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1.1 Explain the importance of a holistic approach to assessment and planning of care or support
within the health and social care work setting, the importance of a holistic approach to assessment and planning of care or support means staff to ensure an effective holistic approach to assessment and planning of care or support through identifying individuals’ concerns and needs that will lead to a whole picture regarding the individuals wellbeing through needs and supports like referrals for an individual with eating disorders or the loss of weigh, lack of nutrition to get a better diagnosis of consequences of care provided, to improve communication and better equity of care.
The holistic approach to assessment and planning of care or support ensure that the individuals wellbeing regarding the physical, the emothional, the mental, the spiritual and the social needs are met in a timely and appropriate way, and that resources are targeted to those who needs them most. The information gathered from a holistic approach to assessment and planning of care or support can also be shared with other carers, friends and relives, other professionals who are important to the individuals wellbeing to improve an individuals management and care, and the data collected can influence commissioning of future services.
Duty of staff to promote a holistic approach to assessment and planning of care or support will ensure an centred person approach that will put the individual at the heart of the care planning process. centred person approach means the way staff approach and support individuals and their families and each other as workers, the aim is to ensure that in all of staff approaches staff work hard to demonstrate person centred values and offer assistance in a way that enhances equal citizenship for the individuals, this can help staff to encourage the individual when providing active participation. Active participation is a way of working that recognises an individuals right to participate in the activities and relationships of everyday life as independently as possible, the individual is regarding as an active partner in their own care and support, rather then a passive recipient. this will ensure an active participation regarding the holistic needs of an individual e.g. the physical, the emotional, the mental, the spiritual and the social needs this can help staff regarding theories of motivation and changing behaviour staff can use this to highlight advantages and benefits of active participation by recording the outcome into the individuals care plan. so staff can work within the individuals person centred values (individuality, rights, choice, privacy, independence, dignity, respect and partnership).
Person centred values is a set of values that are firmly based in citizenship and inclusion, advocating that everyone has the right to exercise choice and control in directing their lives and support, this includes designing good support that will assist individual to do this in a way that makes sense for the individual, this will provide useful information and choice. Asking the individual to read the menu and to make a choice regarding foods and fluids or asking the individual what they may like to wear etc.
having a meeting with the individual their families, friends and relatives, other professional and others important to the individual like their Next of kin, social worker, advocates, GP- regarding to maintain mobility, wellbeing, independence and self-esteem of the individual. This will ensure effective communication according to the individual preferred method of communication. staff then can write the individuals care plan through centred person approach that includes the individual in the centre of the care planning process- this will promote active participation bt enhancing the individuals wellbeing by feeling valued as part of the care team.
describe ways of supporting the individual to lead the assessment and planning process
ACTIVE PARTICIPATION- A way of working that recognises an individuals right to participate in the activities and relationships of everyday life as independently as possible, the individual is regarded as an active partner in their own care or support, rather the a passive recipient.
PERSON CENTRED VALUES-A set of values( individuality, rights, choice, privacy, independence, dignity, respect and partnership) that are firmly based in citizenship and inclusion, advocating that everyone has the right to exercise choice and control in directing their lives and support. This includes designing good support that will assist individual to do this in a way that makes sense for the individual.
PERSON CENTRED APPROACHES- The way we approach and support individuals and their families and other workers. The aim is to ensure that all in our approaches we work hard to demonstrate person centred values and offering assistance in a way that equal citizenship for individuals.
PERSON CENTRED THINKING-A range of useful questions or tools that form the basis of Person Centred Planning. They focus on the individuals, their gifts and skills, what is important to them and what makes good support for them.
PERSON CENTRED PLANNING- A continual process of listening to what is important to the individual now and in the future with support of family and friends and creating action or changes based on this.
PERSON CENTRED REVIEWS- A process that can be used as a statutory review which looks at the individuals life and support, what is working and not working and what’s needs to change now and in the future to create outcomes that are right for the individual.
PERSON CENTERED CARE- An approach to the planning, delivery and evalution of care needs that is based on a strong, effective, and respectful partnership between family and the health and social care work setting. Family Centered Care for children with spical care needs is associated with improved health and wellbeing, improved satisfaction, greater efficiency, impeoved access, better communication, better transition services and positive outcomes.
The individual should be in control of all areas of the planning process and made fully aware of what is happening at each stage. In order for this to happen, everyone involved in the individuals care, puts the person at the centre and listens and learns what the individual wants from their lives, do things the way that they wantand helping them to be part of the community and to work with family, friends and professionals to make changes happen. Its important to remember that although care planning is on a day to day basis the individual you are dealing with do not. They may not feel confident enough to ask questions or challenge decisions regarding their care. It is important to ensure the individual understand that they are in charge. To do this you can:
•Ensure everyone who needs to be involved in the planning is included (family, friends)
•Check at each stage in the planning it is meeting the individuals ideas of how they want their service delivered
•use all available information(eg other professionals)
•Give all the information regarding all options available to them
•Gather feedback from all involved in the persons care to check it is working for them.
