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Care planning - you will have a clear care plan

Care planning

A plan of care is something that describes in an easy accessible way the services and support being provided, and should be put together and agreed with you through the process of care planning.

Agreeing a care plan with your health and social care professional means being able to talk about your situation, how it affects your life, what you want to do, and what you can do for yourself with the right support.  It's about being given all the information you need, being listened to, being able to ask questions, and feeling able to say what's really important to you.  The plan that is agreed should be the result of this process.

Sometimes plans will have to be made without the full involvement of the person, where they are not able to participate, but we will try our best to consult and communicate with them.

Care plans will also recognise that people can be in control of their lives and can regain a meaningful life despite a serious physical or mental health problem.  Staying well and wellbeing approaches, and health promotion initiatives such as smoking cessation, physical health etc. will be an important part of this, as well as Recovery Tools and techniques such as Wellness Recovery Action Planning (WRAP). 

The care plan is a way of working out with you what we are going to do to help you.  We want to help you to be as well as you can be.  We write these plans down in something called a care plan which is how we can make sure everybody is doing what is agreed. 

You have a right to:

  • have someone else (of your choice) involved to help you consider what is being said or discussed
  • be involved in putting the plan together as much as you are able and want to
  • be offered a copy of your care plan, which should be in a format that is most useful to you
  • discuss what is in the plan so that everyone involved understands it and what everyone's roles and responsibilities are
  • talk to someone about the plan if you disagree with anything in it
  • have someone who is responsible for making sure the plan happens
  • a regular review of the plan and your needs

 

What should be in your care plan:

Your care plan should include all the things we have agreed with you.  This will be personal to you and should make sense to you. 

Your care plan will include:

  • Why are we doing this? (needs)
  • What are we planning to achieve? (aims and objectives)
  • How are we going to do it? (actions)
  • Who will do it? (responsibilities)
  • Where will it be done? (times, locations)
  • When will it be done by? (timescales)
  • How do we measure that we've done it? (outcomes) 
  • Any needs relating to REGARDS (race and culture, economic disadvanatage, gender, age, religion/spirituality, disability or sexuality)
  • Numbers to contact (your main contact and any others, including out of hours if needed)

 

What your care plan will look like

Your care plan might be in a letter or on a form or in another way that suits you.  This might include any of the examples shown below.  Please click on any of the images below to open the forms or enlarge the picture.

Many people will have their care plan in a folder like the one shown.  If you haven't got this and would like one then please ask a member of staff.  See below under 'How we record this' to look at the different styles of care plan that might be used. 

We also support ideas of Recovery and Wellbeing 
If you would like to find out more then click here to visit our Recovery and Wellbeing page 
Click here to download a copy of 'My Recovery Plan'

Click here to see our leaflet  - How to get more out of your appointment with your psychiatrist

If you have any questions or concerns about your care plan then please contact the Core Care Standards and CPA Service on 01246 515974.

Care Plan folder small picture
Care Plan Folder
Inpatient care plan small picture
Inpatient care plan
Care plan form C small picture
Care Plan form C
Care Planf for CAMHS small picture
Care Plan for CAMHS

 

Care Planning includes:

  • Gathering and sharing stories: the views of all concerned, including the persons/child’s, family/carers, and professionals views

  • A systematic review of the areas of need

  • Exploring and discussing information: to help work out what’s most important

  • Goal setting: what do we want to achieve?

  • Action planning: what are we going to do, who is responsible, and when will it be reviewed?

  • Risk Management: how do we make your care as safe as possible?

 

We will make sure that you (the person using the service) will:

  • Be involved in putting the plan together, as much as you are able and want to be.

  • Be asked to consent to any treatment, and have any risks and benefits explained. If you aren’t able to consent because of your age or condition, we’ll take account of this.

  • Be offered a copy of the plan, and understand what’s in it.

  • Have someone who is responsible for making sure the plan happens.

 

The plan will be:

  • Recorded so that it can be easily understood.

  • Shared with other people who are involved, such as the GP, and including family and carers where appropriate.

  • Agreed with all those providing services.

  • Checked regularly to make sure it’s still OK.

If you are, or someone you care for is, receiving mental health care from the trust. Information about which clusters are most relevant for your needs is available from the staff that are providing the clinical care. 

