How to Create a Care Plan

Introduction

There is a growing demand for people needing additional care and support (NHS Digital). According to the King’s Fund, in 2021/22, 818,000 people received long-term care and 224,000 accessed short-term care in care/nursing homes or their own homes. Each one of these people will be from different backgrounds and have varying needs, preferences, interests, values and beliefs. Therefore, health and social care providers must consider this when providing care and support, which is where care plans come in.

Care plans are unique written documents that detail an individual’s assessed care needs and choices. They outline the type and level of care required, who should provide it and how. When providing care and support to people in health and social care, a ‘one size fits all’ approach will not meet individual needs and wishes, which is why care plans are vital. They contain personalised information to ensure a care recipient receives the best possible person-centred care and support.

Having an effective care plan is beneficial for health and social care professionals, as it helps them to:

• Stay on the right side of the law, as health and social care legislation requires them to consider individuals’ needs, wishes, beliefs and values when providing care and support.
• Have goals to work towards that can help them remain focused and provide the best possible care, resulting in better outcomes for care recipients.
• Ensure the care and support they provide is consistent, regardless of the caregivers on duty.
• Avoid costly mistakes, e.g. giving the wrong medication or foods, which reduces and manages the risk of harm to care recipients.
• Provide an efficient service to those needing care and support and enhance service user satisfaction.
• Understand the individual and what is important to them, thus providing effective and personalised care to treat the care recipient with dignity and respect.

Care plans are also beneficial for care recipients, as they:

• Enable them to be ‘active partners’, meaning they have shared decision-making regarding their care and support, which empowers them to take control of their lives.
• Prevent accident and emergency visits and hospitalisations, as they contain information to manage medical conditions and promote health and well-being.
• Contain information that ensures the care and support they need aligns with their wishes.
• Promote autonomy to allow them to remain as independent as possible and pursue their interests, which can improve their quality of life.
• Help their family and loved ones better understand their needs and wishes so they can support them more effectively.

This blog post aims to provide further insights into care plans and creating a comprehensive care plan.

Assessing Care Recipient’s Needs

The first step in creating a care plan is to conduct an assessment with the care recipient, their family, friends or carers (where applicable) and other health and social care professionals. The assessment should be holistic, i.e. assessing their physical, emotional, cognitive, and social needs and preferences. Local authorities are usually responsible for this process, i.e. a care needs assessment, and have a legal duty under the Care Act 2014.

It is crucial to thoroughly assess a care recipient’s holistic needs and preferences to understand them better and ensure they receive person-centred care and support. An assessment involves collecting data, analysing information, identifying any issues and goals and determining the type of care and support they need so that their care plan is accurate, effective, and personalised. It puts the care recipient at the centre of their care, which is fundamental in providing high-quality care and promoting their physical and mental health and well-being.

The assessment stage involves multidisciplinary teams of health and social care professionals, known as integrated care. It requires input from various professionals, as each aspect of a person’s care will differ, from diagnosing and providing treatments and medications to making adjustments and alterations to help with everyday tasks. The assessment process may involve (this list is not exhaustive):

• Doctors.
• GP’s.
• Nurses.
• Occupational therapists.
• Mental health professionals.
• Physiotherapists.
• Social workers (usually conduct the assessments).
• Care/nursing home providers.
• Other social care professionals.

Each health and social care professional in the team will bring their own expertise, and there will typically be a named lead who leads the process, i.e. the assessor. They will cooperate and coordinate to decide on the level and type of care needed, the goals to work towards and the outcomes to achieve. They may be involved at different stages of the assessment process or may have ongoing involvement.

The assessment will involve gathering specific information to determine care and support needs, e.g. home adaptations or moving to a care home. The nature of the assessment will depend on the care recipient and their circumstances, and there is usually a specific framework to help with the task. It should be appropriate, proportionate, and tailored to the care recipient and their needs.

Some examples of the information gathered during an assessment may include:

• Personal details and history – who the individual is, their current living arrangements, family and social network, their life story and any other useful background information.
• Medical history – any past illnesses, conditions or treatments, e.g. family history, surgeries, allergies, previous medications, etc.
• Current conditions – any current illnesses, conditions or treatments, e.g. allergies, intolerances, diabetes, heart conditions, obesity, medications, etc.
• Abilities – what the individual can or cannot do physically and mentally and what prevents them from living as they want. It should also include any support they are already receiving.
• Preferences – what are an individual’s wishes regarding their care and support, i.e. how they would like to be supported, and their values and beliefs, e.g. cultural, religious, spiritual and ethical. Also, it should consider what is important to them and how care can help them.
• Information from family and carers – if the care recipient wants to involve them or they lack the mental capacity.

