What is a Care Plan. Who Should Have One?

Making a care plan

Care plan help with organising an individuals care

What is a care plan? How can they help somebody diagnosed with dementia?

Care plans are agreements that are made between you, your family, carers and the health professionals that are responsible for your care.

They can include input and recommendations from social services, NHS bodies such as nurses or your own doctor.

They help the individual and their carers manage the persons day-to-day health needs. Or anything else that the person requires.

An individual may have dressing, washing or personal beliefs that they want expressing in the plan.

Once devised it can be stored in a document or folder. It can be written on paper or recorded electronically. It can be placed in the persons patient notes as reference to those people who care for the individual.

If the carer changes or other bodies or organisations take up caring or provide a service for the individual then they have notes and remarks to refer to.

Who should have a care plan?

A care plan is usually constructed for a person who has a long-term medical condition.

The person with the condition is encouraged to take part in the making of their plan if possible. They can add their own input into how they would like their care carried out.

Where a person has been given a diagnosis of dementia, it is better to try to work out a care plan whilst the dementia is in the early stages. This enable them to have as much personal input from the sufferer as could be reasonably possible.

This helps to work out what care the person will need and how the care will be provided to the person by the agencies involved in providing the care and support. As all conditions and diseases progress at different speeds and affect people in different ways so a care plan is also a good way to record the changing care needs a person has.

If you think this could help you or somebody you know, have a talk to your or the individuals GP, nurse, carer or social worker about the support you need to write one.

Mention things that are important to you or the individual and any goals you want to work towards in the long-term. These can range from how you would like your care to be conducted to any requests you may have as the dementia progresses.

By talking with the family, GP, nurse, carer or social worker, you can say how you want to manage your health and choose what’s best for you. The care plan will be based on what you want, so you’re in control.

What should be in a care plan?

Every organisation will have their own way to devise a care plan. The questions asked will differ slightly from organisation to organisation and from carer to carer based on what service the organisation is providing.

A transport company that drives a person to and from a day centre may devise a care plan based on how able the person is at getting on/off the transport, or a day centre may devise a care plan based on what activities the individuals are able to do.

But in most cases they should include at least 7 main sections based on the individual.

  1. Name of individual
  2. Who the care plan has ben written by
  3. Date
  4. Strengths
  5. Needs
  6. Goals
  7. Actions

An example of a typical care plan written by a transport company might read-

  1. Name – Joe Bloggs
  2. Wrote by – I. Carealot – Helpful Transport
  3. Date – 09/03/12
  4. Strengths – Unable to walk unaided
  5. Needs –  Needs help on and off the bus.
  6. Goals –  Make sure that assistance is available at all times
  7. Actions – Have at least 1 carer in addition to the driver to be present when transporting the person on the bus

You could also have a more general personalised care plan that is more tailored to the individuals needs written by a care professional

What should a care plan address?

Below are some, but not all, the questions a care plan should be addressing

  • Personal goals you want to work towards such as getting out of the house more, or starting an activity.
  • The support and type of care you want, who is in charge of providing and making decisions about these services.
  • What have the support services/organisations agreed to do by way of providing care and when they will do it.
  • Emergency telephone and contact numbers. Who should be contacted if you become  unwell and what if your doctor’s surgery is closed. Who would be contacted first.
  • Medication and prescriptions you need. What intervals and times are the drugs to be given.
  • Eating and allergies. Especially important if the person struggles with communication.
  • Exercise plan. Is the individual able to carry out any exercise. When was the last time the did any exercise.

Once Written Keep for Reference

If you have a care plan made by an organisation you should be able to have your care plan printed out on paper for you to keep at home. If somebody makes one for you and you’re not given a paper copy, you can ask for one.

Your care plan may also be stored on the care organisations/providers computer or whatever filing system they may use.

You as the individual must make sure you express what’s important to you and that you’re happy with any decisions that are put into the plan. In some cases your needs and wants may not be possible to achieve. But unless your family, carers, health and social care workers know what you want, they can’t tailor it to your wishes.

All the information provided should be kept private. It should be seen only by you and the people who give you the care or support.

By making a care plan you and other carers and support groups can look back and read the plan to see if it is working and you are receiving the best care that is possible.

You are able to change your personal care plan if you wish. If a doctor or nursing agency has written it for you, ask to see it at least once a year, This helps to make sure you are getting the best from your care plan and that any changes in your wishes are considered.



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