Care plans in care homes: What do you need in a care plan?

Care homes always carry out an assessment of a person’s needs before they can move into a care home which results in the creation of a care plan but why are care plans needed in care homes and what is included in a care plan?

What is a care plan?

A care home care assessment forms the basis of a person’s care home care plan. It sets out the level of care and support the resident will need, as well as details of their medication, diet, social interests and end of life preferences.

If you have health and social care needs and do not currently receive support, request a care needs assessment from your local authority (or trust if in Northern Ireland).

If you do not, you may receive care that is insufficient for your needs or care that is too intense, resulting in you paying for more care than you need.

A local authority care needs assessment should take place within 4-6 weeks. 

What does a care plan involve?

Every care home provider needs to get to know each person as an individual. They must conduct a needs assessment so they can plan how they will deliver the person’s care. They write this in a care plan, which any care workers delivering the person’s care will read and follow.

If you need support, a care plan is a document that specifies your assessed unique individual needs. It outlines what type of support you should get, how the support will be given, as well as who should provide it.

A care plan is crucial to ensure you receive the right level of care. It is given in line with your wishes and preferences. The care home’s needs assessment is a discussion about what a person wants to achieve by receiving care in the care home.

The assessment is to talk about:

• What they need support with 
• Who they are as a person 
• Their preferences and goals

Care plans are based on individual needs and are consequently different from person to person. Although each care plan is unique, they all serve the same purposes, including:

• Ensuring that you receive the same care regardless of which care worker is on duty
• Ensuring that the care you receive is recorded
• Supporting you to identify and manage your care needs

Care plans are flexible, meaning that when or if your care needs change, the plan will be reviewed and adjusted accordingly to make sure it meets your needs and preferences.

Care home providers recommend that the person seeking care has a family member or person they trust with them for the care assessment. This is particularly important if they are living with dementia, or cannot fully answer questions due to other medical reasons, such as having had a stroke.

What is included in a care plan?

You should always be involved in the care and support planning process to make your wishes known. Regardless of what your preferences are, your care plan should include:

• What your assessed care needs are
• What type of support you should receive
• What kind of mobility equipment you may need
• Your desired outcomes
• Who should provide care
• When care and support should be provided
• Medication
• Cultural and ethnic background, gender, sexuality, and any disabilities
• Dietary needs
• Mental wellbeing
• Records of care provided
• Your wishes and personal preferences
• Cost of the care
• End of life preferences

Depending on what support you need, your care plan could include everything such as visits to see family or trips out to enable you to pursue the hobbies you enjoy such as going to the local pub. 

Why are care plans important?

A care plan is essential to ensure you consistently receive the right level of care long term and that your personal requirements are known by care workers and the people around you.

An effective care plan helps you to understand your condition and live as independently as possible. 

By being involved in your own care planning, you ensure you will be looked after the way you want and that you can keep doing the things you enjoy, such as pursuing hobbies and interests.
Additionally, a care plan is important because it helps your family and other loved ones to understand your wishes and how they can support you as well.

Care home provider Colten Care says it is important to get the input of both the resident and their family when drawing up the care plan.

A Colten Care spokesperson said: “We don’t accept anyone into our care whose needs we can’t meet. That judgement is made irrespective of how they are funded. Individual nursing assessments are done in an open, transparent way. 

“We devised and built our own internal scoring system that determines the care category, for example nursing, assisted care or residential. It is used with enquiries across all our homes and provides a consistency of approach and rationale.”

Who carries out a care plan in the care home? 

Care home providers can ask a member of staff to carry out a care assessment and this is largely done by a nurse. Nurses in the care home are responsible for collecting and maintaining this data. Certified nursing assistants may be required to collect vital signs, such as pulse rate, respiration rate and blood pressure.

At Colten Care: “Assessments are only ever done by nurses. It’s a robust process that provides reassurance across the board.”

It is the same at Royal Star & Garter, with Pauline Shaw, its director of care saying: “Not every care provider does this, but we aim to send an experienced registered nurse.

“The assessor will invariably follow that person’s journey if the application is successful, they will be more involved. And that applicant will be delighted when they come into the care home and see a familiar face.” 

Where does the assessment for the care plan take place?  

Assessments can take place in a person’s home, hospital, care home or another location specified by the person seeking care. 

At care homes run by Royal Star & Garter potential residents receive a face-to-face visit by one of the nursing team.

Pauline Shaw, its director of care says: “We visit in the person’s home or hospital. Occasionally someone will want to combine their assessment with a tour of the care home.

 “I feel there’s a big benefit from doing the assessment in the applicant’s home – the assessor gets so much contextualised information from their visit.

“They can discuss family photos, look at well-loved objects in their home. It allows a bond to develop and build – you have seen their home which is a privilege, you have that intimacy.” 

Here are some questions that may be asked by the care home:

• How do you like to be referred to? He/Him / She/Her They/Them? 
• Do you have a preferred name, and how should we (your care team) address you? (A person’s preferred name might be different to their legal name).
• What elements of your personality should we consider? 
• Does your ethnicity, religion or culture affect your care needs?
• What medication do you take?
• Do you have a history of falls?
• Do you have any memory problems?
• Are there any elements of your life that are particularly important? 
• Tell me about your job history before you retired
• What are the essential routines you like to follow?  
• What are your hobbies and interests?
• Do you smoke? 
• What is your daily alcohol intake?
• Do you have any specific dietary requirements/needs? E.g. vegan, vegetarian, lactose intolerant?   
• Who are the important people in your life? 
• How involved are your family members? 

Is my GP or other health professionals contacted as part of the assessment? 

Care homes may, if necessary, contact your GP and other health professionals to better understand your care needs. 

During the assessments, you should be told if the care home needs to contact your GP, pharmacist or hospital consultant. When such health professionals are contacted, this will be in the applicant’s best interests for a specific reason. 

How long does a care home’s assessment take? 

Care homes will conduct an assessment at the care seeker’s pace and therefore there is no set time period in which an assessment for a care plan will take place. 

Royal Star & Garter’s Pauline Shaw says: “We don’t have a set time for the assessment. They last as long as they last.  It could take an hour, it could take two hours, it could take more. We go at the person’s pace, just as we do when they move into our homes.”

How often do care home needs assessments take place?  

• A care home care plan will be evaluated on a continuous basis. 
• An evaluation will describe how well the resident’s condition responded to the nursing interventions and if identified goals were met or not. 
• If specific goals were not achieved, the nursing care staff will revise the plan with their families and make adjustments where necessary.

In the case of care provider Colten Care – “Assessments are done before and on admission and then at regular intervals and in line with an individual’s changing needs.”