1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise an individual’s ownership and control of it
To maximise an individuals ownership and control of it mean staff to work in a centred person approach and active participation way. By promoting a person centred approaches that include the individual requiring care or support at the heart of the care planning process will also promote active participation by enhancing the individuals wellbeing by feeling valued as part of the care team. To maximise an individuals ownership and control of the assessment and planning process or documentation. The assessment and planning process or documentation are adapted to the individuals preferred method of communication and preferred language. Staff working in a way that promote person centred care through person centred thinking, planning, reviews and family centred care. To provide care needs that are respectful and responsive to an individuals preferences, needs,and values and ensure that the individual values guide all care need decisions according to the individuals cognitive impairments, staff doing everything that is possible to ensure the individual understands the assessment and planning process or documention, this will ensure custom care needs, for example the assessment and planning process or documention can be adapted to maximise an individuals ownership and control of it. for example using different methods of communication such as books, picture cards that describe the questions or choices to enable the individual that lack mental capacity such as individuals that have Alzheimer dementia to understand the assessment and planning process or documentation.
Outcome 2 Be able to facilitate person centred assessment
2.1 Establish with the individual a partnership approach to the assessment process
If I were working with an individual who is frail, has cognitive impairment that was coming into our care home, I would ensure the indivual was reassured that the assessment is as much about him and his needs. the reassurance that everything they state I would be in position to offer support into expressing their needs. again I would tell them that our service is here to support them right from the beginning. arranging a suitable time for them, lengh of time they would be willing to have and any reasonable adjustments they may need beforehand. I would enquire from the individual if they have anyone who might be involved in their care, including friends, family and advocates. it would be up to them to pick someone whom they trust and know has their best interests at heart. by encouraging the individual and all around them to delelop a positive view of themselves , their lives and future. By empowering individuals and their families to take control of their lives. By working having or knowing how to create an opportunity to say how they want to live and what sorts of help, opportunities and development of local capacities they feel would make a positive contribution towards achieving this.
2.2 Establish with the individual how the process should be carried out and who else should be involved in the process
arranging a suitable time for them, length of time they would be willing to have and any reasonable adjustments they may need beforehand. I would enquire from the individual if they have anyone who might be involved in their care, including friends, family and advocates. it would be up to them to pick someone whom they trust and know has their best interests at heart .By responding to the overall vision, life plan or simple wishes and preferences of each individual and involve their families and friends in the process.
2.3 Agree with the individual and others the intended outcomes of the assessment process and care plan
it is the document where day to day requirements and preferences for care and support are detailed, by taking into account the factors that may influence the type and level of care or support to be provided..
2.4 Ensure that assessment takes account of the individual’s strengths and aspirations as well as needs
it is important to get as much information as possible on the pre admission so there can be a understanding of the individuals strengths and aspirations. also assessing the individual for cogition, personal care if they need assistance or guidance, continence, mobility, tissue viability, diet, their social values and beliefs and also how they ould like to be treated if any illness was to occur.
2.5 Work with the individual and others to identify support requirements and preferences
The most important aspect of planning an individuals care is to establish and desired outcomes. Once this has been established, then to support the individual needs to reach the outcomes is easier to establish. Others may help the individual to establish the desired outcomes bit it is important to remember it is their plan, not yours and the desired outcomes will be decided by the individual not you. You need to ask what the person can do themselves, what can be done by family and friends to support the individual and what is needed. Once this has established you will then need to ask how the individual wants to achieve these outcomes.
3.1 Take account of factors that may influence the type and level of care or support to be provided
factors may include beliefs, values and pteferences of the individual, ricks associated with achieving outcomes, availability of services and other support options
3.2 Work with the individual and others to explore options and resources for delivery of the plan
options and resources should consider:
informal support
formal support
care or support services
community facilities
financial resources
individuals personal network
3.3 Contribute to agreement on how component parts of a plan will be delivered and by whom
individuals can say the support they want, how thwy want that support delivered and who they want to deliver it.
when developing the plan you need to encourage and help the individual answer a varity of questions.
3.4 Record the plan in a suitable format
once the plan has been discussed, planned, decided and agreed it needs to be recorded, accessible and understandable to everyone involved in the planning. The plan needs to include details of how it relates to the individual, how it will improve their lives, the support they need including any risk assessments needed to keep them safe from harm,how any decisions will be made and an action plan of how it will all work. The format the plan is recorded in is important.
4.1 Carry out assigned aspects of a care plan
my role is to support and encourage the individual with their decisions regarding their support plan and by ensuring that the process is carried out in the best interests of the individual. making sure the care plan is reviewed regualy if any changes or annually.
