Care planning should be a continuous process, with plans and assessments constantly being updated. This is known as the care plan cycle.
Your clients’ care needs and goals will change over time. Perhaps they’ve been ill or had an injury, their living situation has changed, or they’re just experiencing the expected decline associated with their health condition. As a good care provider, it’s important to respond to these changes and alter your support when necessary.
In this article, we’ll explain look at the care plan cycle in more depth, explain why we need to review care plans, and give you some advice about how to make the care planning process easier.
Table of Contents
What is a care plan?
A care plan is a working document that explains a client’s health and care needs, their goals, and how care workers can support them.
Care plans should be personalised and outcome-driven. This means they should focus on goals that matter to the service user. Rather than simply listing the personal care tasks that a carer should carry out, an outcome-driven care plan puts the client’s wishes and preferences first. Two clients may have similar health needs, but very different goals – and their care plans should reflect that.
Care workers should create a care plan after assessing a client. The care team will work with the client, as well as family and other healthcare professionals if appropriate, to make sure that the care plan fully captures their needs, preferences, and hoped-for outcomes. Find out how to write a personalised care plan.
Some organisations use paper care plans, whereas others use care management software to prepare, access, and review their care plans.
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Why do we need to review care plans?
Care plans should be tailored to each service user, and explain how to meet their needs and goals. However, clients’ needs and goals change over time, so care professionals need to review care plans to make sure that clients are getting the right support.
As an individual’s health needs change, they may require more personal care, housekeeping support, or companionship. A client may set a new goal, and need extra help working towards this.
Care plan reviews also encourage clients to think about their hopes for the future. What goals do they have? Your client may want to work towards walking independently, preparing their own meals, or even attending a loved one’s wedding. Goal-setting should be a big part of care plan reviews – this will help your service users feel motivated and involved with their own care.
And, if you want to ace your next CQC inspection, inspectors will expect to see that you review care plans regularly. When they look at your care plans, they will be looking for evidence that they are:
- Regularly updated, both on a schedule and in response to any changes in a client’s circumstances
- Personalised and accurate, reflecting each client’s current needs
- Followed by all members of staff
- Stored securely
When should we review care plans?
Care plans should be reviewed regularly – this might be on a schedule, or whenever a client’s needs and circumstances change significantly.
You may need to reassess and amend a care plan if a client’s health or mobility deteriorates or improves, or if their living situation changes.
Your organisation may have policies and procedures that explain when you should update care plans. You may be encouraged to review care plans and risk assessments every three, six, or twelve months, for example.
According to the Care Act 2014, a care plan should be “an accurate, up-to-date reflection of the person’s needs.” As a care provider, you have a legal duty to make sure that care plans are up-to-date.
If you believe that a client’s needs have changed, make sure that you review their care plan – even if it’s ahead of schedule.
What is the care plan cycle?
The care plan cycle is the process of creating, using, reviewing, and amending a care plan.
The stages of the care plan cycle are:
- Assessment
- Planning
- Delivering care and monitoring progress
- Reviewing and updating
Some organisations might separate out some of these sections a little more – for example, making delivering care and monitoring two individual stages. However, these four stages give a broad idea of what should happen during the care plan cycle.
Let’s look at these stages in more detail.
Stage 1: Assessment
In stage one of the care plan cycle, you’re assessing your client’s needs, talking about their goals and preferences, and planning how you can support them.
Your client may have already had a care needs assessment from the local authority before they came to you. However, it’s important for your care team to carry out a risk assessment, and independently look at a new service user’s care needs.
A care assessment should involve a discussion of the client’s goals. What would they like to achieve, and what support do they need to get there?
Care assessments should also look at a client’s current daily routine, any issues they experience, their health conditions, any mobility problems, medication, cognitive function, and other details about their physical and mental health. You should also find out about a client’s support system, religious or cultural needs, dietary preferences, and their hobbies and interests.
Stage 2: Planning
After the care assessment, you should produce the care plan.