It also includes a risk assessment to identify hazards and risks to the care recipient and caregivers, evaluate the likelihood and severity of harm and identify the precautions needed to reduce the risks. However, this process is not usually carried out by local authorities but by the organisations responsible for delivering care.

Identifying Goals and Objectives

Care plans are not just there to provide health and social care providers with information on a person’s basic needs, such as nutrition, hydration and medication, but they are crucial in improving a care recipient’s health and well-being and enhancing their overall quality of life. Part of the assessment process is setting clear and measurable goals for the care plan, which is essential for the following reasons:

• It guides and focuses health and social care professionals, care recipients and families. It also ensures effective communication so everyone is on the same page and understands what they need to do to meet care and support needs.
• It helps to provide more personalised care, which can result in more positive outcomes for care recipients, e.g. reduced pain and symptoms, improvements in chronic conditions or mobility and reduced social isolation and loneliness.
• It helps care recipients participate and take ownership of their own care and support, which can increase their motivation to stick to their care plans.
• It allows health and social care professionals to track and assess progress, identify any issues and adjust care strategies (where required) to achieve goals.
• It enables all those involved to understand their role and responsibilities in achieving desired results and who is accountable for what.

Goals should be SMART, i.e.:

• Specific – goals should be specific to the care recipient and align with their needs and preferences, i.e. person-centred and holistic. They should also be clear, well-defined, unambiguous and agreed upon with the care recipient, their family and others (where necessary).
• Measurable – goals should be measurable to monitor progress and determine whether they have been achieved. It can include ‘checkpoints’ for evaluation, e.g. walking with a walking aid.
• Achievable/attainable – goals should be achievable within a certain time frame, i.e. considering the care recipient’s needs, preferences and abilities.
• Realistic/relevant – goals should be relevant to the person requiring care and support and align with their needs and preferences. They should be realistic, which also links to being achievable and attainable.
• Timely/time-bound – goals should have a time frame in which to be achieved, which can help focus and direct efforts and aid completion.

It is important to note that goals are not static and should be reviewed where necessary to ensure they still meet a care recipient’s needs and preferences.

According to Tees, Esk and Wear Valleys NHS Foundation Trust, care plans should include treatment and intervention goals and personal goals towards recovery and self-care. Here are some examples of common goals for care plans:

• Improving mobility – a care recipient may wish to improve their mobility, e.g. moving from their bed to a wheelchair independently. A goal can be to achieve this in a certain timeframe.
• Managing pain – a care recipient is in pain. A goal can be to help manage their pain, e.g. they report their pain is lower on a 0-10 scale than previously.
• Enhancing social interaction – a care recipient is at risk of social isolation and loneliness. A goal can be to improve their social interaction, e.g. they attend a weekly art therapy class and report back how this has helped.
• Reducing medication – a care recipient is on medication, which is difficult to come off without unpleasant symptoms. A goal may include reducing the number or dosage over time so they can stop taking it.
• Dietary and fluid intake – some care recipients, especially older people, are at risk of malnutrition and dehydration, especially when first accessing health and social care services. Goals can include weight loss/gain and maintenance and meeting nutrition and hydration requirements.

Developing a Care Strategy

An important part of care planning is developing a personalised care strategy based on a care recipient’s needs and goals. A strategy is “a general plan or set of plans intended to achieve something, especially over a long period” (Collins English Dictionary). A care plan intends to help care recipients maintain independence, improve their health and well-being and enhance their overall quality of life.

The process for developing a personalised care strategy will depend on each health and social care provider, but it may involve the following:

• Completing an initial holistic assessment that evaluates a care recipient’s health and social care needs, risk factors, physical health, mental health, social and environmental factors, etc. Health and social care professionals work with the care recipient and/or their family during the assessment, leading to a personalised care plan.
• Determining the care recipient’s specific requirements and needs and tailoring the care and support to ensure it is personalised. The care recipient and/or their families must be involved and agree to have a person-centred and effective plan.
• Setting goals so there is something for care recipients, families and health and social care professionals to work towards. It also ensures that the care plan is effective and achievable and they receive the best possible care.
• Implementing the care plan to achieve the goals and enhance the care recipient’s comfort, health and well-being. Anyone responsible for implementing the plan must be involved and trained.
• Evaluating and reviewing the care plan to track the care recipient’s progress and monitoring goals. It may require care plans to be adjusted with the care recipient and their family if they are not progressing or goals are unachieved.