Find out more about Care Pathways and Care Clusters.

Things that might be used in Care Plans

Healthy Lifestyles

Smoking cessation advice.

Health Promotion and healthy lifestyles

Drinkaware includes all kinds of useful information about alcohol and drinking, from fascinating facts to practical tips about alcohol units, how many units are in real drinks and serving sizes, and how the sensible drinking message applies to you and your life.

Talk to Frank includes information and advice on drugs

Sexual Health advice on NHS Choices includes advice about contraception, gay health, menopause, STI’s etc.

Heart Disease Prevention advice from the British Heart Foundation.

Change4life gives advice on healthy eating as part of the: eat well, move more, live longer campaign.

The Mental Health Foundation is committed to reducing the suffering caused by mental ill health, and to help us all lead mentally healthier lives.

Sensible Drinking Rewards

Choosing Health - Mental Health

Consent to treatment

Reference Guide for consent to examination or treatment 2009.

Services and Support

Community Directory Derbyshire

Find your local Food Bank

Holidays for disabled people

Finance and Benefits

Find out about the Personal Independence Payment (PIP) due to replace DLA from April 2012

New toolkit for support organisations on PIP (Personal Independence Payments) from the Department for Work and Pensions

ESA and the work capability assessment a guide to the assessment

Advice on Coping with money worries from NHS Choices

Find out about the bedroom tax, and try out the calculator to see how it might affect you

How the welfare reforms could affect you - Derby City Council

How to appeal against PIP decision

The Core Care Principles run through all the standards. For Care Planning, this is how they apply:

The team makes sure that:

  •         Patients/service users views are listened to and treated with respect

  •         Care plans include evidence-based treatment where possible

  •         They have regular updates on NICE guidance and other good practice

  •         Care Planning is done by appropriately trained and qualified professionals

  •         Care Plans are focused on recovery and promoting well being

  •         Staff use a compassion-focused approach

  •         Care planning can take place in an appropriate and safe environment according to individual need

  •         Care Plans are shared with everyone concerned

  •         Patients/service users have an equal opportunity to be involved in planning care, by being sensitive to diverse needs, and making sure that the care plan is produced in an accessible way

  •         Those listed in the care plan have agreed to provide the service

This is supported by the following Trust policies:

Care Programme Approach and Care Standards Policy and Procedures

Consent to Examination and Treatment Policy and Procedures

Intimate Care Policy and Procedures

Minimum Standards for Health Records Policy and Procedures

Writing Good Care Plans as a Word booklet, or as a .pdf document. This gives information and advice for staff about how to write good care plans: care plans that are clear, accessible, developed in partnership, and meet the needs identified.

The way we record care plans will depend on your needs and what works best for you – these are some examples we might use

Care plan and Review form C

Care Plan for Adult Mental Health Inpatient Care

Care Plan for CAMHS  

Care Plan Folder

Discharge/Leave Care Plan form CD

Forms you might want to use:

Recovery Star

Staying Well Plan SWP

Person-centred Outcome Form - Learning Disabilities

Wellness Recovery Action Planning Booklet

Care Co-ordinators Underpinning Knowledge (mental health service users)

Information Technology training

Information Governance training

Personalised Care Planning e-learning This course is designed to help practitioners manage the healthcare needs of people with long term conditions more effectively. The course is divided into four modules which introduce the Personalised Care Planning process and develops an understanding of associated skills and behaviours: The course is supported by a workbook.

Assessment training

Choice and Partnership Approach

Common Assessment Framework CAF

Care Planning Guidance

Care Quality Commission Essential Standards of Quality and Safety - Outcome 4 Care and Welfare of people who use services

Long term conditions guidance on care plans

Mind Guide to Consent

Wellness Recovery Action Planning (WRAP) by Mary Ellen Copeland aims to promote personal, organizational, and community wellness and empowerment.

The Recovery Star 

Care Planning for looked after children and school leavers

The Quality of Health Principles from Changing our Lives, an organisation that works for people with disabilities 

Mental Health Act Report 2011/12 from the Care Quality Commission highlights problems in care planning and recommends effective use of the CPA - includes a helpful Infograhic summary