must familiarise themselves with the detail of the care and support plan and record any activity in the person’s file. This will usually be the person’s diary sheet, but may be a person centred tool such as a communication log.
|At regular intervals, the key worker will monitor the effectiveness of the care and support plan in meeting the person’s needs, wishes and preferences. This will vary according to the needs of the person and how long the care and support plan has been in place, but should always be done in time to give feedback at the person’s review. If the person, their advocate or someone who holds a Lasting Power of Attorney to make welfare decisions on the their behalf requests an earlier review of the care and support plan, this should be facilitated as soon as possible.
|When appropriate, the person should be helped to plan for the end of their life. See End of Life Care.