When developing a care strategy, it is important to recognise that it is not just about a care recipient’s symptoms, illnesses, medical conditions and struggles. They will also require other aspects of care, such as:

• Physical
• Care recipients have varying physical needs, including nutrition, hydration, basic hygiene, safety, sleep, exercise and medications. Physical care is the activities that help care recipients have good physical health, which will vary between individuals, their needs, preferences and capabilities.
• Emotional
• Care recipients can go through various difficult emotions when needing care and support. They may feel they are losing their independence, which can cause emotional distress. Emotional care can involve verbal and non-verbal actions to provide relief. Marie Curie has information on providing emotional care here.
• Spiritual
• Care recipients, especially those with life-limiting illnesses or approaching the end of their lives, may have spiritual or religious needs. They may also want to connect with others and look for meaning and purpose in life. Therefore, helping and facilitating this is important when providing care. Marie Curie has information on providing spiritual care here.
• Cognitive
• Care recipients may have health conditions that affect their cognitive abilities, e.g. dementia or mental health conditions. As they age, they may become more forgetful and find it difficult to concentrate, pay attention, remember and learn. Incorporating mental stimulation in care is important as it can boost memory, mood and well-being.
• Psychological
• Care recipients diagnosed with an illness or long-term health condition or those needing additional care and support may experience psychological distress, which can impact their mental health and well-being. Care may include talking therapies, complementary therapies and access to mental health services.
• Social
• Care recipients, especially those still in their own homes, are at risk of social isolation and loneliness. Social care may include social opportunities and engagement to stay connected and develop meaningful relationships with others.

As you can see, many factors can influence a care recipient’s health, well-being and quality of life, and they are all interconnected. For example, if a care recipient has a long-term physical condition, it can have significant impacts on their mental health and emotional well-being. It can also cause social isolation if they cannot get out and about. This is why it is crucial to adopt a holistic approach when providing care and support. Looking at a care recipient as a whole can improve their satisfaction and outcomes.

Establishing a Care Routine

Whether a care recipient is receiving care and support in their own homes or a care or nursing home, it is vital to establish a structured care routine, as it has many benefits, for example:

• Benefits to care recipients
• It helps to reduce confusion and anxiety and provides comfort and security to them if they know what to expect.
• It gives them a sense of familiarity and predictability, which is especially important for older people and those with any cognitive conditions, such as dementia.
• It enables them to maintain proper nutrition and hydration, as their bodies will become accustomed to eating and drinking at certain times, and it ensures they receive consistent meals and drinks.
• It helps them regulate their sleep patterns so they get proper rest.
• It gives them more control over their lives, promotes independence and boosts their health, well-being and quality of life.
• Benefits to health and social care professionals and caregivers
• It can help them organise and prioritise various care and support activities by providing a framework to work to.
• It enables them to provide consistent and efficient care and support throughout the day that meets individual needs.
• It makes the job more manageable and helps with time management, as they will know what tasks need to be done and when which can enhance the quality of care.

To establish a structured care routine, it is crucial to properly schedule activities, meals, medication administration, personal care, and rest periods. Here are some tips to achieve this:

• Understand that what works for one care recipient may not work for another. People have different routines, so it is important to ensure they are personalised.
• Collaborate with care recipients, families, carers and other health and social care professionals when assessing needs and developing and changing routines or adjusting plans.
• Allocate sufficient resources to tasks, prioritise and employ time management to adhere to routines and increase efficiency.
• Split the day into mornings, afternoons and evenings, for example:
• Mornings – gentle wake-ups, washing, dressing, breakfast and medication rounds.
• Afternoons– lunches, socialisation and fun activities, including those outdoors.
• Evenings– meals/snacks, washing, changing for bed, and medication rounds.
• Incorporate autonomy into routines, i.e. provide opportunities for care recipients to help, e.g. with meal preparation, or give them sufficient time to do things for themselves where they can, such as getting dressed and washing.
• Include various activities in schedules that encourage socialising, physical activity, creativity and cognitive stimulation. Remember, people have different interests and preferences, so ask them what they enjoy.
• Leave sufficient time to allow for flexibility in routines and adapt to changes in circumstances.
• Adhere to the routine once established, as it helps to reinforce it and maintain consistency.

While it is important to have routines, it is also vital to not be too rigid with schedules and allow for flexibility to accommodate individual preferences and needs. The reason is that routines sometimes need to change, e.g. if there are special events, illnesses or worsening medical conditions.

