Guidance & processes for effective care planning

A care plan is a document that contains all of the information about someone who is receiving care – either through living at a care establishment or living at home with a carer regularly visiting. Elements such as the residents’ conditions are stored on the plan, alongside the care and medication that they will receive.

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What is a care plan?

A care plan is a document that contains all of the information about someone who is receiving care – either through living at a care establishment or living at home with a carer regularly visiting. Elements such as the residents’ conditions are stored on the plan, alongside the care and medication that they will receive.

Who needs a care plan?

Care plans are designed for anyone who receives care, with the intention of supporting their health and well-being.

The resident keeps a copy of their care plan, but they can also request for a family member to have one, which can be beneficial as it allows the family member to stay aware of the care that they are receiving.

CareDocs Blog Best Practice and Advice Guidance and Processes for Effective Care Planning

Care planning guidance

To create a care plan, both the resident and carer should be involved, where possible, so that an entirely accurate plan can be developed. Where they have capacity, the resident must understand all elements of their care plan – including the conditions they have, as well as the care and treatment they will receive – and their input must be valued.

The care plan must be written clearly so that all carers can easily understand what is required of them and what they are expected to do while caring for the resident.

A resident’s family member can also be a part of this process, allowing them to give their input/advice on how the resident should be cared for. This can be beneficial as it helps the carer to further understand the personality of the resident, especially in cases where accurate communication with a resident is difficult.

Having all of these members involved in the plan ensures the most accurate, detailed and effective care plan can be created.

Care planning processes

There is no single and correct method of developing a care plan as all care providers create care plans differently. However, there is some crucial and common information that is necessary on all plans, such as an accurate and exhaustive assessment of the resident, which includes their medical and physical requirements. All of this information is stored on the care plan and, depending on the health of the service user, there may be regular and further assessments to keep up to date with all the conditions that the resident may have.

The next step is often to develop a care strategy that will meet all of the resident’s requirements, which should also include the patient-centered outcomes. This will help ensure that the holistic package of care is having a positive impact and is beneficial for the resident. However, the focus shouldn’t just be on the service user’s weaknesses, it should also identify and try to improve their strengths too.

Here at CareDocs, we are passionate about creating comprehensive, person-centered care plans. Our care planning process is quick and easy to grasp, and our care plans are produced as a digital document that is available for all carers of the resident to access.

We use a unique three-step system to produce our fully personalised care plans:

  1. An assessment is completed by answering a series of simple questions.
  2. CareDocs automatically creates a draft care plan.
  3. The entire care plan can be checked and edited to ensure it includes every detail that you want.
CareDocs Blog Best Practice and advice What is Person Centred Care Planning and Why is it Important

Key features of a care plan

Care plans are generally separated into sections, to make it easy to find the information you need at the time you need it. With CareDocs, the sections include some Activities for Daily Living (ADLs), such as mobility, nutrition and hydration, and personal care, along with supporting care plan sections, such as communication, mental capacity, and medication.

When caring for someone, risks need to be identified and managed to ensure a person’s safety, while maintaining their freedom of choice. A risk assessment must be completed and, where the risk is deemed too high, appropriate steps should be taken to reduce or remove the risk. In CareDocs’ care plans, the risks and associated action plan is placed within the care plan, so anyone viewing the care plan can see all the information required at the same time.

Another common feature of a care plan is to list the outcomes that the patient wants to achieve. For example, they might state that they want to be ‘as independent as possible’. The carer could then develop some ideas to help them reach or maintain this goal, such as leaving clothes on a bed for a person to get dressed independently, but for support to always be available in case the resident requires assistance.

Perhaps the most important feature of a care plan is making it truly person-centred, and ensuring the resident’s preferences, wishes and choices are clearly documented. With CareDocs this is easy, as the assessment questions focus on the individual, and care plans can even be written in the first person.

CareDocs and our approach to care

Here at CareDocs, we’re passionate about helping to deliver healthcare that truly makes a difference. Our care planning and recording software is designed to make it as easy as possible for health professionals, carers and residents to analyse, manage and understand health records, without removing any of the important details.

Our solutions are perfect for those who believe in person-centred care and help support collaborative care planning, and for those wanting to achieve better inspection results.

For more information about how CareDocs can make a difference for your care home, get in touch today to learn more. Our friendly staff can help show you how easy it is to deliver person-centred care with our innovative software. Call us on 0330 056 3333 or email on sales@caredocs.co.uk.

Want more information on this subject? Check out this free ebook:

Introduction to care planning

Originally published on September 3, 2017
Article updated on June 30, 2022

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