Care plans should clearly explain:
- What is important to the client
- What the client can do for themselves
- How care workers should help the client, including when and how often
- When the plan will be reviewed
Care planning software, like PASS, can help you create care plans after you’ve conducted a comprehensive care assessment.
PASS care planning software includes more than 120 care plan templates, so you can quickly produce personalised care plans for your service users. You can add tasks for care workers, include client goals and preferences, and share documents with the care team, so they’re all working from the latest version to provide the right care for the client.
After the care assessment, you should produce the care plan.
Care plans should clearly explain:
- What is important to the client
- What the client can do for themselves
- How care workers should help the client, including when and how often
- When the plan will be reviewed
Stage 3: Delivering care and monitoring
In stage three of the care plan cycle, you’re using the newly-written care plan to support your client. You should also be monitoring the client and mentally reviewing whether the care plan meets their needs.
Using the new care plan, you and your team should now deliver person-centred care to the client. Follow the care plan exactly as written, and document everything.
While you’re delivering care, you should be considering a client’s needs and abilities. Has anything changed?
If a client needs extra support, is more tired or withdrawn, or displays challenging behaviour, note this down. Comprehensive notes can help you spot trends in a client’s health or behaviour – these might be potential early warning signs of health issues, or an indication of something that should be changed in the care plan.
These notes don’t only help you in the future – they can help other care workers who are supporting the client each day. If you work in a care home or residential facility, you’ll often share updates about residents in daily handover meetings.
However, if you provide home care, you might not get this face-to-face time with colleagues. Home care software can help you share updates about clients with carers and approved family members, so that you can spot potential issues early.
While delivering care and monitoring, be prepared to move on to the next stage at any time if the client’s situation changes.
Stage 4: Reviewing and updating
In stage four of the care plan cycle, you’re reviewing the care plan and making any necessary updates.
Reviews and reassessments may happen as a result of a change in the client’s needs, circumstances, and goals. However, even if you haven’t noticed any changes, you should still review care plans on a regular basis.
Like the initial assessments, reviews should be carried out in conjunction with the client and their support system, as well as other healthcare professionals if appropriate.
A good review will look at the client’s previous care plan, and evaluate whether it is still appropriate and effective. You may need to update goals and health information, or make changes to the support that a client requires.
5 ways to improve your care planning
We’ve put together some tips to help you produce excellent person-centred care plans, and support your clients in the best way possible.
- Involve the client and their support system: Where possible, involve clients, their family and friends, and other healthcare professionals. Clients should always be a part of care planning and reviews – after all, they’re the experts on their own needs, preferences and goals. As for their larger support system, they all care about your client’s health and outcomes, and may have additional knowledge that can help your team provide the best care possible.
- Focus on the client’s goals: Make sure that care plans focus on what the client wants. It can be easy to concentrate on their physical health needs, but it’s important to remember that care plans should be outcome-driven. They should focus on specific goals that matter to the client, such as walking independently, attending social groups, or managing pain effectively. Making sure that your care plans are outcome-driven means that every client will receive personalised care, supporting them to achieve goals that matter to them.
- Look for achievable outcomes: Consider whether your client can achieve the goals that they want to set – it may feel discouraging if they fall short. Suggest working towards smaller goals first. For example, encourage a client to walk independently to the bathroom before they try to walk to a nearby shop. Care plans can always be updated when goals have been met.
- Foster a culture of open discussion: Encourage clients and care workers to speak up if they have concerns or feel that a care plan needs to be reviewed ahead of schedule. Be prepared to reassess clients and hold care plan reviews at short notice, so that you’re always providing the right care for your service users.
- Use care planning software: This can make writing care plans and risk assessments quicker and easier. It also makes storage more secure, reducing the risk of unauthorised users finding paper care plans. At the same time, it can also be accessed by multiple care workers at the same time, making it easier for colleagues to stay updated on a client’s condition. Finally, care management software can help you track a service user’s progress – letting you know if there are issues, and when it’s time for a care plan review.
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