Health and social care professionals and caregivers must balance routines and flexibility. It enables them to react to anything unexpected, adapt to changes and have the time to deal with it without feeling overwhelmed. It avoids tight deadlines and permits adjustments and schedule adaptations, reducing their and care recipients’ stress and anxiety.

Involving Caregivers and Support Systems

Families, friends and caregivers have an essential role in a care recipient’s life and often know them better than anyone else. Therefore, their involvement is vital when putting a care plan together for the following reasons:

• They may have additional knowledge, which can be fundamental to providing person-centred care and ensuring the care recipient is treated with dignity and respect.
• It helps family, friends, and carers understand the care recipient’s needs and wishes and their role in providing care and support.
• It can help tailor care and support to the individual’s needs and preferences, improve their experience and promote their well-being (SCIE).

The type of level of involvement will depend on the care recipient’s and family’s circumstances. One family may have limited involvement in the care plan, i.e. they may receive notifications of appointments and outcomes of assessments. Another family may be fully involved in care assessment, planning and reviewing.

In some cases, care recipients may not want family, friends, carers, or support systems to be involved in their care plan or decisions about their care, which must be respected and confidentiality upheld. However, there may be instances, i.e. a lack of mental capacity, where others are involved where the care recipient cannot make decisions for themselves. The care plan must still have their best interests at heart, and their family, friends or carers should be involved as much as possible.

There needs to be clear and open communication between care recipients, their loved ones and health and social care professionals, and they must collaborate to ensure high-quality care to ensure a care plan is effective and personalised to the individual. There should be shared decision-making where decisions are made and reached together regarding the required care and support, and everyone understands their role and responsibilities.

Being a caregiver is rewarding. However, it can also be challenging, and there is a risk of stress and burnout (SOM). The health and social care sector faces numerous pressures, such as high demand, funding cuts, staff shortages and low pay (the Health Foundation). These issues, high workloads and day-to-day challenges can make it difficult for anyone working in this sector and also for families and carers. Here are some suggestions to overcome these challenges:

• Delegate tasks – health and social care professionals may be able to delegate tasks, such as routine healthcare aspects, to competent care workers and even to family members and carers. It can help them prioritise, improve time management and provide better care. The Department of Health and Social Care has further information on this here.
• Support groups – there are many support groups where those working in the sector and also families and carers can meet up with others in similar situations and talk about their experiences, for example:
• Our Frontline – mental health and bereavement support for care workers.
• Local Government Association – supporting the mental health and wellbeing of the adult social care workforce.
• Mind – where to find support for carers.
• Age UK – carer’s support.
• Carers UK – support where you live.
• Carers Trust – support for Unpaid Carers.
• Social media groups, e.g. local carers support groups on Facebook.
• Respite care – this is where families and loved ones have a break while care recipients are cared for in their own homes, a residential home or a day centre by a health and social care professional. It also includes care provided by other family members, friends and neighbours, which can reduce the need for health and social care professionals, especially for short-term care. There are many types of respite care, and the NHS has further information here.

Documenting the Care Plan

The information within a care plan is vital in providing personalised care, keeping care recipients healthy and safe, and ensuring their overall well-being. Therefore, it must be documented, either in writing or electronically, and written in a way that is clear and easy to understand, for example:

• No medical or professional jargon or abbreviations.
• In a language the care recipient and others can understand.
• A comfortable and easy-to-use format and style.

The care plan should also be easily accessible to care recipients and others where required, e.g. families, carers and health and social care professionals.

The information within a care plan will depend on the health and social care provider and the care recipient’s needs and circumstances. Some examples of information to include are as follows (this list is not exhaustive):

• Personal details of the care recipient.
• Details of family members and caregivers.
• Assessed care needs.
• Type of care and support required.
• Adaptations or mobility equipment required.
• Care recipient’s desired outcomes, wishes and preferences.
• Who is responsible for providing care.
• When care and support should be provided.
• Medical history and medications.
• Mental health and well-being.
• Social support.
• Cultural and ethnic background, ethics, religion, gender, sexuality and any disabilities.
• Environmental risks.
• Nutrition and dietary requirements.
• Interests and activities.
• Costs of care and services.
• Communication.
• Records of care provided.
• End-of-life preferences.