4.2 Support others to carry out aspects of a care plan for which they are responsible
all staff need to know the individuals wishes and goals. I would support them by showing them the care plan, communicating with my colleagues to carry out the activities they are responsible for and also the individuals families in their role from time to time. This support can take a variety of forms from providing additional support when needed to just listening to problems people may have. also involving doctors, SALT, Physio etc.
4.3 Adjust the plan in response to changing needs or circumstances
The clan is a living document and will need to be added to, adjusted and changed throughout the course its life. we need to make adjustments to it when changes occur. Some changes may just be hiccups and part of everyday life whilst other change to the supportof the indiviuals needs. Sognificant changes which would need to be reported and responded to regards the individuals care plan. These could include:
•A change in their health
•A change in their mobility
•A change in finances
•A change in their living circumstances
•a change regarding friends and family
•Recreational or work changes
•A change in the individuals activity level
Each situation will need to be assessed and responded to in diffenrnt ways and care plan adjusted according if necessary
5.1 Agree methods for monitoring the way a care plan is delivered
A care plan is a living document which will be under constant supervision. Once an individuals support needs have been established this is not fixed forever. Individuals needs and preferences change all the time. They may require more or less support as their health improves or deteriorates.
There will need to be regular updates to the risk assessments every 6 months on review or when there is a change in the individuals circumstances. We review are care plans monthly and 6 monthly to monitor changes or if needed to up date individuals change. this is discussed with the individual from the beginning of the care package. A lot is depentant on the information received by the individual and family, regular contact should be maintained with all involved and any compliments or complaints and feed back, should be acted upon and care plans reviewed accordingly.
5.2 Collate monitoring information from agreed sources
Information regarding the care plan should be gathered from a variety of sources. The most important person is the individual who’s plan it is. They will need to be consulted regularly on a weekly or monthly basis to ensure the plan is meeting with their wishes and to ensure the care given is correct and working. Also any changes to the individuals circumstances may mean a change is needed to the plan. The carers and families of the individual should also be consulted in the same way. Their feedback is important when monitoring the effectiveness of the plan. We should also ensure and maintain regular contact with other professionals involved in the individuals life, and ensure they are also part of the monitoring/ feedback. These professionals could include GP, district nurses, occupational therapist, speech therapist etc. Ensuring the care plan continues to meet the support needs if the individual
5.3 Record changes that affect the delivery of the care plan
any changes which are made to the individuals care plan must be agreed with the individual first and family first then recorded in the care plan. Everyone involved in the individuals care should be notified. All paperwork is to be completed in the line with our workplace policies and procedures
6.1a Seek agreement with the individual and others about:
• who should be involved in the review process
Reviews are an essential part of any care plan as an individuals care needs and wishes are subject to change on a regular basis. Usually the date for a review will be set and normally this review will include all those people orininal meeting. At a review everyone will consider if the care plan is meeting all the criteria which is set out to do. The most important person involved in the review is the individual at the centre and it should be discussed and agreed with them who else is to be included in the review. This being said, as much feedback from as many sources as possible should be gathered for the review such as family members, carers, the individuals key worker, the care manager and also us as the carers providing the service. Other professionals who could be involved are GP, nurses, speech therapist and any others who may be involved in supporting the individual with their care. The person managing the review will need to check and ensure the review meets the needs of the individual. During the review everyone should be allowed to contribute.
6.1b • criteria to judge effectiveness of the care plan
In order to judge the effectiveness of the care plan it may be necessary to make a checklist to see how well the service is working for the individual.
for example asking:
•What they are pleased about
•What they are concerned about
•what they have tried
•What they have learned
•What they want to happen next
6.2 Seek feedback from the individual and others about how the plan is working
When everyone has contributed to the meeting and all their feedback has been taken into account a decision has to be made regarding any changes which need to be made to the individuals support plan and care needs. Once any changes have been agreed and implemented the revised plan should then be monitored on a regular basis and feedback gathered from all involved. Also observing first hand to see if the care plan is working.
6.3 Use feedback and monitoring/other information to evaluate whether the plan has achieved its objectives
Once a care plan has been implemented it is important to monitor it to ensure it is meeting the individuals needs. The individuals circumstances could change, they need more or less assistance then when the plan was made or the plan may not be working for them in certain areas. The way to monitor the plan is to regularly obtain feedback from all those involved, including the individual.
6.4 Work with the individual and others to agree any revisions to the plan
It is important that any revisions which need to be made to the plan are discussed and agreed with the individual and others included in their care. If the revisions mean a reduction the services available to the individual any alternatives offered still needs to be acceptable to the individual. If the individual is unhappy with any changes which need to take place it is important that they are assisted and guided through the complaints procedure. After each review the date of the next review should be set and agreed with all concerned. a review should be done regularly.
6.5 Document the review process and revisions as required
The following areas should be covered and documented after the review:
•A written report for all involved
•A handover to all staff involved
•A record of how the individual was prepared for the review
•A record of who attended the review
•Record of any changes
•The revised support plan
After the review all those who contributed should be informed of the outcome of the review.
