Send feedbackPrint this page

AG1: Develop, implement and review care plans for individuals

Status: National Occupational Standards (NOS)

About this workforce competence

For this unit you will be expected, with the support of other staff, to develop, implement and review care plans.

There are three elements:

AG1.1  Develop care plans to meet individual needs and preferences

AG1.2  Implement care plans

AG1.3  Review and revise care plans to meet changing needs, preferences and circumstances.

Users of this competence will need to ensure that practice reflects up to date information and policies.

This is an optional unit in the Health and Social Care NVQ/SVQ at Level 4.

This competence replaced HSC416 during rationalisation of the database.

Links

This workforce competence has indicative links with the following dimension and level within the NHS Knowledge and Skills Framework (October 2004):

HWB2: Assessment and care planning to meet people's health and wellbeing needs
Level 3: Assess health and wellbeing needs and develop, monitor and review care plans to meet specific needs

Keywords

Origin

This unit appears in the Health and Social Care Standards as HSC416 Develop, implement and review care plans for individuals.

Glossary

This section provides explanations and definitions of the terms used in this workforce competence. In competences, it is quite common to find words or phrases used which you will be familiar with, but which, in the detail of the competence, may be used in a very particular way.

Scope

This section provides guidance on possible areas to be covered in this competence.

Communicate

using:

  • the individual's preferred spoken language
  • the use of signs
  • symbols
  • pictures
  • writing
  • objects of reference
  • communication passports
  • other non verbal forms of communication
  • human and technological aids to communication

Information

any plans

care needs assessments

records and reports relevant to the individual needs and preferences

Key people

include:

  • family
  • friends
  • carers
  • others with whom the individual has a supportive relationship

Performance Criteria

AG1.1 Develop care plans to meet individual needs and preferences

You must ensure that:

1. you identify and agree the roles and responsibilities of all concerned with the development of care plans

2. you access and review:

  • information about individuals' needs and preferences and any specific requirements they may have
  • literature and knowledge based research relevant to individuals' needs and preferences

3. you work with people within and outside your organisation to ensure the development of the best possible care plans for individuals

4. you involve and support individuals and key people to contribute at every point in the development of the care plans

5. you identify and agree the content of care plans, ensuring that:

  • individual needs and preferences are placed at the centre of care plan activities
  • the plans provide active support for individuals
  • individuals and key people are protected from danger, harm and abuse
  • risks are managed

6. you develop care plans:

  • according to legal and organisational requirements
  • in a format and language that is understandable and useable by all who need and are required to access and use them

7. you check the details and make sure that individuals and key people understand the contents of the plan

8. you provide evidenced based records and reports, that detail:

  • actions and decisions about the content of the plan
  • aspects of the plan where there was any disagreement and how this was resolved

9. you complete, and support individuals to complete, any necessary paperwork when the final plan has been agreed

10. you ensure that the plan is stored and able to be accessed within confidentiality agreements and according to legal, organisational and any service requirements.

AG1.2 Implement care plans

You must ensure that:

1. you support individuals and key people to understand:

  • the arrangements for the implementation of their care plan
  • their roles and responsibilities in implementing the care plan
  • any areas where their preferences have not been able to be met and why
  • how any emerging problems and crises will be addressed
  • how they can compliment, challenge and complain about the care plan and its implementation

2. you identify and agree the roles and responsibilities of all concerned with the implementation of care plans for individuals

3. you carry out your own role and responsibilities in implementing care plans, in ways that illustrate best practice to all with whom you work

4. you support staff involved in the implementation of care plans to:

  • work effectively, holistically, inclusively and provide active support for individuals and key people when implementing care plans activities
  • understand their role and responsibilities in carrying out specific activities
  • understand and use the best methods to implement the care plan activities to meet individual needs and preferences
  • record and report any discomfort and change in individuals when working with individuals and implementing care plan activities

5. you support individuals and key people to identify their views and preferences and provide feedback on the implementation of the care plan

6. you work with all involved to identify and report any changes arising from the impact of the care plan on the health and social well-being of the individual

7. you address any difficulties arising from changes in resources and to the needs, circumstances and preferences of individuals.

AG1.3 Review and revise care plans to meet changing needs, preferences and circumstances

You must ensure that:

1. you identify and agree the roles, responsibilities and criteria for judging the quality and effectiveness of care plans with all involved

2. you work with individuals, key people and others within and outside your organisation to:

  • review all aspects of the care plan
  • agree changes to the care plan
  • identify resources necessary to implement any changes

3. you contribute to, participate in and run meetings and discussions to agree revisions to care plans, taking account of any benefits and risks

4. you ensure that review meetings are arranged and run in ways which promote the full participation of individuals and key people

5. you collate review information and revise care plans within agreed timescales

6. you ensure that individuals and key people understand the revisions that have been made to the care plans and the implications of these for the health and care services that individuals receive

7. you provide evidenced based records and reports, that detail:

  • actions and decisions about the revisions to the plan
  • aspects of the plan where there was any disagreement and how this was resolved

8. you complete, and support individuals to complete, any necessary paperwork when the revised plan has been agreed

9. you ensure that the revised plan is stored and able to be accessed within confidentiality agreements and according to legal, organisational and any service requirements.