While all of the details within the plan are important, it is essential to include information such as:

• Medications – some care recipients will have medical conditions or illnesses that require the use of specific medicines. They may have to take them with food or drink and at certain times and frequencies. They will also have specific dosages, so it is vital to document this to prevent medication errors that could make a person ill or worse.
• Allergies – some care recipients will have severe allergies, e.g. food, which can be life-threatening if exposed to an allergen they are allergic to. Some may also have preventive or emergency medication, such as Adrenaline Auto-Injectors (AAI). If not detailed in the care plan, it can put care recipients at serious risk if they go into anaphylaxis.
• Emergency contacts – if there is an emergency, it is important to have relevant contact details. If a care recipient is at their own home, they need information in one place to know who to contact in an emergency. In residential care and nursing homes, staff must also know who to contact in an emergency, e.g. family members and other health and social care professionals.
• Health and social care provider details – if there are any questions or issues, it is important to have the contact details of the health and social care provider to ensure the care recipient is kept safe and well.

Care plans are only useful if fully implemented and followed by health and social care professionals, staff, care recipients, families and carers. Unfortunately, there have been numerous cases where care recipients have died due to care plans not being followed and understood. Here is one such tragic example: BBC News.

It is vitally important that the information within a care plan is accurate, up-to-date and personalised. It must also be reviewed regularly, especially if a care recipient’s needs or preferences change to provide high-quality, person-centred care.

Reviewing and Adjusting the Care Plan

A care plan is not just a document to complete once and then put away on a shelf or in a computer file. It should be fully implemented and accessible. It also needs regular review and adjustment to ensure it continues to be accurate, person-centred and meets the needs of the individual.

Care recipient’s needs and preferences can change over time. They may have newly diagnosed medical conditions, medications, dietary needs, interests, likes and dislikes. If care plans are out of date, it can result in the care recipient’s needs not being met, which can lead to unachieved goals, dissatisfaction and poor outcomes.

Health and social care standards, regulations and practices are regularly updated, and there is also new research and treatments to consider. It is another reason to review and adjust care plans. Health and social care professionals can use the information from industry updates to improve care and support and help care recipients achieve their goals.

Care plans should be reviewed at least once every year if there are no changes, but this will depend on a care recipient’s circumstances and needs and who provides care and support. For example, it may need reviewing more frequently if a care recipient’s condition worsens or if there are problems with care and support delivery.

Care recipients, loved ones, and health and social care professionals (where applicable) should be involved when care plans are reviewed and adjusted.  It is also crucial to include anyone involved in implementing the care plan.

There may be other things that may highlight that a care plan needs reviewing, for example:

• Ongoing assessment – care recipients are assessed regularly to ensure the care plan meets their needs and the goals within are still valid and achievable. If an assessment shows that the care plan does not reflect a care recipient’s needs, preferences and circumstances, it will need reviewing.
• Feedback from caregivers and healthcare professionals – when implementing the care plan, those working on it may notice issues or are unhappy with the care and support and may ask their local council for a review. Healthcare professionals may also give feedback that triggers a review, e.g. new diagnoses, treatments and medications and any changes to diagnosed conditions and illnesses.
• Observation of the care recipient’s progress – it is important to track the care recipient’s progress by observing and monitoring them to identify if the care plan goals are achievable. Observations can gauge a care recipient’s physical and mental health and well-being and note any changes. For example, a care recipient may need additional support if observations highlight a deterioration in their mobility.

Care plans must be flexible and adaptable if a care recipient’s needs and preferences change to provide the best possible care. They must be reviewed and adjusted to ensure they are up-to-date and accurate and reflect the current circumstances of the care recipient.

Conclusion

With the growing demand for health and social care services, people need to understand more about the help and services available, the role of care plans and why they form an essential part of getting personalised care and support. When someone needs additional help, having a care plan can benefit care providers, givers and recipients.

If an individual and/or their family, loved ones or carers feel they need additional care and support, their first point of contact should be with their local council to get a care needs assessment. If eligible, they will get a care plan detailing what care and support they require to meet their needs and preferences while upholding their dignity and respect.

Care recipients and their families and carers (if applicable) should be active partners in care planning along with relevant health and social care professionals. It should be a collaborative approach where everyone is on the same page to ensure care recipients have positive outcomes, such as improved safety, enhanced health and well-being, independence and autonomy and a good quality of life.

Regardless of where an individual receives care, whether at home, in a day centre, a residential care home or a nursing home, their care plan must be fully implemented, reviewed and adjusted where needed. It is a working document that underpins the successful delivery of care and support. It can make a significant difference to care recipients, families, carers and health and social care workers if done correctly and holistically.