B

AG2 Contribute to care planning and review

Overview

This standard, you will be expected to contribute to the assessment of individual needs and preference and to the development, implementation and review of care plans.

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

Version No 1

Knowledge and Understanding

You will need to know and understand:

  1. codes of practice and conduct, and standards and guidance relevant to your own and the roles, responsibilities, accountability and duties of others when planning, monitoring and reviewing the delivery of service for individuals
  2. current local, National and European legislation and organisational requirements, procedures and practices for:
    1. data protection, including recording, reporting, storage, security and sharing of information
    2. health and safety
    3. risk assessment and management
    4. protecting individuals from danger, harm and abuse
    5. planning, monitoring and reviewing the delivery of service for individuals
    6. working with others to provide integrated services
    7. the different methods of providing support and services
  3. practice and service standards relevant to your work setting and relating to the assessment of individual needs and preferences, and the development, implementation and review of care plans
  4. how and where to access information and support that can inform your practice when assessing individual needs and preferences, and contributing to the development, implementation and review of care plans
  5. government reports, inquiries and research reports relevant to the assessment of individual needs and the development, implementation and review of care plans
  6. theories and best practice relevant to:
    1. the assessment of the holistic needs and circumstances of individuals
    2. care planning, implementation and review generally, and specifically to the individuals with whom you work
  7. methods of monitoring, reviewing and evaluating care plans 
  8. methods of supporting individuals to:
    1. contribute to assessments and reviews
    2. express their needs and preferences
    3. understand and take responsibility for promoting their own health and care
    4. identify how their care needs should be met
    5. assess and manage risks to their health and well-being
  9. role of relationships and support networks in:
    1. the assessment of individual needs
    2. care planning, implementation and review
  10. factors that affect the health, well-being, behaviour, skills, abilities and development of individuals and key people
  11. the significant changes that are likely to affect needs and circumstances of  individuals with whom you work and how these will impact on care needs assessment and the development, implementation and review of care plans
  12. reasons for revising care plans and how to deal with the affect this may have on individuals
  13. legal and organisational requirements on equality, diversity, discrimination, rights, confidentiality and sharing of information on planning, monitoring and reviewing the delivery of service for individuals
  14. how to provide active support and place the preferences and best interest of individuals at the centre of everything you do, whilst enabling them 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
  15. the rights of carers to be supported in the caring role
  16. dilemmas between:
    1. the individual’s rights and their responsibilities for their own care and protection, the rights and responsibilities of key people and your role and responsibilities for their care and protection
    2. the individual’s views, preferences and expectations and how these can and are provided for in the services being delivered
    3. the individual’s rights and the rights of key people
    4. your own values and those of the individual and key people
    5. your own professional values and those of others within and outside your organisations
  17. how to work in partnership with individuals, key people and those within and outside your organisation to enable the individual’s needs, wishes and preferences to be met

Performance Criteria

You must be able to do the following:

  1. identify your own, and the role and responsibilities of others, in assessing the needs and preferences of individuals
  2. access and review information about the individuals needs and preferences and any specific requirements they have
  3. identify and access any extra support you need to enable individuals to communicate their needs and preferences
  4. support individuals and key people to identify and communicate:
    1. the individual’s needs and preferences about their care and support
    2. any risks arising from these
  5. take into account the views of individuals, key people and others  when processing information and providing feedback on the individual’s health and care needs, their preferences and any associated risks
  6. work with all involved to agree the assessed needs and preferences of individuals
  7. identify your role and responsibilities in developing and implementing care plans
  8. contribute to consultations about the development of individuals’ care plans taking into account their assessed needs and preferences
  9. support individuals and key people to understand:
    1. where the individuals’ preferences could not be met within the care plan and why
    2. the arrangements for the implementation of care plans
    3. how to use procedures to compliment, challenge and complain about the content of the care plan and its implementation
  10. support colleagues to carry out the care plan activities for which they are responsible
  11. ensure that you are able to carry out the care plan activities for which you are responsible
  12. when implementing the care plan, you observe, record and report to the appropriate people, any significant changes to the individual’s needs, circumstances and preferences and any risks that may arise from these
  13. check your observations with the individuals, key people and others
  14. support individuals, key people and colleagues to identify and monitor changes in the individuals’ needs, circumstances and preferences
  15. work with all involved to identify and implement any changes arising from the impact of the care plan on the health and social well-being of the individual
  16. check your own responsibilities and those of others in providing feedback on the implementation of the care plan
  17. support individuals and key people to identify:
    1. parts of the care plans which best meet the individuals’ needs and preferences
    2. parts of the care plans that need changing
    3. changes to the individuals’ needs, circumstances and preferences that could affect the care plan and its implementation
  18. provide feedback to the appropriate people on the strengths and limitations of the care plan in meeting the assessed and changing needs, circumstances and preferences of individuals
  19. support individuals and key people to understand how their feedback will be used to inform changes to the care plan
  20. where there is conflict about your feedback and observations, you follow organisational procedures and practices to address the issues raised
  21. contribute to meetings and discussions about revisions to care plans and their implementation
  22. contribute to revising and implementing any changes to care plans that are within your role and responsibilities
  23. support individuals to complete paper work to enable the revised care plan to be implemented
  24. record and report on the review and revisions of the care plan, within confidentiality agreement and according to your role and responsibilities

Additional Information

This National Occupational Standard was developed by Skills for Health.

This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004):

Dimension: HWB2 Assessment and care planning to meet people's health and wellbeing needs.

This standard has replaced HSC328.
AG2 Contribute to care planning and review
Final version approved June 2010 © copyright Skills For Health
For competence management tools visit tools.skillsforhealth.org.uk
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