Knowledge and understanding

You need to apply: 

Legislation and organisational policy and procedures

K1. codes of practice and conduct, and standards and guidance relevant to your setting and own and the roles, responsibilities, accountability and duties of others when developing, implementing and reviewing care plans

K2. current local, national and European legislation and organisational requirements, procedures and practices for:

  • data protection
  • health and safety
  • risk assessment and management
  • employment practices
  • protecting individuals from danger, harm and abuse
  • your responsibility for keeping yourself, individuals and others safe
  • making and dealing with complaints and whistle blowing
  • multi-disciplinary and multi-agency working
  • working in integrated ways to promote the individual's well-being
  • the planning and provision of services
  • developing, implementing and reviewing care plans

K3. key government initiatives which affect the development and review of care plans to meet individual needs, preferences and circumstances

K4. how to access, evaluate and influence organisational and workplace policies, procedures and systems for developing, implementing and reviewing care plans

K5. how to access and record information, decisions and judgements for care plans

K6. how different philosophies, principles, priorities and codes of practice can affect inter-agency and partnership working when developing, implementing and reviewing care plans

Theories and practice

K7. how and where to access literature, information and support to inform your practice when developing, implementing and reviewing care plans

K8. an up-to-date knowledge of:

  • literature related to best practice in the development, implementation and review of care plans
  • government reports, inquiries and research relevant to the development, implementation and review of care plans
  • government reports, inquiries and research into serious failures to protect individuals, families, carers and other key people

K9. theories of:

  • facilitating empowerment and participation of individuals and key people in the development, implementation and review of care plans
  • the role of family and social support networks in meeting individuals' needs
  • how social and economic circumstances may impact on the individuals' social care, well-being and life chances
  • human resource management in relation to the development, implementation and review of care plans
  • human growth and development
  • managing loss and change
  • how stress can affect behaviour
  • how power and influence can be used and abused when developing, implementing and reviewing care plans
  • multi-disciplinary and multi-organisational working

K10. knowledge of the physical, emotional and health conditions of the individuals for whom you are developing, implementing and reviewing care plans and how to use this information to make informed decisions for the content of the care plans

K11. the factors to take account of when evaluating whether your organisation has the resources (human, physical and financial) to provide the services and facilities

K12. how to analyse, interpret and balance:

  • individual needs and preferences
  • views of key people
  • evidence, knowledge and practice based information
  • knowledge of individuals' conditions
  • resources and capacity within your organisation
  • to enable you to assess individuals' needs and preferences, fairly and ethically

K13. methods of supporting individuals and key people to:

  • express their wishes, needs and preferences about the delivery of services and facilities
  • understand and take responsibility for promoting their own health and well-being
  • identify how their care needs should be met
  • assess and manage risks to their health and well-being

K14. methods of supporting staff to work with individuals, key people and others to deliver, implement and evaluate care plans

K15. the stages, procedures, paperwork and people involved in developing, implementing and reviewing care plans

K16. the use of evidence, fact and knowledge based opinions in records and reports and why it is important to differentiate between these and make clear the source of evidence

K17. what is meant by needs-led and service-led planning and their relevance for reviewing care plans

K18. reasons for changing resources and care plans and how to deal with the affect this may have on individuals

K19. why and how the review and revision of care plans may have implications for individuals, key people and the existing provision

Values

K20. legal and organisational requirements on equality, diversity, discrimination, rights, confidentiality and sharing of information when developing, implementing and reviewing care plans

K21. knowledge and practice that underpin the holistic person-centred approach which enable you to work in ways that:

  • place the individuals' preferences and best interests at the centre of everything you do
  • provide active support for the individuals
  • recognise the uniqueness of individuals and their circumstances
  • empower individuals to take responsibility (as far as they are able and within any restrictions placed upon them), and make and communicate their own decisions about their lives, actions and risks when developing, implementing and reviewing care plans

K22. how to manage ethical dilemmas and conflicts for individuals, those who use services and staff/colleagues when developing, implementing and reviewing care plans

K23. how to challenge, and to support individuals, key people and others to challenge information, documents, systems, structures, procedures and practices that are discriminatory

K24. the ways that health and social care values may differ from those of the individuals and key people you are working with

K25. how to form relationships that promote the individuals' rights, choices and well-being.

Top of page


Printed from www.skillsforhealth.org.uk